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, Debbie Steele : Keltner’s Psychiatric Nursing 9th Edition
Chapter 01: Me, Meds, Milieu
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MULTIPLE CHOICE
1. A newly licensed nurse asks a nursing recruiter for a description of nursing practice in the
psychiatric setting. What is the nurse recruiter‘s best response?
a. ―The nurse primarily serves in a supportive role to members of the health care
delivery team.‖
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b. ―The multidisciplinary approach eliminates the need to clearly define the
responsibilities of nursing in such a setting.‖
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c. ―Nursing actions are identified by the institution that distinguishes nursing from
other mental health professions.‖
d. ―Nursing offers unique contributions to the psychotherapeutic management of
psychiatric patients.‖
ANS: D
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Professional role overlap cannot be denied; however, nursing is unique in its focus on and
application of psychotherapeutic management. Neither the facility nor the multidisciplinary
team define the professional responsibilities of its members but rather utilizes their unique
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skills to provide holistic care. Ideally, all team members support each other and have
functions within the team.
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DIF: Cognitive level: Analyzing TOP: Nursing process: Implementation
MSC: Client Needs: Safe, Effective Care Environment
2. Which component of the nursing process will the nurse focus upon to address the
responsibility to match individual patient needs with appropriate services?
a. Planning
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b. Evaluation
c. Assessment
d. Implementation
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ANS: C
Proper assessment is critical for being able to determine the appropriate level of services that
will provide optimal care while considering patient input and at the lowest cost. Planning and
implementation utilizes the assessment data to identify and execute actions (treatment plan)
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that will provide appropriate care. Evaluation validates the effectiveness of the treatment plan.
DIF: Cognitive level: Applying TOP: Nursing process: Assessment
MSC: Client Needs: Safe, Effective Care Environment
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3. An adult diagnosed with paranoid schizophrenia frequently experiences auditory
hallucinations and walks about the unit, muttering. Which nursing action demonstrates the
nurse‘s understanding of effective psychotherapeutic management of this client?
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, a. Discussing the disease process of schizophrenia with the client and their domestic
partner
b. Minimizing contact between this patient and other patients to assure a stress-free
milieu
c. Administering PRN medication when first observing the evidence that the client
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may be hallucinating
d. Independently determining that behavior modification is appropriate to decrease
the client‘s paranoid thoughts
ANS: A
An understanding of psychopathology is the foundation on which the three components of
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psychotherapeutic management rest; it facilitates therapeutic communication and provides a
basis for understanding psychopharmacology and milieu management. Minimizing contact
between the patient and others and administering PRN medication indiscriminately are
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nontherapeutic interventions. Using behavior modification to decrease the frequency of
hallucinations would need to be incorporated into the plan of care by the care team.
DIF: Cognitive level: Applying TOP: Nursing process: Implementation
MSC: Client Needs: Safe, Effective Care Environment
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4. An adult diagnosed with chronic depression is hospitalized after a suicide attempt. Which
intervention is critical in assuring long-term, effective client care as described by
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psychotherapeutic management?
a. Involvement in group therapies
b. Focus of close supervision by the unit staff
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c. Maintaining effective communication with support system
d. Frequently scheduled one-on-one time with nursing staff
ANS: D
A critical element of psychotherapeutic management is the presence of a therapeutic
nurse-patient relationship. One-on-one time with nursing staff will help in establishing this
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connection. While the other options are appropriate and client centered, the nurse-client
relation is critical in the long-term delivery of quality effective care to this client.
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DIF: Cognitive level: Applying TOP: Nursing process: Implementation
MSC: Client Needs: Psychosocial Integrity
5. A patient‘s haloperidol dosage was reduced 2 weeks ago to decrease side effects. What
assessment question demonstrates the nurse‘s understanding of the resulting needs of the
client?
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a. ―Will you have any difficulty getting your prescription refilled?‖
b. ―Have you begun experiencing any forms of hallucinations?‖
c. ―What do you expect will occur since the dosage has been reduced?‖
d. ―What can I do to help you manage this reduction in haloperidol therapy?‖
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ANS: B
It will be necessary for the nurse to assess for exacerbation of the patient‘s symptoms of
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psychosis as well as for a lessening of side effects. Dosage decrease might lead to the return
or worsening of positive symptoms such as hallucinations and delusions, and negative
symptoms such as blunted affect, social withdrawal, and poor grooming. While the other
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options may be appropriate assessment questions, they are not directed at the current needs of
the client which is the identification of emerging psychotic behaviors.
DIF: Cognitive level: Analyzing TOP: Nursing process: Assessment
MSC: Client Needs: Physiologic Integrity
, 6. Which statement forms the foundation upon which a nurse should base the implementationof
psychotherapeutic management to the care of a patient with mental illness?
a. The nurse‘s role in client care is supported by the multidisciplinary team.
b. Omitting any one component will compromise the effectiveness of the treatment.
c. The most important element of psychotherapeutic management is drug therapy.
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d. A therapeutic nurse-patient relationship is the most important aspect of treatment.
ANS: B
When one element is missing, treatment is usually compromised. No single element is more
important than the others; however, patients‘ needs govern the application of the components
and permit judicious use. The remaining options identify components of the
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psychotherapeutic management process.
DIF: Cognitive level: Analyzing TOP: Nursing process: Analysis
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MSC: Client Needs: Safe, Effective Care Environment
7. Which statement most accurately describes a nurse‘s role regarding psychopharmacology?
a. ―You will need to frequently make decisions regarding the administration of PRN
medications to help the client manage anger.‖
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b. ―It‘s a nursing responsibility to adjust a medication dose to assure effective patient
responses.‖
c. ―Nurses administers medications while evaluating drug effectiveness is a medical
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responsibility.‖
d. ―To best assure appropriate response, a patient‘s questions about drug therapy
should be referred to the psychiatrist.‖
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ANS: A
Nursing assessment and analysis of data might suggest the need for PRN medication as
patient anxiety increases or psychotic symptoms become more acute. The nurse is the health
team member who makes this determination. Nurses are responsible for monitoring drug
effectiveness as well as administering medication. Nurses should assume responsibility for
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teaching patients about the side effects of medications. Nurses cannot alter prescribed dosages
of medications unless they have prescriptive privileges.
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DIF: Cognitive level: Analyzing TOP: Nursing process: Analysis
MSC: Client Needs: Safe, Effective Care Environment
8. When considering environmental aspects of milieu management, which intervention has the
highest priority for a client admitted after a failed suicide attempt?
a. Sending the client‘s new medication prescriptions to the pharmacy
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b. Assigning a staff member to one-on-one observation of the client
c. Orienting the client to the milieu‘s public and private spaces
d. Having all potentially dangerous items removed from the client‘s belongings
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ANS: B
Milieu management provides a proactive approach to care. Safety overrides all other
dimensions of the milieu. Initiation of suicide precautions are the priority for this client. All
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the remaining options are appropriate but none protect the client from the risk of another
attempt to self-harm as effectively as one-on-one observation as part of suicide precautions.
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DIF: Cognitive level: Analyzing TOP: Nursing process: Implementation
, MSC: Client Needs: Safe, Effective Care Environment
9. The implementation of which unit policy directed at milieu balance would reflect a need for
reconsideration on the part of the treatment team?
a. All clients will receive verbal and written information explaining unit rules.
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b. Unit clients will engage in all unit activities to assure interaction with both staff
and other clients.
c. All clients will be uniformly expected to present themselves in a nonviolent
manner to both staff and other clients.
d. At times of unit stress, client will return to their rooms.
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ANS: B
The situation described suggests a milieu in which patients have no time for planned
therapeutic encounters with staff; hence, it is a milieu lacking balance. The remaining options
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address unit norms, limit setting, and environmental modifications that are reasonable and will
contribute to a therapeutic milieu.
DIF: Cognitive level: Evaluating TOP: Nursing process: Evaluation
MSC: Client Needs: Safe, Effective Care Environment
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10. Which intervention should the nurse implement when focusing oncommunicating
therapeutically with a client?
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a. Explaining to the client why they will need to ask for a razor
b. Providing the client with options to help achieve smoking cessation
c. Encouraging the client to identify personal stressors
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d. Assuring the client that they can receive telephone call on the unit telephone
ANS: C
A nurse uses therapeutic communication techniques as part of the therapeutic nurse-patient
relationship. An example of such communication is providing the client with an opportunity
to safely identify personal stressors. The remaining options address safety, balance, and norms
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associated with their care.
DIF: Cognitive level: Applying TOP: Nursing process: Implementation
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MSC: Client Needs: Psychosocial Integrity
11. During the risk assessment phase of care for a psychiatric patient, what is the nurse‘s primary
goal?
a. Making an initial assessment
b. Confirming the patient‘s problem
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c. Assessing potential dangerousness to self or others
d. Determining the level of supervision needed for the patient
ANS: C
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Risk assessment involves looking at dangerousness to self or others, the degree of disability,
and whether or not the individual is acutely psychotic to determine the feasibility of
community-based care versus hospital-based care. Risk assessment usually follows the initial
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assessment. Confirmation of the patient‘s problem is not part of the risk assessment protocol.
Arranging entry into the mental health system will follow risk assessment if the patient is
assessed as needing service.
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DIF: Cognitive level: Applying TOP: Nursing process: Assessment
, MSC: Client Needs: Safe, Effective Care Environment
12. Risk assessment for a patient shows these findings: schizophrenia but not currently; not a
danger to self or others; lives in parents‘ home. Which decision regarding placement on the
continuum of care is appropriate?
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a. Hospitalize the patient.
b. Discharge the patient from the system.
c. Refer the patient to outpatient services.
d. Refer the patient to self-help resources in the community.
ANS: C
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Referral should be made to the least restrictive, most effective, and most cost-conscious
source of services. Because the patient is not a danger to self or others, hospitalization is not
needed. However, follow-up as an outpatient would be more appropriate than referral to a
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self-help group, in which structure might be lacking, or discharge from the system.
DIF: Cognitive level: Applying TOP: Nursing process: Planning
MSC: Client Needs: Safe, Effective Care Environment
13. A patient tells the nurse, ―This medicine makes me feel weird. I don‘t think I should take it
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anymore. Do you?‖ The most effective reply that the nurse could make is based on which
psychotherapeutic management model?
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a. Psychopathology
b. Milieu management
c. Psychopharmacology
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d. Therapeutic nurse-patient relationship
ANS: C
Concerns about medication voiced by patients require the nurse to have knowledge about
psychotherapeutic drugs to make helpful responses. The nurse-patient relationship component
is based on use of self. Milieu management is concerned with the environment of care.
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Psychopathology provides foundational knowledge of mental disorders but would be less
relevant in framing a response to the patient than knowledge of psychopharmacology.
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DIF: Cognitive level: Analyzing TOP: Nursing process: Implementation
MSC: Client Needs: Physiologic Integrity
14. A patient tells the nurse, ―This medication makes me feel weird. I don‘t think I should take it
anymore. Do you?‖ What is the nurse‘s best response?
a. ―I wonder why you think that.‖
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b. ―Tell me how the medication makes you feel.‖
c. ―One must never stop taking medication.‖
d. ―You need to discuss this with your psychiatrist.‖
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ANS: B
As part of the psychopharmacology component of psychotherapeutic management, the
responsibility of the nurse is to gather data about patients‘ responses to medication and to be
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alert for side and adverse effects of the medication. The other responses are tangential to the
real issue.
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DIF: Cognitive level: Applying TOP: Nursing process: Implementation
MSC: Client Needs: Physiologic Integrity
