the nursing process in mental health nursing...allergies, vital signs, height and weight, diet, and...

17

C H A P T E R

3The NursingProcess in MentalHealth Nursing

KEY TERMSAssessment

Evaluation

NANDA

Nursing diagnosis

Nursing interventions

Nursing process

Objective data

Outcomes

Prioritize

Subjective data

Therapeutic milieu

LEARNINGOBJECTIVES

After learning the content ofthis chapter, the student will be

able to:

1. Identify the five steps of delivering nursing careusing the nursing process.

2. Describe types of information obtained in apsychosocial assessment.

3. Determine applicable nursing diagnoses foridentified client problems.

4. Plan realistic expected outcomes for resolutionof identified problems.

5. Evaluate client outcome of anticipatedimprovement in functioning and well-being.

6. Apply the nursing process to the care of theclient in the psychiatric setting.

Defining the NursingProcess

The nursing process is a scientific and sys-tematic method for providing effective indi-vidualized nursing care and serves as an aidin resolving client problems. This problem-solving approach allows the nurse to help theclient achieve a maximal level of functioningand well-being. The nursing process is ac-cepted by the nursing profession as a stan-dard for providing ongoing nursing care thatis adapted to individual client needs. Ac-countability to the client and communicationbetween members of the mental health careteam is enhanced by the process (see Chapter21, The Treatment Team). The use of thenursing process also allows nurses to shareinformation that is important to the continu-ity of client care and treatment. The nursecan reevaluate each step of the nursingprocess to adjust, revise, or terminate theplan of care based on new or added informa-tion. It is important to remember that eachclient’s response to therapy and treatmentmay be different. Adjustments can and willbe made as the level of illness and dysfunc-tion affects the independence and well-beingof the client.

Vital to this process is the therapeutic cli-mate of the interaction between the client andmembers of the mental health team. Thenurse is often the first member of the teamthat is in contact with the client. It is at thispoint that a therapeutic milieu is established.The milieu is an environment or surround-ings that are modified to create a setting inwhich the client feels safe, secure, and free toexpress feelings and thoughts without fear ofrejection, retaliation, or punishment. Thenurse can initiate this atmosphere and estab-lish a sense of trust by approaching the clientin an accepting and nonjudgmental manner.This trusting relationship is vital to the suc-cessful outcome of improved functioning andwell-being of the client (see Chapter 5, TheTherapeutic Relationship).

Steps of the NursingProcess

Integral to the nursing process approach tonursing care is an organized method of prob-lem solving called the care plan, which is de-veloped from the data that are gathered dur-ing the initial phase. It consists of five stepsthat provide planned actions for resolving theproblem:

Nursing assessmentNursing diagnosisExpected outcomeNursing interventionsEvaluation

Nursing AssessmentAssessment begins when the client is admit-ted or contact is made for the first time. As-sessment continues as the cycle of the nursingprocess progresses and new information orchanges occur in reference to the client. Anassessment interview is usually conductedwithin the psychiatric setting; however, thepsychosocial needs of a client are part of anynursing assessment, regardless of the setting,because symptoms seen in the mental healthsetting can also be seen in any area of healthcare. A standard assessment tool helps catego-rize the information received by the nurse. Abasic psychosocial nursing assessment usu-ally includes the client’s history and mentalor emotional status and encompasses bothsubjective and objective data.

Subjective Data. Subjective information isprovided by the client. This information mayneed to be validated by other sources such asfamily, friends, law enforcement officers, orothers who are involved. The client’s informa-tion may be supported or contradicted by oth-ers. The data include the client’s history andperception of the present situation or problemin addition to feelings, thoughts, symptoms,or emotions he or she may be experiencing.

18 UNIT I: Introduction to Psychiatric Nursing

When collecting subjective data it is impor-tant for the nurse to be as accurate and de-scriptive as possible. Citing a direct quote of aclient statement is a way of describing whatthe client is saying without attempting to in-terpret the intended meaning. Using theclient’s own words to describe feelings orthoughts often provides insight into percep-tual distortions or illogical thought processes.

examples of leading questions that can beused to obtain data from the client during theassessment interview:

• Tell me what brought you to the hospital to-day.

• Was there any situation that caused you tofeel this way?

• How did you react to the situation?• Tell me how you are feeling about being

here.• Where do you live?• Who lives with you?• What type of work do you do?• Have you been able to work prior to admis-

sion?• What causes the most stress in your life?• What do you do to alleviate the stress?• Do you blame yourself for bad things that

happen to you?• Tell me about things that overwhelm you

each day.• Are you currently taking medication to

help you through the stressful times?

Objective Data. Objective information is ob-served by the nurse or provided by otherswho are familiar with the client or additionalmembers of the health care team. The assess-ment includes the physical, emotional, intel-lectual, and social aspects of the client. Aphysical assessment includes medical history,past illnesses or surgeries, medication history,allergies, vital signs, height and weight, diet,and head-to-toe systems evaluation. Social is-sues may include relationships, family his-tory of mental illness, religious and culturalbeliefs, and specific health practices. Theclient’s emotional state, behavior, and think-ing processes are all part of the mental assess-ment.

19UNIT I: Introduction to Psychiatric Nursing

At a Glance 3-1 Examplesof Subjective Data

• Name and general information about theclient

• Client’s perception of current stressor orproblem

• Current occupational or work situation• Any recent difficulty in relationships• Any somatic complaints• Current or past substance use• Interests or activities previously enjoyed• Sexual activity or difficulties

The subjective information gathered duringthe initial assessment will allow the nurse toestablish a baseline used to formulate the careplan. By asking direct leading questions, thenurse gets a clear picture of certain problemsor issues concerning the client. Successfulgathering of data is based on the ability of thenurse to listen to the client. When the nurseselects a climate that ensures privacy andconfidentiality, the client feels free to openlycommunicate personal feelings. Following are

Mind JoggerHow might a past medical and

psychiatric history help toidentify potential problems?

Just the FactsInput from the client’s family canprovide information about fam-ily dynamics, any present tur-moil or disruption within thefamily, and how the client’sproblem may be affectingother members of the family.

ency between what the client is saying andwhat is displayed in the accompanying be-havior. It is also important to recognize if theclient poses any immediate threat or danger toself or others, in which case safety becomes apriority and must be secured.

Nursing DiagnosisEstablishing a nursing diagnosis from col-lected data is the second step in the nursingprocess. The nurse analyzes all data gatheredand compares it to normal functioning or val-ues to find out if a problem or a potentialproblem exists. A nursing diagnosis is not amedical diagnosis but an identification of aclient problem based on conclusions aboutthe collected data. A nursing diagnosis maybe an actual or potential health problem, de-pending on the situation. The most com-monly used standard is that of the NorthAmerican Nursing Diagnosis Association(NANDA). This is an approved list of prob-lems that the nurse can legally address toward


At a Glance 3-2 Examplesof Objective Data

• Physical exam• Behavior• Mood and affect• Awareness• Thought processes• Appearance• Activity• Judgment• Response to environment• Perceptual ability

A standard mental status examination toolis used to assess cognitive, emotional, and be-havioral information. At a Glance 3-3 pro-vides a summary of a basic mental exam. (TheMini-Mental Status Exam is found in Appen-dix B). It is most important to note both verbalcommunication and nonverbal mannerisms,expressions, and emotions. Look for congru-

At a Glance 3-3 Components of Mental Status Assessment

• Appearance (grooming, dress, hygiene, eye contact, skin markings, posture, facial expression)• Motor activity (pacing, slow, rigid, relaxed, restless, combative, bizarre, gait, hyperactive, retarded,

aggressive)• Attitude (cooperative or uncooperative, friendly, hostile, apathetic, suspicious)• Speech pattern (speed, volume, articulation, congruence, confabulation, slurring, dysphasia)• Mood (intensity, depth, duration, anxious, sad, euphoric, labile, fearful, irritable, depressed)• Affect (flat or absence of emotional expression, blunted, congruence with mood, appropriate or inap-

propriate)• Level of awareness (level of consciousness, attention span, comprehension, processing)• Orientation (time, place, person)• Memory (recent and remote)• Understanding of illness/insight (ability to perceive and understand illness—symptoms as related to

illness)• Ability to describe stressors (internal or psychologic/physical in nature, and external or actual loss)• Thought processes (speed, content, organization, logical or illogical, delusions, abstract or concrete)• Perceptual disturbances (hallucinations, illusions, depersonalization, distortions)• Judgment (problem-solving and decision-making ability)• Adaptive or maladaptive defense mechanisms• Relationships (attainment and maintenance of satisfying interpersonal relationships)

a measurable outcome. A list of nursing diag-noses approved by NANDA is found in Ap-pendix C.

Formulating a nursing diagnosis consists ofthree parts: (1) the actual or potential problemrelated to the client’s condition, (2) thecausative or contributing factors, and (3) a be-havior or symptom that supports the problem.A nursing diagnosis is correctly written as fol-lows: (problem) risk for injury, related to (con-tributing factor) marital breakup, evidencedby (behavior) suicidal ideation and gestures.Although a medical diagnosis is not used asthe etiology of a nursing problem, signs andsymptoms of the condition may be reflectedin the cause. This is illustrated by a clientwho has sensory-perceptual alteration, re-lated to auditory hallucinations, evidenced bytalking to people who are not physically pres-ent. Determining the problem provides thegroundwork for planning nursing interven-tions to meet the needs of the client for whichthe nurse is responsible.

Once applicable nursing diagnoses havebeen determined, they are prioritized accord-ing to the intensity and immediate urgency ofthe problem. Any health condition that endan-gers life will receive a high priority. Situationsthat are recurrent or chronic may be given alower priority and will be addressed at a latertime. A client with suicidal ideation or intent,for example, would have an immediate risk forself-injury. This problem would require thenurse’s attention first. Based on Maslow’s hier-archy of needs, basic physiologic needs such asoxygen, food, water, warmth, elimination, andsleep must be met before other needs of safetyand security, love and belonging, self-esteem,and self-actualization can be achieved. Thismodel can be seen as a staircase in which aclient may vacillate between steps. Given thatthe client can move up and then back down,the nurse should understand that the prioritygiven to a problem can change at any time dur-ing the treatment process. To illustrate this con-cept, a client who has begun to identifystrengths and display positive self-talk (self-esteem level need) is told by another client that

she is stupid and ugly. The client has now re-fused to eat for two meals. At this point the nu-tritional needs of the client become the priority.


It is also important to give priority to theproblem that the client is currently experienc-ing (actual) over a problem that may happen(potential). An actual problem has priorityover one that could possibly occur during thecourse of the illness. Acute withdrawal symp-toms in the client with multiple substanceabuse would have priority over the potentialfor social isolation in that individual.

Expected OutcomesThe next phase of the nursing process in-volves planning measurable and realistic out-comes that will anticipate the improvementor stabilization of the problem identified inthe nursing diagnosis. These outcomes are de-fined in terms of short-term goals that addressthe immediate unmet needs of the client andlong-term goals that achieve the maximal

Just the FactsMaslow’s hierarchy of needs is a basedon the theory that one level of needs mustbe met before moving on to thenext step.• Self-actualization• Self-esteem• Love and belonging• Safety and security• Basic physiologic needs

Just the FactsNursing diagnoses and careshould be planned to includereligious, cultural, and ethnicpractices of the client.

level of health that is realistic for the individ-ual client at the time of discharge and as amember of society. These goals should be de-termined in collaboration with the client, soas to increase cooperation and compliancewith therapeutic interventions.

Listed below are examples of both short-term and long-term outcome criteria for thenursing diagnosis, sensory/perceptual alter-ation, related to auditory hallucinations.

Short-Term Outcomes• Client symptoms of auditory hallucinations

will decrease within 48 hours.• Client does not harm self or others in next

48 hours.• Client identifies feelings associated with

hallucinations with each episode.• Client reports decrease in anxiety level

within 24 hours.

Long-Term Outcomes• Client demonstrates understanding of need

for continued compliance with medicationtherapy by discharge.

• Client demonstrates awareness that halluci-nations are the result of internal conflictwithin 1 week.

• Client identifies and demonstrates ways tomaintain contact with reality at onset ofsymptoms by discharge.

• Client identifies environmental factors thatprecipitate the hallucinations by discharge.

• Client participates in activities that rein-force reality during hospitalization within1 week.

Nursing InterventionsNursing interventions are actions taken bythe nurse to assist the client in achieving theanticipated outcomes. It is important to planactions that are appropriate for the individualclient and take into consideration the level offunctioning that is realistic for that person.What may be realistic for one person may beunattainable for another. The written plan is acollaborative effort between all members ofthe health care team and is communicated to

each health care worker. This helps to ensurethe continuity of care and consistency in theimplementation of interventions by all per-sonnel. Consistency is a vital component ofthe therapeutic milieu.

There are many clinical units that usestandardized or computer-generated careplans or clinical pathways. In the currentmanaged-care concept, these are designed tobe cost-effective and improve the efficiencywith which treatment is carried out. Regard-less of the method used, the care plan identi-fies the outcomes and interventions that areto be addressed by each discipline of the careteam. Specifically, the nursing care planidentifies those interventions for which thenurse has responsibility. It is imperative thatthe unique needs and problems of eachclient are retained as central to that person’splan of care.

Nursing interventions that focus on mentalhealth care do not involve intensive physicalcare nursing skills. Rather, the nurse focuses onobserving behaviors and symptoms, improvingcommunication strategies, and assisting theclient in problem-solving with improved over-all functioning. Nursing interventions are im-plemented according to the nurse’s level ofpractice (see Chapter 21, Mental Health Care inNonpsychiatric Settings). Achievement of theanticipated outcomes is difficult for psychiatricclients. Many require extensive reinforcementand reassurance to change behaviors and un-derstand the underlying emotional issues. At aGlance 3-4 provides a list of nursing interven-tion strategies for working with psychiatricclients.


Just the FactsNursing interventions are in-tended to encourage, main-tain, and re-establish a level ofmental and physical function-ing that promotes the well-being of the client.

This step of the nursing process should fo-cus on helping clients rechannel their energiesin a constructive manner. The nursing inter-ventions should be based on scientific princi-ples for resolution of the identified problemand should be safe for the client and others in-volved. Other chapters in this text will in-clude appropriate nursing actions for clientswith the various categories of mental disor-ders. As strategies are implemented and docu-mented, a picture of client progress evolves.

Data collection is continuous during the im-plementation phase. Client response to inter-ventions provides valuable information thatassists the nurse in determining whether theclient is making progress toward the definedoutcome criteria. Additional data also aid inthe planning of ongoing nursing care.

EvaluationDuring the evaluation phase of the nursingprocess, the nurse evaluates the success of thenursing interventions in meeting the criteriaoutlined in the expected outcomes. Either thegoal has been achieved, some progress hasbeen made toward the intended outcome, or nosteps forward have been observed or docu-mented. Specific client behaviors may be re-viewed by the entire mental health care teamto determine the overall success of the treat-


At a Glance 3-4 Nursing Strategies for Mental Health Nurses

• Respect and accept each client as he or she is.• Allow client opportunity to set own pace in working with problems.• Nursing interventions should center on the client as a person, not on control of the symptoms. Symp-

toms are important, but not as important as the person having them.• Remember, all behavior has meaning—an attempt to prevent the occurrence or decrease the intensity

of anxiety.• Recognize your own feelings toward clients and deal with them.• Go to the client who needs help the most.• Do not allow a situation to develop or continue in which a client becomes the focus of attention in a

negative manner.• If client behavior is bizarre, base your decision to intervene on whether the client is endangering self

or others.• Ask for help—do not try to be a hero when dealing with a client who is out of control!• Avoid highly competitive activities, that is, having one winner and a room full of losers.• Make frequent contact with clients—it lets them know they are worth your time and effort.• Remember to assess the physical needs of your client.• Have patience! Move at the client’s pace and ability.• Suggesting, requesting, or asking works better than commanding.• Therapeutic thinking is not thinking about or for, but with the client.• Be honest so the client can rely on you.• Make reality interesting enough that the client prefers it to his or her fantasy.• Compliment, reassure, and model appropriate behavior.

Mind JoggerHow might client desire and

motivation to participate ingoal achievement influence

the manner in which the careplan is implemented?

ment plan. If a goal has been partially met,there may be supporting data to indicate con-tinuance of the current plan of care. This ap-proach recognizes that the client may needmore time to make changes and adjust to them.A distinction must be made between a lack ofclient motivation and the need for continuanceof the current plan to help the client achievethe outcomes. Some interventions may havebeen ineffective, and thus new strategies maybe needed to help meet the needs of the client.It is also important to reevaluate the outcomecriteria; the expected outcome may not actu-ally be achievable for this client.

The evaluation phase is a form of valida-tion for the entire nursing process in the de-livery of care to the client. Continued datacollection may indicate new problems or al-terations in the original nursing diagnoses.Criteria are reevaluated to clarify realisticand measurable terms for the individualclient. Nursing strategies are reevaluated foreffectiveness. This persistence in maintain-ing a therapeutic approach toward resolu-tion of client problems provides the con-tinuity needed to expedite the treatmentprocess.

Application of theNursing Process

As you study the various mental disorders andsituations in this textbook, you will find a sec-tion in most chapters that reinforces the appli-cation of the nursing process. However, to fa-cilitate your understanding of this process asit relates to the mental health setting, we needto apply this concept to an actual client situa-tion. The following situation will demonstratethe application of the process for three appli-cable nursing diagnoses.

Sample Client Situation: Endof the RoadFreda is a 47-year-old public school teacherwho received word several days ago that heronly child, 23-year-old Benjamin, was arrestedfor armed robbery. Benjamin is married andthe father of two small children. Two monthsago, Freda discovered that her husband of 26years is having an affair. Freda blames herselffor his indiscretion, stating that she is over-weight and unattractive. She says that hewould be better off without her anyway. Shefeels that she is a failure as both a mother anda wife. She is unable to concentrate in theclassroom and has considered a leave of ab-sence from her job. Last night Freda’s husbandtold her he was leaving her and wanted a di-vorce. Freda is brought to the emergency roomthis morning after being found unresponsiveby her daughter-in-law, Andrea. Andrea givesthe nurse an empty bottle of Xanax (alprazo-lam). She also tells the nurse that Freda hasbeen drinking a lot of wine in the past fewmonths. After initial treatment, Freda is ad-mitted to the psychiatric unit with a diagnosisof depressive episode: situational crisis withsuicide attempt.

Nursing AssessmentThe mental health nurse obtains the followingdata.


Just the FactsThe nurse is the only mem-ber of the mental health teamwho can continuously evalu-ate client response toplanned care.

Mind JoggerHow is documentation vital to

the process step of evalua-tion?

Objective Data• Suicide attempt with Xanax and alcohol• Was found unresponsive by daughter-in-law• Is overweight and has unkempt appearance• Son has been arrested for armed robbery• Has two small grandchildren she loves• Husband has asked for divorce after several

months of infidelity• Has been drinking more in past few months

Subjective Data• “I don’t blame him for finding someone

else. I am so fat and ugly.”• “He would be better off without me any-

way. I’m such a mess.”• “I must have done something wrong for my

son to be in so much trouble. I can’t do any-thing right.”


CARE PLANNursing Diagnoses

Risk for self-injury, re-lated to suicide at-tempt, evidenced bysuicide overdose withuse of alcohol

Coping, ineffective indi-vidual, related to lifeevents, as evidenced bydrinking more and in-ability to meet role expectations

Expected Outcomes

Does not engage in self-destructive behaviorwhile hospitalized

Begins to explore rea-sons for substanceabuse by 48 hours

Expresses feelings of sad-ness and despair in 48hours

Signs contract that shewill not harm herself in24 hours

Performs activities ofdaily living in next 2days

Communicates feelingsabout current situationin next 2 days

Participates in determin-ing goals for improve-ment in 2 days

Identifies at least twoadaptive coping strate-gies in 2 days

Implements one adaptivecoping strategy by theend of 1 week

Identifies support sys-tems available to herby the end of 1 week

Nursing Interventions

Monitor frequently forsigns of oversedation

Monitor vital signs everyhalf-hour

Assess for social with-drawal or isolation

Assess for self-destructive thoughts

Remove potentially dan-gerous items fromroom

Provide quiet, soothingenvironment

Monitor mood, affect,and behavior

Help to perform activi-ties of daily living

Encourage to make deci-sions about self-care

Encourage expression offeelings

Help to identify internalfactors of self-blame

Teach and model adap-tive coping strategies

Encourage to use adap-tive coping skills

Praise efforts and suc-cesses in coping

Evaluation

Recovers from overdosewithout complications

Expresses feelings aboutsubstance abuse

Discusses harmful effectsof substance use

Participates in goal-planning sessions

Identifies self-talk that isdestructive

Has not harmed self dur-ing hospitalization

Develops supportive net-work of family, friends,and support group

Independently performsactivities of daily living

Makes independent deci-sions about self-care

Openly discusses feelingsand emotional re-sponse to life situa-tions

Identifies self-defeatingthoughts and behaviors

Demonstrates use ofadaptive coping strategies

continuescontinues

• “I can’t even think clearly enough to teachmy kids what I’m supposed to. I might aswell quit.”

• “The only good thing in my life are my little grandkids. They deserve better thanme.”

Summary

The nursing process is a scientific, organized,problem-solving method of addressing thosesituations for which nursing can legally inter-vene. Nursing problems are often the result ofmedical conditions. The physician who treatspsychiatric disorders is a psychiatrist. The psy-chiatrist is responsible for treating the medicalor psychiatric disorder. As a member of themental health team, the nurse is responsiblefor assessing and communicating informationconcerning the current status of the client tothe physician and other members of the team.

Nursing problems or nursing diagnoses areformulated so that they are related to the


Mind JoggerWhat other nursing diagnoses

apply to Freda’s assessmentdata? What outcomes might

be expected?

CARE PLAN (Continued)

Nursing Diagnoses

Self-esteem, situationallow, related inability tohandle life events, evi-denced by feelings ofself-blame and inade-quacy

Expected Outcomes

Refrains from self-blameand negative self-talkby end of 1 week

Participates in self-carewith interest in self-improvement in 2 days

Identifies positive life ac-complishments andpersonal strengths in 3days

Identifies internal factorsthat harm self-esteemin 1 week

Participates in unit activi-ties in 2 days

Discusses realistic goalsfor self-improvementby discharge

Nursing Interventions

Establish trusting rela-tionship

Provide safe and sup-portive environment

Encourage to discuss lifeevents

Assist to distinguish be-tween life situationsover which she doesand does not havecontrol

Help to recognize nega-tive self-talk and self-defeating statements

Encourage to keep jour-nal of negative and de-feating thoughts

Encourage social interac-tion with others

Assist to identify per-sonal strengths and ac-complishments

Provide positive rein-forcement for expres-sion of positive feelingsand thoughts

Evaluation

Demonstrates trust inmental health team

Identifies realistic viewsof life events

Demonstrates ability torecognize negativethought patterns

Reframes negative self-talk with more realisticperspective

Uses positive statementsto describe self

Identifies strengths andacknowledges accom-plishments

Interacts with others us-ing positive approach

cause or contributing factor for the symptoms.They are defined after relevant subjective andobjective data from the client assessment havebeen reviewed. The nursing diagnosis state-ment is taken from a standardized list ap-proved by the North American Nursing Diag-nosis Association (NANDA). This statementincludes the actual or potential nursing prob-lem, the causative factor, and the supportingsymptoms or behavior. Nursing diagnoses areprioritized according to the severity and im-mediacy of the problem. Basic physiologicneeds such as oxygen, food, warmth, andsleep will obviously be met first. Maslow’s hi-erarchy of needs is often used to provide ageneral guide for nurses in determining prior-ities for problem resolution.

Definition of the problem allows the nurseto determine what evidence will demonstratethe client’s progress toward resolving the situ-ation. This information is stated in an ex-pected outcome with realistic and measurablecriteria to decide when the goal has been ac-complished. A description of the objectiveand subjective data provides evidence of

whether the client is making progress andgives the nurse a blueprint to guide observa-tion and contact with the client. Nursing in-terventions are planned and implemented tofacilitate the effectiveness of the entire treat-ment process. Information is also shared withother team members to ensure the continuityand consistency of the approach that is beingused to achieve client improvement.

Interventions are evaluated by determiningwhether the outcome criteria have been ac-complished within the expected timeframe. Ifa goal is only partially achieved or has notbeen met, it is important to reevaluate theplan and develop new or additional actions toaddress the deficit. The nursing process is anongoing continuum from admission to dis-charge and outpatient status. The problem-solving method used to approach client carecan also be taught to clients as a way of deal-ing with the problems and situations of life ingeneral. In this way, nurses have modeled oneof the most effective and adaptive copingstrategies available for clients with mentalhealth disorders.


BibliographyDoenges, M. E., Townsend, M. C., & Moorhouse,

M. F. (1995). Psychiatric care plans (3rd ed.).Philadelphia, PA: F. A. Davis.

FILL IN THE BLANK

Fill in the blank with the correct answer.

1. The nursing process is a(n)approach that assists the client in achiev-ing a maximal level of functioning andwell-being.

2. An environment that is modified to createa setting in which the client feels safe, se-cure, and free to openly express feelingsand thoughts is a(n) .

3. Information that is provided by the clientis data.

4. Information that is observed by the nurseor provided by others who are familiarwith the client situation is referred to as

data.

5. A nursing diagnosis consists of a problemthat is related to a(n) , andbehavior or symptoms that support theproblem.

6. Goals and outcomes should be plannedwith the client.

MATCHING

Match the following terms to the most appro-priate phrase.

a. Actual or potential problem the nurse canlegally address.

b. Measurable and realistic goal that antici-pates the improvement or stabilization ofthe client.

c. Collection of subjective and objective dataconcerning the psychosocial needs of aclient.

d. Defining immediacy or intensity of prob-lems to determine the order in which theywill be addressed.

e. Actions taken to assist client to achieveanticipated outcomes.

f. Determines success of strategies used inmeeting anticipated criteria.

1. Assessment

2. Prioritize

3. Nursing diagnosis

4. Nursing interventions

5. Evaluation

6. Expected outcome

MULTIPLE CHOICE

Select the best answer from the multiple-choice items.

1. The nurse is assessing a client withchronic schizophrenia who has stoppedtaking medication and is being admittedwith acute psychotic symptoms. Theclient’s perception of the present problemwould best be documented by the nurse:

a. Using exact words in client statements.

b. With information obtained from thefamily.

c. By observing behavior for severalhours.

d. As interpreted from the client’s words.


Student Worksheet

2. Which of the following is most importantin establishing a trusting environment forthe organized delivery of nursing care to aclient?

a. Cooperation of the client

b. A completed psychosocial assessment

c. The client’s perception of the currentsituation

d. Accepting and nonjudgmental attitudeof the nurse

3. Which of the following is a component ofthe client’s mental status nursing assess-ment?

a. Past medical history

b. Mood and affect

c. Medical diagnosis

d. Nursing diagnosis

4. When prioritizing nursing diagnoses todetermine the order in which they shouldbe addressed, which of the followingwould receive highest priority?

a. Ineffective coping strategies

b. Low self-esteem

c. Suicidal ideation

d. Social isolation

5. Which of the following terms would bedescriptive of a client’s attitude?

a. Blunted

b. Remote

c. Retarded

d. Apathetic

SCENARIO: ALONE AND LOST

Matthew is a 26-year-old carpenter who upuntil 5 days ago was employed by a buildingcontractor. At the time of his termination,Matthew was told by his supervisor that hiswork had not been consistently satisfactoryand to avoid legal problems, he was beingfired. Matthew has been living with his girl-

friend and her two children for the past 3years. Two days after he lost his job, his girl-friend told him she was seeing someone elseand wanted him to move out. Matthew isbrought to the emergency room by the policewho state he was wandering around a parkinglot at 2:00 a.m., is disoriented, and is unableto tell them who he is or what he was doing inthe parking lot. He told the police he is lostand doesn’t know where he should go.What subjective data should the nurse obtainfrom Matthew at the time of admission?

What objective data is available from thosewho know about his situation?

Complete the following nursing diagnosisstatements for Matthew’s situation:Anxiety (severe), related to ,evidenced by .Coping, ineffective individual, related to

, evidenced by.

Personal identity disturbance, related to, evidenced by

.


the nursing process in mental health nursing...allergies, vital signs, height and weight, diet, and...

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