Chapter 8
According to the American Nurses Association standards of practice for psychiatric/mental health nurses, which specific intervention can be implemented by any psychiatric/mental health nurse generalist?
A. Milieu therapy
B. Psychotherapy
C. Consultation
D. Prescriptive authority
What is Milieu Therapy
Correct Answer: A
Milieu therapy, which is the scientific structuring of the environment in order to affect behavioral change, is a nursing intervention that can be implemented by any psychiatric/mental health nurse generalist.
Which of the following best describes the
role of the psychiatric social worker as a member of the interdisciplinary treatment team?
A. Provides ongoing assessment of client’s mental and physical condition
B. Functions under the supervision of the psychiatric nurse
C. Serves as the leader of the treatment team
D. Conducts individual, group, and family therapy
What is Conducts individual, group, and family therapy?
Correct Answer: D
The psychiatric social worker is a member of the interdisciplinary treatment team and conducts individual, group, and family therapy.
Which nursing diagnosis is written correctly?
A. Risk for social isolation related to low self-esteem evidenced by staying in room during the day
B. Low self-esteem related to major depressive disorder evidenced by childhood abuse
C. Imbalanced nutrition: less than body requirements related to suspiciousness evidenced by 20-lb. weight loss
D. Conduct disorder related to childhood sexual abuse evidenced by hostile and aggressive behaviors
What is Imbalanced nutrition: less than body requirements related to suspiciousness evidenced by 20-lb. weight loss?
Correct Answer: C
Imbalanced nutrition: less than body requirements related to suspiciousness evidenced by 20 lbs. weight loss is a correctly written nursing diagnosis.
§Evidence of a nutritional problem is documented and the cause of the problem, suspiciousness, is identified.
§“Imbalanced nutrition: less than body requirements…” is an approved diagnostic stem.
A client, diagnosed with borderline personality disorder, approaches the nursing station often with various requests. The nurse intervenes by stating, “You may approach the nurse’s station only once an hour.” Which nursing intervention
has been employed?
A. Providing reality orientation
B. Ensuring physical need fulfillment
C. Setting limits on behavior
D. Providing client education
What is Setting limits on behavior?
Correct Answer: C
In this situation the nurse is responsible for setting limits on unacceptable behavior in the therapeutic milieu.
Consistency in carrying out the consequences of violation of the established limits is essential if learning is to be reinforced.
Which charting entry is an example of the documentation of a subjective symptom?
A. Temperature 101.40°F
B. No muscle rigidity or drooling noted.
C. Patient is hypervigilant and scanning the environment.
D. Patient states, “I’m seeing green men in my room.”
What is Patient states, “I’m seeing green men in my room.”?
Correct Answer: D
The patient statement “I’m seeing green men in my room,” is documentation of a subjective symptom reported by the patient.
This therapy is a scientific structuring of the environment in order to effect behavioral changes and to improve the psychological health and functioning of the individual.
SOAPIE is an acronym that can be used for this type of nursing process validation?
What is Problem-Oriented Recording?
AKA POR
According to this individual, basic physiological needs MUST be met before focusing on other needs and wants.
Who is Maslow?
A diagrammatic teaching and learning strategy that allows students and faculty to visualize interrelationships between medical diagnoses, nursing diagnoses, assessment data, and treatments.
What is concept mapping?
What is:
• Medication administration
• Development of a one-to-one relationship
• Setting limits on unacceptable behavior
• Client education