mental health practice questions

The nurse is caring for a Native American client who says, "I don't want you to touch me. I'll take care of myself." Which nursing response is most therapeutic? Select one: a. "Okay, if that's what you want. I'll just leave this cup for you to collect your urine." b. "Why are you being so difficult? I only want to help you." c. "It sounds as though you want to take care of yourself. Let's work together so you can do things for yourself." d. "If you don't want our care, why did you come here?"

c. "It sounds as though you want to take care of yourself. Let's work together so you can do things for yourself."

Match the nursing approach for each of the continuum of emotional responses.

Calm: professional, helpful, available Anxious: active listening, allow pt to vent, be supportive and informative, address their immediate concern (so it doesn't escalate), offer alternatives Agitated: be more directed, provide short/concise instructions Aggression: maintain physical distance, know escape routes, come up with physical intervention plan from team approach to control situation Tension Reduction: following physical intervention, reestablish therapeutic rapport with pt, initiate debriefing with pt (what happened, what could have been done differently)

A client is admitted for psychiatric observation after being arrested for breaking windows in the home of his former girlfriend, who had refused to see him. His history reveals abuse as a child by a punitive father, torturing family pets, and one arrest for disorderly conduct. The nursing diagnosis that should be considered for development is: Select one: a. Post-traumatic syndrome b. Risk for other-directed violence c. Risk for injury d. Disturbed thought processes

b. Risk for other-directed violence The defining characteristics for risk for violence directed at others include a history of being abused as a child, having committed other violent acts, and demonstrating poor impulse control.

Match the type of aggression with the description

_____: Individual brings to the current situation factors such as attitudes, beliefs, and behavioral tendencies which leads to aggression. Fear-driven: attack others in effort to avoid getting hurt themselves; protect themselves Irritable: chronically angry at the world, constantly looking to get upset, to have something set him/her off Instrumental: learned from past experience that aggression helps achieve what they want, manipulation

Two staff nurses applied for promotion to nurse manager. The nurse not promoted initially had feelings of loss but then became supportive of the new manager by helping make the transition smooth and encouraging others. Which term best describes this nurse's response? Select one: a. Altruism b. Sublimation c. Passive aggression d. Suppression

a. Altruism Altruism is the mechanism by which an individual deals with emotional conflict by meeting the needs of others and vicariously receiving gratification from the responses of others.

The nurse directs the intervention team who must take an aggressive client to seclusion. Other clients have been removed from the area. Before approaching the client, the nurse should ensure that staff: Choose all that apply Select one or more: a. Appoint a person to clear a pat and open, close or lock doors. b. Move behind the client to use the element of surprise. c. Select the person who will communicate with the client. d. Quickly approach the client and take hold of the closest arm or leg. e. Remove jewelry, glasses, and harmful items from their persons.

a. Appoint a person to clear a pat and open, close or lock doors. c. Select the person who will communicate with the client. e. Remove jewelry, glasses, and harmful items from their persons.

A pt is taking a monoamine oxidase inhibitor (MAOI). The RN assesses the client closely because: a. Headache, hypertension, and nausea and vomiting may indicate toxicity. b. Hypotensive crisis may be precipitated by foods rich in tyramine and typtophan. c. Hypotension may indicate toxicity d. These medications increase the amount of MAOI in the liver.

a. Headache, hypertension, and nausea and vomiting may indicate toxicity. Headache, hypertension, tachycardia, nausea, and vomiting are precursors to hypertensive crisis brought about by the ingestion of foods rich in tyramine and tryptophan while the client is taking an MAOI. These medications act by decreasing the amount of MAOI in the liver, which is necessary for the breakdown and utilization of tyramine, and tryptophan. Hypertensive crisis may lead to circulatory collapse, intracranial hemorrhage, and death.

During the termination phase of the nurse-client relationship, the clinic nurse observes that the client continuously demonstrates bursts of anger. The most appropriate interpretation of the behavior is that the client... Select one: a. Is displaying typical behaviors that can occur during termination. b. Requires further treatment and is not ready to be discharged. c. Needs to be referred to the psychiatrist as soon as possible. d. Needs to be admitted to the hospital.

a. Is displaying typical behaviors that can occur during termination.

A supervisor assigns a worker a new project. The worker initially agrees but feels resentful. The next day when asked about the project, the worker says, "I've been working on other things." When asked 4 hours later, the worker says, "Someone else was using the copier, so I couldn't finish it." The worker's behavior demonstrates: Select one: a. Passive aggression b. Acting out c. Rationalization d. Projection

a. Passive aggression A passive-aggressive person deals with emotional conflict by indirectly expressing aggression towards others. Compliance on the surface masks covert resistance. Resistance is expressed through procrastination, inefficiency, and stubbornness in response to assigned tasks.

Two staff nurses applied for a charge nurse position. After the promotion was announced, the nurse who was not promoted said, "The nurse manager had a headache the day I was interviewed." Which defense mechanism is evident? Select one: a. Projection b. Splitting c. Introjection d. Conversion

a. Projection Projection is the hallmark of blaming, scapegoating, thinking prejudicially, and stigmatizing others.

A person who is speaking about a rival for a significant other's affection says in a gushy, syrupy voice, "What a lovely person. That's someone I simply adore." The individual is demonstrating: Select one: a. Reaction formation b. Repression c. Denial d. Projection

a. Reaction formation Reaction formation is an unconscious mechanism that keeps unacceptable feelings out of awareness by using the opposite behavior.

Which of the following are not an effective nursing approach when setting limits? Choose all that apply. Select one or more: a. The nurse is to make a decision on behalf of the client if the client cannot make a decision in a short period of time. b. Give clear, objective choices with consequences that are reasonable and enforceable. c. Allow the client to choose a reward for acceptable behavior. d. Explain the reason for the action you are requesting.

a. The nurse is to make a decision on behalf of the client if the client cannot make a decision in a short period of time. The nurse is to allow the person time to make a decision. c. Allow the client to choose a reward for acceptable behavior. Options and consequences should be offered by the staff so that they are reasonable, fair and maintain unit rule.

A pt is started on a regimen of lamotrigine (Lamictal) 50 mg daily for bipolar depression. The pt shows the nurse a red and purple rash on his arm that is blistering and peeling. What is the most likely explanation? a. The rash is a rare adverse effect which causes a toxic epidermal necrolysis. b. The pt is experiencing a benign rash to the medication which can be treated with diphenhydramine (Benadryl). c. The med increases the pt's sensitivity to sunlight resulting in a sunburn from not using protection. d. The rash is a common side effect which resolves after the medication reaches therapeutic range.

a. The rash is a rare adverse effect which causes a toxic epidermal necrolysis. Stevens-Johnson syndrome is a serious rash requiring hospitalization and discontinuation of treatment. The incidence of this rash is approximately 0.08% in patients being prescribed Lamictal for mental health issues (higher for those being prescribed it for seizure disorders). The rash develops during in the first few months of the medication being titrated especially if the medication is increased too quickly. The potential to develop Steven-Johnson syndrome increase when Lamictal is used as adjunct therapy with Valproic Acid (Depakote).

A 22-year old college student presented to the EC with HTN (BP 200/110), tachycardia, cramping, hyperreflexia, and myoclonus. He was taking phenelzine (Nardil) and had been out to a restaurant with friends. What is the most likely food/drink that could have interacted with the med? a. Grapefruit juice b. Red wine c. Cucumbers d. Eggs

b. Red wine Monoamine inhibitors (MAOIs) inhibit the enzyme (MAO) that breaks down monoamine neurotransmitters (i.e., dopamine, norephinephrine, serotonin) once they have been pumped back into the presynaptic cell. While taking MAOIs, certain foods and alcohol that are high in the amino acid tyramine (aged, pickled, processed) can cause a severe hypertensive crisis and should be avoided. Alcohol (specifically beer and red wine) should be avoided or should be limited to only 4 ounces per day.

An aggressive client was placed in four-point restraints and given an intramuscular dose of anxiolytic medication. Systematic assessment to guide interventions during the period of restraint should include: Choose all that apply Select one or more: a. Vital signs b. Nutritional needs c. Level of awareness d. Hydration e. Elimination needs f. Range of Motion and comfort needs

a. Vital signs All the options should be assessed. Each pertains to biological and safety needs for the client. Nurses must follow hospital protocol for care. Generally, clients should be observed for level of consciousness at 15-minutes intervals, given food at normal meal times or more often if they are hyperactive, given flouids hourly, have vital signs checked at 4 hour intervals or less if medications administration has caused hypotension, taken to the bathroom every 2 hours, and released from restraints and given range of motion every 2 hours. b. Nutritional needs All the options should be assessed. Each pertains to biological and safety needs for the client. Nurses must follow hospital protocol for care. Generally, clients should be observed for level of consciousness at 15-minutes intervals, given food at normal meal times or more often if they are hyperactive, given flouids hourly, have vital signs checked at 4 hour intervals or less if medications administration has caused hypotension, taken to the bathroom every 2 hours, and released from restraints and given range of motion every 2 hours. c. Level of awareness All the options should be assessed. Each pertains to biological and safety needs for the client. Nurses must follow hospital protocol for care. Generally, clients should be observed for level of consciousness at 15-minutes intervals, given food at normal meal times or more often if they are hyperactive, given flouids hourly, have vital signs checked at 4 hour intervals or less if medications administration has caused hypotension, taken to the bathroom every 2 hours, and released from restraints and given range of motion every 2 hours. d. Hydration All the options should be assessed. Each pertains to biological and safety needs for the client. Nurses must follow hospital protocol for care. Generally, clients should be observed for level of consciousness at 15-minutes intervals, given food at normal meal times or more often if they are hyperactive, given flouids hourly, have vital signs checked at 4 hour intervals or less if medications administration has caused hypotension, taken to the bathroom every 2 hours, and released from restraints and given range of motion every 2 hours. e. Elimination needs All the options should be assessed. Each pertains to biological and safety needs for the client. Nurses must follow hospital protocol for care. Generally, clients should be observed for level of consciousness at 15-minutes intervals, given food at normal meal times or more often if they are hyperactive, given flouids hourly, have vital signs checked at 4 hour intervals or less if medications administration has caused hypotension, taken to the bathroom every 2 hours, and released from restraints and given range of motion every 2 hours. f. Range of Motion and comfort needs All the options should be assessed. Each pertains to biological and safety needs for the client. Nurses must follow hospital protocol for care. Generally, clients should be observed for level of consciousness at 15-minutes intervals, given food at normal meal times or more often if they are hyperactive, given flouids hourly, have vital signs checked at 4 hour intervals or less if medications administration has caused hypotension, taken to the bathroom every 2 hours, and released from restraints and given range of motion every 2 hours.

Pt on tranylcypromine (Parnate) requests info on foods that are acceptable to eat while taking the med. RN tells the pt that it is safe to eat: a. Oranges b. Smoked fish c. Cheddar cheese d. Raisins

a. oranges Tranylcypromine is classified as a monoamine oxidase inhibitor (MAOI) and, as such, tyramine-containing food should be avoided. Types of food to be avoided include, but are not limited to, those items identified except for oranges which are permissible. Additionally, beer, wine, caffeinated beverages, picked meats, yeast preparations, avocados, bananas, and plums are to be avoided.

A nurse is caring for a client in active alcohol withdrawals on a med-surg unit. The client is observed speaking in a loud voice, using profanity with clenched fists. Which of the following actions should the nurse take? Select one: a. Insist that the client stop yelling. b. Request that other staff members remain close by. c. Walk away form the client. d. Move as close to the client as possible.

b. Request that other staff members remain close by. Use the team approach in crisis situations. do not intervene alone. The nurse should request that other staff members remain close by to assist if necessary.

RN is providing med instrux to a pt taking doxepin (Sinequan) daily. Which statement by the pt indicates a need for further instructions? a. "I need to avoid alcohol while taking the medication." b. "I need to take the medication in the morning before breakfast." c. "The effects of the medication may not be noticed for at least two weeks." d. "If I miss a dose, I need to take it as soon as possible unless it is almost time for the next dose."

b. "I need to take the medication in the morning before breakfast." The pt should be instructed to take the med (a single dose) at bedtime and not in the morning because it causes fatigue and drowsiness. The pt is instructed to take the medication as directed, and if a dose is missed to take it as soon as possible unless it is almost time for the next dose. The pt is told that medication effects may not be noticed for at least 2 weeks, and to avoid alcohol or other CNS depressants during therapy.

A client relates angrily to the nurse that his wife says he is selfish. Which response by the nurse would be most helpful? Select one: a. "Everyone is a little bit selfish." b. "You sound angry - tell me more about what went on." c. "I don't think that you are selfish." d. "That's just her opinion."

b. "You sound angry - tell me more about what went on."

An RN is caring for a pt in acute mania who is being treated with carbamazepine (Tegretol). The RN reviews the lab results of the drug plasma level and determines that the plasma level is in a therapeutic range if which of the following is noted? a. 18 mcg/ml b. 10 mcg/ml c. 1 mcg/ml d. 20 mcg/ml

b. 10 mcg/ml When carbamazepine is administered, plasma levels of the medication need to be monitored periodically to check for absorption of the medication. The amount of the medication prescribed is based on the results of this laboratory test. The therapeutic plasma level of carbamazepine is 3 to 14 mcg/ml.

The principle on which nursing intervention should be predicated when a client's aggression quickly escalates is: Select one: a. Ask the client what will be most helpful to him or her. b. Begin with the least restrictive measure possible. c. Staff should match client's affective level, tone of voice, and so forth. d. Immediately use physical containment measures.

b. Begin with the least restrictive measure possible. Legal constraints require that staff use the least restrictive measure possible. This becomes the principle for intervention.

The RN notes that a pt receiving lithium therapy is drowsy, has slurred speech, and is experiencing muscle twitching and impaired coordination. The RN takes which of the following actions? a. Increase fluids to 2000 ml per day b. Calls the physician c. Doubles the next lithium dose d. Holds one dose of lithium

b. Calls the physician Signs and symptoms of lithium toxicity include vomiting and diarrhea, and nervous system changes such as slurred speech, incoordination, drowsiness, muscle weakness, or twitching. Before administering any further doses, the RN should notify the physician. As long as there are no contraindications, the pt should routinely take in between 2000 to 3000 ml of fluid per day while taking this med.

A person who feels unattractive repeatedly says, "Although I'm not beautiful, I am smart." This is an example of: Select one: a. Devaluation b. Compensation c. Identification d. Repression

b. Compensation Compensation is an unconscious process that allows an individual to make up for deficits in one area by excelling in another area to raise self-esteem.

A patient is undergoing diagnostic tests. the patient says, "Nothing is wrong with me except a stubborn chest cold." the spouse reports that the patient smokes, coughs daily, and has lost 15 pounds and is easily fatigued. Which defense mechanism is the patient using? Select one: a. Projection b. Denial c. Regression d. Displacement

b. Denial Denial is an unconscious blocking of threatening or painful information or feelings.

The client says to the nurse "I am going to die, I wish my family would stop hoping for a cure! I get so angry when they carry on like this! After all, I'm the one who's dying." The most therapeutic response is: Select one: a. "I think we should talk more about your anger with your family." b. Have you shared your feelings with your family?" c. "You're feeling angry that your family continues to hope for you to be cured." d. "Well, it sounds like you're being pessimistic. After all, years ago people died of pneumonia."

b. Have you shared your feelings with your family?"

The nurse is preparing the client for the termination phase of the nurse-client relationship. The nurse prepares to implement which nursing task is most appropriate for this phase? Select one: a. Identifying expected outcomes. b. Making appropriate referrals. c. Developing realistic solutions. d. Planning short term goals.

b. Making appropriate referrals.

An individual experiences sexual dysfunction and blames it on a partner by calling the person unattractive and unromantic. Which defense mechanism is evident? Select one: a. Compensation b. Rationalization c. Introjection d. Regression

b. Rationalization Rationalization involves unconsciously making excuses for one's behavior, inadequacies, or feelings.

The client on the mental health unit who should be assessed as being at highest risk for directing violent behavior towards others is... Select one: a. The client who has severe depression with delusions of worthlessness. b. The client who has paranoid delusions that she is being followed by members of the mafia. c. The client who has obsessive-compulsive disorder and performs many rituals. d. The client who has completed alcohol withdrawal and is beginning a rehabilitation program.

b. The client who has paranoid delusions that she is being followed by members of the mafia. This client has the greatest disruption of ability to perceive reality accurately. People who feel persecuted may strike out against those believed to be persecutors.

A pt who is on chlorpromazine (Thorazine) is preparing for discharge. In developing a health promotion plan for the pt, the RN instructs the pt: a. To have the therapeutic blood levels drawn because there is a narrow range between the therapeutic and toxic levels of the medication. b. To avoid prolonged exposure to the sun. c. On the signs and symptoms of relapse for depression. d. To adhere to a strict tyramine-resticted diet.

b. To avoid prolonged exposure to the sun. Chlorpromazine is an antipsychotic med often used in the treatment of psychosis.P hotosensitivity is sometimes a side effect of the phenothiazine class of antipsychotic medications to which chlorpromazine (Thorazine) belongs.Options 1, 2, and 4 are unrelated to the administration of this med.

An RN is caring for a pt who has been taking clozapine (Clozaril) for the treatment of a schizophrenic disorder, and the RN reviews the labs that have been prescribed for the pt. Which lab result will the RN specifically review to monitor for an adverse effect associated with the use of this med? a. Blood urea nitrogen b. White blood cell count c. Hemoglobin level d. Cholesterol level

b. White blood cell count Hematological reactions can occur in the patient taking clozapine and include agranulocytosis and mild leukopenia.The white blood cell count should be assessed before initiating treatment and should be monitored closely during the use of this medication.The client should also be monitored for signs indicating anranulocytosis, which may include sore throat, malaise, and fever.Options 2, 3, and 4 are unrelated to the use of this medication.

A client is pacing the hall near the nurses' station, swearing loudly. An appropriate initial intervention for the nurse would be to address the client by name and say... Select one: a. "Please quiet down" b. "You need to go to your room to get control of yourself." c. "You seem upset. Tell me about it." d. "Hey, what's up?"

c. "You seem upset. Tell me about it." Intervention should begin with analysis of the client and the situation. With this response the nurse is attempting to hear the client's feelings and concerns. This leads to the next step of planing an intervention.

An RN is developing a teaching plan for a pt who will be receiving phenelzine sulfate (Nardil). The RN plans to tell the pt to avoid: a. Vasodilators b. Cherries and blueberries c. Aged cheeses d. Digitalis preparations

c. Aged cheeses Phenelzine sulfate is in the monoamine oxidase inhibitor (MAOI) clase of antidepressant medications. An individual on an MAOI must avoid aged cheeses, alcoholic beverages, avocados, bananas, and caffeine drinks. There are also other food items to avoid, including chocolate, meat tenderizers, picked herring, raisins, sour cream, yogurt, and soy sauce. Meds that should be avoided include amphetamines, antiasthmatics, and certain antidepressants. The pt should also avoid antihistamines, anti-HTN meds, levodopa (L-Dopa), and meperidine (Demerol).

"Dry as a bone, red as a beat, hot as a hare, blind as a bat, and mad as a hatter" describes the symptoms of: a. Neurleptic melignant syndrome b. Lithium toxicity c. Anticholinergic toxicity d. Serotonin Syndrome

c. Anticholinergic toxicity Anticholinergic toxicity is a potentially fatal condition characterized by skin that is hot, dry and flushed, blurred vision, and CNS effects (hallucinations and delirium). Death can result from respiratory depression caused by the blockage of muscarinic cholinergic receptors.Many of the psychiatric drugs have anticoloinergic side effects, especially the tricyclic antidepressants and phenothiazine antipsychotics.These should be used cautiously in older adults and in patients taking multiple drugs with anticholinergic properties.

Which patient behavior is a criterion for mechanical restraint? Select one: a. Refusing a medication dose. b. Screaming profanities. c. Assaulting a staff person. d. Throwing a pillow at another patient. e. Spitting at a family member during visiting hours.

c. Assaulting a staff person. Indications for the use of mechanical restraint include protecting the patient form self-harm and preventing the patient from assaulting others.

A pt who has been diagnosed with Schizoaffective Disorder, Bipolar Type has an order to receive valproicacid (Depakene) 500mg once daily. To maximize the patient's safety, the RN schedules administration of the med: a. With breakfast b. Before breakfast c. At bedtime d. With lunch

c. At bedtime Depakote (valproic acid) can be given twice or three times a day. However, when it is given once a day...it is at bedtime as the higher dose all at once causes drowsiness. This also helps when checking blood levels because the patient's last dose would have been in the evening and the blood draw is in the morning. It can cause stomach upset so its good to eat something before ingesting the dose. Valproic acid is a mood stabilizer and anticonvulsant that causes central nervous system (CNS) depression. For this reason, the side effects include sedation, dizziness, ataxia, and confusion. When the patient is taking this medication as a single daily dose, administering it at bedtime negates the risk of injury from sedation and enhances patient safety. Otherwise, it may be given after meals to avoid gastrointestinal upset.

The first task in assessing violent behavior should be Select one: a. Establishing a treatment plan. b. Obtaining information from observers. c. Determination of the cause. d. Admission to the hospital. e. Ascertaining degree of injuries.

c. Determination of the cause. Cause directs treatment.

The medication protocol the nurse should use to provide immediate intervention for an angry psychotic client whose aggressive behavior continues to escalate despite verbal intervention is: Select one: a. Trazodone b. Valproic Acid c. Haloperidol d. Lithium

c. Haloperidol Haloperidol is a short-acting antipsychotic that is useful in calming angry, aggressive clients regardless of their diagnosis.

Two hours after a client lost control and required restraints and PRN medication, she is out of restraints, calm, and sitting in her room reading. The post-intervention debriefing process is initiated by the nurse and includes: Choose all that apply Select one or more: a. Suggesting that the client may wish to apologize. b. Avoiding mentioning the incident. c. Helping the client identify the precipitating event. d. Reestablishing therapeutic communication and rapport with client. e. Reviewing possible alternative coping strategies.

c. Helping the client identify the precipitating event. The post-intervention debriefing process should be attempted when the client is calm. This processing helps the client and staff understand what happened and how further incidents of violence can be avoided. Identification of the precipitating event is critical. Once this is accomplished, the client and nurse can discuss possible alternative coping strategies and role play those chosen. d. Reestablishing therapeutic communication and rapport with client. The post-intervention debriefing process should be attempted when the client is calm. This processing helps the client and staff understand what happened and how further incidents of violence can be avoided. Identification of the precipitating event is critical. Once this is accomplished, the client and nurse can discuss possible alternative coping strategies and role play those chosen. e. Reviewing possible alternative coping strategies. The post-intervention debriefing process should be attempted when the client is calm. This processing helps the client and staff understand what happened and how further incidents of violence can be avoided. Identification of the precipitating event is critical. Once this is accomplished, the client and nurse can discuss possible alternative coping strategies and role play those chosen.

The nurse is meeting a new client on the unit. Which action, by the nurse, is most effective in initiating the nurse-client relationship? Select one: a. Describe the nurse's family and ask the client to describe his/her family. b. Wait until the client indicates a readiness to establish a relationship. c. Introduce self and explain the purpose and the plan for the relationship. d. Ask the client why he/she was brought to the hospital.

c. Introduce self and explain the purpose and the plan for the relationship.

The most therapeutic response a nurse could make to a student who begins to cry upon learning that a failing grade was received on a final exam is: Select one: a. "It won't seem so important 5 years from now." b. "You'll make it next time." c. "How close were you to passing?" d. "Failing an exam is an upsetting thing to happen."

d. "Failing an exam is an upsetting thing to happen."

A patient who is experiencing moderate anxiety says, "I feel undone." An appropriate response for the nurse would be: Select one: a. What would you like me to do to help you? b. "Why do you suppose you are feeling anxious?" c. "You must get your feelings under control before we can continue." d. "I'm not sure I understand. Give me an example."

d. "I'm not sure I understand. Give me an example." Increased anxiety results in scattered thoughts an an inability to articulate clearly. Clarification helps the patient identify his or her thoughts and feelings.

A home care RN visits a pt at home. Clonazepam (Klonopin) has been prescribed for the pt, and the RN teaches the pt about the med. Which statement by the pt indicates that further teaching is necessary? a. "I can take my medication at bedtime if it tends to make me feel drowsy." b. "My drowsiness will decrease over time with continued treatment." (could be a sign of acute toxicity; ATI, p. 175) c. "I should take my medication with food to decrease stomach problems." (true; ATI, p. 176) d. "If I experience slurred speech, it will disappear in about 8 weeks."

d. "If I experience slurred speech, it will disappear in about 8 weeks." Pts who are experiencing signs and symptoms of toxicity with the administration of clonazepam exhibit slurred speech, sedation, confusion, respiratory depression, hypotension, and eventually coma. Some drowsiness may occur but will decrease with continued use. The med may be taken with food to decrease GI irritation. The other options are correct and represent an accurate understanding of the med.

A client looks at a mirror and cries out, "I look like a bird. This is not my face." The nurse responds therapeutically by saying: Select one: a. "What kind of a bird do you think you are?" b. "Maybe the light is playing tricks on you." c. "Why do you think that you look like a bird?" d. "That must be very distressing to you, your face does not look different to me."

d. "That must be very distressing to you, your face does not look different to me."

A violent patient is restrained. What is the nurse's first priority? Select one: a. Obtain an order from the health care provider. b. Debrief the patient. c. Administer a sedating medication. d. Ensure the patient's safety.

d. Ensure the patient's safety. Once in restraints, a patient must be directly observed and formally assessed at frequent, regular intervals for level of awareness, level of activity, safety with the restraints, hydration, toileting needs, nutrition and comfort.

A client has, in the past, had a nursing diagnosis of ineffective coping related to impulsively acting out anger as evidenced by striking others. An appropriate plan for forestalling such incidents would be: Select one: a. Offer one-on-one supervision to help the client maintain control. b. Request that the client receive lorazapam (Ativan) every 4 hours to reduce anxiety. c. Explaining that restrain and seclusion will be used if violence occurs. d. Helping a client identify incidents that trigger impulsive acting out.

d. Helping a client identify incidents that trigger impulsive acting out. Identification of trigger incidents allows the client and nurse to plan interventions that reduce irritation and frustration, which lead to acting out anger, and eventually to put into practice more adaptive coping strategies.

A patient tells a nurse, "My new friend is the most perfect person one could imagine; kind, considerate, and good looking. I can't find a single flaw." This patient is demonstrating: Select one: a. Compensation b. Projection c. Denial d. Idealization

d. Idealization Idealization is an unconscious process that occurs when an individual attributes exaggerated positive qualities to another.

Mrs. F. has remained close to the nurse all day. When the nurse talked with other clients during dinner, Mrs. F. tried to regain the nurse's attention and began to shout, "You're just like my mother. You pay attention to everyone but me!" The best interpretation of this behavior is that... Select one: a. Mrs. F. has been spoiled by her family. b. The nurse has failed to meet Mrs. F's needs. c. Mrs. F. is exhibiting resistance. d. Mrs. F. is demonstrating transference.

d. Mrs. F. is demonstrating transference.

Lorazepam (Ativan) is prescribed for a pt to manage anxiety. Which of the following, if noted on the pt's record, would indicate the need to consult with the physician before administering the med? a. History of hypothyroidism b. History of diabetes mellitus c. History of coronary artery disease d. Positive pregnancy test

d. Positive pregnancy test Lorazepam is contraindicated in pts who are pregnant (Category D) or breastfeeding because this drug crosses the placenta and breast milk posing potential danger to the fetus or newborn infant in view of their pharmacologic effects, side effects, or complications. It is also not prescribed for pts who have a hypersensitivity or cross-sensitivity with other benzodiazepines. It is contraindicated in pts who are comatose, with preexisting CNS depression, those with uncontrolled severe pain, and those with narrow-angle glaucoma.

A client who was brought into the emergency room by EMS intoxicated, suddenly removes a knife from his coat pocket and threatens to kill himself or anyone who tries to stop him from leaving the room. A psychiatric emergency code is called and the client is safely disarmed and placed in restraints. the rationale for use of restraints was that the client: Select one: a. Presented a clear escape risk. b. Was psychotic. c. Clearly evidenced a thought disorder, rendering him incapable of rational decision. d. Presented a clear and present danger to self and others.

d. Presented a clear and present danger to self and others. The client's threat to kill himself and others with the knife he possessed constituted a clear and persent danger to self and others.

What is the team intervention techniques used in nonviolent crisis intervention? Select one: a. CARE: Combine, Assign, Redirect, Explain b. ARD: Assess, Restrain, Debrief c. APT: Assess, Plan, Treat d. TIP: Team, Isolate, Plan

d. TIP: Team, Isolate, Plan The TIP technique focuses on having a team of two to three staff members with one being the team leader who approaches the client and maintains one-to-one communication. Isolation of the individual and situation helps decrease stimuli, provides for a more therapeutic environment and confidentiality, as well as maintaining a safe and therapeutic milieu. . A plan should be reviewed with the team on how best to to balance or offset the person's behavior with therapeutic responses by the staff. Taking physical control of a person when he has lost complete control is the most therapeutic process possible, if the action by staff is carried out in an nonharmful, nonviolent manner.

With conventional (typical) antipsychotics, the higher the potency, a. the higher the risk for sedation. b. The lower the risk for dystonia. c. The lower the risk for EPS. d. The higher the risk of EPS.

d. The higher the risk of EPS. Conventional (first generation) antipsychotics with high potency have a stronger D2 receptor blockade than those with low potency, thereby decreasing dopamine levels in the nigrostriatal pathway.This can result in drug-induced extrapyramidal side-effects involving movement, including parkinsonism (tremor, bradykinesia, rigidity), dyskinesias, and akathesia.

An effective nursing intervention for helping angry clients learn to manage anger without violence would be: Select one: a. Administering antianxiety medications. b. Administering antipsychotic medications c. Providing negative reinforcement such as restraint or seclusion in response to angry outbursts, whether or not violence is present. d. Using cognitive strategies to identify a thought that increases anger, find proof for or against the belief, and substitute reality-based thinking.

d. Using cognitive strategies to identify a thought that increases anger, find proof for or against the belief, and substitute reality-based thinking. Anger has a strong cognitive component, so using cognition to manage anger is logical.

Which statement about aggression would serve as the rational for care planning using behavioral techniques? Aggression... Select one: a. runs in families and is manifested as early as infancy. b. results from low levels of the neurotransmitter serotonin. c. results from abnormalities in the temporal lobe of the brain. d. is motivated by rewards received for previous aggression.

d. is motivated by rewards received for previous aggression. Behavioral therapy does not accept aggressive drives as being instinctual or biological. It views aggressive behavior as a learned response that tends to be repeated if reinforced.