Chapter 10: The Psychiatric-Mental Health Nursing Process - Nurselytic

Questions 20

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Chapter 10 Questions

Question 1 of 5

Which of the following questions would be most helpful in beginning an initial assessment interview for a patient who has just been admitted to a psychiatric inpatient unit?

Correct Answer: B

Rationale: The initial assessment interview aims to establish rapport and understand the patient?s primary reason for admission. Asking 'What brings you into the hospital today?' is open-ended, patient-centered, and elicits the patient?s perception of their problem, setting the stage for further assessment. Previous admissions, suicidal thoughts, and relationships are important but secondary to understanding the current reason for admission.

Question 2 of 5

A patient is being admitted to the psychiatric unit. While explaining his reason for seeking admission, he describes how his 32-year-old son recently died of a heart attack. Which response by the nurse would enhance the effectiveness of this interview?

Correct Answer: C

Rationale: A therapeutic response acknowledges the patient?s emotions and fosters rapport. 'This must be a very difficult time for you' reflects empathy and encourages further sharing. Options A and B shift focus to others, and option D involves inappropriate self-disclosure, which may detract from the patient?s needs.

Question 3 of 5

A patient was admitted to the hospital after a suicide attempt made after his daughter was killed in an automobile accident during which he had been driving and survived with only minor injuries. Even though the accident was unavoidable, he feels responsible. During the assessment interview, the patient begins to describe the last conversation he had with his daughter before he lost control of the automobile. As he speaks about his daughter, his voice trembles, and a silent tear rolls down his face. He makes a visible attempt to straighten up and smiles superficially at the nurse, stating, 'I?ll get over this. I just need to keep a stiff upper lip. I think all I need to do is stay overnight. I?ll be as good as new by tomorrow.' Which response by the nurse would be most appropriate?

Correct Answer: C

Rationale: The patient?s statement reflects minimization or denial of his emotional distress and suicide attempt. Using reflection, 'As good as new?' prompts the patient to explore his feelings further without judgment. Option A shifts focus prematurely, option B reinforces denial, and option D is confrontational, potentially shutting down communication.

Question 4 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 5 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.

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