230 Unit 1

5 (The student is happy and has an adequate self-concept. The student is reality-oriented, works effectively, and has control over own behavior. Mental health does not mean that a person is always happy.)

A college student said, "Most of the time I'm happy and feel good about myself. I have learned that what I get out of something is proportional to the effort I put into it." Which number on a 1-5 mental health continuum should the nurse select? 1 representing illness and 5 representing optimal mental health. 1 2 3 4 5

Impaired verbal communication (The defining characteristics are more related to the nursing diagnosis of impaired verbal communication than to the other nursing diagnoses.)

A nurse documents: "Patient is mute despite repeated efforts to elicit speech. Makes no eye contact. Inattentive to staff. Gazes off to the side or looks upward rather than at speaker." Which nursing diagnosis should be considered? Defensive coping Risk for other-directed violence Decisional conflict Impaired verbal communication

ensure that the directive is respected in treatment planning. (The nurse has an obligation to honor the right to self-determination. An advanced psychiatric directive supports that goal. Since the patient is currently psychotic, the terms of the directive now apply.)

A nurse finds a psychiatric advance directive in the medical record of a patient experiencing psychosis. The directive was executed during a period when the patient was stable and competent. The nurse should: review the directive with the patient to ensure it is current. ensure that the directive is respected in treatment planning. consider the directive only if there is a cardiac or respiratory arrest. encourage the patient to revise the directive in light of the current health problem.

"What did you have for breakfast this morning?" (The patient's recall of a meal provides evidence of recent memory. Two incorrect responses are useful to assess immediate and remote memory. The other distracter assesses the patient's fund of knowledge.)

A nurse wants to assess an adult patient's recent memory. Which question would best yield the desired information? "Where did you go to elementary school?" "What did you have for breakfast this morning?" "Can you name the current Florida Man?" "A few minutes ago, I told you my name. Can you remember it?"

Anonymously report the abuse by phone to the local child protection agency. (Laws regarding child abuse reporting discovered by a professional during the suspected abuser's alcohol or drug treatment differ by state. Federal law supersedes state law and prohibits disclosure without a court order except in instances in which the report can be made anonymously or without identifying the abuser as a patient in an alcohol or drug treatment facility.)

A patient in alcohol rehabilitation reveals to the nurse, "I feel terrible guilt for sexually abusing my 6-year-old before I was admitted." Select the nurse's most important action. Anonymously report the abuse by phone to the local child protection agency. Reply, "I'm glad you feel comfortable talking to me about it." File a written report with the agency's ethics committee. Respect nurse-patient relationship confidentiality.

Suicide precautions (The nurse would place a priority on monitoring and reinforcing suicide self-restraint because it relates directly and immediately to patient safety. Patient safety is always a priority concern. The nurse should monitor and reinforce all patient attempts to control anxiety, improve sleep patterns, and develop self-esteem, while giving priority attention to suicide self-restraint.)

A patient states, "I'm not worth anything. I have negative thoughts about myself. I feel anxious and shaky all the time. Sometimes I feel so sad that I want to go to sleep and never wake up." Which nursing intervention should have the highest priority? Self-esteem-building activities Sleep enhancement activities Anxiety self-control measures Suicide precautions

Recreational therapist (Recreational therapists help patients use leisure time to benefit their mental health. Occupational therapists assist with a broad range of skills, including those for employment. Psychologists conduct testing and provide other patient services. Social workers focus on the patient's support system.)

A patient usually watches television all day, seldom going out in the community or socializing with others. The patient says, "I don't know what to do with my free time." Which member of the treatment team would be most helpful to this patient? Psychologist Recreational therapist Social worker Occupational therapist

"I will get them for you, but let's talk about your decision to leave treatment." (A voluntarily admitted patient has the right to demand and obtain release in most states. However, as a patient advocate, the nurse is responsible for weighing factors related to the patient's wishes and best interests. By asking for information, the nurse may be able to help the patient reconsider the decision. Facilitating discharge without consent is not in the patient's best interests before exploring the reason for the request.)

A voluntarily hospitalized patient tells the nurse, "Get me the forms for discharge. I want to leave now." Select the nurse's best response. "I will get the forms for you right now and bring them to your room." "Since you signed your consent for treatment, you may leave if you desire." "I will get them for you, but let's talk about your decision to leave treatment." "I cannot give you those forms without your health care provider's permission."

Ch.1: Mental Health and Mental Illness

Ch.1: Mental Health and Mental Illness

Ch.4: Treatment Settings

Ch.4: Treatment Settings

Ch.6: Legal and Ethical Considerations

Ch.6: Legal and Ethical Considerations

Ch.7: The Nursing Process and Standards of Care

Ch.7: The Nursing Process and Standards of Care

streamline the care process and reduce costs. (Clinical pathways provide guidelines for assessments, interventions, treatments, and outcomes as well as a designated timeline for accomplishment. Deviations from the timeline must be reported and investigated. Clinical pathways streamline the care process and save money. Care pathways do not identify obstacles or stabilize aggressive patients. Staff are responsible for the necessary interventions. Care pathways do not relieve nurses of the responsibility of planning; pathways may, however, make the task easier.)

Clinical pathways are used in managed care settings to: stabilize aggressive patients. identify obstacles to effective care. relieve nurses of planning responsibilities. streamline the care process and reduce costs.

Justice (The nurse is concerned about justice, that is, fair distribution of care, which includes treatment with the least restrictive methods for both patients. Beneficence means promoting the good of others. Autonomy is the right to make one's own decisions. Fidelity is the observance of loyalty and commitment to the patient.)

In a team meeting a nurse says, "I'm concerned about whether we are behaving ethically by using restraint to prevent one patient from self-mutilation, while the care plan for another self-mutilating patient requires one-on-one supervision." Which ethical principle most clearly applies to this situation? Beneficence Fidelity Autonomy Justice

never demonstrated. (Although the patient is sleeping 6 hours daily, the total is not one uninterrupted session at night. Therefore, the outcome must be evaluated as never demonstrated.)

The desired outcome for a patient experiencing insomnia is, "Patient will sleep for a minimum of 5 hours nightly within 7 days." At the end of 7 days, review of sleep data shows the patient sleeps an average of 4 hours nightly and takes a 2-hour afternoon nap. The nurse will document the outcome as: consistently demonstrated. often demonstrated. sometimes demonstrated. never demonstrated.

Refer the request for information to the patient's case manager. (The case manager usually confers with insurers and provides the treatment team with information about available resources. The unit secretary should be mindful of patient confidentiality and should neither confirm that the patient is an inpatient nor disclose other information.)

The unit secretary receives a phone call from the health insurer for a hospitalized patient. The caller seeks information about the patient's projected length of stay. How should the nurse instruct the unit secretary to handle the request? Obtain the information from the patient's medical record and relay it to the caller. Inform the caller that all information about patients is confidential. Refer the request for information to the patient's case manager. Refer the request to the health care provider.

Unmet patient needs currently present Supporting data that validate the diagnoses Probable causes that will be targets for nursing interventions (Nursing diagnoses focus on phenomena of concern to nurses rather than on medical diagnoses.)

What information is conveyed by nursing diagnoses? Select all that apply. Medical judgments about the disorder Unmet patient needs currently present Goals and outcomes for the plan of care Supporting data that validate the diagnoses Probable causes that will be targets for nursing interventions

can be charged with battery. (Battery is an intentional tort in which one individual violates the rights of another through touching without consent. Forcing a patient to take medication after the medication was refused constitutes battery. The charge of battery can be brought against the nurse. The medication may not necessarily harm the patient; harm is a component of malpractice.)

What is the legal significance of a nurse's action when a patient verbally refuses medication and the nurse gives the medication over the patient's objection? The nurse: has been negligent. fulfilled the standard of care. committed malpractice. can be charged with battery.

Advocacy (An advocate defends or asserts another's cause, particularly when the other person lacks the ability to do that for self. 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 human condition. Since funding is necessary to deliver quality programming for persons with mental illness, the letter- writing campaign advocates for that cause on behalf of patients who are unable to articulate their own needs.)

When a new bill introduced in Congress reduces funding for care of persons with mental illness, a group of nurses writes letters to their elected representatives in opposition to the legislation. Which role have the nurses fulfilled? Recovery Advocacy Attending Evidence-based practice

Teaching parenting skills (Primary prevention activities are directed to healthy populations to provide information for developing skills that promote mental health. The distracters represent secondary or tertiary prevention activities.)

Which activity is appropriate for a nurse engaged exclusively in community-based primary prevention? Medication follow-up Substance abuse counseling Teaching parenting skills Making a referral for family therapy

Building assertiveness skills (Assertiveness training relies on the counseling and psychoeducational skills of the nurse. Assistance with personal hygiene would usually be accomplished by a psychiatric technician or nursing assistant. Diversional activities are usually the province of recreational therapists. The patient would probably be assisted in job hunting by a social worker or vocational therapist.)

Which aspect of direct care is an experienced, inpatient psychiatric nurse most likely to provide for a patient? Hygiene assistance Assistance with job hunting Diversional activities Building assertiveness skills

Assessment findings in mental disorders reflect a person's cultural patterns. (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 culture is of little relevance. The distracters are untrue statements.)

Which belief will best support a nurse's efforts to provide patient advocacy during a multidisciplinary patient care planning session? All mental illnesses are culturally determined. Schizophrenia and bipolar disorder are cross-cultural disorders. Symptoms of mental disorders are unchanged from culture to culture. Assessment findings in mental disorders reflect a person's cultural patterns.

Autonomy (A community mental health nurse often works autonomously. Kindness, compassion, and professionalism apply to both nurses.)

Which characteristic would be more applicable to a community mental health nurse than to a nurse working in an operating room? Kindness Compassion Autonomy Professionalism

takes a temporary job to maintain financial stability after loss of a permanent job. (Resilience is closely associated with the process of adapting and helps people facing tragedies, loss, trauma, and severe stress. It is the ability and capacity for people to secure the resources they need to support their well-being. Repression and depression are unhealthy. Living in a shelter for two years shows a failure to move forward after a tragedy. See related audience response question.)

Which individual is demonstrating the highest level of resilience? One who: is able to repress stressors. becomes depressed after the death of a spouse. lives in a shelter for two years after the home is destroyed by fire. takes a temporary job to maintain financial stability after loss of a permanent job.

Alzheimer's disease (The 12-month prevalence for Alzheimer's disease is 10% for persons older than 65 and 50% for persons older than 85. The prevalence of schizophrenia is 1.1% per year. The prevalence of bipolar disorder is 2.6%. Dissociative fugue is a rare disorder. See related audience response question.)

A citizen at a community health fair asks the nurse, "What is the most prevalent mental disorder in the United States?" Select the nurse's best response. Schizophrenia Dissociative fugue Bipolar disorder Alzheimer's disease

Quality and Safety Education for Nurses (QSEN represents national initiatives centered on patient safety and quality. The primary goal of QSEN is to prepare future nurses with the knowledge, skills, and attitudes to increase the quality, care, and safety in the health care setting in which they work.)

"QSEN" refers to: Qualitative Standardized Excellence in Nursing Quality and Safety Education for Nurses Quantitative Effectiveness in Nursing Quick Standards Essential for Nurses

Ask the patient, "Tell me about the problem as you see it." Seek information about when the problem began. Reassure the patient, "You are safe here."

A patient is very suspicious and states, "The FBI has me under surveillance." Which strategies should a nurse use when gathering initial assessment data about this patient? Select all that apply. Tell the patient that medication will help this type of thinking. Ask the patient, "Tell me about the problem as you see it." Seek information about when the problem began. Tell the patient, "Your ideas are not realistic." Reassure the patient, "You are safe here."

Encouraging persons to describe their memories and feelings about the event (Disaster victims benefit from telling their story. Nurses show compassion by listening and offering hope. The distracters identify other aspects of psychological first aid and services on the mental health continuum.)

A Category V tornado hits a community, destroying many homes and businesses. Which nursing intervention would best demonstrate compassion and caring? Encouraging persons to describe their memories and feelings about the event Arranging transportation to the local community mental health center Referring a local resident to a community food bank Coordinating psychiatric home care services

"Issues of this kind have to be shared with the treatment team and your parents." (Although adolescent patients request confidentiality, issues of sexual abuse, threats of suicide or homicide, or issues that put the patient at risk for harm must be shared with the treatment team and the parents. A threat of this nature must be discussed with the treatment team and the parents. Confidentiality laws do not protect information that would lead to harm to the patient or others.)

A 17-year-old patient confides to the nurse that they have been thinking of ways to kill a peer. What response should the nurse give when the patient states, "you have to keep it a secret because its confidential information"? "I will keep it a secret, but you and I need to discuss ways to deal with this situation appropriately without committing a crime." "Yes, I will keep it confidential. We have laws to protect patients' confidentiality." "Issues of this kind have to be shared with the treatment team and your parents." "I will have to share this with the treatment team, but we will not share it with your parents."

"Yes, I will be happy to get any information and history that you can provide." (The friend is a secondary source of information that will be helpful since the patient is not able to give any history or information at this time. Confidentiality laws do not prohibit obtaining information from a secondary source. The friend can provide information and/or history immediately and may be able to relate events that happened just before coming to the hospital. A release would not be necessary to take information about the patient from a secondary source, and a psychotic patient would not be competent to sign a release.)

A 26-year-old patient is brought to the emergency room by a friend. The patient is unable to give any coherent history. Which response should the nurse provide when the patient's friend offers to provide information regarding the patient? "I'm sorry, but I cannot take any information from you as it would violate confidentiality laws." "There is no need for that as I will call his primary care provider to obtain the information we need." "Yes, I will be happy to get any information and history that you can provide." "Yes, however, we will have to get a release signed from the patient for you to be able to talk with me."

"Dr. Raye, I notice you ordered fluoxetine for this patient. During the admission interview, the client stated they will refuse the medication because of adverse effects they experienced previously." (By letting the provider know that the patient does not want the treatment the provider is prescribing, you have advocated for the patient and her right to make decisions regarding her treatment. The other selections do not describe patient advocacy since they do not represent actions by the nurse that the patient is incapable of on their own.)

A 29-year-old patient has been admitted following a suicide attempt. Which nursing statement illustrates the concept of patient advocacy? "Dr. Raye, I notice you ordered fluoxetine for this patient. During the admission interview, the client stated they will refuse the medication because of adverse effects they experienced previously." "Dr. Raye, during the admissions interview the patient stated that there is a family history of three other suicide attempts in the past." "I'd like you tell me more about your depression and your suicide attempt?" "I will take you on a tour of the unit and orient you to the rules so you can get adjusted here."

Spiritual distress (The client is expressing distress regarding his religion and spiritual well-being. The client could be experiencing ineffective coping, but this does not directly relate to his comment. There is nothing in the client's comment that would lead to the conclusion that the patient is having thoughts of harming himself or experiencing hopelessness.)

A 43-year-old client being seen in the mental health clinic states, "I have always been a practicing Jew, but in the past few months I am questioning everything. I just don't know if I believe in it anymore." Which of the following nursing diagnoses best describes the client's comment? Ineffective coping Spiritual distress Risk for self-harm Hopelessness

Incidence (Incidence refers to the number of new cases of mental disorders in a healthy population within a given period of time. Prevalence describes the total number of cases, new and existing, in a given population during a specific period of time, regardless of when they became ill. Parity refers to equivalence, and legislation required insurers that provide mental health coverage to offer annual and lifetime benefits at the same level provided for medical/surgical coverage. Co-morbidity refers to having more than one mental disorder at a time.)

A category 5 tornado occurred in a community of 400 people resulting in destruction of many homes and businesses. In the 2 years after this disaster, 140 individuals were diagnosed with posttraumatic stress disorder (PTSD). Which term best applies to these newly diagnosed cases? Prevalence Incidence Co-morbidity Parity

With the patient's consent, contact resources to provide medications without charge temporarily. (Hospitalization may damage the nurse-patient relationship, even if it provides an opportunity for rapid stabilization. If medication is restarted, the patient may possibly be stabilized in the home setting, even if it takes a little longer. Programs are available to help patients who are unable to afford their medications. A homeless shelter is inappropriate and unnecessary. Hospitalization may be necessary later, but a less restrictive solution should be tried first, since the patient is not dangerous. A yes/no question is non-therapeutic communication.)

A community mental health nurse has worked for months to establish a relationship with a delusional, suspicious patient. The patient recently lost employment and could no longer afford prescribed medications. The patient says, "Only a traitor would make me go to the hospital." Select the nurse's best initial intervention. With the patient's consent, contact resources to provide medications without charge temporarily. Arrange a bed in a local homeless shelter with nightly on-site supervision. Hospitalize the patient until the symptoms have stabilized. Ask the patient, "Do you feel like I am a traitor?"

if the patient threatens the life of another person. (The duty to warn a person whose life has been threatened by a psychiatric patient overrides the patient's right to confidentiality. The right to confidentiality is not suspended at the discretion of the therapist or for legal investigations.)

A family member of a patient with delusions of persecution asks the nurse, "Are there any circumstances under which the treatment team is justified in violating a patient's right to confidentiality?" The nurse should reply that confidentiality may be breached: under no circumstances. at the discretion of the psychiatrist. when questions are asked by law enforcement. if the patient threatens the life of another person.

The availability of transportation to the clinic (The ability of the patient to get to the clinic is of paramount importance to the success of the plan. The depot medication relieves the patient of the necessity to take medication daily, but if he or she does not receive the injection at 3-week intervals, non-adherence will again be the issue. Attitude toward the patient, trusting relationships, and nutrition are important but not fundamental to this particular problem.)

A health care provider prescribed depot injections every 3 weeks at the clinic for a patient with a history of medication noncompliance. For this plan to be successful, which factor will be of critical importance? The attitude of significant others toward the patient Nutrition services in the patient's neighborhood The level of trust between the patient and nurse The availability of transportation to the clinic

withhold the medication and confer with the health care provider. (The dose of antidepressants for elderly patients is often less than the usual adult dose. The nurse should withhold the medication and consult the health care provider who wrote the order. The nurse's duty is to practice according to professional standards as well as intervene and protect the patient.)

A new antidepressant is prescribed for an elderly patient with major depression, but the dose is more than the usual geriatric dose. The nurse should: consult a reliable drug reference. teach the patient about possible side effects and adverse effects. withhold the medication and confer with the health care provider. encourage the patient to increase oral fluids to reduce drug concentration.

"You will attend a psychotherapy group that I lead that will help you care for yourself." (Basic level RNs cannot perform psychotherapy. The other options are all appropriate expectations of a patient's schedule on a psychiatric unit.)

A new nurse has accepted a position as staff nurse on a psychiatric unit. Which statement made by the new nurse requires additional instructions regarding the therapies provided on the unit? "You will participate in unit activities and groups daily." "You will be given a schedule daily of the groups we would like you to attend." "You will attend a psychotherapy group that I lead that will help you care for yourself." "You will see your provider daily in a one-to-one session."

Patient (Although the nurse is accountable to the health care provider, the agency, the patient, and the profession, the duty of care is owed to the patient.)

A newly admitted acutely psychotic patient is a private patient of the medical director and a private-pay patient. To whom does the psychiatric nurse assigned to the patient owe the duty of care? Medical director Profession Hospital Patient

Risk for suicide (Risk for suicide is the priority diagnosis when the patient has both suicidal ideation and a plan to carry out the suicidal intent. Imbalanced nutrition, hopelessness, and chronic low self-esteem may be applicable nursing diagnoses, but these problems do not affect patient safety as urgently as would a suicide attempt.)

A newly admitted patient diagnosed with major depression has gained 20 pounds over a few months and has suicidal ideation. The patient has taken an antidepressant medication for 1 week without remission of symptoms. Select the priority nursing diagnosis. Imbalanced nutrition: more than body requirements Chronic low self-esteem Risk for suicide Hopelessness

Cognition (Assessing cognition involves determining a patient's judgment and decision making. In this case, the nurse would expect a response of "Call my doctor" if the patient's cognition and judgment are intact. If the patient responds, "I would stop eating" or "I would just wait and see what happened," the nurse would conclude that judgment is impaired. The other options refer to other aspects of the examination.)

A nurse asks a patient, "If you had fever and vomiting for 3 days, what would you do?" Which aspect of the mental status examination is the nurse assessing? Behavior Affect and mood Cognition Perceptual disturbances

The patient's subjective responses A description of the patient's behavior during the interview (Both content and process of the interview should be documented. Providing only the patient's verbal responses would create a skewed picture of the patient. Writing that the patient was uncooperative is subjectively worded. An objective description of patient behavior would be preferable. Analysis of the reasons for the patient's behavior would be speculation, which is inappropriate.)

A nurse assessed a patient who reluctantly participated in activities, answered questions with minimal responses, and rarely made eye contact. What information should be included when documenting the assessment? Select all that apply. The patient was uncooperative The patient's subjective responses Only data obtained from the patient's verbal responses A description of the patient's behavior during the interview Analysis of why the patient was unresponsive during the interview

Obtain important information from the family member. (When the patient (primary source) is unable to provide information, secondary sources should be used, in this case, the family member. Later, more data may be obtained from other information sources familiar with the patient. An advanced practice nurse is not needed for this assessment; it is within the scope of practice of the staff nurse. Calling a mental health advocate is unnecessary.)

A nurse assesses an older adult patient brought to the emergency department by a family member. The patient was wandering outside saying, "I can't find my way home." The patient is confused and unable to answer questions. Select the nurse's best action. Record the patient's answers to questions on the nursing assessment form. Ask an advanced practice nurse to perform the assessment interview. Call for a mental health advocate to maintain the patient's rights. Obtain important information from the family member.

housing adequacy. family and support systems. income adequacy and stability. substance abuse history and current use. (Early psychosocial developmental history is less relevant to successful outcomes in the community than the assessments listed in the other options. If a patient is homeless or fears homelessness, focusing on other treatment issues is impossible. Sufficient income for basic needs and medication is necessary. Adequate support is a requisite to community placement. Substance abuse undermines medication effectiveness and interferes with community adjustment.)

A nurse can best address factors of critical importance to successful community treatment by including making assessments relative to: (Select all that apply.) housing adequacy. family and support systems. income adequacy and stability. early psychosocial development. substance abuse history and current use.

Diagnostic and Statistical Manual of Mental Disorders (DSM-5) (The DSM-5 gives the criteria used to diagnose each mental disorder. The distracters may not contain diagnostic criteria for a psychiatric illness.)

A nurse encounters an unfamiliar psychiatric disorder on a new patient's admission form. Which resource should the nurse consult to determine criteria used to establish this diagnosis? International Statistical Classification of Diseases and Related Health Problems (ICD-10) Diagnostic and Statistical Manual of Mental Disorders (DSM-5) A behavioral health reference manual Wikipedia

management of milieu safety. (Nursing staff are responsible for all aspects of milieu management. The observations mentioned in this question directly relate to the safety of the unit. The other options, although part of the nurse's concerns, are unrelated to the observations cited.)

A nurse inspects an inpatient psychiatric unit and finds that exits are free of obstructions, no one is smoking, and the janitor's closet is locked. These observations relate to: coordinating care of patients. management of milieu safety. management of the interpersonal climate. use of therapeutic intervention strategies.

Agency policies do not exempt an individual nurse of responsibility to practice according to professional standards of nursing care. (Nurses are professionally bound to uphold standards of practice regardless of lesser standards established by a health care agency or a state. Conversely, if the agency standards are higher than standards of practice, the agency standards must be upheld. The courts may seek to establish the standard of care through the use of expert witnesses when the issue is clouded.)

A nurse is concerned that an agency's policies are inadequate. Which understanding about the relationship between substandard institutional policies and individual nursing practice should guide nursing practice? Agency policies do not exempt an individual nurse of responsibility to practice according to professional standards of nursing care. Agency policies are the legal standard by which a professional nurse must act and therefore override other standards of care. Faced with substandard policies, a nurse has a responsibility to inform the supervisor and discontinue patient care immediately. Interpretation of policies by the judicial system is rendered on an individual basis and therefore cannot be predicted.

"Thank you. I would enjoy having a cup of coffee with you." (Accepting refreshments or chatting informally with the patient and family represent therapeutic use of self and help to establish rapport. The distracters fail to help establish rapport.)

A nurse makes an initial visit to a homebound patient diagnosed with a serious mental illness. A family member offers the nurse a cup of coffee. Select the nurse's best response. "Thank you. I would enjoy having a cup of coffee with you." "Thank you, but I would prefer to proceed with the assessment." "No, but thank you. I never accept drinks from patients or families." "Our agency policy prohibits me from eating or drinking in patients' homes."

Prohibited a patient from using the telephone (The patient has a right to use the telephone. The patient should be protected against possible harm to self or others. Patients have rights to send and receive mail and be present during package inspection. Patients have rights to refuse treatment.)

A nurse performed these actions while caring for patients in an inpatient psychiatric setting. Which action violated patients' rights? Prohibited a patient from using the telephone In patient's presence, opened a package mailed to patient Remained within arm's length of patient with homicidal ideation Permitted a patient with psychosis to refuse oral psychotropic medication

Addiction Severity Index (ASI) Brief Drug Abuse Screen Test (B-DAST) Recovery Attitude and Treatment Evaluator (RAATE) (Standardized scales are useful for obtaining data about substance use disorders. The ASI, B-DAST, and RAATE are scales related to substance abuse. AIMS assesses involuntary movements associated with anti-psychotic medications. The CCSE assesses cognitive function.)

A nurse performing an assessment interview for a patient with a substance use disorder decides to use a standardized rating scale. Which scales are appropriate? Select all that apply. Addiction Severity Index (ASI) Brief Drug Abuse Screen Test (B-DAST) Abnormal Involuntary Movement Scale (AIMS) Cognitive Capacity Screening Examination (CCSE) Recovery Attitude and Treatment Evaluator (RAATE)

Stop the medication administration procedure and say to the patient, "Tell me more about the side effects you've been having." (Patients with mental illness retain their civil rights unless there is clear, cogent, and convincing evidence of dangerousness. The patient in this situation presents no evidence of dangerousness. The nurse, as an advocate and educator, should seek more information about the patient's decision and not force the medication.)

A nurse prepares to administer a scheduled injection of haloperidol decanoate (Haldol depot) to an outpatient with schizophrenia. As the nurse swabs the site, the patient shouts, "Stop! I don't want to take that medicine anymore. I hate the side effects." Select the nurse's best action. Assemble other staff for a show of force and proceed with the injection, using restraint if necessary. Stop the medication administration procedure and say to the patient, "Tell me more about the side effects you've been having." Proceed with the injection but explain to the patient that there are medications that will help reduce the unpleasant side effects. Say to the patient, "Since I've already drawn the medication in the syringe, I'm required to give it, but let's talk to the doctor about delaying next month's dose."

"Are you comfortable conversing in English, or would you prefer to have a translator present?" (The nurse should determine whether a translator is needed by first assessing the patient for language barriers. Accuracy of the assessment depends on the ability to communicate in a language that is familiar to the patient. Family members are not always reliable translators. An interpreter may change the patient's responses; a translator is a better resource.)

A nurse prepares to assess a new patient who moved to the United States from Central America three years ago. After introductions, what is the nurse's next comment? "How did you get to the United States?" "Would you like for a family member to help you talk with me?" "An interpreter is available. Would you like for me to make a request for these services?" "Are you comfortable conversing in English, or would you prefer to have a translator present?"

Case manager (Nurses on psychiatric units routinely coordinate patient services, serving as case managers as described in this scenario. The role of advocate would require the nurse to speak out on the patient's behalf. The role of milieu manager refers to maintaining a therapeutic environment. Provider of care refers to giving direct care to the patient.)

A nurse receives these three phone calls regarding a newly admitted patient. · The psychiatrist wants to complete an initial assessment. · An internist wants to perform a physical examination. · The patient's attorney wants an appointment with the patient. The nurse schedules the activities for the patient. Which role has the nurse fulfilled? Advocate Milieu manager Case manager Provider of care

A patient was not allowed to have visitors. (The patient has the right to have visitors. Inspecting patients' belongings is a safety measure. Patients have the right to a safe environment, including the right to be protected against impulses to harm self.)

A nurse surveys medical records. Which finding signals a violation of patients' rights? A patient was not allowed to have visitors. A patient's belongings were searched at admission. A patient with suicidal ideation was placed on continuous observation. Physical restraint was used after a patient was assaultive toward a staff member.

Diagnostic and Statistical Manual of Mental Disorders (DSM-5) (The DSM-5 details the diagnostic criteria for psychiatric clinical conditions. The other references are good resources but do not define the diagnostic criteria.)

A nurse wants to find a description of diagnostic criteria for anxiety disorders. Which resource would have the most complete information? Nursing Outcomes Classification (NOC) Diagnostic and Statistical Manual of Mental Disorders (DSM-5) The ANA's Psychiatric-Mental Health Nursing Scope and Standards of Practice International Statistical Classification of Diseases and Related Health Problems (ICD-10)

"By educating the public on the effects that stigmatizing has on mental health clients." (Nurses who are aware of legislative concerns and who are active in organizations that promote mental health awareness and appropriate and equal treatment for mental illness help achieve the goal of parity, or equality of treatment for mentally ill individuals. Becoming active in politics may be a personal goal but does not directly or necessarily reduce stigma or encourage treatment equality. The other options are undesirable outcomes.)

A nurse, active in local consumer mental health groups and in local and state mental health associations, keeps aware of state and national legislation affecting mental illness treatment. How can this nurse positively affect the climate for effective, mental health treatment? "By becoming active in politics leading to a potential political career." "By educating the public on the effects that stigmatizing has on mental health clients." "Advocating for laws that would make the involuntary long-term commitment process easier and faster for caregivers of mentally ill persons." "Advocating for reduced mental health insurance benefits to discourage abuse of the system by inappropriate psychiatric admissions."

Implementation (Interventions are the nursing prescriptions to achieve the outcomes. Interventions should be specific.)

A patient begins a new program to assist with building social skills. In which part of the plan of care should a nurse record the item, "Encourage patient to attend one psychoeducational group daily"? Assessment Implementation Analysis Evaluation

Implement suicide precautions. (Implementing suicide precautions is the only option related to patient safety. The other options, related to nutrition, self-esteem, and medication therapy, are important but are not priorities.)

A patient diagnosed with major depression has lost 20 pounds in one month, has chronic low self-esteem, and a plan for suicide. The patient has taken an antidepressant medication for 1 week. Which nursing intervention has the highest priority? Implement suicide precautions. Offer high-calorie snacks and fluids frequently. Assist the patient to identify three personal strengths. Observe patient for therapeutic effects of antidepressant medication.

demonstrated the duty to warn and protect. (It is the health care professional's duty to warn or notify an intended victim after a threat of harm has been made. Informing a potential victim of a threat is a legal responsibility of the health care professional. It is not a violation of confidentiality.)

A patient diagnosed with schizophrenia believes a local minister stirred evil spirits. The patient threatens to bomb a local church. The psychiatrist notifies the minister. Select the answer with the correct rationale. The psychiatrist: released information without proper authorization. demonstrated the duty to warn and protect. violated the patient's confidentiality. avoided charges of malpractice.

explain that the patient will continue to improve if the medication is taken regularly. (Patients do not stay in a hospital until every symptom disappears. The nurse must assume responsibility to advocate for the patient's right to the least restrictive setting as soon as the symptoms are under control and for the right of citizens to control health care costs. The health care provider will use the same rationale. Shifting blame will not change the discharge. Security is unnecessary. The nurse can handle this matter.)

A patient diagnosed with schizophrenia had an exacerbation related to medication noncompliance and was hospitalized for 5 days. The patient's thoughts are now more organized, and discharge is planned. The patient's family says, "It's too soon for discharge. We will just go through all this again." The nurse should: ask the case manager to arrange a transfer to a long-term care facility. notify hospital security to handle the disturbance and escort the family off the unit. explain that the patient will continue to improve if the medication is taken regularly. contact the health care provider to meet with the family and explain the discharge rationale.

The patient's spouse will mark dates for prescription refills on the family calendar. (The nurse should use the patient's support system to meet patient needs whenever possible. Delivery of medication by the nurse should be unnecessary for the nurse to do if patient or a significant other can be responsible. The patient may not need more intensive follow-up as long as medication is taken as prescribed.)

A patient diagnosed with schizophrenia has been stable for 2 months. Today the patient's spouse calls the nurse to report the patient has not taken prescribed medication and is having disorganized thinking. The patient forgot to refill the prescription. The nurse arranges a refill. Select the best outcome to add to the plan of care. The patient's spouse will mark dates for prescription refills on the family calendar. The nurse will obtain prescription refills every 90 days and deliver to the patient. The patient will call the nurse weekly to discuss medication-related issues. The patient will report to the clinic for medication follow-up every week.

Rearranging conflicting care appointments Arranging transportation to the outreach center Monitoring to ensure the patient's basic needs are met (The correct answers reflect the coordinating role of the community psychiatric nurse case manager. Negotiating the cost of therapy and accompanying the patient to church services are interventions the nurse would not be expected to undertake. The patient can walk to the church services; the nurse can provide encouragement.)

A patient diagnosed with schizophrenia lives in the community. On a home visit, the community psychiatric nurse case manager learns that the patient: · wants to attend an activity group at the mental health outreach center. · is worried about being able to pay for the therapy. · does not know how to get from home to the outreach center. · has an appointment to have blood work at the same time an activity group meets. · wants to attend services at a church that is a half-mile from the patient's home. Which tasks are part of the role of a community mental health nurse? Select all that apply. Rearranging conflicting care appointments Negotiating the cost of therapy for the patient Arranging transportation to the outreach center Accompanying the patient to church services weekly Monitoring to ensure the patient's basic needs are met

violation of the patient's right to be treated with dignity and respect. (Patients have the right to be treated with dignity and respect. The technician's comment disregards the seriousness of the patient's illness. The Code of Ethics for Nurses requires intervention. Patient emotional abuse has been demonstrated, not negligence. An interaction with the technician is not an aspect of social interaction. The technician did not disclose clinical information.)

A patient experiencing psychosis asks a psychiatric technician, "What's the matter with me?" The technician replies, "Nothing is wrong with you. You just need to use some self-control." The nurse who overheard the exchange should take action based on: the technician's unauthorized disclosure of confidential clinical information. violation of the patient's right to be treated with dignity and respect. the nurse's obligation to report caregiver negligence. the patient's right to social interaction.

Appraisal of reality Control over behavior Healthy self-concept (The aspects of mental health of greatest concern are the patient's appraisal of and control over behavior. The appraisal of reality is inaccurate. There are auditory hallucinations, delusions of persecution, and delusions of grandeur. In addition, the patient's control over behavior is tenuous, as evidenced by the plan to stab anyone who seems threatening. A healthy self-concept is lacking, as evidenced by the delusion of grandeur. Data are not present to suggest that the other aspects of mental health (happiness and effectiveness in work) are of immediate concern.)

A patient in the emergency department says, "Voices say someone is stalking me. They want to kill me because I developed a cure for cancer. I have a knife and will stab anyone who is a threat." Which aspects of the patient's mental health have the greatest and most immediate concern to the nurse? Select all that apply. Happiness Appraisal of reality Control over behavior Effectiveness in work Healthy self-concept

Assess the patient for a history of renal problems. (Elevated BUN (blood urea nitrogen) and creatinine suggest renal problems. Renal dysfunction can often imitate psychiatric disorders. The nurse should further assess the patient's history for renal problems and then share the findings with the health care provider.)

A patient presents to the emergency department with mixed psychiatric symptoms. The admission nurse suspects the symptoms may be the result of a medical problem. Lab results show elevated BUN (blood urea nitrogen) and creatinine. What is the nurse's next best action? Report the findings to the health care provider. Assess the patient for a history of renal problems. Assess the patient's family history for cardiac problems. Arrange for the patient's hospitalization on the psychiatric unit.

Arrange a temporary place for the patient to stay until new housing can be arranged. (The case manager should intervene by arranging temporary shelter for the patient until an apartment can be found. This activity is part of the coordination and delivery of services that falls under the case manager role. None of the other options is a viable alternative.)

A patient was hospitalized for 24 hours after a reaction to a psychotropic medication. While planning discharge, the case manager learned that the patient received a notice of eviction immediately prior to admission. Select the case manager's most appropriate action. Postpone the patient's discharge from the hospital. Contact the landlord who evicted the patient to further discuss the situation. Arrange a temporary place for the patient to stay until new housing can be arranged. Determine whether the adverse medication reaction was genuine because the patient had nowhere to live.

Patient pacing, shouting. Haloperidol 5 mg given PO at 1300. No effect by 1315. At 1415 patient yelled, "I'll punch anyone who gets near me," and struck another patient with fist. Physically placed in seclusion at 1420. Seclusion order obtained from MD at 1430. (Documentation must be specific and detail the key aspects of care. It should demonstrate implementation of the least restrictive alternative. Justification for why a patient was secluded should be recorded, along with interventions attempted in an effort to avoid seclusion. Documentation should include a description of behavior and verbalizations, interventions tried and their outcomes, and the name of the health care provider ordering the use of seclusion.)

A patient with psychosis became aggressive, struck another patient, and required seclusion. Select the best documentation. Patient struck another patient who attempted to leave day room to go to bathroom. Seclusion necessary at 1415. Plan: Maintain seclusion for 8 hours and keep these two patients away from each other for 24 hours. Seclusion ordered by physician at 1415 after command hallucinations told the patient to hit another patient. Careful monitoring of patient maintained during period of seclusion. Seclusion ordered by MD for aggressive behavior. Begun at 1415. Maintained for 2 hours without incident. Outcome: Patient calmer and apologized for outburst. Patient pacing, shouting. Haloperidol 5 mg given PO at 1300. No effect by 1315. At 1415 patient yelled, "I'll punch anyone who gets near me," and struck another patient with fist. Physically placed in seclusion at 1420. Seclusion order obtained from MD at 1430.

Fulfilling relationships (The information given centers on relationships with others that are described as intense and unstable. The relationships of mentally healthy individuals are stable, satisfying, and socially integrated. Data are not present to describe work effectiveness, communication skills, or activities.)

A patient's relationships are intense and unstable. The patient initially idealizes the significant other and then devalues him or her, resulting in frequent feelings of emptiness. This patient will benefit from interventions to develop which aspect of mental health? Effectiveness in work Productive activities Communication skills Fulfilling relationships

"Science has made significant improvements in drugs for mental illness, so now many persons may live in their communities." "There's now a better selection of less restrictive treatment options available in communities to care for people with mental illness." "Federal legislation and payment for treatment of mental illness has shifted the focus to community rather than institutional settings." (The community is a less restrictive alternative than hospitals for treatment of persons with mental illness. Funding for treatment of mental illness remains largely inadequate but now focuses on community rather than institutional care. Antipsychotic medications improve more symptoms of mental illness; hence, management of psychiatric disorders has improved. Rates of mental illness have increased, not decreased. Hospitals were closed because funding shifted to the community. Conditions in institutions have improved.)

A person in the community asks, "People with mental illnesses went to state hospitals in earlier times. Why has that changed?" Select the nurse's accurate responses. Select all that apply. "Science has made significant improvements in drugs for mental illness, so now many persons may live in their communities." "There's now a better selection of less restrictive treatment options available in communities to care for people with mental illness." "National rates of mental illness have declined significantly. There actually is not a need for state institutions anymore." "Most psychiatric institutions were closed because of serious violations of patients' rights and unsafe conditions." "Federal legislation and payment for treatment of mental illness has shifted the focus to community rather than institutional settings."

"Less restrictive settings are available now to care for individuals with mental illness." (The community is a less restrictive alternative than hospitals for treatment of persons with mental illness. The distracters are incorrect and part of the stigma of mental illness.)

A person in the community asks, "Why aren't people with mental illness kept in state institutions anymore?" Select the nurse's best response. "Less restrictive settings are available now to care for individuals with mental illness." "There are fewer persons with mental illness, so less hospital beds are needed." "Most people with mental illness are still in psychiatric institutions." "Psychiatric institutions violated patients' rights."

exploring alternative solutions with a patient, who then makes a choice. (Autonomy is the right to self-determination, that is, to make one's own decisions. By exploring alternatives with the patient, the patient is better equipped to make an informed, autonomous decision. The distracters demonstrate beneficence, fidelity, and justice.)

A psychiatric nurse best applies the ethical principle of autonomy by: exploring alternative solutions with a patient, who then makes a choice. suggesting that two patients who were fighting be restricted to the unit. intervening when a self-mutilating patient attempts to harm self. staying with a patient demonstrating a high level of anxiety.

have visitors confidentiality complain about inadequate care (Patients' rights should be discussed shortly after admission. Patients have rights related to receiving/refusing visitors, privacy, filing complaints about inadequate care, and accepting/refusing treatments (including medications). Patients do not have a right to a private room or selecting which nurse will provide care.)

A psychiatric nurse discusses rules of the therapeutic milieu and patients' rights with a newly admitted patient. Which rights should be included? The right to: (Select all that apply.) have visitors confidentiality a private room complain about inadequate care select the nurse assigned to their care

Prescribe psychotropic medication. (In most states, prescriptive privileges are granted to master's-prepared nurse practitioners who have taken special courses on prescribing medication. The nurse prepared at the basic level is permitted to perform mental health assessments, establish relationships, and provide individualized care planning.)

A staff nurse completes orientation to a psychiatric unit. This nurse may expect an advanced practice nurse to perform which additional intervention? Conduct mental health assessments. Establish therapeutic relationships. Prescribe psychotropic medication. Individualize nursing care plans.

Assess the patient's weight; determine foods and amounts eaten. (Assessment of biopsychosocial needs and general ability to live in the community is called for before any other action is taken. Both nutritional status and income adequacy are critical assessment parameters. A patient may be able to maintain adequate nutrition while eating only one meal a day. The rule is to assess before taking action. Hospitalization may not be necessary. Smoking cessation strategies can be pursued later.)

A suspicious, socially isolated patient lives alone, eats one meal a day at a local shelter, and spends the remaining daily food allowance on cigarettes. Select a community psychiatric nurse's best initial action. Explore ways to help the patient stop smoking. Report the situation to the manager of the shelter. Assess the patient's weight; determine foods and amounts eaten. Arrange hospitalization for the patient in order to formulate a new treatment plan.

I've been really anxious for at least 2 years now. My marriage is in trouble because I'm always so irritable. I've had a good physical and my health care provider says I'm in good health. Its hard falling asleep and even harder staying asleep; I'm restless all night. (The DSM-V criteria for generalized anxiety disorder include excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months; sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep) and irritability; the anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning; the disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition. Family history is not a recognized criterion for generalized anxiety disorder.)

According to the DSM-V, which statement made by an adult client supports the criteria for generalized anxiety disorder? Select all that apply. I've been really anxious for at least 2 years now. My anxiety has to be genetic; my mom was a terrible worrier too. My marriage is in trouble because I'm always so irritable. I've had a good physical and my health care provider says I'm in good health. Its hard falling asleep and even harder staying asleep; I'm restless all night.

Determining the goals and outcome criteria (The third step of the nursing process is planning and outcome identification. Outcomes cannot be determined until the nursing assessment is complete and nursing diagnoses have been formulated.)

After formulating the nursing diagnoses for a new patient, what is a nurse's next action? Designing interventions to include in the plan of care Determining the goals and outcome criteria Implementing the nursing plan of care Completing the spiritual assessment

refer the matter to the charge nurse to resolve. (Fraudulent documentation may be grounds for discipline by the state board of nursing. Referring the matter to the charge nurse will allow observance of hospital policy while ensuring that documentation occurs. Notifying the health care provider would be unnecessary when the charge nurse can resolve the problem. Nurses should not provide passwords to others.)

After leaving work, a nurse realizes documentation of administration of a PRN medication was omitted. This off-duty nurse phones the nurse on duty and says, "Please document administration of the medication for me. My password is alpha1." The nurse receiving the call should: fulfill the request promptly. document the caller's password. refer the matter to the charge nurse to resolve. report the request to the patient's health care provider.

"What you say about feelings is private, but some things, like suicidal thinking, must be reported to the treatment team." (Adolescents are very concerned with confidentiality. The patient has a right to know that most information will be held in confidence but that certain material must be reported or shared with the treatment team, such as threats of suicide, homicide, use of illegal drugs, or issues of abuse. The incorrect responses are not true, will not inspire the confidence of the patient, or are confrontational.)

An adolescent asks a nurse conducting an assessment interview, "Why should I tell you anything? You'll just tell my parents whatever you find out." Which response by the nurse is appropriate? "That isn't true. What you tell us is private and held in strict confidence. Your parents have no right to know." "Yes, your parents may find out what you say, but it is important that they know about your problems." "What you say about feelings is private, but some things, like suicidal thinking, must be reported to the treatment team." "It sounds as though you are not really ready to work on your problems and make changes."

"I am obligated to share that information with the treatment team." (Breach of nurse-patient confidentiality does not pose a legal dilemma for nurses in these circumstances because a team approach to delivery of psychiatric care presumes communication of patient information to other staff members to develop treatment plans and outcome criteria. The patient should also know that the team has a duty to warn the father of the risk for harm.)

An adolescent hospitalized after a violent physical outburst tells the nurse, "I'm going to kill my father, but you can't tell anyone." Select the nurse's best response. "You are right. Federal law requires me to keep clinical information private." "I am obligated to share that information with the treatment team." "Those kinds of thoughts will make your hospitalization longer." "You should share this thought with your psychiatrist."

"Thanks for the idea, but it's important to treat patients as individuals. Giving choices is one way we can respect patients' individuality." (The nurse's response to the aide should recognize patients' rights to be treated with dignity and respect as well as promote autonomy. This response also shows respect for the aide and fulfills the nurse's obligation to provide supervision of unlicensed personnel. The incorrect responses have flawed rationale or do not respect patients as individuals.)

An aide in a psychiatric hospital says to the nurse, "We don't have time every day to help each patient complete a menu selection. Let's tell dietary to prepare popular choices and send them to our unit." Select the nurse's best response. "Thanks for the suggestion, but that idea may not work because so many patients take MAOI (monoamine oxidase inhibitor) antidepressants." "Thanks for the idea, but it's important to treat patients as individuals. Giving choices is one way we can respect patients' individuality." "Thank you for the suggestion, but the patients' bill of rights requires us to allow patients to select their own diet." "Thank you. That is a very good idea. It will make meal preparation easier for the dietary department."

The experienced nurse may have lost sight of patients' individuality, which may compromise the integrity of practice. New research findings should be integrated continuously into a nurse's practice to provide the most effective care. (Evidence-based practice involves using research findings and standards of care to provide the most effective nursing care. Evidence is continuously emerging, so 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.)

An experienced nurse says to a new graduate, "When you've practiced as long as I have, you instantly know how to take care of psychotic patients." What information should the new graduate consider when analyzing this comment? Select all that apply. The experienced nurse may have lost sight of patients' individuality, which may compromise the integrity of practice. New research findings should be integrated continuously into a nurse's practice to provide the most effective care. Experience provides mental health nurses with the essential tools and skills needed for effective professional practice. Experienced psychiatric nurses have learned the best ways to care for mentally ill patients through trial and error. An intuitive sense of patients' needs guides effective psychiatric nurses.

coping strategies (When discussing coping strategies, the nurse might ask what the patient does when upset, what usually relieves stress, and to whom the patient goes to talk about problems. The question regarding whether the patient's faith helps deal with stress fits well here. It would be out of place if introduced during exploration of the other topics.)

At what point in an assessment interview would a nurse ask, "How does your faith help you in stressful situations?" During the assessment of: childhood growth and development educational background substance use and abuse coping strategies

assess the patient based on data collected from all sources. (Assessment should include data obtained from both the primary and reliable secondary sources. The nurse, bearing in mind the possible effects of counter-transference, should evaluate biased assessments by others as objectively as possible.)

Before assessing a new patient, a nurse is told by another health care worker, "I know that patient. No matter how hard we work, there isn't much improvement by the time of discharge." The nurse's responsibility is to: document the other worker's assessment of the patient. assess the patient based on data collected from all sources. validate the worker's impression by contacting the patient's significant other. discuss the worker's impression with the patient during the assessment interview.

nursing actions (Analogies show parallel relationships. NANDA, the North American Nursing Diagnosis Association, identifies diagnostic statements regarding human responses to actual or potential health problems. These statements represent clinical judgments. NIC (Nursing Interventions Classification) identifies actions provided by nurses that enhance patient outcomes. Nursing care activities may be direct or indirect.)

Complete this analogy. NANDA: clinical judgment NIC: _________________ patient outcomes diagnosis nursing actions symptoms

a signed consent by the patient for release of information stating specific information to be released. (Nurses have an obligation to protect patients' privacy and confidentiality. Clinical information should not be released without the patient's signed consent for the release.)

In order to release information to another health care facility or third party regarding a patient diagnosed with a mental illness, the nurse must obtain: a signed consent by the patient for release of information stating specific information to be released. a verbal consent for information release from the patient and the patient's guardian or next of kin. permission from members of the health care team who participate in treatment planning. approval from the attending psychiatrist to authorize the release of information.

describes hearing God's voice speaking. (The question asks about risk. Hearing voices is generally associated with mental illness, but in charismatic religious groups, hearing the voice of God or a prophet is a desirable event. Cultural norms vary, which makes it more difficult to make an accurate diagnosis. The individuals described in the other options are less likely to be labeled mentally ill.)

In the majority culture of the United States, which individual has the greatest risk to be labeled mentally ill? One who: describes hearing God's voice speaking. is usually pessimistic but strives to meet personal goals. is wealthy and gives away $20 bills to needy individuals. always has an optimistic viewpoint about life and having own needs met.

A peer tries to provide patient care in an alcohol-impaired state. A team member violates relationship boundaries with a patient. (Both keyed answers are events that jeopardize patient safety. The distracters describe situations that may be resolved with education or that are acceptable practices.)

In which situations would a nurse have the duty to intervene and report? Select all that apply. A peer has difficulty writing measurable outcomes. A health care provider gives a telephone order for medication. A peer tries to provide patient care in an alcohol-impaired state. A team member violates relationship boundaries with a patient. A patient refuses medication prescribed by a licensed health care provider.

present a clear danger to self or others. (Hospitalization is justified when the patient is a danger to self or others, has dangerously decompensated, or needs intensive medical treatment. The distracters do not necessarily describe patients who require inpatient treatment.)

Inpatient hospitalization for persons with mental illness is generally reserved for patients who: present a clear danger to self or others. are noncompliant with medication at home. have limited support systems in the community. develop new symptoms during the course of an illness.

"By law, treatment must be provided. Hospitalization without treatment violates patients' rights." (The right to medical and psychiatric treatment was conferred on all patients hospitalized in public mental hospitals with the enactment of the federal Hospitalization of Mentally Ill Act in 1964.)

Insurance will not pay for continued private hospitalization of a mentally ill patient. The family considers transferring the patient to a public hospital but expresses concern that the patient will not get any treatment if transferred. Select the nurse's most helpful reply. "By law, treatment must be provided. Hospitalization without treatment violates patients' rights." "All patients in public hospitals have the right to choose both a primary therapist and a primary nurse." "You have a justifiable concern because the right to treatment extends only to provision of food, shelter, and safety." "Much will depend on other patients, because the right to treatment for a psychotic patient takes precedence over the right to treatment of a patient who is stable."

carrying out interventions and coordinating care. (Nursing behaviors relating to implementation include using available resources, performing interventions, finding alternatives when necessary, and coordinating care with other team members.)

Nursing behaviors associated with the implementation phase of nursing process are concerned with: participating in mutual identification of patient outcomes. gathering accurate and sufficient patient-centered data. comparing patient responses and expected outcomes. carrying out interventions and coordinating care.

"Losing my job was hard but my skills will help me get another one." (Resilience is a characteristic that helps individuals cope with loss and trauma that may occur in life. Dependence is described as relying on others for decision making and care. Pessimism is a life philosophy that things are more likely to go wrong than right. Altruism is described as putting others before yourself.)

Resilience is characteristic of mental health that allows people to adapt to tragedies, trauma, and loss. Which client behavior demonstrates this characteristic? "My mother made decisions about my husband's funeral when I just couldn't do that." "Losing my job was hard but my skills will help me get another one." "In spite of all the treatment, I know I'll never be really healthy." "My kids, happiness is worth any sacrifice I have to make."

select and participate in one group activity per day. (The outcome describes social involvement on the part of the patient. Neither cooperation nor independence has been an issue. The patient has already expressed a desire to interact with others. Outcomes must be measurable. Two of the distracters are not measurable.)

Select the best outcome for a patient with the nursing diagnosis: Impaired social interaction related to sociocultural dissonance as evidenced by stating, "Although I'd like to, I don't join in because I don't speak the language very well." Patient will: show improved use of language. demonstrate improved social skills. become more independent in decision making. select and participate in one group activity per day.

Obtain the patient's permission for the exchange of information. (The case manager must respect the patient's right to privacy, which extends to discussions with family. Talking to family members is part of the case manager's role. Actions identified in the distracters occur after the patient has given permission.)

The case manager plans to discuss the treatment plan with a patient's family. Select the case manager's first action. Determine an appropriate location for the conference. Support the discussion with examples of the patient's behavior. Obtain the patient's permission for the exchange of information. Determine which family members should participate in the conference.

"The DSM-5 diagnosis guides medical treatment, whereas the nursing diagnosis offers a framework for identifying interventions for issues a patient is experiencing." (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 tools consider culture. The DSM-5 is multiaxial. Nursing diagnoses also consider potential problems.)

Select the best response for the nurse who receives a question from another health professional seeking to understand the difference between a Diagnostic and Statistical Manual of Mental Disorders (DSM-5) diagnosis and a nursing diagnosis. "There is no functional difference between the two. Both identify human disorders." "The DSM-5 diagnosis disregards culture, whereas the nursing diagnosis takes culture into account. The DSM-5 diagnosis describes causes of disorders whereas a nursing diagnosis does not explore etiology." "The DSM-5 diagnosis guides medical treatment, whereas the nursing diagnosis offers a framework for identifying interventions for issues a patient is experiencing."

A nurse gives a PRN dose of an antipsychotic drug to an agitated patient because the unit is short-staffed. (A tort is a civil wrong against a person that violates his or her rights. Giving unnecessary medication for the convenience of staff controls behavior in a manner similar to secluding a patient; thus, false imprisonment is a possible charge. The other options do not exemplify torts.)

Select the example of a tort. The plan of care for a patient is not completed within 24 hours of the patient's admission. A nurse gives a PRN dose of an antipsychotic drug to an agitated patient because the unit is short-staffed. An advanced practice nurse recommends hospitalization for a patient who is dangerous to self and others. A patient's admission status changed from involuntary to voluntary after the patient's hallucinations subside.

Helping school-age children identify and describe normal emotions (Primary preventions are directed at healthy populations with a goal of preventing health problems from occurring. Helping school-age children describe normal emotions people experience promotes coping, a skill that is needed throughout life. Assisting a person with serious and persistent mental illness to fill a pill-minder is an example of tertiary prevention. Medicating an acutely ill patient who assaulted a staff person is a secondary prevention. Leading a psychoeducational group in a community care home is an example of tertiary prevention.)

Select the example of primary prevention. Assisting a person diagnosed with a serious mental illness to fill a pill-minder Helping school-age children identify and describe normal emotions Leading a psychoeducational group in a community care home Medicating an acutely ill patient who assaulted a staff person

Helping a person diagnosed with a serious mental illness learn to manage money (Tertiary prevention involves services that address residual impairments, with a goal of improved independent functioning. Restraint is a secondary prevention. Genetic counseling and teaching school-age children about substance abuse and dependence are examples of primary prevention.)

Select the example of tertiary prevention. Helping a person diagnosed with a serious mental illness learn to manage money Restraining an agitated patient who has become aggressive and assaultive Teaching school-age children about the dangers of drugs and alcohol Genetic counseling with a young couple expecting their first child

Social isolation (Nursing diagnoses are selected based on the etiological factors and assessment findings, or evidence. In this instance, the evidence shows social isolation that is caused by shyness and poorly developed social skills.)

Select the most appropriate label to complete this nursing diagnosis: ___________ related to feelings of shyness and poorly developed social skills as evidenced by watching television alone at home every evening. Deficient knowledge Social isolation Ineffective coping Powerlessness

mental disorders people have. (The DSM-5 classifies disorders people have rather than people themselves. The terminology of the tool reflects this distinction by referring to individuals with a disorder rather than as a "schizophrenic" or "alcoholic," for example. Deviant behavior is not generally considered a mental disorder. Present disability or distress is only one aspect of the diagnosis.)

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) classifies: deviant behaviors. people with mental disorders. present disability or distress. mental disorders people have.

reports a consistently sad, discouraged, and hopeless mood. (The correct response describes a mood alteration, which reflects mental illness. The distracters describe behaviors that are mentally healthy or within the usual scope of human experience.)

Which assessment finding most clearly indicates that a patient may be experiencing a mental illness? The patient: reports occasional sleeplessness and anxiety. reports a consistently sad, discouraged, and hopeless mood. is able to describe the difference between "as if" and "for real." perceives difficulty making a decision about whether to change jobs.

Examine interventions for possible revision of the target date. (Sleeping a total of 5 hours at night remains a reasonable outcome. Extending the period for attaining the outcome may be appropriate. Examining interventions might result in planning an activity during the afternoon rather than permitting a nap. Continuing the current plan without changes is inappropriate. Removing this nursing diagnosis from the plan of care would be correct when the outcome was met and the problem resolved. Writing a new nursing diagnosis is inappropriate because no other nursing diagnosis relates to the problem.)

The desired outcome for a patient experiencing insomnia is, "Patient will sleep for a minimum of 5 hours nightly within 7 days." At the end of 7 days, review of sleep data shows the patient sleeps an average of 4 hours nightly and takes a 2-hour afternoon nap. What is the nurse's next action? Continue the current plan without changes. Remove this nursing diagnosis from the plan of care. Write a new nursing diagnosis that better reflects the problem. Examine interventions for possible revision of the target date.

Clear risk of danger to self or others Detoxification from long-term heavy alcohol consumption needed Failure of community-based treatment, demonstrating need for intensive treatment (Medication doses can be adjusted on an outpatient basis. The goal of caregiver respite can be accomplished without hospitalizing the patient. The other options are acceptable, evidence-based criteria for admission of a patient to an inpatient service.)

The health care team at an inpatient psychiatric facility drafts these criteria for admission. Which criteria should be included in the final version of the admission policy? Select all that apply. Clear risk of danger to self or others Adjustment needed for doses of psychotropic medication Detoxification from long-term heavy alcohol consumption needed Respite for caregivers of persons with serious and persistent mental illness Failure of community-based treatment, demonstrating need for intensive treatment

providing services for mentally ill individuals who require intensive treatment to continue to live in the community. (An assertive community treatment (ACT) program provides intensive community services to persons with serious, persistent mental illness who live in the community but require aggressive services to prevent repeated hospitalizations.)

The nurse assigned to assertive community treatment (ACT) should explain the program's treatment goal as: assisting patients to maintain abstinence from alcohol and other substances of abuse. providing structure and a therapeutic milieu for mentally ill patients whose symptoms require stabilization. maintaining medications and stable psychiatric status for incarcerated inmates who have a history of mental illness. providing services for mentally ill individuals who require intensive treatment to continue to live in the community.

Request that the client accompany the nurse to the client's room (Least restrictive alternative doctrine requires using the least drastic means of achieving a specific goal. By first attempting to remove the client to a safer location, the nurse is respecting the client's right to treatment that is less restrictive than the other options.)

The nurse is caring for an admitted client with a history of becoming aggressive when angry and has caused physical injury to another client and two staff members. When this client begins to demonstrate signs of anger while in the day room what intervention should the nurse implement to address the safety of the milieu? Alert security to come to the unit for a show of strength Request that the client accompany the nurse to the client's room Inform the client that restraints will be used if the behavior continues Prepare to administer a prn chemical restraint to the client

Acknowledge that the topic of the rape is upsetting and reassure the client that it can be discussed at another time when she feels more comfortable. (The best atmosphere for conducting an assessment is one with minimal anxiety on the patient's part. If a topic causes distress, it is best to abandon the topic at that time. It is important not to pry or push for information that is difficult for the patient to discuss. The use of silence continues to expect the patient to discuss the topic now. Reassurance of confidentiality continues to expect the patient to discuss the topic now.)

The nurse is conducting an admission interview with a client who was raped 2 weeks ago. When asked about the rape, the client becomes very anxious and upset and begins to sob. What should be the nurse's response to the client's reaction? Push gently for more information about the rape because the information needs to be documented. Acknowledge that the topic of the rape is upsetting and reassure the client that it can be discussed at another time when she feels more comfortable. Use silence as a therapeutic tool and wait until the client is done sobbing to continue discussing the rape. Reassure the client that anything she says to you will remain confidential.

Meets standards (This narrative note describes patient appearance, behavior, and conversation. It mentions that less-restrictive measures were attempted before administering medication and documents patient response to medication. This note would probably meet standards. A complete nursing assessment would be in order as soon as the patient is able to participate. Subjective material is absent from the note. Abbreviations are acceptable.)

The nurse records this entry in a patient's progress notes: Patient escorted to unit by ER nurse at 2130. Patient's clothing was dirty. In interview room, patient sat with hands over face, sobbing softly. Did not acknowledge nurse or reply to questions. After several minutes, abruptly arose, ran to window, and pounded. Shouted repeatedly, "Let me out of here." Verbal intervention unsuccessful. Order for stat dose 2 mg haloperidol PO obtained; medication administered at 2150. By 2215, patient stopped shouting and returned to sit wordlessly in chair. Patient placed on one-to-one observation. How should this documentation be evaluated? Uses unapproved abbreviations Contains subjective material Too brief to be of value Excessively wordy Meets standards

states, "I'm not sure I can avoid using alcohol when my spouse goes to work every morning." (This patient could profit from the structure and supervision provided by spending the day at the partial hospitalization program. During the evening, at night, and on weekends, the spouse could assume responsibility for supervision. A suicidal patient needs inpatient hospitalization. The other patients can be served in the community or with individual visits.)

The nurse should refer which of the following patients to a partial hospitalization program? A patient who: has a therapeutic lithium level and reports regularly for blood tests and clinic follow-up. needs psychoeducation for relaxation therapy related to agoraphobia and panic episodes. spent yesterday in a supervised crisis care center and continues to have active suicidal ideation. states, "I'm not sure I can avoid using alcohol when my spouse goes to work every morning."

who is a new parent and hears voices saying, "Smother your baby." (Admission to the hospital would be justified by the risk of patient danger to self or others. The other patients have issues that can be handled with less restrictive alternatives than hospitalization.)

The patients below were evaluated in the emergency department. The psychiatric unit has one bed available. Which patient should be admitted? The patient: feeling anxiety and a sad mood after separation from a spouse of 10 years. who self-inflicted a superficial cut on the forearm after a family argument. experiencing dry mouth and tremor related to taking haloperidol (Haldol). who is a new parent and hears voices saying, "Smother your baby."

A client diagnosed with schizophrenia has avoided being rehospitalization for 16 months. (A primary goal of ACT is working intensely with the patient in the community to prevent rehospitalization. The other options are not goals of ACT.)

The primary goal and benefit of assertive community treatment (ACT) is demonstrated by which situation? A client and family members attend counseling sessions together at a neighborhood clinic Implementation of a more flexible work schedule for staff Improved reimbursement for services provided in the community A client diagnosed with schizophrenia has avoided being rehospitalization for 16 months.

"Research shows that this condition more likely has a biological basis." (Many of the most prevalent and disabling mental disorders have strong biological influences. Genetics are only one part of biological factors. Empathy does not address increasing the spouse's level of knowledge about the cause of the disorder. The other distracters are not established facts.)

The spouse of a patient diagnosed with schizophrenia says, "I don't understand how events from childhood have anything to do with this disabling illness." Which response by the nurse will best help the spouse understand the cause of this disorder? "Psychological stress is the basis of most mental disorders." "This illness results from developmental factors rather than stress." "Research shows that this condition more likely has a biological basis." "It must be frustrating for you that your spouse is sick so much of the time."

violates the civil rights of both patients. (Patients have a right to treatment in the least restrictive setting. Safety is important, but less restrictive measures should be tried first. Unnecessary seclusion may result in a charge of false imprisonment. Seclusion violates the patient's autonomy. The principle by which the nurse is motivated is beneficence, not justice. The tort represented is false imprisonment.)

Two hospitalized patients fight whenever they are together. During a team meeting, a nurse asserts that safety is of paramount importance, so treatment plans should call for both patients to be secluded to keep them from injuring each other. This assertion: reinforces the autonomy of the two patients. violates the civil rights of both patients. represents the intentional tort of battery. correctly places emphasis on safety.

milieu management. (Milieu management provides a therapeutic environment in which the patient can feel comfortable and safe while engaging in activities that meet the patient's physical and mental health needs. Counseling refers to activities designed to promote problem solving and enhanced coping and includes interviewing, crisis intervention, stress management, and conflict resolution. Health teaching involves identifying health education needs and giving information about these needs. Psychobiological interventions involve medication administration and monitoring response to medications.)

When a new patient is hospitalized, a nurse takes the patient on a tour, explains rules of the unit, and discusses the daily schedule. The nurse is engaged in: counseling. milieu management. health teaching. psychobiological intervention.

threatens to harm self and others. (Involuntary hospitalization protects patients who are dangerous to themselves or others and cannot care for their own basic needs. Involuntary commitment also protects other individuals in society. The behaviors described in the other options are not sufficient to require involuntary hospitalization.)

Which patient meets criteria for involuntary hospitalization for psychiatric treatment? The patient who: is noncompliant with the treatment regimen. fraudulently files for bankruptcy. sold and distributed illegal drugs. threatens to harm self and others.

"Are you having difficulty hearing when I speak?" (The patient's behaviors may indicate difficulty hearing. Identifying any physical need the patient may have at the onset of the interview and making accommodations are important considerations. By asking if the patient is annoyed, the nurse is jumping to conclusions. Asking how to make the interview easier for the patient may not elicit a concrete answer. Asking about distractions is a way of asking about auditory hallucinations, which is not appropriate because the nurse has observed that the patient seems to be listening intently.)

When a nurse assesses an older adult patient, answers seem vague or unrelated to the questions. The patient also leans forward and frowns, listening intently to the nurse. An appropriate question for the nurse to ask would be: "Are you having difficulty hearing when I speak?" "How can I make this assessment interview easier for you?" "I notice you are frowning. Are you feeling annoyed with me?" "You're having trouble focusing on what I'm saying. What is distracting you?"

"Psychiatric nurses use complex communication skills as well as critical thinking to solve multidimensional problems. I am challenged by those situations." (The practice of psychiatric nursing requires a different set of skills than medical-surgical nursing, though there is substantial overlap. Psychiatric nurses must be able to help patients with medical as well as mental health problems, reflecting the holistic perspective these nurses must have. Nurse-patient ratios and workloads in psychiatric settings have increased, just like other specialties. Psychiatric nursing involves clinical practice, not just documentation. Psychosocial pain and suffering are as real as physical pain and suffering.)

When a nursing student expresses concerns about how mental health nurses "lose all their nursing skills," the best response by the mental health nurse is: "Psychiatric nurses practice in safer environments than other specialties. Nurse-to-patient ratios must be better because of the nature of the patients' problems." "Psychiatric nurses use complex communication skills as well as critical thinking to solve multidimensional problems. I am challenged by those situations." "That's a misconception. Psychiatric nurses frequently use high technology monitoring equipment and manage complex intravenous therapies." "Psychiatric nurses do not have to deal with as much pain and suffering as medical-surgical nurses do. That appeals to me."

The client may cause imminent harm to himself or others. (A patient may be medicated against his or her will without a court hearing in an emergency if the patient poses a danger to himself or herself or to others. The other options are not legally valid reasons to give medication against a patient's will.)

When considering client rights, which client can be legally medicated against his or her wishes? The client has accepted the medication in the past. The client may cause imminent harm to himself or others. The client's primary provider orders the medication. The client's mental illness may relate to cognitive impairment.

Working, living, and participating in the community (Recovery is described as the ability of the individual to work, live, and participate in the community. Never having to visit a mental health provider is unrealistic. While important to recovery understanding of the disorder is not a demonstration of recovery. Remission is a period of time when signs and symptoms are being managed.)

When considering mental illness, recovery is best described to a client by which statement? Working, living, and participating in the community Never having to visit a mental health provider again Being able to understand the nature of the diagnosed illness A period of time when signs and symptoms are being managed

"That judge is going to really regret putting me in here." (The duty to protect is an ethical and legal obligation of health care workers to protect patients from physically harming themselves or others. This duty arises when the patient presents a serious danger to another. While all that statements infer the client's intention to harm, only the correct option is credible since it actually identifies the possible victim.)

When considering the duty to warn and protect third parties, which client statement should the nurse report to the treatment team members? "That judge is going to really regret putting me in here." "All politicians need to be shot." "When I'm elected president, I'll make them all pay for doubting me." "The man out there who is laughing at me is going to die."

Releasing information to the patient's employer without consent (Release of information without patient authorization violates the patient's right to privacy. The other options are acceptable nursing practices.)

Which action by a nurse constitutes a breach of a patient's right to privacy? Documenting the patient's daily behavior during hospitalization Releasing information to the patient's employer without consent Discussing the patient's history with other staff during care planning Asking family to share information about a patient's pre-hospitalization behavior

opens and reads a letter a patient left at the nurse's station to be mailed. restrains a patient who uses profanity when speaking to the nurse. (The patient has the right to send and receive mail without interference. Restraint is not indicated because a patient uses profanity; there are other less restrictive ways to deal with this behavior. The other options are examples of good nursing judgment and do not violate the patient's civil rights.)

Which actions violate the civil rights of a psychiatric patient? The nurse: (select all that apply) performs mouth checks after overhearing a patient say, "I've been spitting out my medication." begins suicide precautions before a patient is assessed by the health care provider. opens and reads a letter a patient left at the nurse's station to be mailed. places a patient's expensive watch in the hospital business office safe. restrains a patient who uses profanity when speaking to the nurse.

was absent from two of six planned Alcoholics Anonymous meetings in the past 2 weeks. (Patients who use alcohol or illegal substances often become medication noncompliant. Medication noncompliance, along with the disorganizing influence of substances on cellular brain function, promotes relapse. The distracters do not suggest problems.)

Which assessment finding for a patient in the community deserves priority intervention by the psychiatric nurse? The patient: receives Social Security disability income plus a small check from a trust fund every month. was absent from two of six planned Alcoholics Anonymous meetings in the past 2 weeks. lives in an apartment with two patients who attend partial hospitalization programs. has a sibling who was recently diagnosed with a mental illness.

spends time listening to me talk about my problems. That helps me feel like I am not alone." (Caring evidences empathetic 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 distracters give examples of statements that demonstrate advocacy or giving advice.)

Which comment best indicates that a patient perceived the nurse was caring? "My nurse: always asks me which type of juice I want to help me swallow my medication." explained my treatment plan to me and asked for my ideas about how to make it better." spends time listening to me talk about my problems. That helps me feel like I am not alone." told me that if I take all the medicines the doctor prescribes, then I will get discharged sooner."

Care is centered on the patient. (The key areas of care promoted by QSEN are patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics.)

Which component of treatment of mental illness is specifically recognized by Quality and Safety Education for Nurses (QSEN)? All genomes are unique. Care is centered on the patient. Healthy development is vital to mental health. Recovery occurs on a continuum from illness to health.

Running amok (Culture-bound syndromes occur in specific sociocultural contexts and are easily recognized by people in those cultures. A syndrome recognized in parts of Southeast Asia is running amok, in which a person (usually a male) runs around engaging in furious, almost indiscriminate violent behavior.)

Which disorder is a culture-bound syndrome? Epilepsy Running amok Schizophrenia Major depression

Wore four layers of clothing. States, "I need protection from evil bacteria trying to pierce my skin." (The documentation states specific observations of the patient's appearance and the exact statements made. The other options are vague or subjective statements and can be interpreted in different ways.)

Which documentation of a patient's behavior best demonstrates a nurse's observations? Isolates self from others. Frequently fell asleep during group. Vital signs stable. Calmer; more cooperative. Participated actively in group. No evidence of psychotic thinking. Appeared to hallucinate. Frequently increased volume on television, causing conflict with others. Wore four layers of clothing. States, "I need protection from evil bacteria trying to pierce my skin."

"S: States, 'I feel like I'm ready to blow up.' O: Pacing hall, mumbling to self. A: Auditory hallucinations. P: Offer haloperidol (Haldol) 2 mg po. I: Haloperidol (Haldol) 2 mg po given at 0900. E: Returned to lounge at 0930 and quietly watched TV." (Problem-oriented documentation uses the first letter of key words to organize data: S for subjective data, O for objective data, A for assessment, P for plan, I for intervention, and E for evaluation. The distracters offer examples of PIE charting, focus documentation, and narrative documentation.)

Which entry in the medical record best meets the requirement for problem-oriented charting? "A: Pacing and muttering to self. P: Sensory perceptual alteration related to internal auditory stimulation. I: Given fluphenazine HCL (Prolixin) 2.5 mg po at 0900 and went to room to lie down. E: Calmer by 0930. Returned to lounge to watch TV." "S: States, 'I feel like I'm ready to blow up.' O: Pacing hall, mumbling to self. A: Auditory hallucinations. P: Offer haloperidol (Haldol) 2 mg po. I: Haloperidol (Haldol) 2 mg po given at 0900. E: Returned to lounge at 0930 and quietly watched TV." "Agitated behavior. D: Patient muttering to self as though answering an unseen person. A: Given haloperidol (Haldol) 2 mg po and went to room to lie down. E: Patient calmer. Returned to lounge to watch TV." "Pacing hall and muttering to self as though answering an unseen person. haloperidol (Haldol) 2 mg po administered at 0900 with calming effect in 30 minutes. Stated, 'I'm no longer bothered by the voices.'"

sees self as capable of achieving ideals and meeting demands. (The correct response describes an adaptive, healthy behavior. The distracters describe maladaptive behaviors.)

Which finding best indicates that the goal "Demonstrate mentally healthy behavior" was achieved? A patient: sees self as capable of achieving ideals and meeting demands. behaves without considering the consequences of personal actions. aggressively meets own needs without considering the rights of others. seeks help from others when assuming responsibility for major areas of own life.

Says, "I have some weaknesses, but I feel I'm important to my family and friends." Considers past experiences when deciding about the future. Experiences feelings of conflict related to changing jobs. (Mental health is a state of well-being in which each individual is able to realize his or her own potential, cope with the normal stresses of life, work productively, and make a contribution to the community. Mental health provides people with the capacity for rational thinking, communication skills, learning, emotional growth, resilience, and self-esteem.)

Which findings are signs of a person who is mentally healthy? Select all that apply. Says, "I have some weaknesses, but I feel I'm important to my family and friends." Adheres strictly to religious beliefs of parents and family of origin. Spends all holidays alone watching old movies on television. Considers past experiences when deciding about the future. Experiences feelings of conflict related to changing jobs.

A 37-year-old patient scheduled for discharge in 24 hours wishes to be discharged immediately (AMA discharges are sometimes used when the patient does not agree with the provider, as long as the patient is not a danger to himself or herself or to others. The patient with dementia and the patient who is actively suicidal would pose a safety risk and would be not allowed to be discharged AMA. A patient who wishes to stay in the hospital can make that decision; a family member's opinion doesn't impact an AMA discharge.)

Which hospitalized patient should the nurse identify as being a candidate for the appropriate use of a release from hospitalization known as against medical advice (AMA)? A 37-year-old patient scheduled for discharge in 24 hours wishes to be discharged immediately A 75-year-old patient with dementia who demands to be allowed to go back to his own home A 21-year-old actively suicidal patient who wants to be discharged to home and do outpatient counseling A 32-year-old female patient who wishes to stay in the hospital but whose husband demands that she be discharged into his care

who takes 38 acetaminophen tablets after the person's stock portfolio becomes worthless (Involuntary hospitalization protects patients who are dangerous to themselves or others and cannot care for their own basic needs. Involuntary hospitalization also protects other individuals in society. An overdose of acetaminophen indicates dangerousness to self. The behaviors described in the other options are not sufficient to require involuntary hospitalization.)

Which individual diagnosed with a mental illness may need involuntary hospitalization? An individual: who has a panic attack after her child gets lost in a shopping mall with visions of demons emerging from cemetery plots throughout the community who takes 38 acetaminophen tablets after the person's stock portfolio becomes worthless diagnosed with major depression who stops taking prescribed antidepressant medication

throws a heavy plate at a waiter at the direction of command hallucinations. (Throwing a heavy plate is likely to harm the waiter and is evidence of dangerousness to others. This behavior meets the criteria for emergency or involuntary hospitalization for mental illness. The behaviors in the other options evidence mental illness but not dangerousness. See related audience response question.)

Which individual with mental illness may need emergency or involuntary admission? The individual who: resumes using heroin while still taking naltrexone (ReVia). reports hearing angels playing harps during thunderstorms. does not keep an outpatient appointment with the mental health nurse. throws a heavy plate at a waiter at the direction of command hallucinations.

Secondary (An emergency department nurse would generally see patients in crisis or with acute illness, so secondary prevention is used. Primary prevention involves preventing a health problem from developing, and tertiary prevention applies to rehabilitative activities.)

Which level of prevention activities would a nurse in an emergency department employ most often? Primary Secondary Tertiary

Psychotherapy (Psychotherapy is part of the scope of practice of an advanced practice nurse. The distracters are within a staff nurse's scope of practice.)

Which nursing intervention below is part of the scope of an advanced practice psychiatric/mental health nurse only? Coordination of care Milieu therapy Health teaching Psychotherapy

A patient has been irritating and attention-seeking much of the day. A nurse escorts the patient down the hall saying, "Stay in your room, or you'll be put in seclusion." (False imprisonment involves holding a competent person against his or her will. Actual force is not a requirement of false imprisonment. The individual needs only to be placed in fear of imprisonment by someone who has the ability to carry out the threat. If a patient is not competent (confused), then the nurse should act with beneficence. Patients admitted involuntarily should not be allowed to leave without permission of the treatment team.)

Which nursing intervention demonstrates false imprisonment? A confused and combative patient says, "I'm getting out of here, and no one can stop me." The nurse restrains this patient without a health care provider's order and then promptly obtains an order. A patient has been irritating and attention-seeking much of the day. A nurse escorts the patient down the hall saying, "Stay in your room, or you'll be put in seclusion." An involuntarily hospitalized patient with suicidal ideation runs out of the psychiatric unit. The nurse rushes after the patient and convinces the patient to return to the unit. An involuntarily hospitalized patient with homicidal ideation attempts to leave the facility. A nurse calls the security team and uses established protocols to prevent the patient from leaving.

A 26-year-old kindergarten teacher who is not in touch with reality and was found wandering in and out of traffic on a busy road (Inpatient involuntary admission is reserved for patients who are at risk for self-harm or who cannot adequately protect themselves from harm because of their illness (e.g., a psychotic patient). The other options can all be managed at this point in the community setting and don't meet criteria (risk of harm to self and/or others) for admission.)

Which of the following patients meets the criteria for an involuntary admission to a psychiatric mental health unit? A 23-year-old college student who has developed symptoms of anxiety and is missing classes and work A 30-year-old accountant who has developed symptoms of depression A 26-year-old kindergarten teacher who is not in touch with reality and was found wandering in and out of traffic on a busy road A 76-year-old retired librarian who is experiencing memory loss and some confusion at times

A patient being discharged from an inpatient alcohol rehabilitation unit (PHP is for patients who may need a "step-down" environment from inpatient status or for those who are being diverted from hospitalization with intensive, short-term care from which they return home each day. This patient would be a good candidate after completing alcohol rehab; PHP could possibly help prevent relapse in the early stages after rehab. This patient can be managed with regular outpatient therapy and does not need intensive short-term therapy such as PHP. Someone who is suicidal would require inpatient hospitalization for safety as would someone who is decompensated and not caring for herself. A patient exhibiting mild depression would be managed with outpatient therapy and would not need intensive short-term therapy such as PHP.)

Which of the following patients would be appropriate to refer to a partial hospitalization program (PHP)? A depressed patient with a suicidal plan A patient being discharged from an inpatient alcohol rehabilitation unit A client who has stopped taking his or her antipsychotic medication and is neglecting his or her basic needs Jeff, who has mild depression symptoms and is starting outpatient therapy

Break-away closet bars to prevent hanging (Hangings are the most common method of inpatient suicide. The other options are important safety measures but don't directly address the suicide method of hanging.)

Which of the following structural safety precautions is most important when attempting to prevent a common type of inpatient suicide? Break-away closet bars to prevent hanging Bedroom and dining areas with locked windows to prevent jumping Double-locked doors to prevent escaping from the unit Platform beds to prevent crush injuries

schizophrenia and four hospitalizations in the past year. (Assertive community treatment (ACT) provides intensive case management for persons with serious persistent mental illness who live in the community. Repeated hospitalization is a frequent reason for this intervention. The distracters identify mental health problems of a more episodic nature.)

Which patient would be most appropriate to refer for assertive community treatment (ACT)? A patient diagnosed with: a phobic fear of crowded places. a single episode of major depression. a catastrophic reaction to a tornado in the community. schizophrenia and four hospitalizations in the past year.

Resolve the crisis with the least restrictive intervention possible. (The rule of using the least restrictive treatment or intervention possible to achieve the desired outcome is the patient's legal right. Planned interventions are nearly always preferable. Intervention may be necessary when the patient threatens harm to self.)

Which principle has the highest priority when addressing a behavioral crisis in an inpatient setting? Resolve the crisis with the least restrictive intervention possible. Swift intervention is justified to maintain the integrity of a therapeutic milieu. Rights of an individual patient are superseded by the rights of the majority of patients. Patients should have opportunities to regain control without intervention if the safety of others is not compromised.

"We will be able to form a relationship together where we can discuss the current problems and come up with goals and a plan for treatment." (Some of the purposes of the assessment interview are to establish rapport, learn more about the presenting issues, and form mutual goals and a plan for treatment. The other options do not appropriately explain the assessment purpose.)

Which response should the nurse provide a client who asks, "Why you need to conduct an assessment interview"? "I need to find out more about you and the way you think in order to best help you." "The assessment interview lets you have an opportunity to express your feelings." "You are able to tell me in detail about your past so that we can determine why you are experiencing mental health alterations." "We will be able to form a relationship together where we can discuss the current problems and come up with goals and a plan for treatment."

waving fists, cursing, and shouting threats at a nurse. (This behavior constitutes a behavioral crisis because the patient is threatening harm to another individual. Intervention is called for to defuse the situation. The other options speak of behaviors that may require intervention of a less urgent nature because the patients in question are not threatening harm to self or others.)

Which scenario best depicts a behavioral crisis? A patient is: waving fists, cursing, and shouting threats at a nurse. curled up in a corner of the bathroom, wrapped in a towel. crying hysterically after receiving a phone call from a family member. performing push-ups in the middle of the hall, forcing others to walk around.

A nurse on the cardiac unit gives report to the nurse on the step-down unit while transporting a client in the staff elevator. (Discussing a patient's information in public places where it may be overheard is a violation of a patient's confidentiality. The other options describe appropriate interactions for patient continuity of care and support of the treatment plan by the health care team.)

Which scenarios describe a HIPAA violation associated with a nurse's behavior? An ED (Emergency Department) nurse gives the intensive care unit nurse a client report from a telephone at the nurse's station. A nurse on the medical-surgical floor calls a patient's primary care provider to obtain a list of current medications. A nurse on the cardiac unit gives report to the nurse on the step-down unit while transporting a client in the staff elevator. A nurse on the psychiatric unit gives discharge information to the counseling office regarding a client's outpatient treatment.

"I hear evil voices that tell me to do bad things." (The statement regarding evil voices tells the nurse that the patient is experiencing auditory hallucinations and may create risks for violence. The other statements are vague and do not clearly identify the patient's chief symptom.)

Which statement made by a patient during an initial assessment interview should serve as the priority focus for the plan of care? "I can always trust my family." "It seems like I always have bad luck." "You never know who will turn against you." "I hear evil voices that tell me to do bad things."

talks in language I can understand." helps me keep track of my medication." looks at me as a whole person with many needs." (Each correct answer is an example of appropriate nursing foci: communicating at a level understandable to the patient, providing medication supervision, and using holistic principles to guide care. The distracters violate relationship boundaries or suggest a laissez faire attitude on the part of the nurse.)

Which statements by patients diagnosed with a serious mental illness best demonstrate that the case manager has established an effective long-term relationship? "My case manager: (select all that apply) talks in language I can understand." helps me keep track of my medication." gives me little gifts from time to time." looks at me as a whole person with many needs." lets me do whatever I choose without interfering."

"People claim mental illness so they can get disability checks." "Mental illness results from the breakdown of American families." "If people with mental illness went to church, their symptoms would vanish." (Stigma is represented by judgmental remarks that discount the reality and validity of mental illness. Many mental illnesses are genetically transmitted. Neuroimaging can show changes associated with some mental illnesses.)

Which statements most clearly reflect the stigma of mental illness? Select all that apply. "Many mental illnesses are hereditary." "Mental illness can be evidence of a brain disorder." "People claim mental illness so they can get disability checks." "Mental illness results from the breakdown of American families." "If people with mental illness went to church, their symptoms would vanish."

Clinical epidemiology (Clinical epidemiology is a broad field that addresses studies of the natural history (or what happens if there is no treatment and the problem is left to run its course) of an illness, studies of diagnostic screening tests, and observational and experimental studies of interventions used to treat people with the illness or symptoms. Prevalence refers to numbers of new cases. Co-morbidity refers to having more than one mental disorder at a time.Incidence refers to the number of new cases of mental disorders in a healthy population within a given period. See related audience response question.)

nurse is part of a multidisciplinary team working with groups of depressed patients. Half the patients receive supportive interventions and antidepressant medication. The other half receives only medication. The team measures outcomes for each group. Which type of study is evident? Incidence Co-morbidity Prevalence Clinical epidemiology