A nursing instructor teaches students about the purpose of using the nursing process in the care of psychiatric clients. Which of the following statements by a student indicates that learning has occurred?

"The nursing process is a method for interviewing."

"The nursing process is used to assist clients to adapt to stressors."

"The nursing process is used primarily to minimize allegations of negligence."

"The nursing process is used to provide support for the psychiatric diagnosis."

Answer and Explanation

The Correct Answer is B

Choice A Reason:
While interviewing is a component of the nursing process, specifically during the assessment phase, describing the nursing process solely as a method for interviewing is incomplete. The nursing process encompasses much more, including diagnosis, planning, implementation, and evaluation.

Choice B Reason:
This statement accurately reflects the purpose of the nursing process. It is a systematic method used by nurses to assist clients in adapting to stressors, whether they are physical, psychological, or social. The process involves assessing the client's needs, diagnosing issues, planning and implementing interventions, and evaluating the outcomes.

Choice C Reason:
The nursing process does play a role in minimizing allegations of negligence by providing a structured approach to care, but this is not its primary purpose. The main goal is to deliver individualized and effective care to clients, not just to protect against legal issues.

Choice D Reason:
Supporting a psychiatric diagnosis is part of the nursing process, but the statement is too narrow to describe the overall purpose. The nursing process is used to plan and provide personalized care, which goes beyond just supporting a diagnosis.

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Correct Answer is D

Explanation

Choice A Reason:
An adventitious crisis is not applicable here. This type of crisis is usually a result of a natural or man-made disaster, war, or major accident, which is not the case with the client's situation.

Choice B Reason:
Maturational crises are associated with life transitions or developmental stages, such as retirement or menopause. While the client is older, the crisis is not due to a normal life transition but rather an unexpected event.

Choice C Reason:
Developmental crises occur as a person moves through the stages of life. The client's crisis does not stem from a developmental issue but from an external event that has disrupted their life.

Choice D Reason:
Situational crises arise from external sources that an individual may face throughout life, such as the death of a loved one, loss of a job, or severe illness. The client's inability to cope with the sudden death of their spouse is a situational crisis.

A. Stop the car in the client's driveway and call the authorities. B. Honk the car horn to get the client's attention. C. Calmly speak the client's name out of the car window. D. Keep driving in a path that is going away from the client's house.

Correct Answer is D

Explanation

Choice A reason:

Stop the car in the client’s driveway and call the authorities. This statement is wrong because stopping in the driveway could escalate the situation and put the nurse in immediate danger. The nurse should avoid any actions that might provoke the client or put herself in harm’s way.

Choice B reason:

Honk the car horn to get the client’s attention. This statement is wrong because honking the horn could startle the client, potentially leading to a violent reaction. Sudden loud noises can exacerbate agitation in individuals with schizophrenia.

Choice C reason:

Calmly speak the client’s name out of the car window. This statement is wrong because engaging with the client directly while they are armed is unsafe and could provoke aggression. The nurse should avoid direct interaction until the situation is secured.

Choice D reason:

Keep driving in a path that is going away from the client’s house. This is the correct action as it ensures the nurse’s safety by distancing herself from the potentially dangerous situation. Once at a safe distance, the nurse can contact the authorities for assistance.

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A nursing instructor teaches students about the purpose of using the nursing process in the care of psychiatric clients. Which of the following statements by a student indicates that learning has occurred?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for an older adult client following the sudden death of their spouse. The client feels stuck in their ability to deal with work and family responsibilities. The nurse should recognize that the client is experiencing which type of crisis?

Correct Answer is D

Explanation

A home health nurse drives up to the house of her client, who has schizophrenia with manic episodes. The client is sitting on his front porch with a shotgun in his arms. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse working in a mental health facility is utilizing milieu therapy to provide a therapeutic environment for their clients. Which of the following steps of the nursing process is the nurse demonstrating?

A nurse is discussing therapeutic milieu with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of therapeutic milieu?

A nurse is caring for a client on the Mental Health Unit. The client refuses to get out of bed, go to activities, or participate in any of the unit’s programs. Which of the following responses should the nurse make?

A nurse is assessing a client who is receiving treatment with multiple antipsychotic medications and who suddenly became ill. The findings include blood pressure changes, fever, and diaphoresis. The nurse should recognize that which of the following adverse effects may be occurring?

The nurse is caring for a client in an acute mental health unit. The client states, “I believe my food is poisoned.” Which of the following should be an appropriate action by the nurse?

A nurse is caring for a client diagnosed with a mental illness. Which of the following actions by the nurse demonstrates the ethical concept of autonomy?

A nurse overhears a client diagnosed with schizophrenia talking to herself. The client keeps stating, "The flakalas are here. The flakalas are here." The nurse should recognize the client's use of the word "flakala" as an example of which of the following alterations in speech?