Psych Student NCLEX Questions
A patient being seen in the emergency department immediately after being sexually assaulted appears calm and controlled. The nurse analyzes this behavior as indicating which defense mechanism? a. Denial b. Projection c. Rationalization d. Intellectualization
(A) Denial RATIONALE: Denial is refusal to admit to a painful reality and may be a response by a victim of sexual abuse. In this case the patient is not acknowledging the trauma of the assault either verbally or nonverbally. Projection is transferring one's internal feelings, thoughts, and unacceptable ideas and traits to someone else. Rationalization is justifying the unacceptable attributes about oneself. Intellectualization is the excessive use of abstract thinking or generalizations to decrease painful thinking.
A patient experiencing disturbed thought processes believes that his food is being poisoned. Which communication technique should the use to encourage the patient to eat? a. Using open-ended questions and silence b. Sharing personal preference regarding food choices c. Documenting reasons why the patient does not what to eat d. Offering opinions about the necessity of adequate nutrition
ANSWER: (A) Using open-ended questions and silence RATIONALE: Open-ended questions and silence are strategies use to encourage patients to discuss their problems. Sharing personal food preferences is not a patient-centered intervention. The remaining options are not helpful to the patient because they do not encourage the patient to express feelings. The nurse should not offer opinions and should encourage the patient to identify the reasons for the behavior.
Which of the following persons has the highest risk factors for physical abuse? A. Emma, a 7-month-old baby who has colic and doesn't sleep through the night B. Roland, a 53-year-old man with cardiovascular disease living with his son C. Penny, a 28-year-old wife whose husband has a diagnosis of an anxiety disorder D. Rose, a 77-year-old woman living with her daughter and son-in-law
ANSWER: D. Rose, a 77-year-old woman living with her daughter and son-in-law. RATIONALE: Older women dependent on family members for care are at higher risk for abuse. The other options do not describe specific characteristics that put them at higher risk for abuse. Reference: pp. 534-535
Which nursing intervention is best for facilitating communication with a psychiatric client who speaks a foreign language? a. Rely on nonverbal communication. b. Select symbolic pictures as aids. c. Speak in universal phrases. d. Use the services of an interpreter.
D: An interpreter will enable the nurse to better assess the client's problems and concerns. Nonverbal communication is important; however for the nurse to fully determine the client's problems and concerns, the assistance of an interpreter is essential. The use of symbolic pictures and universal phrases may assist the nurse in understanding the basic needs of the client; however these are insufficient to assess the client with a psychiatric problem.
Which statement demonstrates the BEST understanding of the nurse's role regarding ensuring that each client's rights are respected? a. "Autonomy is the fundamental right of each and every client." b. "A patient's rights are guaranteed by both state and federal laws." c. "Being respectful and concerned will ensure that I'm attentive to my patient's rights." d. "Regardless of the patient's conditions, all nurses have the duty to respect patient rights."
(C) "Being respectful and concerned will ensure that I'm attentive to my patients' rights." RATIONALE: The nurse needs to respect and have concern for the patient; this is vital to protecting the patient's rights. While it is true the autonomy is a basic client right, there are other rights that must also be both respected and facilitated. State and federal laws do protect a patient's rights, but it is sensitivity to those rights that will ensure that the nurse secures these rights for the patient. It is a fact that safeguarding a patient's rights are a nursing responsibility, but stating that fact does not show understanding or respect for the concept.
A client who is pacing and wringing his hands states, "I just need to walk" when questioned by the nurse about what he is feeling. Which of the following responses by the nurse is most therapeutic? A. "You need to sit down and relax." B. "Are you feeling anxious?" C. "Is something bothering you?" D. "You must be experiencing a problem now."
ANS: B Asking, "Are you feeling anxious?" helps the client to specifically label the feeling as anxiety so that he can begin to understand and manage it. Some clients need assistance with identifying what they are feeling so they can recognize what is happening to them. Stating, "You need to sit down and relax," is not appropriate because the client needs to continue his pacing to feel better. Asking if something is bothering the client or saying that he must be experiencing a problem is vague and does not help the client identify his feelings as anxiety.
The nurse has a client who checks and rechecks her home in response to an obsessive thought that her house will burn down. The nurse and client explore the likelihood that the house will actually burn. The client states this event is not likely. This counseling demonstrates principles of a. desensitization. b. cognitive restructuring. c. relaxation technique. d. flooding.
ANS: B Cognitive restructuring involves the client in testing automatic thoughts and drawing new conclusions. Option A: Desensitization involves graduated exposure to a feared object. Option C: Relaxation training teaches the client to produce the opposite of the stress response. Option D: Flooding exposes the client to a large amount of an undesirable stimulus in an effort to extinguish the anxiety response.
A severely dehydrated teenager admitted to the hospital with hypotension and tachycardia undergoes evaluation for electrolyte disturbances. Her history includes anorexia nervosa and a 20-lb (9.1-kg) weight loss in the last month. She is 5′ 7" (1.7 m) tall and weighs 80 lb (36.3 kg). Which nursing intervention takes highest priority? A. Initiating caloric and nutritional therapy as ordered B. Instituting behavioral modification therapy as ordered C. Addressing the client's low self-esteem D. Regularly monitoring vital signs and weight
ANSWER: A. Initiating caloric and nutritional therapy as ordered Rationale: The client with anorexia nervosa is at risk for death from self-starvation. Therefore, initiating caloric and nutritional therapy takes highest priority. Behavioral modification (in which client privileges depend on weight gain) and psychoanalysis (which addresses the client's low self-esteem, guilt, anxiety, and feelings of hopelessness and depression) are important aspects of care but are secondary to stabilizing the client's physical condition. Monitoring vital signs and weight is important in evaluating nutritional therapy but doesn't take precedence over providing adequate caloric intake to ensure survival
The nurse is providing care to a client admitted to the hospital with a diagnosis of acute anxiety disorder. The patient says to the nurse, " I have a secret I want to tell you. You won't tell anyone about it, will you?" What is the most appropriate nursing response? A. "No, I won't tell anyone." B. "I cannot promise to keep a secret." C. "It depends on what the secret is about." D. "If you tell me the secret, I may need to document it."
ANSWER: B RATIONALE: The nurse should never promise to keep a secret. Secrets are never appropriate in a therapeutic relationship. The nurse needs to be honest and tell the client that a promise cannot be made to keep the secret. The other options are inappropriate responses because they either promise to keep the secret or provide the criteria for when a secret may be appropriately kept.
Eating Disorders Question An effective intervention to facilitate individual coping for clients with eating disorders is to: a. provide the client with limited information on a need-to-know basis. b. prohibit the client from making decisions regarding care. c. provide the flexibility in activities of daily living. d. have the treatment team determine the client's plan of care.
ANSWER: C Rational: Provide flexibility in activities of daily living. Allowing the client the ability to determine daily activities encourages autonomy and increases the client's sense of responsibility.
During her aunt's wake, before a mother can stop her 4-year-old child, the child runs up to the casket. An appointment is made with a nurse practitioner when the child starts twisting and pulling out hair. Which nursing diagnosis should the nurse practitioner assign to this child? A. Complicated grieving B. Altered family processes C. Ineffective coping D. Body image disturbance
ANSWER: C Ineffective coping is defined as an inability to form a valid appraisal of the stressors, inadequate choices of practiced responses, and/or the inability to use available resources. This child is coping with the anxiety generated by viewing her deceased aunt by pulling out hair. If this behavior continues, a diagnosis of the impulse control disorder, trichotillomania, may be assigned.
The nurse cares for a patient with antisocial personality disorder. Which of the following statements, if made by the patient to the nurse, BEST indicates improvement in the patient's condition? A. "I get into trouble because I don't think before I act." B. "My parents have difficulty accepting my independence." C. "I've spent very little time actually enjoying life." D. "It's sad that others don't recognize my potential."
Answer A. Rationale: Introspective remark that shows the patient is beginning to realize that he or she acts out of anxiety or tension without realizing the consequences of her actions.
In the emergency department, a client with facial lacerations states that her husband beat her with a shoe. After the health care team repairs her lacerations, she waits to be seen by the crisis intake nurse, who will evaluate the continued threat of violence. Suddenly the client's husband arrives, shouting that he wants to "finish the job." What is the first priority of the health care worker who witnesses this scene? a. Remaining with the client and staying calm b. Calling a security guard and another staff member for assistance c. Telling the client's husband that he must leave at once d. Determining why the husband feels so angry
Answer B. The health care worker who witnesses this scene must take precautions to ensure personal as well as client safety, but shouldn't attempt to manage a physically aggressive person alone. Therefore, the first priority is to call a security guard and another staff member. After doing this, the health care worker should inform the husband what is expected, speaking in concise statements and maintaining a firm but calm demeanor. This approach makes it clear that the health care worker is in control and may diffuse the situation until the security guard arrives. Telling the husband to leave would probably be ineffective because of his agitated and irrational state. Exploring his anger doesn't take precedence over safeguarding the client and staff.
Declan is being discharged from the psychiatric unit on risperidone (Risperdal). You are providing medication teaching to Declan and his mother, who is his primary caregiver. Which of the following statements is the appropriate response to Declan's mother's question regarding the risk for extrapyramidal side effects (EPSs) while taking risperidone? A. All antipsychotic medications have an equal chance of producing EPSs. B. Newer antipsychotic medications have a higher risk for EPSs. C. Risperidone is a newer antipsychotic medication and has a lower risk of EPSs than older antipsychotics. D. Advise Declan's mother to ask the provider to change the medication to clozapine instead of risperidone.
Answer C. Risperidone is a newer, atypical antipsychotic. All newer antipsychotic medications have a lower incidence of EPSs than older, traditional antipsychotics. The other responses are untrue. There is no reason to advise a medication change at this time. Text page: 219
You are providing teaching to Lana, a preoperative patient just before surgery. She is becoming more and more anxious as you talk. She begins to complain of dizziness and heart pounding, and she is trembling. She seems confused. Your best response is to: A. reinforce the preoperative teaching by restating it slowly. B. have Lana read the teaching materials instead of verbal instruction. C. have a family member read the preoperative materials to Lana. D. not attempt any teaching at this time.
Answer D Rationale Patients experiencing severe anxiety, as the symptoms suggest, are unable to learn or solve problems. The other options would not be effective because you are still attempting to teach someone who has a severe level of anxiety. Reference: p. 279
Situation: In a home visit done by the nurse, she suspects that the wife and her child are victims of abuse. Which of the following is the most appropriate for the nurse to ask? a. "Are you being threatened or hurt by your partner? b. "Are you frightened of you partner" c. "Is something bothering you?" d. "What happens when you and your partner argue?"
Answer: (A) "Are you being threatened or hurt by your partner? The nurse validates her observation by asking simple, direct question. This also shows empathy. B, C, and D are indirect questions which may not lead to the discussion of abuse.
A patient's unresolved feelings related to loss would be most likely observed during which phase of the therapeutic nurse-patient relationship? a. Trusting b. Working c. Orientation d. Termination
Answer: (D) Termination Rationale: In the termination phase, the relationship comes to a close. Ending treatment sometimes may be traumatic for patients who have come to value the relationship and the help. Because loss is an issue, any unresolved feelings related to loss may resurface during this phase. The remaining options are not specifically associated with this issue of unresolved feelings.
A 32-year-old woman with borderline personality disorder and a history of attempted suicide has been married for 8 years, and her husband is filing for divorce. She was found wandering in a state of confused panic about her neighborhood and brought to the ED. She feels extremely anxious and abandoned. Which initial intervention is appropriate for this emotional crisis? A. Stay with the patient and reassure her. B. Administer anti-anxiety medication. C. Provide positive reinforcement. D. Draw up a no-suicide contract.
Answer: A The initial intervention for an emotional crisis reflecting psychopathology is to stay with the patient and reassure her until her panic subsides. People with borderline personality disorder (BPD) feel insecure and inherently worthless. They are often erratic and have difficulty establishing long-term relationships, although symptoms tend to lessen with age. The main feature of BPD is a persistent pattern of instability in interpersonal relationships, self-image, and emotion. Characteristics include attempts to avoid real or imagined abandonment and impulsiveness in at least two areas.
A client is admitted to the psychiatric unit with a diagnosis of alcohol intoxication and suspected alcohol dependence. Other assessment findings include an enlarged liver, jaundice, lethargy, and rambling, incoherent speech. No other information about the client is available. After the nurse completes the initial assessment, what is the first priority? A. Instituting seizure precautions, obtaining frequent vital signs, and recording fluid intake and output B. Checking the client's medical records for health history information C. Attempting to contact the client's family to obtain more information about the client D. Restricting fluids and leaving the client alone to "sleep off" the episode
Answer: A, Instituting seizure precautions, obtaining frequent vital signs, and recording fluid intake and output**Rationale: A nurse who lacks adequate information to determine which level of care a client requires must take all possible precautions to ensure the client's physical safety and prevent complications. To do otherwise could place the client at risk for potential complications. After taking all possible precautions, the nurse can begin seeking health history information and, as needed, modify the plan of care. Fluids are typically increased unless contraindicated by a preexisting medical condition.
A patient experiencing disturbed thought processes believes that his food is being poisoned. Which communication technique should the use to encourage the patient to eat? a. Using open-ended questions and silence b. Sharing personal preference regarding food choices c. Documenting reasons why the patient does not want to eat d. Offering opinions about the necessity of adequate nutrition
Answer: A, using open-ended questions & silence
Which child is demonstrating behaviors that support a diagnosis of adolescent onset conduct disorder? A. A 12-year-old male who steals a bicycle as a gang initiation B. A 9-year-old male who smokes half a pack of cigarettes a day C. A 12-year-old female who regularly bullies her younger siblings D. A 9-year-old female who engages in sexually provocative behaviors
Answer: A. A 12-year-old male who steals a bicycle as a gang initiation Rationale: In adolescent-onset conduct disorder, no symptoms are present prior to age 10. Affected adolescents tend to act out misconduct with their peer group. Males are more likely to fight, steal, vandalize, and have school discipline problems, whereas girls tend to lie, be truant, run away, abuse substances, and engage in prostitution.
The nurse overhears the client diagnosed with dementia tell a story about something that the nurse knows is not true. Which action by the nurse is best? A. Correct the information as presented. B. Allow the client to continue the story. C. Refer the client for reminiscence therapy. D. Orient the client to person, place, and time.
Answer: B Rationale: Allowing the client to continue the story supports a positive self-image; confabulation serves a defense against memory impairment; avoiding confrontation over fabricated stories will alleviate factors affecting dementia, and avoid increasing demands on the client's coping mechanisms.
A client in a primary care facility just learned that she must have a breast biopsy. As the nurse tries to give her information about the procedure, he notices that the client is perspiring and pale. Her breathing is rapid at about 28/ min and she says, "you'll have to excuse me; i don't quite understand what you're trying to tell me." The nurse should assess the client's anxiety as: A. mild B. moderate C. severe D. panic
Answer: B Rationale: Moderate anxiety decreases problem solving and may hamper one's ability to understand information. VS may increase somewhat and the person is visibly anxious. In mild anxiety, the person's ability to understand information may actually increase. Severe anxiety causes restlessness, decreased perception, and an inability to take direction. During a panic attack, the person is completely distracted, unable to function, and may lose touch with reality.
A client is brought to an emergency department after being violently raped. Which nursing action is appropriate? A. Discourage the client from discussing the event as this may lead to further emotional trauma. B. Remain nonjudgmental and actively listen to the client's description of the event. C. Meet the client's self-care needs by assisting with showering and perineal care. D. Provide cues, based on police information, to encourage further description of the event.
Answer: B The most appropriate nursing action is to remain nonjudgmental and actively listen to the client's description of the event. It is important to also communicate to the victim that he or she is safe and that it is not his or her fault. Nonjudgmental listening provides an avenue for client catharsis needed in order to begin the process of healing.
A male client admitted to the psychiatric unit for treatment of substance abuse says to the nurse, "It felt so wonderful to get high." Which of the following is the most appropriate response? a. "If you continue to talk like that, I'm going to stop speaking to you." b. "You told me you got fired from your last job for missing too many days after taking drugs all night." c. "Tell me more about how it felt to get high." d. "Don't you know it's illegal to use drugs?"
Answer: B. Confronting the client with the consequences of substance abuse helps to break through denial. Making threats (A) is not an effective way to promote self-disclosure or establish a rapport with the client. Although the nurse should encourage the client to discuss feelings, the discussion should focus on how the client felt before, not during, an episode of substance abuse (C). Encouraging elaboration about his experience while getting high may reinforce the abusive behavior. The client undoubtedly is aware that drug use is illegal; a reminder to this effect (D) is unlikely to alter behavior.
A high school student is referred to the school nurse for suspected substance abuse. Following the nurse's assessment and interventions, what would be the most desirable outcome? A. The student discusses conflicts over drug use. B. The student accepts a referral to a substance abuse counselor. C. The student agrees to inform his parents of the problem. D. The student reports increased comfort with making choices.
Answer: B. The student accepts a referral to a substance abuse counselor. **Rationale: All of the outcomes stated are desirable; however, the best outcome is that the student would agree to seek the assistance of a professional substance abuse counselor.
The client asks the nurse about the Milieu therapy. The nurse responds knowing that the primary focus of milieu therapy can be best described by which of the following? A. A form of behavior modification therapy B. A cognitive approach of changing the behavior C. A change in living learning or working environment D. A behavioral approach to changing behavior
Answer: C Rationale: All other answers describe forms of Cognitive Behavior therapy. Milieu, from the French word "middle" translates as surroundings and environoments. Milieu therapy is the treatment of a mental disorder by making changes to the immediate patient's surroundings and environment including life circumstances.
In the day unit of an outpatient mental health program, the nurse finds the client diagnosed with undifferentiated schizophrenia dancing alone next to the radio. Suddenly, the client stops dancing and stares at the nurse in a menacing manner. Which action by the nurse is best? a. leave for a short time promising to return soon. b. remain silent and stand still until the client speaks c. start talking to the client about a neutral topic d. point out that the client that has stopped dancing and seems upset
Answer: D Rational: presents reality and reflects feelins; the next remark might be, "can you tel me what you are thinking about?", which describes an observation, and ask client for more information nursing care includes: client safety, administration of antipsychotic drugs, decreasing risk for sensory stimuli,removing from areas of tension, validating reality, not arguing, recognizing that client is experiencing hallucinations, responding to feeling or tone of hallucination or deusion
You are providing teaching to Lana, a preoperative pt just before surgery. She is becoming more and more anxious as you talk. She begins to complain of dizziness and heart pounding, and she is trembling. She seems confused. Your best response is to: A. reinforce the preoperative teaching by restating it slowly. B. have Lana read the teaching materials instead of verbal communication. C. have a family member read the preoperative materials to Lana. D. not attempt any teaching at this time.
Answer: D Rational: Patients experiencing severe anxiety, as the symptoms suggest, are unable to learn or solve problems. The other options would not be effective because you are still attempting to teach someone who has a severe level of anxiety.
Claire is a student nurse working with Carl, an 82-year-old patient with dementia. She finds herself frustrated at times by not knowing how best to care for or communicate with Carl. Which of the following statements she could make to Carl illustrates best care practice? A. Lighthearted banter: "Carl, you look great today in your new sweater, you handsome devil!" B. Limit setting: "Carl, you cannot yell out in your room. You are upsetting other patients." C. Firm direction: "You will take a shower this morning; there is no debating about it so don't try to argue." D. Positive regard: "Carl, I am glad to be here caring for you today. Let's talk about your plans for the day."
Answer: D The attitude of unconditional positive regard is the nurse's single most effective tool in caring for people with dementia. It induces patients to cooperate with care, reduces catastrophic outbreaks, and increases family members' satisfaction with care.
Q: A client was hospitalized following a suicide attempt after losing a job. One week later, the nurse observes a sudden apparent improvement in the client. The nurse understands that the most probable reason for the apparent improvement is that the client: A. has gotten some information about a new job B. has established supportive relationships with the personnel C. has been relieved of a stressful work environment D. may be committed to suicide and has a workable plan
Answer: D. Rationale: The most probable reason for sudden apparent improvement in a suicidal client is that the client may be committed to suicide and has a workable plan. A client who has decided to commit suicide will appear to the nurse to be improved. This sudden improvement comes about as a consequence of the client resolving all ambivalence about committing suicide.
Kyla asks you to explain what basal sleep requirement is. Your best response is: A) "The basal temperature of your bode needed to induce the best sleep." B) "The sleep time by your body needed to repair cellular damage." C) "The amount of sleep needed to be fully awake and perform well in daytime." D) "The amount of sleep needed to transition to REM sleep."
C) "The amount of sleep needed to be fully awake and perform well in daytime." Rational: Basal sleep requirement is the amount of sleep required to feel fully awake and able to sustain normal levels of performance during the periods of wakefulness. The other options do not describe basal sleep requirement.
In a toddler, which of the following injuries is most likely the result of child abuse? A. A hematoma on the occipital region of the head B. A 1-inch forehead laceration C. Several small, dime-sized circular burns on the child's back D. A small isolated bruise on the right lower extremity
C. Several small, dime-sized circular burns on the child's back Rationale: Small circular burns on a child's back are no accident and may be from cigarettes. Toddlers are injury prone because of their developmental stage, and falls are frequent because of their unsteady gait; head injuries aren't uncommon. A small area of ecchymosis isn't suspicious in this age-group.
The nurse is assessing a client who has a current history of alcohol dependence for signs of major withdrawal. What findings would the nurse expect to find? 1. Hypotension, bradycardia 2. Cold, clammy skin, decreased body temperature 3. Tachycardia, severe diaphoresis 4. Anxiety and increased appetite
CORRECT 3. Tachycardia, severe diaphoresis. A faster heart rate and excessive sweating are associated with major withdrawal from alcohol. Rationale: 1. Hypotension, bradycardia. Symptoms associated with major withdrawal, also known as delirium tremens (DTs), are not low BP and a slow heartbeat, but hypertension and tachycardia. 2. Cold, clammy skin, decreased body temperature. These are not the manifestations of withdrawal. Severe diaphoresis and elevated body temperature are physical symptoms of impending DTs. 3. Tachycardia, severe diaphoresis. A faster heart rate and excessive sweating are associated with major withdrawal from alcohol. 4. Anxiety and increased appetite. Clients experiencing a minor withdrawal from alcohol may experience anxiety and GI-related symptoms such as nausea, vomiting, and anorexia.
1. During family support group, a family member states, "I have an anxiety disorder, but I never experienced anything like my sister's dissociative disorder." Your best response is: a) "Some people believe that clients who say they have multiple personalities are trying to elicit sympathy. Is that what you think?" b) "It may be that she has awareness of something you've repressed." c) "Anxiety disrupts your ability to function. It's the same for your loved one, who defends against anxiety by separating thoughts from feelings." d) "Do you know of any physical abuse in your sister's childhood? That is often part of a dissociative client's history."
Correct Answer: c) "Anxiety disrupts your ability to function. It's the same for your loved one, who defends against anxiety by separating thoughts from feelings." Rationale: 1. "Anxiety disrupts your ability to function. It's the same for your loved one, who defends against anxiety by separating thoughts from feelings." This statement imparts information and promotes recognition of the commonality between the disorders. 2. "Do you know of any physical abuse in your sister's childhood? That is often part of a dissociative client's history." Although this may be relevant information, the family support group is not the place to explore this content. 3. "Some people believe that clients who say they have multiple personalities are trying to elicit sympathy. What do you think?" There is nothing in the family member's statement that questions the validity of the diagnosis. A more informative response imparts knowledge. 4. "She may have awareness of something you've repressed." The family support group is not the place to explore this content. Confrontation will serve to make the family member defensive; whereas a safe and trusting environment may provide an opportunity to reflect upon past events.
The nurse is working with a client who despite making a heroic effort was unable to rescue a neighbor trapped in a house fire. Which client-focused action should the nurse engage in during the working phase of the nurse-client relationship? 1. Exploring the client's ability to function. 2. Exploring the client's potential for self-harm. 3. Inquiring about the client's perception or appraisal of why the rescue was unsuccessful. 4. Inquiring about and examining the client's feelings for any that may block adaptive coping.
Correct answer 4. Rationale: The client must first deal with feelings and negative responses before the client can work through the meaning of the crisis. The correct answer pertains directly to the client's feelings and is client-focused. The remaining options do not directly focus on or address the client's feelings. Test-taking strategy: Focus on the subject, the working phase of the nurse-client relationship. Also, note the words client-focused action. Think about interventions that occur in this phase. Select the option that focuses on the feelings of the client.
Nursing care for the client diagnosed with substance abuse is based on which principle? a) The client has difficulty making decisions. b) The client expects too much of himself. C) The client attempts to appease to others at all costs D) The client has a limited ability to tolerate anxiety
Correct answer is D. Alcoholism occurs when drinking begins to cause problems in a person's life, drinking increases due to problems, physical and psychological dependence develops; during counseling of an alcoholic, important to identify problems related to drinking, help person to see/admit problems, establish a control of drinking problem through AA,use disulfiram assist person to identify factors that trigger drinking.
Which nursing approach is BEST when caring for a client diagnosed with a conversion reaction paralysis? a) Give special attention to the paralyzed limb b) Point out to the client that paralysis reflects anxiety c) Minimize the sick role and secondary gains d) Attempt to have the client move periodically
Correct answer: C Rationale: Emphasis for clients with conversion reaction is to minimize the sick role, and support the client's strength; its important to remember the client is not consciously attempting to have needs met by others, but is trying to relieve anxiety in an acceptable way, minimizing the instability allows care to be focused on the client's feelings and acceptance of those feelings without encouraging regression and dependence.
The nurse cares for pts in the psych ER. Which of the following pts should the nurse see FIRST? 1. A pt receiving haloperidol (Haldol) experiencing an oculogyric crissis. 2. A pt receiving thioridazine (Mellaril) experiencing akathisia. 3. A pt receiving risperidone (Risperdal) experiencing blurry vision. 4. A pt receiving fluphenazine (Prolixin) expriercing sedation.
Rational: 1) CORRECT: eyes are locked upward; acute dystonic reaction; notify physician and physician will order an anticholinergic agent to correct this reaction 2) inability to sit or stand still, foot tap, pace; does not require immediate attention; physician will change antipsychotic medication or give antiparkinsonian agent 3)does not require immediate attention; physician will change antipsychotic medication 4) common during first few weeks of therapy; does not require immediate attention
The spouse of a phobic patient is troubled by his wife's sudden fear of cars. He asks the nurse, "What should I do when she gets frightened?" The nurse should urge the husband to A. Ride with his wife in the car B. Encourage his wife to go for a ride in the car C. Allow his wife to avoid cars D. Encourage his wife to discuss her fears
Rationale for C: Well-meaning friends and family often encourage a patient to encounter the feared object; this only increases apprehension and anger on the part of the patient; by allowing his wife to avoid the car, her husband accepts her position while therapy is under way.
When a client tells the nurse she was raped by her date several weeks ago, the most likely reason for taking so long to report the incidence is her: A. embarrassment about having a physical examination. B. feelings of guilt for somehow having caused it. C. initial fear that no one would believe her. D. worry over contracting a sexually transmitted disease.
Rationale: B Many rape victims feel that they are somehow at fault for the rape and harbor feelings of guilt. This guilt stands in the way of reporting the rape to the authorities. Reference: p. 556
During a private conversation, a client with borderline personality disorder asks the nurse to keep his secret and then displays multiple, self-inflicted, superficial lacerations on the forearms. What is the nurse's best response? A) "That's it! You're on suicide precautions." B) "I'm going to tell your physician. Do you want to tell me why you did that?" C) "Tell me what type of instrument you used. I'm concerned about infection." D)"The team needs to know when something important occurs in treatment. I need to tell the others, but let's talk about it first."
Rationale: Correct answer: D This response informs the client of the nurse's planned actions and allows time to discuss the client's actions. Option A and B put the client on a defensive and may lead to a power struggle. Option C ignores the psychological implications of the client's actions.
A patient is displaying bizarre behavior after being brought in by ambulance (BIBA) to the ER. Understanding that an acute medical illness, environmental stressors, and many other possible factors may be the cause, or at least a contributing cause, of the behavior, what would be the nurse's priority in treatment? A. Move the patient to a quiet room to reduce stimulation, reduce the lighting level, and offer a blanket before leaving the patient alone to cool off. B. Call the psychiatric unit and ask for the patient to be transferred there. C. Trade off this patient's care with a male nurse or CNA if you are a female for safety reasons. D. Leave the treatment room until the patient calms down E. Calmly engage with the patient, while maintaining a safe distance, and ensuring a clear path of retreat.
The correct answer is "E". Personal safety, as well as patient safety, is always a primary consideration in any situation. Engaging the patient from a safe distance, while maintaining a clear route of escape, allows the nurse to begin assessing the patient without putting themselves at unreasonable levels of risk.
The nurse meets with a patient on the psychiatric unit when another patient diagnosed with antisocial personality disorder walks into the room and sits down. Which of the following responses by the nurse is BEST? a) "This patient and I are talking. If you'd like to sit with us for a while, you'll have to remain quiet." b) "How do you feel about another patient joining us?" c) "Do you have something you'd like to discuss?" d) "Right now we are talking. Please return to the ward and I'll talk to you later."
a) "This patient and I are talking. If you'd like to sit with us for a while, you'll have to remain quiet." FIRM LIMIT-SETTING REQUIRED FOR PATIENT WITH ANTISOCIAL BEHAVIOR; CONFRONT BEHAVIORS CONSISTENTLY b) "How do you feel about another patient joining us?" IS NOT APPROPRIATE FOR PATIENT TO INTERRUPT CONVERSATION BETWEEN NURSE AND ANOTHER PATIENT c) "Do you have something you'd like to discuss?" CANNOT INFRINGE ON OTHER'S RIGHT TO PRIVACY d) "Right now we are talking. Please return to the ward and I'll talk to you later." CORRECT - THIS PATIENT MUST BE MADE TO REALIZE THAT HE CANNOT INFRINGE ON ANOTHER PATIENT'S RIGHT TO PRIVACY AND TIME WITH THE NURSE; NURSE AVOIDS SHOWING IRRITATION AND NON-PUNITIVELY PUTS LIMITS ON HIS BEHAVIOR
The nurse is completing an admission assessment for a client admitted to the medical unit with a diagnosis of Acute Alcohol Intoxication. When asked to describe his drinking pattern and amount, the client states, "I only drink when I am under a lot of stress". The client's response indicated what defense mechanism? a. Rationalization b. Regression c. Denial d. Projection
a. Rationalization
A week ago, a tornado destroyed the client's home and seriously injured her husband. The client has been walking around the hospital in a daze without any outward display of emotions. She tells the nurse that she feels like she's going crazy. Which of the following actions should the nurse use first? a. Explain the effects of stress on the mind and body. b. Reassure the client that her feelings are typical reactions to serious trauma. c. Reassure the client that her symptoms are temporary. d. Acknowledge the unfairness of the client's situation.
b. The nurse initially reassures the client that her feelings and behaviors are typical reactions to serious trauma to help decrease anxiety and maintain self-esteem. Explaining the effects of stress on the body may be helpful later. Telling the client that her symptoms are temporary is less helpful. Acknowledging the unfairness of the client's situation does not address the client's needs at this time.
Which factors are most essential for the nurse to assess when providing crisis intervention for a client? a. The clients communication and coping skills b. The clients anxiety level and ability to express feelings. c. The clients perception of the triggering event and availability of situation. d. The clients use of reality testing and level of depression.
c. The clients perception of the triggering event and availability of situation. explanation: the most important factors to determine in this situation are clients perception of crisis event and availability of support( including family and friends) to provide basic needs. Although nurse should assess other factors, they are not as essential as determining why the client considers this a crisis and whether he can meet his present needs.
