Passpoint - Foundations of Psychiatric Nursing

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."

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?"

Which statement by a client with paraphilia indicates a potential for relapse?

"I can't imagine why the judge sent me here."

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 homosexual client tells the nurse that "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 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

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

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 must undergo a hysterectomy for uterine cancer. Which nursing action would best meet the woman's body image changes?

Encourage her to verbalize her feelings.

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 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 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.

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.

A nurse would observe a client undergoing electroconvulsive therapy (ECT) for which common adverse effect?

Short-term memory loss

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.

Assertive behavior involves which of the following elements?

Standing up for your rights while respecting the rights of others

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.

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.

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

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 client with a psychiatric disorder was voluntarily admitted and now wishes to be discharged from the hospital, against medical advice. Which aspect would be most important for the nurse to determine in this situation?

degree of danger to self and others

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 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 implements care for a client in a dissociative fugue. What does the nurse recognize may have preceded this diagnosis?

exposure to a major stressor recent history of rape

A client tells the nurse that he is only interested in sex when his partner wears cowboy boots and a scanty nightgown. Which term will the nurse use to describe this behavior?

fetishism

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

According to Erikson, an adolescent who's suffering from gender dysphoria can't progress through which developmental task?

identity versus role confusion

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.

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 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.

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 client is receiving electroconvulsive therapy (ECT) for the treatment of severe depression. After ECT, what is the priority nursing intervention?

Assess the client's vital signs.

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 nurse is reviewing a client's medication blood level values for a commonly administered psychiatric medication. Which medication, prescribed in individualized dosages according to the blood levels of the drug, would the nurse expect to find in this client's medication orders?

Lithium carbonate