Chapter 9, The Nursing Process in Psychiatric–Mental Health Care Video Solutions, Psychiatric-Mental Health Nursing: Evidence-Based Concepts, Skills, and Practices

Problem 1

A client admitted for severe depression is brought to the inpatient unit. Applying the nursing process, which action would the nurse do first?
a. Develop relevant diagnoses.
b. Assess mental and physical health status.
c. Establish outcomes such as “The client will not express suicidalthoughts.”
d. Offer to teach the client stress management techniques.

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Problem 2

A 44-year-old woman is in the outpatient mental health clinic for anorexia nervosa. The nurse performs a thorough psychosocial and physical assessment, which reveals, among other things, that the 5?6?? client weighs 95 lb (43.1 kg). The client also describes severely ritualistic behaviors, such as cutting food into V-inch pieces and eating only certain foods on certain days. When planning the client’s care, the nurse and the client identify outcomes. Which of the following would be most appropriate for this client?
a. The client will gain 4 lb (1.8 kg) per week until she reaches her goal weight of 130 lb (58.9 kg).
b. The client will eliminate ritualistic behaviors within 1 month of initiating therapy.
c. The client will learn to identify situations that trigger anxiety.
d. The client will acknowledge that she is emaciated and looks very ill.

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Problem 3

A 70-year-old client has been referred to the mental health clinic by his primary care provider. The client’s wife died suddenly 3 months ago, and he has been severely depressed since. He states that he cries all the time and can’t sleep or eat well. Based on these data, which of the following nursing diagnostic categories is most appropriate?
a. Hopelessness
b. Dysfunctional grieving
c. Spiritual distress
d. Ineffective coping

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Problem 4

A nurse diagnoses her client with Impaired Social Interaction related to self-concept disturbance, as evidenced by the client’s verbalized inability to experience satisfying relationships with peers or family. When choosing interventions to address this problem, the nurse designs interventions to accomplish which of the following?
a. Improve the client’s social environment.
b. Help the family cope with the client.
c. Address the client’s self-concept.
d. Help the client make new friends.

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Problem 5

The nurse is evaluating a client’s plan of care 5 days after his admission to a closed unit. The client, a 15-year-old boy, has a history of inflicting daily self-injury by cutting himself. The plan included the outcome that the client would stop injuring himself. The nurse contracted with the client that he would seek out a staff member whenever he felt like hurting himself and would gain privileges for making that admission. Which of the following would be the best indicator that the plan is effective and the outcome is being met?
a. The client reports that he has not cut himself in 3 days.
b. No fresh cuts are on the client’s body, and staff members report that he has been seeking them out for help.
c. The client has only one new cut in 3 days and has been able to refrain from cutting without the staff’s help.
d. The client reports that when he feels like hurting himself, he begins exercising instead.

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