ATI LPN
Psychiatric Nursing: Contemporary Practice 6th Edition
Chapter 10 : The Psychiatric-Mental Health Nursing Process Questions
Question 1 of 5
After assessing a patient, the nurse noted the following: he was tearful, he tried to kill himself before coming into the hospital, he had no immediate plan for another suicide attempt, he was unable to concentrate, and he reported having trouble sleeping and having little or no appetite. The nurse also noted that the patient?s appearance was unkempt, that he spoke in a low monotone, and that he was unable to establish and maintain eye contact. Based on this information, which nursing diagnoses would be the most appropriate?
Correct Answer: C
Rationale: The patient?s recent suicide attempt, tearfulness, and depressive symptoms (poor concentration, sleep issues, low appetite, unkempt appearance) indicate a high risk for suicide, making 'Risk for Suicide' the most appropriate diagnosis. Ineffective Role Performance is less immediate, and there?s no evidence for infection or self-mutilation risk.
Question 2 of 5
A staff nurse on a psychiatric unit knows that patients often have trouble sleeping because of their psychiatric conditions. Which of the following would reflect a psychiatric nursing intervention to appropriately address this problem?
Correct Answer: A
Rationale: Limiting evening snacks and beverages, especially those with caffeine, promotes sleep hygiene by reducing stimulants and bladder disturbances, addressing sleep issues common in psychiatric conditions. Volleyball before bed may increase arousal, enforcing bedtime is rigid and non-therapeutic, and naps can disrupt nighttime sleep.
Question 3 of 5
The nurse is determining the success of a patient?s plan of care by evaluating outcome indicators. The nurse understands that these indicators are usually determined initially at which time?
Correct Answer: D
Rationale: Outcome indicators are specific, measurable criteria established during the goal-setting process in the nursing plan of care. This occurs after assessment and diagnosis, aligning interventions with desired outcomes. Discharge, assessment, and initial interviews precede or inform goal-setting.
Question 4 of 5
Based on assessment data, the nurse formulates the nursing diagnosis for a patient as sleep pattern disturbance. After teaching the patient how to relax before bedtime, the nurse determines that the teaching was effective by which outcome?
Correct Answer: B
Rationale: The goal of teaching relaxation techniques is to improve sleep quality. 'Reports feeling rested on awakening in the morning within 3 days' directly indicates effective sleep, aligning with the intervention?s purpose. Discussing feelings, requesting medication, or short sleep intervals do not confirm improved sleep quality.
Question 5 of 5
A patient was brought to the emergency department for an injury he received while working as a migrant worker. It soon becomes evident that the patient cannot speak English. A nurse on duty offers to find an interpreter so the patient can communicate with the medical staff. The nurse?s offer is an example of which type of nursing intervention?
Correct Answer: C
Rationale: Cultural brokering involves facilitating communication and understanding between individuals of different cultural or linguistic backgrounds, such as securing an interpreter for a non-English-speaking patient. Milieu therapy manages the therapeutic environment, conflict resolution addresses disputes, and structured interaction is less specific.