Foundations of Psychiatric Nursing passpoint
The nurse is reinforcing discharge instructions for a female client that has a spinal cord injury at the C4 level. Which information should the nurse include with the instructions?
"After a spinal cord injury, women usually remain fertile; therefore, you may consider contraception if you don't want to become pregnant."
A client with depression is ready for discharge from the hospital and tells the nurse, "It would be good for me if we could meet for coffee if I start feeling down again." Which statement indicates that the nurse understands the boundaries of the therapeutic relationship?
"Before you leave the hospital, I will make sure you have information about the crisis center."
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."
The nurse in a psychiatric unit has formed a therapeutic relationship with a client with a borderline personality disorder. When the client is readmitted to the unit for a suicide attempt, the nurse exclaims to another staff nurse, "Why? Everything was going well. How could they do this to me?" What response by the staff nurse reflects an understanding of the client's borderline disorder?
"Clients with borderline disorder act out to relieve anxiety, and something must have provoked a great deal of anxiety."
A 21-year-old college student works full time and takes college courses in the evening. The client reports having difficulty concentrating. Which response by the nurse is best?
"Describe your sleep patterns to me."
The nurse is having a conversation with a depressed client. The client states, "Do you think I should tell my family how I feel?" What is the most therapeutic response by the nurse?
"Do you think you should tell your family?"
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 is the nurse's best response 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?"
The nurse is preparing to discharge a client with depression from inpatient care. The client tells the nurse, "You helped me more than anyone else in this place. I am hoping you will still be there to help me once I am discharged." How should the nurse respond?
"I am glad you found our work together productive. I am confident you will continue to improve with the support of the outpatient program team."
A client who was recently fired is now having gastrointestinal issues. What statement made by the client does the nurse document as the use of ineffective coping mechanisms?
"I am having a few glasses of wine after searching for jobs in the evening."
The nurse has established an effective nurse-client relationship with a client diagnosed with depression. Which statement made by the client indicates to the nurse that the termination phase has been effective?
"I am looking forward to going back to work."
Which statement by a client with paraphilia indicates a potential for relapse?
"I can't imagine why the judge sent me here."
The nurse is admitting a client diagnosed with depression. Which statements by the nurse should be made in the orientation phase of the nurse-client relationship? Select all that apply.
"I won't share any information with your family without your permission." "We'll be meeting every day at 10:00 a.m. for 15 minutes." "Tell me what brought you here today."
A client on short-term mental health disability leave undergoes required psychiatric evaluation and counseling. The client requests that their evaluation and counseling records be e-mailed to the client's Human Resources representative. How should the nurse respond?
"It's best not to e-mail your personal records because doing so might jeopardize your right to privacy."
An obese client has returned to the unit after receiving electroconvulsive therapy (ECT). A nurse requests assistance in moving the client from the stretcher to the bed. Which direction should the nurse give to a nurse who volunteers to help?
"Obtain the sliding board or two other people to assist us."
A client who had a myocardial infarction 8 weeks ago tells a nurse, "My wife wants to make love, but I don't think I can. I'm worried that it might kill me." Which response from the nurse would be most appropriate?
"Tell me about your feelings."
A newly hired nurse is assigned to a mental health clinic and is unfamiliar with mental health nursing. The nurse asks another nurse what is the goal of crisis intervention. What is the best response by the nurse?
"The goal is psychological resolution of the immediate crisis."
A client is brought to the crisis center by family members after giving away all of the family's possessions. When gathering data from the client, which statement would lead the nurse to suspect possible suicidal ideation?
"There's no hope. I feel like going to sleep and never waking up."
An adult client arrives at the emergency department and has just learned that a parent has died as a result of an automobile accident. The client states, "No, I don't believe it. It can't be true." How should the nurse respond?
"This is shocking news. May I sit with you for a while?"
A client being treated for infertility confides to the nurse that they haven't told their partner about being treated for a sexually transmitted infection in the past. What would be the most therapeutic response for the nurse to give?
"What concerns do you have about sharing this information?"
A client who identifies as gay tells the nurse, "My family is not supportive." What is the best response by the nurse?
"What do you mean by not supportive?"
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?"
In a group therapy setting, one member is very demanding, repeatedly interrupting others, and taking most of the group time. What would be the appropriate response by the nurse?
"Will you briefly summarize your point to allow time for everyone?"
The nurse is caring for a client with a social anxiety disorder who has difficulty sharing with the treatment team. The nurse believes using self-disclosure may assist the therapeutic relationship. Which approach to self-disclosure is most appropriate for the nurse to use?
"Would you like to hear how I cope when I feel anxious in new social situations?"
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."
The nurse has identified that several of the newer unlicensed assistive personnel (UAP) are not always maintaining adequate professional boundaries when interacting with clients. Which action(s) should the nurse take? Select all that apply.
-Identify clients who are more likely to attempt to challenge appropriate relationship boundaries during team meetings. -Provide staff in-services that involve clinical vignettes and scenarios related to common professional boundary issues. -Provide written policies with examples about what constitutes unethical behavior and the consequences for this behavior.
A caregiver is suspected of neglect and abuse. What warning signals should the nurse document and report? Select all that apply.
-The caregiver does not allow the client to speak for him or herself, have visitors, or be alone with others. -The caregiver places blame on the client for his or her illness or limitations. -The caregiver has alcohol on his or her breath and acts as though he or she is impaired.
The nurse on the acute inpatient psychiatric unit is determining which clients on the unit should be placed in the rooms closest to the nurse's station to facilitate frequent observation. In which order does the nurse prioritize the clients? Place the clients in order from the highest priority for being in a room close to the nursing station to the lowest priority. All options must be used.
-a client with depression who has just been admitted due to a suicide attempt -a client with a delusional disorder who is disoriented to both place and time -a client with conduct and borderline personality disorders who acts out impulsively -a client with bipolar disorder who is experiencing an episode of hypomania -a client with an anxiety disorder who performs frequent compulsive rituals
A manager observes a nurse interacting with clients on a psychiatric unit. Which nursing action(s) would cause the manager to intervene? Select all that apply.
-talking with a client about personal issues such as the nurse's recent divorce -spending more time than necessary with a client and showing favoritism -asking a client to meet for lunch outside the hospital setting -posting a picture of the nurse and client on social media
The nurse uses the PLISSIT model to help clients with gender issues or sexual problems. Place the levels in progressive order.
1. permission giving 2. limited information 3.specific suggestions 4. intensive therapy
A client on an inpatient psychiatric unit has been taking a tricyclic antidepressant (TCA) without satisfactory results, so the health care provider changes the medication to a monoamine oxidase inhibitor (MAOI). Prior to administering the medication, what should the nurse be sure to check?
Adequate time has elapsed between discontinuing the first medication and beginning the second.
The nurse documents, "The client described her husband's abuse in an emotionless tone and with a flat facial expression." When reviewing the documentation, the nurse recognizes this statement is describing which aspect of the client's disposition?
Affect
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 with ulcerative colitis has recently had a colostomy and is anxious. The client reports to the nurse, "I don't think I can ever have a sexual relationship now that I have this." Which response by the nurse would be most appropriate?
Allow the client to express concerns.
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
After learning that a roommate has tested positive for the human immunodeficiency virus (HIV), a client asks a nurse about moving to another room on the psychiatric unit because the client does not feel "safe" now. What should the nurse do first?
Ask the client to describe their fears
A client confides to a nurse, "I have urges and desires to have sex with children." What should the nurse's most appropriate response be?
Ask the client, "Have you ever acted on these desires?"
A client was sexually assaulted after returning home from the store late one evening. The client arrives, tearful, at the emergency department. What is the priority intervention for this client?
Assess the client's physical and mental state.
The nurse is assigned to care for a client of Japanese descent who is having a surgical procedure. While talking with the client, the nurse is aware that the client is not maintaining eye contact. Which intervention should be performed at this time?
Be aware that this is a cultural norm and continue talking.
A community mental health nurse recognizes that one of the primary roles of the 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
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
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
A client with long-term body-focused repetitive behaviors including trichotillomania (hair pulling) finds support through an online website. The client begins to attend local meetings and realizes that a nurse from the clinic also attends. When approached outside of these meetings, how should the nurse respond?
Discuss this to define the relationship.
Nurses are aware that older clients' physiological changes of aging can complicate drug therapy. Which statement that describes how elderly clients react to medications must nurses be cognizant of?
Elderly clients are at risk for increased adverse effects to medications.
A hospitalized client becomes angry and belligerent toward a nurse after speaking on the phone with the parent. The nurse learns that the parent cannot visit as expected. Which interventions might the nurse use to help the client deal with the displaced anger? Select all that apply.
Explore the client's unmet needs. Invite the client to a quiet place to talk. Assist the client in identifying alternate ways of approaching the problem.
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
A healthcare provider has ordered a new antipsychotic medication for a client with schizophrenia whose previous medication no longer provides the expected symptom relief. The client tells the nurse, "I can't afford the additional cost of this new medication." What is the first action the nurse should take to be a client advocate?
Help the client explore other financial options for obtaining medication reimbursement with a social worker.
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
A client with an ileostomy tells the nurse he cannot have an erection. What pertinent information should the nurse know?
Impotence is uncommon after an ileostomy.
A nurse is reviewing a client's chart and sees a health care practitioner's order for electroconvulsive therapy (ECT). Which following indication would the nurse expect to find that is the appropriate use for this therapy?
Major depression with psychotic features
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 family member visiting on an acute care psychiatric unit approaches the nurse's station and reports that an older adult client is walking in the hall without clothing. Which action should the nurse take first?
Obtain a blanket or robe with which to cover the client in the hallway.
A client while playing chess with a younger client, verbally confronts him for the for lack of attentiveness. Later, the younger client intentionally hides some of the older client's chess pieces. The nurse observes the younger client's actions and recognizes this behavior is a typical example of which disorder?
Passive-aggressive
The nurse observes two clients playing basketball during exercise activity. The clients are engaged in aggressive communication and begin to fight. Which nursing intervention is most appropriate?
Remove the clients to separate areas and set limits
A nurse learns that another staff nurse in an outpatient mental health clinic has recently sought money from a group of mental health center clients to invest in a new business. How should the nurse respond to learning this information?
Report concerns to the nursing supervisor.
As the nurse arrives to visit a family 2 days after release from the hospital, she hears shouting and swearing between the mother and father and several loud crashes, just as she is going to knock on the door. What action by the nurse is the most appropriate?
Return to the car and call the police.
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. The nurse realizes this client is demonstrating which type of behavior?
Splitting
Assertive behavior involves which of the following elements?
Standing up for your rights while respecting the rights of others
The terms "judgment" and "insight" are sometimes used incorrectly. How would the nurse appropriately define insight?
The ability to understand the nature of one's problem or situation
A male client is undergoing estrogen therapy for future sexual reassignment surgery. Which outcome should the nurse assist in evaluating?
The client will develop breasts.
Mental health laws in each state specify when restraints can be used and which type of restraints are allowed. Most laws stipulate which information regarding the use of restraints?
Use if the client poses a present danger to himself or others
A client in the emergency department, with a family history of suicide, expresses suicidal ideation and feelings of worthlessness. The nurse is collecting data on the client. Which factor is the most important for the nurse to consider for this client?
Whether the client has an active suicide plan and the means to carry it out
The school nurse is assisting with the performance of screening for children with possible autistic spectrum disorder (ASD). Which child does the nurse determine is at greatest risk for this disorder?
a child that has a sibling with ASD
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.
An older adult client has begun anticonvulsant therapy for the treatment of seizures following a stroke. Which assessment finding is essential to report to the health care provider?
altered level of consciousness that fluctuates daily
Nursing care for a client after electroconvulsive therapy (ECT) should include:
assessment of short-term memory loss.
A client is in the emergency department after being sexually assaulted by a stranger. Which nursing intervention has priority?
assisting in identifying family or friends who could provide immediate support
A nurse is conducting a sexual awareness group of known pedophiles. What will the nurse highlight as the primary focus of this group?
cognitive restructuring
A nurse is caring for a client admitted to the inpatient psychiatric unit. When is it most important to introduce information about the end of the nurse-client relationship?
during the orientation phase
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 from the emergency department to the locked psychiatric unit after attempting suicide by taking 200 acetaminophen tablets. The client is now 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.
A client is transferred to the locked psychiatric unit from the emergency department after attempting suicide by taking 200 acetaminophen 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.
A nurse is using drawing, puppetry, and other forms of play therapy while caring for a terminally ill, school-age child. What is the primary nursing goal of play therapy for this child?
expression of feelings that the child cannot articulate
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 action is an example of:
false imprisonment.
A client reports having a strong desire to live and be treated as the opposite sex and is uncomfortable with the current anatomical sex. Based on the client's comments, for what psychiatric condition will the nurse assess?
gender dysphoria
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.
A client is taking antihypertensive medication and tells the nurse who's monitoring the blood pressure that he can't have sexual intercourse with his wife anymore. What likely cause should the nurse discuss with the client?
his blood pressure medication
A client was admitted for treatment of the symptoms of bipolar disorder after failing to comply with community treatment and continuing to expose their sexual partners to a sexually transmitted form of hepatitis. The court appointed a guardian because this client was not able to understand the consequences of the decisions being made. Which terms describes the status of this client?
legally incompetent
A client is scheduled to retire in the next month and phones the nurse therapist stating, "I can't cope." Which reaction is this client exhibiting?
maturational crisis
The nurse attempts to establish a therapeutic relationship with a client in the behavioral health unit. The nurse is reading the client's chart, becomes familiar with the medications the client is taking, and arranges for a meeting. What phase of the nurse-client relationship is the nurse demonstrating?
orientation phase
The nurse's goal in crisis intervention is to provide:
problem-solving techniques and structured activities.
A client was sexually assaulted when returning home from the store late one evening. The client arrives, tearful, to the emergency department. What is the priority intervention for this client?
remaining with the client and assisting the client through the crisis
A client refuses his evening dose of haloperidol 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.
A nurse is assisting with the development of a plan of care for a client who has undergone electroconvulsive therapy (ECT). Which intervention would most likely be included?
reorienting the client to time and place
The basis for building a strong, therapeutic nurse-client relationship begins with a nurse's:
self-awareness and understanding.
A nurse is obtaining data from a client with the potential diagnosis of gender dysphoria. The nurse knows that the diagnostic criteria for this disorder in a male must include a persistent identification with femaleness and which other sign or symptom?
significant impairment in social, occupational, or other important areas of functioning
Which outcome developed by the health care team is appropriate for a client diagnosed with pedophilia?
verbalizing appropriate methods to meet sexual needs upon discharge
A nurse implements care for a client in a dissociative fugue. What does the nurse recognize may have preceded this diagnosis? Select all that apply.
witnessing a murder recent history of rape surviving a tornado