(Test Bank) Varcarolis Essentials Of Psychiatric Mental Health Nursing: A Clinical Approach

Halter, 3

Nursing

Test Bank

3rd Edition

• $15.00 $50.00

---

Description

Test Bank for Varcarolis Essentials Of Psychiatric Mental Health Nursing: A Clinical Approach, The downloadable file consists of 332 pages, and the total size of the file is 1.26 MB. Purchase now only for highly discounted price.

Author(s): Halter

---

---

Study Note Preview

Chapter 1: Practicing the Science and Art of Psychiatric Nursing Test Bank MULTIPLE CHOICE 1.Which outcome, focused on recovery, would be expected in the plan of care for a patient living in the community with serious and persistent mental illness? Within 3 months, the patient will: a.deny suicidal ideation. b.report a sense of well-being. c.take medications as prescribed. d.attend clinic appointments on time. ANS: B Recovery emphasizes managing symptoms, reducing psychosocial disability, and improving role performance. The goal of recovery is to empower the individual with mental illness to achieve a sense of meaning and satisfaction in life and to function at the highest possible level of wellness. The incorrect options focus on the classic medical model rather than recovery. DIF: Cognitive Level: Application REF: Pages: 2-3 TOP: Nursing Process: Outcomes Identification MSC: NCLEX: Health Promotion and Maintenance 2.A patient is hospitalized for depression and suicidal ideation after their spouse asks for a divorce. Select the nurse’s most caring comment. a.“Let’s discuss some means of coping other than suicide when you have these feelings.” b.“I understand why you’re so depressed. When I got divorced, I was devastated too.” c.“You should forget about your marriage and move on with your life.” d.“How did you get so depressed that hospitalization was necessary?” ANS: A The nurse’s communication should evidence caring and a commitment to work with the patient. This commitment lets the patient know the nurse will help. Probing and advice are not helpful or therapeutic interventions. DIF: Cognitive Level: Application REF: Pages: 6-8 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 3.In the shift-change report, an off-going nurse criticizes a patient who wears heavy makeup. Which comment by the nurse who receives the report best demonstrates advocacy? a.“This is a psychiatric hospital. Craziness is what we are all about.” b.“Let’s all show acceptance of this patient by wearing lots of makeup too.” c.“Your comments are inconsiderate and inappropriate. Keep the report objective.” d.“Our patients need our help to learn behaviors that will help them get along in society.” ANS: DAccepting patients’ needs for self-expression and seeking to teach skills that will contribute to their well-being demonstrate respect and are important parts of advocacy. The on-coming nurse needs to take action to ensure that others are not prejudiced against the patient. Humor can be appropriate within the privacy of a shift report but not at the expense of respect for patients. Judging the off-going nurse in a critical way will create conflict. Nurses must show compassion for each other. DIF: Cognitive Level: Application REF: Page: 8 TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment 4.A nurse assesses a newly admitted patient with depression. Which statement is an example of “attending”? a.“We all have stress in life. Being in a psychiatric hospital isn’t the end of the world.” b.“Tell me why you felt you had to be hospitalized to receive treatment for your depression.” c.“You will feel better after we get some antidepressant medication started for you.” d.“I’d like to sit with you a while so you may feel more comfortable talking with me.” ANS: D Attending is a technique that demonstrates the nurse’s commitment to the relationship and reduces feelings of isolation. This technique shows respect for the patient and demonstrates caring. Generalizations, probing, and false reassurances are nontherapeutic. DIF: Cognitive Level: Application REF: Page: 8 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 5.A patient shows the nurse an article from the Internet about a health problem. Which characteristic of the web site’s address most alerts the nurse that the site may have biased and prejudiced information? a.Address ends in “.org.” b.Address ends in “.com.” c.Address ends in “.gov.” d.Address ends in “.net.” ANS: B Financial influences on a site are a clue that the information may be biased. “.com” at the end of the address indicates that the site is a commercial one. “.gov” indicates that the site is maintained by a government entity. “.org” indicates that the site is nonproprietary; the site may or may not have reliable information, but it does not profit from its activities. “.net” can have multiple meanings. DIF: Cognitive Level: Comprehension REF: Page: 5 TOP: Nursing Process: Evaluation MSC: NCLEX: Health Promotion and Maintenance 6.A nurse says, “When I was in school I learned to call upset patients by name to get their attention, but I read a descriptive research study that says that this approach doesn’t work. I’m going stop calling patients by name.” Which statement is the best appraisal of this nurse’s comment?a.One descriptive research study rarely provides enough evidence to change practice. b.Staff nurses apply new research findings only with the help from clinical nurse specialists. c.New research findings should be incorporated into clinical algorithms before using them in practice. d.The nurse misinterpreted the results of the study. Classic tenets of practice do not change. ANS: A Descriptive research findings provide evidence for practice but must be viewed in relation to other studies before practice changes. One study is not enough. Descriptive studies are low on the hierarchy of evidence. Clinical algorithms use flow charts to manage problems and do not specify one response to a clinical problem. Classic tenets of practice should change as research findings provide evidence for change. DIF: Cognitive Level: Analysis REF: Pages: 3-4 TOP: Nursing Process: Evaluation MSC: NCLEX: Health Promotion and Maintenance 7.Two nursing students discuss career plans after graduation. One student wants to enter psychiatric nursing. The other student asks, “Why would you want to be a psychiatric nurse? All they do is talk. You’ll lose your skills.” Select the best response by the student interested in psychiatric nursing. a.“Psychiatric nurses practice in safer environments than other specialties. Nurse-to-patient ratios must be better because of the nature of patients’ problems.” b.“Psychiatric nurses use complex communication skills, as well as critical thinking, to solve multidimensional problems. I’m challenged by those situations.” c.“I think I’ll be good in the mental health field. I do not like clinical rotations in school, so I don’t want to continue them after I graduate.” d.“Psychiatric nurses don’t have to deal with as much pain and suffering as medical surgical nurses. That appeals to me.” ANS: B The practice of psychiatric nursing requires a different set of skills than medical surgical nursing, although substantial overlap does exist. Psychiatric nurses must be able to help patients with medical and mental health problems, reflecting the holistic perspective these nurses must have. Nurse-patient ratios and workloads in psychiatric settings have increased, similar to other specialties. Psychiatric nursing involves clinical practice, not simply documentation. Psychosocial pain is real and can cause as much suffering as physical pain. DIF: Cognitive Level: Application REF: Page: 3 TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment 8.Which research evidence would most influence a group of nurses to change their practice? a.Expert committee report of recommendations for practice b.Systematic review of randomized controlled trials c.Nonexperimental descriptive study d.Critical pathway ANS: BResearch findings are graded using a hierarchy of evidence. A systematic review of randomized controlled trials is Level A and provides the strongest evidence for changing practice. Expert committee recommendations and descriptive studies lend less powerful and influential evidence. A critical pathway is not evidence; it incorporates research findings after they have been analyzed. DIF: Cognitive Level: Application REF: Pages: 4-6 TOP: Nursing Process: Analysis MSC: NCLEX: Safe, Effective Care Environment 9.A bill introduced in Congress would reduce funding for the care of people with mental illnesses. A group of nurses write letters to their elected representatives in opposition to the legislation. Which role have the nurses fulfilled? a.Advocacy b.Attending c.Recovery d.Evidence-based practice ANS: A An advocate defends or asserts another’s cause, particularly when the other person lacks the ability to do that for him- or herself. Examples of individual advocacy include helping patients understand their rights or make decisions. On a community scale, advocacy includes political activity, public speaking, and publication in the interest of improving the individuals with mental illness; the letter-writing campaign advocates for that cause on behalf of patients who are unable to articulate their own needs. DIF: Cognitive Level: Comprehension REF: Page: 8 TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment 10.An informal group of patients discuss their perceptions of nursing care. Which comment best indicates a patient’s perception that his or her nurse is caring? a.“My nurse always asks me which type of juice I want to help me swallow my medication.” b.“My nurse explained my treatment plan to me and asked for my ideas about how to make it better.” c.“My nurse told me that if I take all the medicines the doctor prescribes I will get discharged soon.” d.“My nurse spends time listening to me talk about my problems. That helps me feel like I’m not alone.” ANS: D Caring evidences empathic understanding, as well as competency. It helps change pain and suffering into a shared experience, creating a human connection that alleviates feelings of isolation. The remaining options give examples of statements that demonstrate advocacy or giving advice. DIF: Cognitive Level: Application REF: Pages: 3-4|Page: 8 TOP: Nursing Process: Evaluation MSC: NCLEX: Psychosocial Integrity11.A patient who immigrated to the United States from Honduras was diagnosed with schizophrenia. The patient took an antipsychotic medication for 3 weeks but showed no improvement. Which resource should the treatment team consult for information on more effective medications for this patient? a.Clinical algorithm b.Clinical pathway c.Clinical practice guideline d.International Statistical Classification of Diseases and Related Health Problems (ICD) ANS: A A clinical algorithm is a guideline that describes diagnostic and/or treatment approaches drawn from large databases of information. These guidelines help the treatment team make decisions cognizant of an individual patient’s needs, such as ethnic origin, age, or gender. A clinical pathway is a map of interventions and treatments related to a specific disorder. Clinical practice guidelines summarize best practices about specific health problems. The ICD classifies diseases. DIF: Cognitive Level: Application REF: Page: 6 TOP: Nursing Process: Evaluation MSC: NCLEX: Safe, Effective Care Environment 12.Which historical nursing leader helped focus practice to recognize the importance of science in psychiatric nursing? a.Abraham Maslow b.Hildegard Peplau c.Kris Martinsen d.Harriet Bailey ANS: B Although all these leaders included science as an important component of practice, Hildegard Peplau most influenced its development in psychiatric nursing. Maslow was not a nurse, but his theories influence how nurses prioritize problems and care. Bailey wrote a textbook in the 1930s on psychiatric nursing interventions. Kris Martinsen emphasized the importance of caring in nursing practice. DIF: Cognitive Level: Knowledge REF: Page: 4 TOP: Nursing Process: N/A MSC: NCLEX: Psychosocial Integrity 13.A nurse consistently strives to demonstrate caring behaviors during interactions with patients. Which reaction by a patient indicates this nurse is effective? A patient reports feeling: a.distrustful l of others. b.connected with others. c.uneasy about the future. d.discouraged with efforts to improve. ANS: B A patient is likely to respond to caring with a sense of connectedness with others. The absence of caring can make patients feel distrustful, disconnected, uneasy, and discouraged. DIF: Cognitive Level: Comprehension REF: Pages: 7-8 TOP: Nursing Process: EvaluationMSC: NCLEX: Psychosocial Integrity MULTIPLE RESPONSE 1.An experienced nurse says to a new graduate, “When you’ve practiced as long as I have, you’ll instantly know how to take care of psychotic patients.” What is the new graduate’s best analysis of this comment? Select all that apply. a.The experienced nurse may have lost sight of patients’ individuality, which may compromise the integrity of practice. b.New research findings must be continually integrated into a nurse’s practice to provide the most effective care. c.Experience provides mental health nurses with the tools and skills needed for effective professional practice. d.Experienced psychiatric nurses have learned the best ways to care for psychotic patients through trial and error. e.Effective psychiatric nurses should be continually guided by an intuitive sense of patients’ needs. ANS: A, B Evidence-based practice involves using research findings to provide the most effective nursing care. Evidence is continually emerging; therefore, nurses cannot rely solely on experience. The effective nurse also maintains respect for each patient as an individual. Overgeneralization compromises that perspective. Intuition and trial and error are unsystematic approaches to care. DIF: Cognitive Level: Application REF: Pages: 2-3|Page: 6 TOP: Nursing Process: Analysis MSC: NCLEX: Safe, Effective Care Environment 2.Which patient statements identify qualities of nursing practice with high therapeutic value? (Select all that apply.) “The nurse: a.talks in language I can understand.” b.helps me keep track of my medications.” c.is willing to go to social activities with me.” d.lets me do whatever I choose without interfering.” e.looks at me as a whole person with different needs.” ANS: A, B, E Each correct answer demonstrates caring is an example of appropriate nursing foci: communicating at a level understandable to the patient, using holistic principles to guide care, and providing medication supervision. The incorrect options suggest a laissez-faire attitude on the part of the nurse, when the nurse should instead provide thoughtful feedback and help patients test alternative solutions or violate boundaries. DIF: Cognitive Level: Application REF: Pages: 6-8 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial IntegrityChapter 2: Mental Health and Mental Illness Test Bank MULTIPLE CHOICE 1.A nurse explains multiaxial diagnoses to a psychiatric technician. Which information is accurate? a. It is a template for treatment planning. b. Nursing and medical diagnoses are included. c. Assessments of several aspects of functioning are included. d. It incorporates the framework of a specific biopsychosocial theory. ANS: C The use of five axes requires an assessment beyond the diagnosis of a mental disorder and includes relevant medical conditions, psychosocial and environmental problems, and global assessment of functioning. The Diagnostic and Statistical Manual of Mental Disorders (fourth edition, text revision) (DSM-IV-TR) is not a template for treatment planning and does not use a specific biopsychosocial theory. Nursing diagnoses are not included in multiaxial diagnoses. DIF: Cognitive Level: Comprehension REF: Page: 18 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 2.Which documentation of diagnosis would a nurse expect for a person with mental illness? a. I Rheumatoid arthritis II 100 III Posttraumatic stress disorder IV Arrested for shoplifting 2 months earlier V None b. I Mental retardation II Histrionic personality disorder III 75 IV Hypertension V Home destroyed by tornado last year c. I Schizophrenia, paranoid II Death of spouse last year III 40 IV None V Alcohol abuse d. I Generalized anxiety disorder II Avoidant personality disorder III Fibromyalgia IV Declared bankruptcy 6 months ago V 60 ANS: D The option beginning with a diagnosis of generalized anxiety disorder places a clinical disorder on Axis I, a personality disorder on Axis II, a medical problem on Axis III, a psychosocial problem on Axis IV, and global assessment of functioning (GAF) on Axis V. The other options misplace and incorrectly order the clinical data. DIF: Cognitive Level: Application REF: Page: 18 TOP: Nursing Process: Assessment MSC: NCLEX: Safe, Effective Care Environment 3.A patient is admitted to the psychiatric hospital for assessment and evaluation. Which assessment finding best indicates that the patient has a mental illness? The patient: a. describes coping and relaxation strategies used when feeling anxious. b. describes mood as consistently sad, discouraged, and hopeless. c. can perform tasks attempted within the limits of own abilities. d. reports occasional problems with in- somnia. ANS: B A patient who reports having a consistently negative mood is describing a mood alter- ation. The incorrect options describe mentally healthy behaviors and common problems that do not indicate mental illness. DIF: Cognitive Level: Application REF: Page: 19 TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 4.The goal for a patient is to increase resiliency. Which outcome should a nurse add to the plan of care? Within 3 days, the patient will: a. describe feelings associated with loss and stress. b. meet own needs without considering the rights of others.c. identify healthy coping behaviors in response to stressful events. d. allow others to assume responsibility for major areas of own life. ANS: C The patient’s ability to identify healthy coping behaviors indicates adaptive, healthy be- havior and demonstrates an increased ability to recover from severe stress. Describing feelings associated with loss and stress does not move the patient toward adaptation. The remaining options are maladaptive behaviors. DIF: Cognitive Level: Analysis REF: Page: 14 TOP: Nursing Process: Outcomes Identification MSC: NCLEX: Psychosocial Integrity 5.A nurse at a behavioral health clinic sees an unfamiliar psychiatric diagnosis on a patient’s insurance form. Which resource should the nurse consult to discern the criteria used to establish this diagnosis? a. DSM-IV-TR b. Nursing Diagnosis Manual c. A psychiatric nursing textbook d. A behavioral health reference manual ANS: A The DSM-IV-TR gives the criteria used to diagnose each mental disorder. The Nursing Diagnosis Manual focuses on nursing diagnoses. A psychiatric nursing textbook or be- havioral health reference manual may not contain diagnostic criteria. DIF: Cognitive Level: Application REF: Page: 14|Page: 17 TOP: Nursing Process: Analysis| Nursing Process: Diagnosis MSC: NCLEX: Safe, Effective Care Environment 6.A nurse must assess several new patients at a community mental health center. Conclusions concerning current functioning should be made on the basis of: a. the degree of conformity of the indi- vidual to society’s norms. b. the degree to which an individual is logical and rational. c. a continuum from mentally healthy to unhealthy. d. the rate of intellectual and emotional growth.ANS: C Because mental health and mental illness are relative concepts, assessment of func- tioning is made by using a continuum. Mental health is not based on conformity; some mentally healthy individuals do not conform to society’s norms. Most individuals occa- sionally display illogical or irrational thinking. The rate of intellectual and emotional growth is not the most useful criterion to assess mental health or mental illness. DIF: Cognitive Level: Application REF: Pages: 13-14 TOP: Nursing Process: Diagnosis| Nursing Process: Analysis MSC: NCLEX: Psychosocial Integrity 7.A 40-year-old adult living with parents states, “I’m happy but I don’t socialize much. My work is routine. When new things come up, my boss explains them a few times to make sure I understand. At home, my parents make decisions for me, and I go along with them.” A nurse should identify interventions to improve this patient’s: a. self-concept. b. overall happiness. c. appraisal of reality. d. control over behavior. ANS: A The patient feels the need for multiple explanations of new tasks at work and, despite being 40 years of age, allows both parents to make all decisions. These behaviors indi- cate a poorly developed self-concept. DIF: Cognitive Level: Application REF: Pages: 12-14 TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity 8.A patient tells a nurse, “I have psychiatric problems and am in and out of hospitals all the time. Not one of my friends or relatives has these problems.” Select the nurse’s best response. a. “Comparing yourself with others has no real advantages.” b. “Why do you blame yourself for having a psychiatric illness?” c. “Mental illness affects 50% of the adult population in any given year.” d. “It sounds like you are concerned that others don’t experience the same challenges as you.” ANS: D Mental illness affects many people at various times in their lives. No class, culture, or creed is immune to the challenges of mental illness. The correct response also demon-strates the use of reflection, a therapeutic communication technique. It is not true that mental illness affects 50% of the population in any given year. Asking patients if they blame themselves is an example of probing. DIF: Cognitive Level: Application REF: Pages: 14-15 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 9.A critical care nurse asks a psychiatric nurse about the difference between a DSM-IV-TR diagnosis and a nursing diagnosis. Select the psychiatric nurse’s best re- sponse. a. “No functional difference exists be- tween the two diagnoses. Both serve to identify a human deviance.” b. “The DSM-IV-TR diagnosis disregards culture, whereas the nursing diagnosis includes cultural variables.” c. “The DSM-IV-TR diagnosis profiles present distress or disability, whereas a nursing diagnosis considers past and present responses to actual men- tal health problems.” d. “The DSM-IV-TR diagnosis influences the medical treatment; the nursing di- agnosis offers a framework to identify interventions for problems a patient has or may experience.” ANS: D The medical diagnosis is concerned with the patient’s disease state, causes, and cures, whereas the nursing diagnosis focuses on the patient’s response to stress and possible caring interventions. Both the DSM-IV-TR and a nursing diagnosis consider culture. The DSM-IV-TR is multiaxial. Nursing diagnoses also consider potential problems. DIF: Cognitive Level: Application REF: Page: 17|Pages: 21-22 TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment 10.A nurse finds a new patient uncommunicative about recent life events. The nurse suspects marital and economic problems. The social worker’s assessment is not avail- able. The most effective action the nurse can take is to: a. ask the patient who shares a room with him or her. b. consult Axis IV of the DSM-IV-TR in the medical record. c. focus questions on the topics of mari-tal and economic issues. d. delay discussion of these topics until the social worker’s assessment is available. ANS: B The physician’s admission note identifies psychosocial and environmental problems on Axis IV pertinent to the patient’s situation, providing another source of information for the nurse. Asking the patient who shares a room with him or her violates patient privacy rights. Persistent questioning may cause the patient to withdraw. Delaying the discus- sion until the social worker’s assessment is available is not an effective solution. DIF: Cognitive Level: Application REF: Page: 18 TOP: Nursing Process: Assessment MSC: NCLEX: Safe, Effective Care Environment 11.A newly admitted patient is profoundly depressed, mute, and motionless. The patient has refused to bathe and eat for a week. Which score would be expected on the pa- tient’s global assessment of functioning? a. 100 b. 80 c. 50 d. 10 ANS: D The patient is unable to maintain personal hygiene, oral intake, or verbal communica- tion. The patient is dangerous to self because of the potential for starvation. A GAF score of 100 indicates high-level functioning. A score of 80 or 50 suggests higher func- tional abilities than the patient presently displays. DIF: Cognitive Level: Analysis REF: Page: 19 TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 12.The spouse of a patient with schizophrenia says, “I don’t understand why childhood experiences have anything to do with this disabling illness.” Select the nurse’s response that will best help the spouse understand this condition. a. “Psychological stress is actually at the root of most mental disorders.” b. “We now know that all mental illness- es are the result of genetic factors.” c. “It must be frustrating for you that your spouse is sick so much of the time.” d. “Although this disorder more likely has a biological rather than psychological origin, the support and involvement of caregivers is very important.” ANS: D Many of the most prevalent and disabling mental disorders have been found to have strong biological influences. Helping the spouse understand the importance of his or her role as a caregiver is also important. Empathy is important but does not increase the spouse’s level of knowledge about the cause of the patient’s condition. Not all mental illnesses are the result of genetic factors. Psychologic stress is not at the root of most mental disorders. DIF: Cognitive Level: Application REF: Pages: 15-16 TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance 13.Which belief by a nurse supports the highest degree of patient advocacy during a multidisciplinary patient care planning session? a. All mental illnesses are culturally de- termined. b. Schizophrenia and bipolar disorder are cross-cultural disorders. c. Symptoms of mental disorders are constant from culture to culture. d. Some symptoms of mental disorders reflect a person’s cultural patterns. ANS: D A nurse who understands that a patient’s symptoms are influenced by culture will be able to advocate for the patient to a greater degree than a nurse who believes that cul- ture is of little relevance. All mental illnesses are not culturally determined. Schizophre- nia and bipolar disorder are cross-cultural disorders, but this understanding has little relevance to patient advocacy. Symptoms of mental disorders change from culture to culture. DIF: Cognitive Level: Application REF: Pages: 21-22 TOP: Nursing Process: Planning MSC: NCLEX: Safe, Effective Care Environment 14.A patient’s history shows intense and unstable relationships with others. The patient initially idealizes an individual and then devalues the person when the patient’s needs are not met. Which aspect of mental health is a problem? a. Effectiveness in work b. Communication skills c. Productive activities d. Fulfilling relationshipsANS: D The information provided centers on relationships with others, which are described as intense and unstable. The relationships of mentally healthy individuals are stable, satis- fying, and socially integrated. Data are not present to describe work effectiveness, communication skills, or activities. DIF: Cognitive Level: Application REF: Pages: 12-13 TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 15.In the majority culture of the United States, which individual is at greatest risk to be incorrectly labeled mentally ill? a. Person who is usually pessimistic but strives to meet personal goals b. Wealthy person who gives $20 bills to needy individuals in the community c. Person with an optimistic viewpoint about life and getting his or her own needs met d. Person who attends a charismatic church and describes hearing God’s voice ANS: D Hearing voices is generally associated with mental illness; however, in charismatic reli- gious groups, hearing the voice of God or a prophet is a desirable event. In this situa- tion, cultural norms vary, making it more difficult to make an accurate DSM-IV-TR diag- nosis. The individuals described in the other options are less likely to be labeled as mentally ill. DIF: Cognitive Level: Application REF: Pages: 21-22 TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 16.A psychiatric nurse addresses Axis I of the DSM-IV-TR as the focus of care but also considers the presence of other long-term, nonmedical disorders that may affect treat- ment. To which axis should the nurse refer for this information? a. II b. III c. IV d. V ANS: A Axis II refers to personality disorders and mental retardation. Together, Axis I and Axis II constitute the classification of abnormal behavior diagnosed in the individual. Axis III in- dicates any relevant general medical conditions. Axis IV reports psychosocial and envi-ronmental problems that may affect the diagnosis, treatment, and prognosis. Axis V is the GAF score. DIF: Cognitive Level: Comprehension REF: Pages: 18-19 TOP: Nursing Process: Planning MSC: NCLEX: Safe, Effective Care Environment 17.A mentally ill person’s current global assessment of functioning (GAF) score is 10. Select the nurse’s highest priority related to this patient’s care. a. Safety b. Hygiene c. Nutrition d. Socialization ANS: A This low GAF score indicates a consistent risk for self-harm exists; therefore the nurse’s highest priority is safety. DIF: Cognitive Level: Analysis REF: Pages: 21-22 TOP: Nursing Process: Planning MSC: NCLEX: Safe, Effective Care Environment 18.A participant at a community education conference asks, “What is the most prevalent mental disorder in the United States?” Select the nurse’s best response. a. “Why do you ask?” b. “Schizophrenia” c. “Affective disorders” d. “Anxiety disorders” ANS: D The prevalence for schizophrenia is 1.1% per year. The prevalence of all affective dis- orders (e.g., depression, dysthymia, bipolar) is 9.5%. The prevalence of anxiety disor- ders is 13.3%. DIF: Cognitive Level: Comprehension REF: Page: 15 TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance 19.A nurse wants to find a description of diagnostic criteria for a person with schizophrenia. Which resource should the nurse consult? a. U.S. Department of Health and Hu- man Services b. Journal of the American Psychiatric Association c. North American Nursing Diagnosis