EXAM 1: Foundations of Psych Nursing

Two nurses are discussing a client's condition in the elevator. The employer of the mentioned client overhears the conversation and fires the client. The nurses may be liable for which accusation?

"Breach of confidentiality

A 22-year-old male client diagnosed with antisocial personality disorder asks the nurse if he can have an additional smoke break because he's anxious. Which of the following responses would be best?

"Clients are permitted to smoke at designated times. You'll have to follow the rules."

A 21-year-old college student who has been staying up late at night to study reports that she's been having difficulty concentrating. Which response by the nurse is best?

"Describe your sleep patterns to me."

On admission to the inpatient psychiatric unit, a client's facial expression indicates severe panic. The client repeatedly states, "I know the police are going to shoot me. They found out that I'm the child of the devil." What should the nurse say to initiate a therapeutic relationship with the client?

"Hello, my name is ___. I'm a nurse, and I'll care for you when I'm on duty. Should I call you ___, or do you prefer something else?"

A client in an acute care center lacerates her wrists. She has a history of conflicts and acting out. The client tells the nurse, "I did a good job didn't I?" Which of the following responses would be appropriate?

"What were you feeling before you hurt yourself?"

A nurse is assessing a psychiatric client's ability to make sound judgments. Which assessment request best helps evaluate the client's judgment?

"What would you do if you smelled gas in your house?"

In a group therapy setting, one member is very demanding, repeatedly interrupting others, and taking most of the group time. The appropriate response by the nurse would be:

"Will you briefly summarize your point because others need time also?"

An agitated client demands to see her chart so she can read what has been written about her. Which statement is the nurse's best response to the client?

"You have the right to see your chart. Please discuss this with your primary care provider."

(SELECT ALL THAT APPLY) In the emergency department, a client reveals to the nurse a lethal plan for committing suicide and agrees to a voluntary admission to the psychiatric unit. Which information will the nurse discuss with the client to answer the question, ""How long do I have to stay here?""

(1) "You may leave the hospital at any time unless you are suicidal.", (2) "Let's talk more after the health team has assessed you.", (4) "Because you could hurt yourself, you must be safe before being discharged."

(SELECT ALL THAT APPLY) A client is prescribed bupropion (Wellbutrin) to treat depression. The nurse should monitor the client for which adverse reactions associated with bupropion therapy?

(1) Seizures, (2), Anxiety, (3) Insomnia

(SELECT ALL THAT APPLY) The nurse is teaching a client about the antidepressant amitriptyline (Elavil). Which points should she include in her teaching plan?

(1) Smoking may lower the drug level., (2) Avoid prolonged exposure to the sun., (5) Increase fluid and fiber intake to prevent constipation.

(SELECT ALL THAT APPLY) The nurse has developed a relationship with a client who has an addiction problem. Which information would indicate that the therapeutic interaction is in the working stage?

(1) The client addresses how the addiction has contributed to family distress., (4) The client discusses the financial problems related to the addiction., (6) The client acknowledges the addiction's effects on the children.

SELECT ALL THAT APPLY client suffering posttraumatic stress disorder is prescribed sertraline (Zoloft), 50 mg by mouth once daily. Which actions should the nurse take when administering this drug?

(2) Mix the oral concentrate with 4 oz (120 ml) of water, ginger ale, or lemon-lime soda., (3) Administer the oral solution immediately after dilution., (4) Instruct the client to check with the prescriber or pharmacist before taking over-the-counter preparations., (5) Advise the client to use caution when performing hazardous tasks that require alertness.

(SELECT ALL THAT APPLY) The nurse is explaining the Bill of Rights for psychiatric patients to a client who has voluntarily sought admission to an inpatient psychiatric facility. Which of the following rights should the nurse include in the discussion?

(2) Right to refuse treatment, (4) Right to confidentiality, (5) Right to personal mail

An elderly client is prescribed fluoxetine (Prozac), 40 mg by mouth twice per day, for treatment of depression. The client has difficulty swallowing, so the pharmacy dispenses the oral solution containing 20 mg/5 ml. How many milliliters of solution should the nurse administer to achieve the prescribed dose?

10

Physical tolerance and withdrawal symptoms can occur with stimulants. Stimulant withdrawal is characterized by which symptoms?

A violation of confidentiality because she informed the officer that the client wasn't there

In group therapy, a client angrily speaks up and responds to a peer, "You're always whining, and I'm getting tired of listening to you! Here is the world's smallest violin playing for you." Which of the following roles is the client playing?

Aggressor

A client is taking clozapine (Clozaril) and complains of a sore throat. This symptom may be an indication of which adverse reaction?

Agranulocytosis

Which principle of the psychoanalytic model is particularly useful to psychiatric nurses?

All behavior has meaning.

A client is brought to the facility in an agitated state and is admitted to the psychiatric unit for observation and treatment. While putting personal items away, the client talks rapidly and folds and unfolds garments several times. The client can't seem to settle down. Which nursing diagnosis is most applicable at this time?

Anxiety

The nurse is caring for a client who continually has paranoid thoughts. How should the nurse interact with this client?

Approach him in a nonthreatening way.

Which of the following statements describes how elderly clients react to medications?

At risk for increased adverse effects

During an initial assessment, a client reports the following behaviors: social inhibition, hypersensitivity to negative evaluation, fear of criticism, and social ineptitude. The nurse suspects which of the following personality disorders?

Avoidant

Which of the following statements accurately describes therapeutic communication?

Avoiding judgment and false reassurance

A community mental health nurse recognizes that one of the primary roles of her position is advocacy. Which action is most important when fulfilling an advocacy role?

Being politically involved

On admission to the mental health unit, a client tells the nurse she's afraid to leave the house for fear of criticism. She informs the nurse "My nose is so big. I know everyone is looking at me and making fun of me. I had plastic surgery and it still looks awful!" These symptoms are an indication of which disorder?

Body dysmorphic disorder

Which task may be delegated to a nursing assistant in an acute mental health setting?

Checking for sharp objects

A client admitted to the facility continually acts out a preoccupation with hand washing. What term should the nurse use to document this behavior?

Compulsion

The nurse collecting data on a client asks the client the meaning of the proverb "People in glass houses shouldn't throw stones." What is the nurse assessing by asking this question?

Concept formation

An extremely manipulative client is evoking angry feelings in a nurse. Which action should the nurse take first?

Confront the client about his manipulative behavior.

A client in an acute care mental health program refuses his morning dose of an oral antipsychotic medication and believes he's being poisoned. The nurse should respond by taking which action?

Consulting with the physician about a plan of care

Upon returning home from work, a young man discovers that his mother has been in a serious automobile accident. Initially, he responds to the news by stating, "No, I don't believe it. It can't be true." Which defense mechanism is he using?

Denial

A person loses an important advertising account and has a flat tire while driving home. That evening, the person begins to find fault with everyone. Which defense mechanism is the person using?

Displacement

When should the nurse introduce information about the end of the nurse-client relationship?

During the orientation phase

Which nursing intervention is initially most important when restraining a violent client?

Ensuring that the restraints have been applied correctly

A nurse places a client in full leather restraints. How often must the nurse check the client's circulation?

Every 15 minutes

A client in an acute care setting tells the nurse, "I don't think I can face going home tomorrow." The nurse replies, "Do you want to talk more about it?" The nurse is using which technique?

Exploring

A voluntary client in a facility decides to leave the unit before treatment is complete. To detain the client, the nurse refuses to return the client's personal effects. This is an example of which of the following?

False imprisonment

Physical tolerance and withdrawal symptoms can occur with stimulants. Stimulant withdrawal is characterized by which symptoms?

Fatigue, mental depression, and confusion

A client reports losing his job, not being able to sleep at night, and feeling upset with his wife. The nurse responds to the client, "You may want to talk about your employment situation in group today." The nurse is using which therapeutic technique?

Focusing

Which goal is most important for a nurse to concentrate on when leading a group session using a therapeutic milieu?

Focusing on the here and now

A client is admitted to a psychiatric unit in a state of emotional distress after his wife filed for divorce and he lost his job. Which assessment should take priority for this client?

Identify the client's perception of the event.

The nurse is performing an assessment on a newly admitted client. She asks the client to remember three words: apple, house, and umbrella. Then she asks the client, "What are the three words I want you to remember?" What is the nurse assessing?

Immediate recall

An adolescent, age 17, rarely expresses feelings and usually remains passive. However, when angry, her face becomes flushed and her blood pressure rises to 170/100 mm Hg. Her parents are passive and easygoing. The adolescent may be using which defense mechanism to handle anger?

Introjection

Which commonly administered psychiatric medication is prescribed in individualized dosages according to the blood levels of the drug?

Lithium carbonate (Lithane)

Which psychological or personality factor is likely to predispose an individual to medication abuse?

Low self-esteem and unresolved rage

Which of the following indications is the appropriate use for electroconvulsive therapy (ECT)?

Major depression with psychotic features

A client in group therapy is restless. His face is flushed and he makes sarcastic remarks to group members. The nurse responds by saying, "You look angry." The nurse is using which technique?

Making observations

A family member visiting on an acute care psychiatric unit approaches the nurse's station and reports that an elderly client is walking in the hall without her clothing. The nurse doesn't assist the client and suggests that the family member inform the nurse assigned to that client. Which term describes the nurse's action?

Negligent

Which of the following observations should a nurse identify as a group process when monitoring a group therapy session?

Nonverbal language expressed within the group

A client doesn't make eye contact with the nurse during an interview. The nurse suspects that the client's behavior has a cultural basis. What should the nurse do first?

Observe how the client and his family and friends interact with each other and with other staff members.

A man at a pizza parlor verbally confronts the waiter for lack of attentiveness. Later, in the back room, the waiter spits on the man's pizza. This is an example of a behavior typical of which disorder?

Passive-aggressive

Which statement is a guideline to help nurses effectively avoid liability?

Practice within the scope of the Nurse Practice Act.

A client asks the nurse, "Do you think I should leave my husband?" The nurse responds, "You aren't sure if you should leave your husband?" The nurse is using which therapeutic technique?

Reflecting

The nurse is documenting a plan of care for a client who has undergone electroconvulsive therapy (ECT). The nurse should include which intervention?

Reorienting the client to time and place

An 8-year-old girl and her 5-year-old sister tell the school nurse that their mother frequently yells and spits in their faces when she is mad at them. The nurse hesitates to intervene because she knows the family personally. Which action by the nurse is appropriate?

Report the information to child protective services.

Which term refers to the primary unconscious defense mechanism that keeps intense anxiety-producing situations out of a person's conscious awareness?

Repression

A women seeking help at a community mental health center complains of fatigue, sensitivity to criticism, decreased libido, and feeling self conscious. She also has aches and pains. A nursing diagnosis for this client might include:

Situational low self-esteem.

A client with borderline personality disorder dramatically expresses feelings about each nurse on the staff, stating that only one nurse is understanding and trustworthy — the nurse the client is talking to at the time. This client is demonstrating which behavior?

Splitting

Assertive behavior involves which of the following elements?

Standing up for your rights while respecting the rights of others

Nursing implications for a client taking central nervous system (CNS) stimulants include monitoring the client for which conditions?

Tachycardia, weight loss, and mood swings

A client reports severe pain in the back and joints. Upon reviewing the client's history, the nurse notes a diagnosis of depression and frequent hospitalizations for somatic illnesses. What should the nurse encourage this client to do?

Tell the physician about the pain so that its cause can be determined.

The nurse is administering atropine sulfate to a client who is about to undergo electroconvulsive therapy (ECT). Which data collection finding indicates that the medication is effective?

The client states that his mouth is dry.

What occurs during the working phase of the nurse-client relationship?

The nurse and client evaluate and modify the goals of the relationship.

A client is admitted to an inpatient psychiatric unit. After data collection and admission procedures are completed, the nurse states, "I'll try to be available to talk with you when needed and will spend time with you each morning from 10:00 until 10:30 in a specific corner of the dayroom." What is the main rationale for communicating these planned nursing interventions?

To establish a trusting relationship

What is the nurse's most important role in caring for a client with a mental health disorder?

To establish trust and rapport

A nurse immediately tells the truth about a medication error that she made. This nurse is following which ethical principle?

Veracity

A recently engaged 22-year-old woman loses her fiancé in a drunken driving accident. She complains of difficulty eating, sleeping, and working. Her reaction is considered:

a crisis caused by traumatic stress.

The nurse enters the room of a client who is visibly shaken. The nurse states, "You seem upset." The client doesn't respond, so the nurse sits down with the client and remains silent. By using this therapeutic communication technique the nurse is exercising her knowledge that silence is:

a means of allowing the client space in which to respond and a way of communicating patience.

During a mental status examination, a client may be asked to explain such proverbs as "Don't cry over spilled milk." The purpose is to evaluate the client's ability to think:

abstractly.

Unhealthy personal boundaries are a product of dysfunctional families and a lack of positive role models. Unhealthy boundaries may also be a result of:

abuse and neglect.

The nurse documents, "The client described her husband's abuse in an emotionless tone and with a flat facial expression." This statement describes the client's:

affect.

Sedative-hypnotic drugs are indicated for:

anxiety and insomnia.

Nursing care for a client after electroconvulsive therapy (ECT) should include:

assessment of short-term memory loss.

Conditions necessary for the development of a positive sense of self-esteem include:

consistent limits.

The nurse is caring for a client diagnosed with body dysmorphic disorder. When the client verbalizes disapproval of her physical features, the nurse should:

encourage verbalizations about fears and stressful life situations.

A client is transferred to the locked psychiatric unit from the emergency department after attempting suicide by taking 200 acetaminophen (Tylenol) tablets. Now the client is awake and alert but refuses to speak with the nurse. In this situation, the nurse's first priority is to:

ensure safety by initiating suicide precautions.

The nurse is using drawing, puppetry, and other forms of play therapy while treating a terminally ill, school-age child. The primary purpose of these techniques is to help the child:

express feelings that he can't articulate.

An appropriate way for the nurse to set limits for a newly admitted client who puts out cigarettes on the floor of the room designated for smoking is to:

hand the client an ashtray and state that he must use it or he won't be allowed to smoke.

Mental health laws in each state specify when restraints can be used and which type of restraints are allowed. Most laws stipulate that restraints can be used:

if the client poses a present danger to himself or others.

Erikson described the psychosocial tasks of the developing person in his theoretical model. He proposed that the primary developmental task of the young adult (ages 18 to 25) is:

intimacy versus isolation.

A client with antisocial personality disorder smokes where it's prohibited and refuses to follow other unit and facility rules. The client gets others to do his laundry and other personal chores, splits the staff, and will work only with certain nurses. The plan of care for this client should focus primarily on:

isolating the client to decrease contact with easily manipulated clients.

Touching other people without their permission, reading someone else's mail, and using personal possessions without asking permission are all examples of:

poor boundaries.

The nurse's goal in crisis intervention is to provide:

problem-solving techniques and structured activities.

The goal of crisis intervention is:

psychological resolution of the immediate crisis.

The charge nurse in an acute care setting assigns a client, who is on one-to-one suicide precautions, to a psychiatric aide. This assignment is considered:

reasonable nursing practice because one-to-one requires the total attention of a staff member.

A client refuses his evening dose of haloperidol (Haldol) then becomes extremely agitated in the day room while other clients are watching television. He begins cursing and throwing furniture. The nurse's first action is to:

remove all other clients from the day room.

The basis for building a strong therapeutic nurse-client relationship begins with the nurse's:

self-awareness and understanding.

Common adverse effects of electroconvulsive therapy (ECT) include:

short-term memory loss.

According to Freud's psychosexual theory, the ego has several functions. The primary function of the ego is to:

test reality and direct behavior.

The terms "judgment" and "insight" are sometimes used incorrectly. Insight is the ability to:

understand the nature of one's problem or situation.

A client in the emergency department expresses suicidal ideation and feelings of worthlessness. He has a family history of suicide. The nurse is collecting data on the client. The most important factor to consider is:

whether the client has an active suicide plan and the means to carry it out.