EAQ: Psych

While caring for an older adult client, what symptom requires an immediate reassessment of the client's needs and plan of care? 1. Memory loss or confusion 2. Neglect of self-care 3. Increased daily fatigue 4. Withdrawal from usual activities

Correct Answer: 1 Rationale: All are common signs of depression due to the aging process, however, memory loss or confusion may require immediate intervention. The development of confusion indicates that the client's ability to maintain equilibrium has not been achieved and that further disequilibrium is occurring, setting the client up for safety issues. Confusion may also be related to more serious physical conditions that can occur which require medical intervention.

Addicted clients commonly expect discrimination and lack of empathy from others. How can the nurse best overcome these expectations? 1. Demonstrating a nonjudgmental attitude 2. Explaining that an addiction is a disease 3. Offering reassurance that the client is accepted 4. Confronting these attitudes when they are expressed

Correct Answer: 1 Rationale: Behaviors that reflect acceptance and consistency are the best approaches to overcoming these client expectations. What the nurse does is a better indicator of acceptance than the words or explanations that are verbalized. The nurse's actions over time are better indicators of acceptance than is verbal reassurance. Confrontational measures increase anxiety and are not therapeutic.

A nurse working in a crisis center understands that a crisis can best be defined as what? 1. A threat to equilibrium 2. An imbalance of emotions 3. The perception of the problem by the client 4. The circumstance that requires help other than personal resources

Correct Answer: 1 Rationale: Caplan's theory states that a crisis is an internal disturbance caused by a stressful event that alters the usual way of coping with a threat to the self; this temporarily disturbs the equilibrium of the person involved. An imbalance of emotions is not the definition of a crisis. The perception of the problem by the client is not the definition of a crisis; it is the assessment that the nurse must make in the first phase of crisis intervention. The circumstance that requires help other than personal resources is not the definition of a crisis, but instead is how a crisis is resolved.

A nursing team holds a conference to develop goals for the care of a withdrawn, shy male client with low self-esteem who is afraid to talk to members of the opposite sex. Which objective should be given priority and documented in the client's plan of care? 1. "The client will increase his self-esteem" 2. "The client will understand his sexual disorder" 3. "The client will examine his feelings toward women" 4. "The client will increase his knowledge of sexual function"

Correct Answer: 1 Rationale: If the goal to increase the client's self-esteem is met, the client's relationship with others should improve in all aspects, including sexual. Increasing insight may be helpful but should not receive priority. The client may or may not have a sexual disorder. Examining his feelings toward women is not appropriate at this time; examining these feelings is nonproductive until the client's self-esteem improves. Increasing the client's knowledge of sexual function may be done, but improvement of self-esteem should receive priority.

After a client on the mental health unit with a known history of opioid addiction has a visit from several friends, a nurse finds the client in a deep sleep and unresponsive to attempts at arousal. The nurse assesses the client's vital signs and determines that an overdose of an opioid has occurred. Which findings support this conclusion? 1. BP of 70/40 mmHg, weak pulse, RR of 10 breaths/min 2. BP of 180/100mmHg, tachycardia, RR of 18 breaths/min 3. BP of 120/80mmHg, regular pulse, RR of 20 breaths/min 4. BP of 140/90 mmHg, irregular pulse, RR of 28 breaths/min

Correct Answer: 1 Rationale: Opioids cause central nervous system depression, resulting in severe respiratory depression, hypotension, tachycardia, and unconsciousness. The other findings, particularly the respirations, are not indicative of an overdose of an opioid.

What is the most appropriate long-term goal for a client experiencing dysfunctional grieving after the death of a spouse? 1. Resuming previously enjoyed activities 2. Eating at least 2 meals a day with another person 3. Decreasing negativistic thinking about other people 4. Relocating to a state in which other family members reside

Correct Answer: 1 Rationale: Resuming previously enjoyed activities is realistic, specific, and measurable; it relates to the client's acceptance of a new reason for being. Eating at least two meals a day with another person may be an unrealistic goal. There are no data to indicate that the client is thinking negatively about others. Relocating to a state in which other family members reside may be an unrealistic goal, or the client may not want to do this.

A nurse decides to use the CAGE screening questionnaire with a client admitted for substance abuse. What is the client abusing? 1. Alcohol 2. Barbituarates 3. Hallucinogens 4. Multiple drugs

Correct Answer: 1 Rationale: The CAGE questionnaire is one of the simplest and most reliable screening tools for alcohol abuse. CAGE is an acronym for the key words ( Cut down, Annoyed, Guilty, and Eye-opener) in the four questions asked of people suspected of abusing alcohol. The CAGE questionnaire is not designed to screen clients for barbiturate, hallucinogen, or multiple drug abuse.

What is the basic therapeutic tool used by the nurse to foster a client's psychologic coping? 1. Self 2. Milieu 3. Helping process 4. Client's intellect

Correct Answer: 1 Rationale: The self is often the most important tool available to the nurse to help a client cope; to be therapeutic, the nurse must be present, actively listening, and attentive. The environment is important, but it is not the most basic tool. The nurse first must use the self before the helping process can begin. The client's intellect is not generally a therapeutic tool used by the nurse.

A nurse understands that value clarification is a technique useful in therapeutic communication because initially it helps clients do what? 1. Become aware of their personal values 2. Gain information related to their needs 3. Make correct decisions related to their health 4. Alter their value systems to make them more socially acceptable

Correct Answer: 1 Rationale: Value clarification is a technique that reveals individuals' values so the individuals become more aware of them and their effect on others. Gaining information, making correct health decisions, and altering value systems to make them more socially acceptable are not outcomes of value clarification.

The nurse is assigned to work with a 20-year-old client on an inpatient unit. In assessing the woman, the nurse notes that she is mute, does not show any type of movement, is unresponsive, and appears unaware of her surroundings. What is the best term for the nurse to use to describe these symptoms? 1. Alogia 2. Catatonia 3. Echopraxia 4. Affective flattening

Correct Answer: 2 Rationale: Catatonia is the term to describe stupor, rigidity, or extreme flexibility of the limbs; excitability; confusion; and lack of verbal expression. Alogia is a term used to describe an inability to speak or near-absence of speech. Echopraxia is the term for the mimicking or repetition of the actions of another person. Affective flattening is the term for blunted or constricted facial expression.

A client who uses a complex ritual says to the nurse, "I feel so guilty. None of this makes any sense. Everyone must really think I'm crazy." What is the most therapeutic response by the nurse? 1. "Your behavior is bizarre, but it serves a useful purpose" 2. "You're concerned about what other people are thinking about you" 3. "I am sure people understand that you can't help this behavior right now" 4. "Guilt serves no useful purpose. It helps you stay stuck where you are"

Correct Answer: 2 Rationale: Paraphrasing encourages further ventilation of feelings and concerns by the client. Telling the client that the behavior is bizarre but that it serves a useful purpose is a negative response that may increase the client's fears about being "crazy." Saying "I'm sure people understand that you can't help this behavior right now" provides false reassurance and implies that the client is out of control, which may increase the fears. Telling the client that guilt serves no useful purpose and just helps the client stay stuck denies the client's feelings.

During a group therapy session one of the clients asks a client with the diagnosis of antisocial personality disorder why the client is in the hospital. What response might the nurse expect from a client with this disorder? 1. "I need a lot of help with my troubles" 2. "Society makes people follow rules that don't apply to me" 3. "This might help me straighten out my life" 4. "I decided that its time that I own up to my problems"

Correct Answer: 2 Rationale: The client is incapable of accepting responsibility for self-created problems and blames society for the behavior. An admission that the client needs a lot of help, that the therapy may help the client straighten out, or that it's time for the client to own up to problems demonstrates insight, and these individuals rarely develop insight into their problems.

Which psychotherapeutic theory uses hypnosis, dream interpretation, and free association as methods to release repressed feelings? 1. Behaviorist model 2. Psychoanalytic model 3. Psychobiologic model 4. Social-interpersonal model

Correct Answer: 2 Rationale: The psychoanalytic model studies the unconscious and uses the strategies of hypnosis, dream interpretation, and free association to encourage the release of repressed feelings. The behaviorist model holds that the self and mental symptoms are learned behaviors that persist because they are consciously rewarding to the individual; this model deals with behaviors on a conscious level of awareness. The psychobiologic model views emotional and behavioral disturbances as stemming from a physical disease; abnormal behavior is directly attributed to a disease process. This model deals with behaviors on a conscious level of awareness. The social-interpersonal model affirms that crucial social processes are involved in the development and resolution of disturbed behavior; this model deals with behavior on a conscious level of awareness.

A client in a mental health facility is demonstrating manic-type behavior by being demanding and hyperactive. What is the nurse's major objective? 1. Easing the client's feelings of guilt 2. Maintaining a supportive, structured environment 3. Pointing out reality through continued communication 4. Broadening the client's contacts with other people on the unit

Correct Answer: 2 Rationale: These clients are acutely aware of and sensitive to the environment; they need a structured environment in which stimuli are minimized and a feeling of acceptance and support is present. Lessening the client's feelings of guilt is a vague objective; it is not measurable. Pointing out reality through continued communication is not the priority. Reality orientation is not needed as much as maintaining a safe structured environment is. The client needs minimal, not increased, stimuli.

During a one-on-one interaction with a client with paranoid-type schizophrenia, the client says to the nurse, "I've figured out how foreign agents have infiltrated the news media. They want to shut me up before I spill the beans." How should the nurse describe this statement when documenting this client's response? 1. Nihilistic delusion 2. Delusions of persecution 3. Delusions of control 4. Delusions of grandeur

Correct Answer: 2 Rationale: Thoughts of being pursued by powerful agents because of one's special attributes or powers are fixed false beliefs and are referred to as delusions of persecution. There is no evidence to indicate that there are nihilistic delusions of total or partial nonexistence. There is also no evidence to support that external forces are controlling the client (delusions of control) or that the client has false beliefs of being a famous figure (delusions of grandeur).

A client in the psychiatric hospital is attempting to communicate by stating, "Sky, flower, angry, green, opposite, blanket." The nurse recognizes what term as describing this type of communication? 1. Echolalia 2. Word salad 3. Confabulation 4. Flight of ideas

Correct Answer: 2 Rationale: Word salad is an incoherent mixture of words. Echolalia is a pathologic repetition of another's words or phrases. Confabulation is the unconscious filling in of memory gaps with imagined or untrue experiences. Flight of ideas is a speech pattern of rapid transition from topic to topic. The client's statement is too limited to be considered flight of ideas.

A client is admitted to the psychiatric hospital after many self-inflicted nonlethal injuries over the preceding month. Of which level of suicidal behavior is the client's behavior reflective? 1. Threats 2. Ideation 3. Gestures 4. Attempts

Correct Answer: 3 Rationale: A suicidal gesture involves superficial, nonlethal injuries; the client has no intent to die as a result of the injuries. A suicidal threat is a person's verbal statement of intent to commit suicide; there is no action. Suicidal ideation is a person's thoughts regarding suicide; there is no definitive intent or action expressed. A suicide attempt is an actual implementation of a severe self-injurious act; there is an attempt to cause serious self-harm or death.

A nurse is counseling clients who are attending an alcohol rehabilitation program. Which substance poses the greatest risk of addiction for these clients? 1. Heroin 2. Cocaine 3. Nicotine 4. Marijuana

Correct Answer: 3 Rationale: Although polysubstance abuse is common, clients undergoing rehabilitation from alcohol dependence are more likely to use or develop a dependence on nicotine, another legal substance, than on an illegal substance such as heroin, cocaine, or marijuana.

A client has had repeated hospitalizations for aggressive, violent behavior. While on the mental health service, the client becomes very angry, starts screaming at the nurse, and pounds the table. What is the priority nursing assessment at this time? 1. Range of expressed anger 2. Extent of orientation to reality 3. Degree of control over the behavior 4. Determination of whether the anger is justified

Correct Answer: 3 Rationale: Degree of control over the behavior is the most important assessment because it will influence the nurse's intervention. Depending on the extent of the client's control, the nurse may or may not need assistance. It is not the degree of anger but instead the behavior it precipitates that is important to assess. The extent of orientation to reality may or may not influence the ability to control behavior. Anger is always justifiable to the person; the determination of whether the anger is justified will not help the nurse address the client's behavior.

What clinical manifestation best indicates to the nurse that the mental status of a client with the diagnosis of schizophrenia, paranoid type, is improving? 1. Absence of mild to moderate anxiety 2. Development of insight into the problem 3. Decreased need to use defense mechanisms 4. Ability to function effectively in activities of daily living

Correct Answer: 4 Rationale: A person who can handle the activities of daily living and function in society is considered mentally stable. Some anxiety is necessary and unavoidable; anxiety causes problems when it is overwhelming for an extended period. Insight into one's problems is of no use if one is unable to function in society. Everyone uses defense mechanisms; the extent to which they are used helps determine mental health.

In addition to hallucinating, a client yells and curses throughout the day. What should the nurse do? 1. Ignore the client's behavior 2. Isolate the client until the behavior stops 3. Explaining the meaning of the behavior to the client 4. Seek to understand what the behavior means to the client

Correct Answer: 4 Rationale: All behavior has meaning; before planning intervention, the nurse must try to understand what the behavior means to the client. Ignoring behavior does little to alter it and may even cause further acting out. Isolation may increase anxiety and precipitate more acting-out behavior. The nurse cannot explain the meaning of the client's behavior; only the client can.

A nurse is assessing a client with major depression. Which clinical manifestation reflects a disturbance in affect related to depression? 1. Echolalia 2. Delusions 3. Confusion 4. Hopelessness

Correct Answer: 4 Rationale: Feelings of hopelessness are symptomatic of depression; the individual feels unable to find any solution to problems and therefore feels overwhelmed. Echolalia, the pathological meaningless repetition of another's words or phrases, is associated with schizophrenia, not with depression. Delusions are associated with psychotic disorders such as schizophrenia, not depression. Confusion is not common because these individuals are in contact with reality.

A 3-year-old child is found to have a pervasive developmental disorder not otherwise specified. What should the nurse consider most unusual for the child to demonstrate? 1. Interest in music 2. Ritualistic behavior 3. Attachment to odd objects 4. Responsiveness to the parents

Correct Answer: 4 Rationale: One of the symptoms that an autistic child displays is lack of responsiveness to others; there is little or no extension to the external environment. Music is nonthreatening, comforting, and soothing. Repetitive behavior provides comfort. Repetitive visual stimuli, such as a spinning top, are nonthreatening and soothing.

When assessing the characteristics of an adolescent with anorexia nervosa, how does the nurse expect to describe the adolescent? 1. Manic 2. Rebellious 3. Hypoactive 4. Perfectionistic

Correct Answer: 4 Rationale: Perfectionistic standards and extremes of self-discipline are an attempt to maintain control and meet the client's own and others' expectations. People with anorexia nervosa are often anxious and depressed, not manic. People with anorexia nervosa are frequently compliant in an attempt to meet the expectations of others. People with anorexia nervosa usually use excessive exercise routines as a means of losing weight. Also, many are trying to become the thin, fit ideal woman depicted in the media.

A nurse is caring for a newly admitted client with obsessive-compulsive disorder. When should the nurse anticipate that the client's anxiety level will increase? 1. As the day progresses 2. When family members visit 3. During a physical assessment by the nurse 4. When limits are set on the performance of a ritual

Correct Answer: 4 Rationale: Setting limits on the performance of a ritual will increase the client's anxiety. The ritual is a defense that the client needs at this time to control anxiety. The client needs time to develop other defenses before the ritual can be limited. The precipitation of anxiety in a client with obsessive-compulsive disorder is usually unrelated to the time of day. Visits from family members may or may not precipitate anxiety. Researchers have implicated trauma to the basal ganglia or cortical connections or a genetic predisposition as the origin of obsessive-compulsive disorder. A physical assessment by the nurse may or may not precipitate anxiety. The presentation of a nonjudgmental, supportive attitude by the nurse should decrease, not increase, anxiety.

A client with a personality disorder is playing cards with another person in the lounge. When the other person cheats at cards, the client responds by aggressively scattering the cards around the room. What does the nurse conclude about the client's personality? 1. Poor reality testing 2. A violent personality 3. An antisocial personality 4. Inadequate impulse control

Correct Answer: 4 Rationale: The client is angry and reacts impulsively; the action is unplanned and is not under the client's control. No data are provided to suggest that the client is out of contact with reality; the client is reacting to a real situation with anger. There is no identifiable cluster of behaviors to suggest that the client has a violent personality. There is no pattern of behavior to suggest an antisocial personality, which may or may not involve impulse control.

A nurse is caring for a client with an obsessive-compulsive personality disorder that involves rituals. What should the nurse conclude about the ritual? 1. It has a purpose but it is useless 2. It is performed after long urging 3. It appears to be performed willingly 4. It seems illogical but is needed by the person.

Correct Answer: 4 Rationale: The client's exact adherence to the compulsive ritual relieves anxiety, at least temporarily. Furthermore, it meets a need and is necessary to the client. The compulsive act is purposeless repetition and useful only in that it temporarily eases the client's anxiety. Urging has no effect getting the the client to start or stop the ritualistic behavior. The person cannot stop the activity; it is not under his voluntary control.

An individual whose employment has been terminated because his company has been acquired by another company is brought by a family member to the mental health clinic because of extreme depression. While talking with the nurse the client says, "I'm a useless, worthless person. No wonder I lost my job." What type of delusion does the nurse identify? 1. Reference 2. Persecution 3. Alien control 4. Self-deprecation

Correct Answer: 4 Rationale: The client's statement is self-derogatory and reflects a low self-appraisal. There is no evidence that the client feels that he is the object of attention from others in the environment, that the client feels harassed, or that the client feels that others are controlling or manipulative.

The husband of a young mother who has attempted suicide tells the nurse that he told his wife he would bring their 26-month-old daughter to visit his wife and asks if that would be possible. What is the best response by the nurse? 1. "Probably so, but you'd better check with her primary healthcare provider first" 2. "Of course! Children of all ages are welcome to visit relatives" 3. "It could be very upsetting for your child to see her mother so depressed" 4. "Tell me what your wife said when you offered to bring your child for a visit"

Correct Answer: 4 Rationale: The nurse should determine whether the spouse has discussed the child visiting with the client before commenting further. The responses "Probably so, but you'd better check with her primary healthcare provider first" and "Of course! Children of all ages are welcome to visit relatives" assume that the client has consented to the visit; this assumption may be incorrect. The response "It may be very upsetting for your child to see her mother so depressed" makes an assumption that requires more data and discussion to validate.

The wife of a client who is dying tells the nurse that although she wants to visit her husband daily, she can visit only twice a week because she works and has to take care of the house and their cat and dog. What defense mechanism does the nurse conclude that the client's wife is using? 1. Projection 2. Sublimation 3. Compensation 4. Rationalization

Correct Answer: 4 Rationalization is offering a socially acceptable or logical explanation to justify an unacceptable feeling or behavior. Projection is the denial of emotionally unacceptable feelings and the attribution of the traits to another person. Sublimation is the substitution of a socially acceptable behavior for an unacceptable feeling or drive. Compensation is making up for a perceived deficiency by emphasizing another feature perceived as an asset.

A client is found to have a mood disorder, hypomanic episode. To support the diagnosis, the nurse should identify the signs and symptoms associated with this disorder. Select all that apply. 1. Distractibility 2. Flight of ideas 3. Low self-esteem 4. Increased need for sleep 5. Psychomotor retardation

Correct Answers: 1, 2 Rationale: These individuals have a short attention span; their attention is easily drawn to unimportant or irrelevant external stimuli. These individuals shift from one idea or topic to another and express their thoughts in a rapid flow of speech. These individuals have an inflated self-esteem or grandiosity. These individuals have a decreased need for sleep. These individuals have psychomotor agitation or an increase in goal-directed activity.

Which statements describe a mentally healthy person? Select all that apply. 1. One who accepts aging 2. One who engages available strengths 3. One who maintains minimum autonomy 4. One who sustains positive relationships 5. One who engages available weaknesses

Correct Answers: 1, 2, 4 Rationale: A mentally healthy person is one who accepts the aging self as an active being. A mentally healthy person is one who engages available strengths to compensate for weaknesses in order to create personal meaning. A mentally healthy person is one who sustains positive relationships with others. A mentally healthy person is one who maintains maximum autonomy by mastering the environment. A mentally healthy person does not engage available weaknesses.

A nurse is preparing a teaching plan to educate a relative of a client with schizophrenia about the early signs of relapse. What signs should the nurse plan to include? Select all that apply. 1. Appearing disheveled 2. Socializing with peers 3. Staying alone in the house 4. Joining a local church singing grup 5. Exhibiting indifference to family activities

Correct Answers: 1, 3, 5 Rationale: Appearing disheveled, a negative sign, may indicate schizophrenic relapse, because the individual does not have the interest or energy to complete the activities of daily living. Staying at home alone can be a sign of mental illness relapse, because the individual is becoming isolated and not socializing. Indifference to family activities may indicate mental illness relapse, because it may reflect feelings of apathy or a lack of emotional energy to become involved with others. Socializing with peers is a sign of mental health, because the individual is interacting with others; humans are highly social beings. Joining a church singing group indicates mental health, because the individual is interacting with others and is interested in an activity.

How can a nurse minimize agitation in a disturbed client? 1. By ensuring constant staff contact 2. By increasing environmental sensory stimulation 3. By limiting unnecessary interactions with the client 4. By discussing the reasons for the client's suspicions

Correct Answers: 3 Rationale: Limiting unnecessary interactions will decrease stimulation and therefore agitation. Constant client and staff contact increases stimulation and agitation. Increasing environmental sensory stimulation bombards the client's sensorium and increases agitation. Not all disturbed clients are suspicious. This client is unlikely to benefit from this discussion at this time.