Psych Mental Health
What finding should the PN report to the nurse concerning possible abuse of a child? A. A 4-month-old infant with fever that cannot be consoled. B. A toddler who cries when the father enters the room. C. An adolescent who refuses to speak to a parent. D. A 3-year-old who begins bed-wetting during hospitalization.
A toddler who cries when the father enters the room. Rationale: Since toddlers usually struggle with stranger anxiety and welcome the presence of a parent, the PN should report a toddler who begins to cry when the father enters the room, which may indicate fear related to possible abuse. (A, is a common finding that is consistent with fever in an infant. Adolescents commonly struggle with independence and dependency, a development task, which may be characterized by refusal to speak to a parent (C). The stress of hospitalization can cause a previously toilet-trained child to wet the bed, especially at night (D).
The PN is assessing a client who has been noncompliant with a prescribed diabetic diet and exercise regimen. This client is using which defense mechanism? A. Denial. B. Projection. C. Dissociation. D. Displacement.
A. Denial Rationale: The client is using (A) to avoid the seriousness of the illness, which interferes with treatment. (B) occurs when an individual attributes his or her own unacceptable traits, ideas, or impulses to another. (C) occurs when an idea, thought, emotion or other mental process is separated from the consciousness and thereby loses emotional significance. (D) occurs when one avoids emotional conflict and anxiety by transferring emotions, ideas or wishes from one object to a substitute that is less anxiety-producing.
The PN is collecting admission data for a young man with a hx of chronic mental illness who is admitted to the mental health unit. What client information is most important in guiding the PN in the data collection? A. Displays aggressive and assaultive behavior. B. Expresses denial to comply with treatment. C. Requests to leave against medical advice. D. States he knows how to fit his diagnosis.
A. Displays aggressive and assaultive behavior. Rationale: When collecting admission data, it is more important to implement safety and staff protective measures for the client's display of aggressive and assaultive behavior (A). Although (B, C and D) are supported by the client's basic rights and self-determination, the client's admission is likely related to a crisis state and emergency admission provides safety for the client until the healthcare provider can assess, diagnosis, initiate treatment, and legal judgements, if indicated.
A male client who is diagnosed with schizophrenia, catatonic type, is admitted to the mental health unit and does not verbally communicate to any of the staff. His wife states that he became increasingly anxious, withdrawn, and stayed in bed staring at the wall since his recent job promotion. Which nursing diagnosis should the PN implement for this client? A. Impaired verbal communication related to severe anxiety. B. Personal identity disturbance related to workplace stress. C. Fear of responsibility related to a promotional opportunity. D. Ineffective individual coping related to unresolved conflict.
A. Impaired verbal communication related to severe anxiety. Rationale: Impaired verbal communication can result from maladaptive neurobiological responses that results from a precipitating stressor, which is most likely severe anxiety aroused by this client's recent job promotion (A). (B, C, and D do not address the concept of psycho-cognitive functioning in schizophrenia.)
The PN is talking with a male client about his recent job loss. What is the most important factor to explore with the client? A. Importance of the job to the client. B. Size of his support system. C. Awareness of his opinions. D. His family's feelings about the loss.
A. Importance of the job to the client. Rationale: The client's perception of his loss is a key factor (A). What may be trivial to one person may seem overwhelming to another. If the client does not perceive the event as problematic, a crisis may be averted. (B, C, and D are less relevant.)
What is the most prevalent type of elder abuse? A. Neglect. B. Physical abuse. C. Financial abuse. D. Emotional abuse.
A. Neglect Rationale: Neglect (A), whether intentional or unintentional, is the most prevalent type of elder abuse and occurs when a caregiver fails to provide basic needs such as food, clothing, or assistance with ADL's. (B) accounts for approximately one fourth elder abuse and is the result of bodily harm, such as hitting, burning, pushing, or molesting the older adult. (C) is more common than physical abuse and occurs when the older adult's property or resources are mismanaged or misused. (D) includes intentional use of threats, humiliation, intimidation and isolation and occurs in more the one third of all cases of elder abuse.
The PN is answering questions for a family member whose parent has early Alzheimer's Disease (AD). Which information should the PN provide? A. AD is a form of dementia that consists of progressive loss of recent memory and disorientation to time and place. B. AD is a form of chronic dementia that may improve with medication, diet, behavioral and environmental management. C. AD is secondary dementia that is characterized by brain atrophy that causes progressive cognitive degeneration and inability to function. D. AD is primary, irreversible, and fatal dementia that is caused by deposits of beta-amyloid protein causing senile plaques in the brain.
AD is primary, irreversible, and fatal dementia that is caused by deposits of beta-amyloid protein causing senile plaques in the brain. Rationale: Alzheimer's disease is best described in (D). The client is most likely manifesting early symptoms of AD (A), so an explanation that clearly defines the irreversible and fatal progression of AD provides the family member with the best information. (B and C are not accurate.)
A female client who is admitted to the outpatient surgical center for a bilateral tubal ligation starts to cry while waiting to go to surgery. Which therapeutic statement should the PN offer the client? A. "I'm here for you. Everything is going to be all right." B. "Can you tell me what is bothering you?" C. "Do you want your husband to come to the bedside?" D. "Don't be afraid. The procedure is safe."
B. "Can you tell me what is bothering you?" Rationale: The goal of therapeutic communication is to focus on the client and her concerns. The therapeutic technique of clarification (B) assists the client to put into words the vague feelings or ideas that she is experiencing. (A and D provide false reassurance and are non-therapeutic.) (C dismisses the client's feelings and anxiety which should be explored to allow the client to verbalize her immediate distress.)
Which response should the PN offer to express empathy to a female client who is depressed and continues to talk about her grief over recent losses? A. "Lets focus on topics today that have given you some happiness." B. "Tell me more about what you are feeling." C. "I lost my parents last year and still feel sad." D. "I had several family losses in one month and continued working."
B. "Tell me more about what you are feeling." Rationale: (B) is the best response because it focuses on the needs of the client and indicates that the PN is interested in what the client has to say. (A) is an attempt to refocus the subject and dismisses the client's grief, which keeps the communication process superficial. (C and D are self-focusing responses.)
A male client who learns his results for HIV is seropositive tells the PN that he is experiencing constant heart palpitations, cannot concentrate, and walks about trembling. What reaction to the diagnosis is the client demonstrating? A. Guilt. B. Acute anxiety. C. Suicidal ideations. D. Disappointment.
B. Acute anxiety Rationale: Acute anxiety (B) is manifested by physiological responses, such as a fight or flight reaction, which includes increases in heart rate, vigilance, pacing, jitterness, and a feeling of impending doom. (A, C, D do not demostrate feelings of anxiety.)
A male client who is hospitalized for an acute episode of schizophrenia is sitting in the dayroom of the mental health unit without any clothes on. He is telling everyone who looks at him that he is "the body beautiful." Which intervention should the practical nurse implement? A. Tell the client to put his clothes on immediately. B. Cover the client while assisting him to his room. C. Ignore the behavior to prevent the client's repetition of the behavior. D. Seclude the client until he can regain control of impulsive behavior.
B. Cover the client while assisting him to his room. Rationale: Sexual expression, such as public nudity by a client with schizophrenia, is socially unacceptable and intrusive to others. Although the client may not be able to control sexual thoughts or impulses, neutral and nonjudgmental nursing interventions should be implemented to protect the client from the social consequences of his own judgement. (A and C, do not provide the client with privacy and respect.) (D, removes the client from public view, the best action is to ensure the client's dignity and privacy immediately.)
Based on Maslow's hierarchy of needs, which nursing strategies should the practical nurse implement to promote a client's self-esteem? A. Supporting needs for intimacy. B. Promoting physical appearance. C. Assisting with obtaining financial help. D. Identifying contributions of the person.
B. Promoting physical appearance. Rationale: Promoting physical appearance (B) contributes to a client's self-esteem, which is Maslow's fourth level of needs. The need for intimacy (A) is reflected on the third level, love and belonging. The need for financial help (C) is on the second level, safety and security. Identifying contributions of the person (D) are reflected on level five, self-actualization.
The PN is interacting with a male client who is worried about being admitted to the mental health unit. Which self-reported characteristic should the PN acknowledge as most indicative of the client's healthy boundary of self-concept? A. Lets others define his self-concept. B. Takes responsibility to meet his own needs. C. Gives to others for the sake of giving. D. Believes others should anticipate his needs.
B. Takes responsibility to meet his own needs. Rationale: The client who acts responsibly in meeting his own needs (B) best describes a client's healthy boundary, so acknowledging this self-appraised self-concept provides the best feed back. Giving as much as possible for the sake of giving (C), believing others can anticipate the client's own needs (D) and letting others define the client (A) are examples of unhealthy boundaries, rather than assertive behavior.
A client admitted with major depressive disorder 3 weeks ago and received a prescription for sertraline (Zoloft) on admission. Today the client self-reports feeling great. It is most important for the PN to consider which information when implementing care for this client? A. The relationship between the depth of depression and suicide ideation exists. B. The client may be increased risk for suicide as the depression lifts. C. The medication takes 2 weeks to be effective, so the treatment is working well. D. The client is improving, so discharge planning should be considered.
B. The client may be at increased risk for suicide as the depression lifts. Rationale: Severely depressed clients may have suicidal ideation but lack the cognitive to plan an attempt and the energy to implement a plan. As depression lifts, the client may be better able to plan a suicide attempt and may have sufficient energy to carry out a plan, so (B) is the most important consideration. (A, B and C are accurate considerations, but for this client (B) is the most important.
A male client who believes he has a brain tumor after numerous diagnostic tests that indicate no evidence of organic disease tells the PN, "No one believes me! I have the symptoms: terrible headaches and episodes of blurred vision. Last week I felt weak and even vomited. I'm going to die." Which response by the PN fosters cognitive restructuring? A. "Tell me about your relationships with the significant women in your life." B. "Sharing your thoughts and feelings about death can be helpful." C. "There are other possible explanations for your symptoms." D. "Based on your diagnostic results, your concern is unfounded."
C. "There are other possible explanations for your symptoms." Rationale: Clients with illness anxiety disorder often ignore any possibilities except those that support their distorted thinking and questioning the evidence is a cognitive restructuring technique that can be effective. Learning that his symptoms can have other causes other than a brain tumor can help the client restructure his beliefs about his health. Asking the client to examine his relationships (A) is an insight-oriented communication technique, not cognitive restructuring. (B) acknowledges the client's statement about his death but does not help the client reexamine his beliefs about his symptoms. (C) is confrontational and ineffective.
A female client is anxious about a scheduled diagnostic procedure and keeps asking the same question of every staff person. How should the practical nurse respond? A. Encourage the client to watch television as a distraction. B. Reinforce with the client the need for the procedure regardless. C. Affirm the client's anxiety and ask if she wants to talk. D. Reassure the client that the procedure is performed for others every day.
C. Affirm the client's anxiety and ask if she wants to talk. Rationale: Understanding the client's anxiety and offering to talk about it gives the client an opportunity to express her feelings and work through the anxiety. Although distraction, reinforcement and reassurance can be useful, they do not help the client cope with anxiety.
A male client who is a minor motor vehicle collision (MVC) while on the job is brought to the urgent care clinic. The healthcare provider prescribes a urine drug screen, but the client repeatedly refuses to provide a specimen. Which action should the PN implement? A. Collect a urine specimen using a sterile catheter. B. Detain the client in the clinic until he cooperates. C. Document the client's refusal in the medical record. D. Palpate the pubic symphysis for urinary retention.
C. Document the client's refusal in the medical record. Rationale: A client has the right to refuse treatment, so the PN should document the client's refusal in the medical record (C). (A) can be considered assault or battery since the client refuses the procedure. (B) violates the client's rights to determine his choice in care. (D) is not indicated at this time.
A 35-year-old male client is admitted after a suicide attempt. Which action should the PN implement when interacting with the client? A. Redirect conversations that focus on the topic of suicide. B. Recommend that the client focus on peers rather than self-absorption. C. Encourage the client to express feelings rather than suppress them. D. Discuss the impact that suicidal behaviors have on his family.
C. Encourage the client to express feelings rather than suppress them. Rationale: Expressing feelings in a therapeutic environment decreases hopelessness, so encouraging the client to express any feelings (C), particularly suicidal thoughts, is the priority. Avoiding the discussion of a suicide (A) impedes recognition and early intervention for suicidal ideations, such as detail and lethality of suicidal plan. A client who is suicidal often finds it difficult to move from self-absorption to others' perspective (B and D) because of his own feelings of unworthiness, fear of rejection by others and low self-esteem.
What is the primary purpose for the PN to use the therapeutic communication? A. Maintain relationships. B. Mutually share information. C. Promote growth and change in clients. D. Offer advice, suggestions, and spontaneous messages.
C. Promote growth and change in clients. Rationale: Promoting growth and change in clients (C) is a goal of therapeutic communication. Social communication includes the maintaining the social relationship (A), mutual sharing of information (B), and offering advice, suggestions and spontaneous messages (D).
A male client arrives at the mental health clinic and tells the PN that he is overwhelmed and does not know how to talk about his life. Based on the client's comments, what aspect of the client's life should the PN explore first with the client? A. Coping mechanisms. B. Problem resolution. C. Support system. D. Perception of the event.
C. Support system Rationale: The client is alluding to the lack of support, so determining if the client has family, friends, clergy, or coworkers should be identified first. (A, B, and D are other factors that should be explored after the nurse-client relationship is established.)
Which behavior should the PN identify as aggressive in a client who is admitted to the mental health unit? A. Acts passive when personal rights are challenged. B. Uses statements that express feelings of victimization. C. Verbally attacks and demeans peers in group settings. D. Addresses others with mister or misses before last name.
C. Verbally attacks and demeans peers in group settings. Rationale: Aggressive behavior is characterized by demeaning or attacking speech patterns (C). Passive behavior (A and B) is characterized by feelings of victimization and personal rights violations. Respect is implied with addressing others with salutations (D) and last names.
A debilitated, older female client with Alzheimer's disease who is admitted to the hospital is bewildered and begins to kick and push away an unlicensed assistive personnel. What action should the PN take? A. Orient the client to time, person and place. B. Remind the client that the staff members are available to help her. C. Place soft restraints on the client to prevent injury. D. Ask a person who is familiar to the client to sit at the bedside.
D. Ask a person who is familiar with the client to sit at the bedside. Rationale: Clients with AD are unable to engage in self care and have difficulty adapting to new environments and information. A familiar person (D) can provide comfort and distraction and can ease the client's transition to the hospital. The client is not able to understand or retain reorientation or teaching (A and B). Alternative measures, such as distraction, should be used before restraints (C), which often increase anxiety and combativeness.
Which drug is commonly prescribed for a client with ADHD? A. Haloperidol (Haldol) B. Imipramine (Tofranil) C. Fluphenazine (Prolixin) D. Methylphenidate (Ritalin)
D. Methylphenidate (Ritalin) Rationale: A central nervous system stimulant, such as Ritalin (D), provides effective treatment for clients with ADHD (A, B, and C are not used with ADHD.)
The mother of a child who is brought to the clinic unconscious is hysterical, yelling, becoming increasingly agitated and throws her bottle of water on the floor. Which response should the practical nurse make? A. Use an authoritative approach to confront her to control her behaviors. B. Inform her that this behavior is unacceptable in the clinic. C. Call for security officers to assist her from the premises. D. Step aside and reassure the mother that the staff is present to help.
D. Step aside and reassure the mother that the staff is present to help. Rationale: The client is exhibiting excessive agitation, which has the potential for violence. To ensure a safe environment, the PN should maintain a distance that avoids the client's physical reach and reassure her that the staff are here to help.
An adolescent female who is admitted with bulimia tells the PN that she does not have an eating disorder. Which finding should the PN report that is most indicative of long-standing purging behaviors? A. Polyuria. B. Excessive facial hair. C. Dental enamel erosion. D. Elevated blood pressure.
Dental enamel erosion. Rationale: Dental enamel erosion results from repeated exposure of the teeth to gastric hydrochloric acid in vomitus and is most characteristic of long-standing purging behaviors seen in bulimia. Polyuria related to diuretic use and facial hair related to significant body fat loss and reduced estrogen production is more likely characteristic of anorexia nervosa. Hypotension, not elevated blood pressure, may be seen with bulimia.