N395 Final
A community mental health nurse counsels a group of patients about the upcoming flu season. What instruction does the nurse provide for patients who are prescribed lithium? -"Call the clinic if you have nausea, vomiting, and/or diarrhea or are unable to stay well hydrated." -"Remember that lithium reduces your immunity, so you are more vulnerable to catching the flu." -"The flu is contagious. Isolate yourself if you get the flu so that you avoid exposing others to it." -"Because you take lithium, you may have flu symptoms that are not typically experienced by others."
"Call the clinic if you have nausea, vomiting, and/or diarrhea or are unable to stay well hydrated."
Select the completion of this sentence that demonstrates that an adult is coping in a healthy way: "I am feeling so angry right now... -I'm afraid I'm going to cry." -I would like to punch something." -I want to talk to someone about it." -I want to curl up and sleep for a long time."
I want to talk to someone about it."
An elderly widow tells the nurse, "Since my sister-in-law's death, her husband has been making advances at me. He tried to come in my home with a bottle of wine. Even though he's family, I'm afraid of what might happen if I let him in." Which action should the nurse take first? -Support the widow to clarify her thoughts and feelings about the situation. -Explain to the widow how to obtain an order of protection (restraining order). -Positively reinforce the widow for addressing the problem with a caring professional. -Educate the widow about sexual assault and violence, including the importance of prevention.
Positively reinforce the widow for addressing the problem with a caring professional.
While weighing patients on an eating disorders unit, the nurse overhears a psychiatric technician say, "I wish I had an eating disorder; maybe I'd lose a little weight." What is the nurse's best action? -Report the clinical observation to the nursing supervisor. -Ask the psychiatric technician, "What did you mean by that comment?" -Privately discuss the importance of sensitivity with the psychiatric technician. -Immediately interrupt the interaction between the patient and psychiatric technician.
Privately discuss the importance of sensitivity with the psychiatric technician.
A parent tells the nurse about the death of a child 2 years ago. Which comment by this parent warrants the nurse's priority attention? -"I still have some of my child's toys and clothes." -"A parent should never live longer than their child." -"I never returned to church again after the death of my child." -"My child has been dead a long time, but it seems like only yesterday."
"A parent should never live longer than their child."
A young adult has reported heavy use of alcohol and prescription drug use since mid-adolescence. This individual now has an ataxic gait and uses a cane. Which comment by the nurse presents reality would demonstrating compassion? -"I know you must feel self-conscious about using a cane at your age, but it will help prevent falls." -"Addiction is a fatal disease. If you continue to drink like you have done in the past, you will not live a another 10 years." -"It's time to face your addiction. You are disappointing your family and must stop drinking for the sake of the people who love you." -"Addiction is powerful. You are young and yet cannot walk without a cane. Your health has been significantly affected by your long-term use of drugs and alcohol."
"Addiction is powerful. You are young and yet cannot walk without a cane. Your health has been significantly affected by your long-term use of drugs and alcohol."
On the sixth anniversary of her spouse's death, a widow says, "Sometimes life does not seem worth living anymore. I wish I could go to sleep and never wake up." Which response by the nurse has priority? -"Are you considering suicide?" -"You still have so much to live for." -"Grief can sometimes last for many years." -"Why do you continue to grieve something from long ago?"
"Are you considering suicide?"
A nurse begins a therapeutic relationship with a patent diagnosed with schizophrenia. The patient has severe paranoia. Which comment by the nurse is most appropriate? -"Let's begin by talking about the goals you have for yourself." -"I understand that you have problems with fear and suspiciousness of others." -"As you get to know me better, I hope you will feel comfortable talking to me." -"I am part of your treatment team. Our goal is to help stabilize your symptoms."
"As you get to know me better, I hope you will feel comfortable talking to me."
A patient tells the nurse, "After many years, I finally quit smoking. Now I use e-cigarettes only." Which is an appropriate response? -"Using e-cigarettes is now more socially acceptable than using traditional cigarettes." -"Congratulations on quitting, but e-cigarettes contain nicotine and other hazardous chemicals." -"Nicotine is a powerful addiction. Quitting smoking is a big step towards adopting a healthier lifestyle." -"I am glad you have quit smoking. Your loved ones will no longer ve exposed to the hazards of secondhand smoke."
"Congratulations on quitting, but e-cigarettes contain nicotine and other hazardous chemicals."
An adult plans to attend an upcoming 10-year high school reunion. This person says to the nurse, "I am embarrassed to go. I will not look as good as my classmates. I haven't been successful in my career." Which comment by the nurse addresses this cognitive distortion? -"You look fine to me. Do think you will have fun at your reunion?" -"Everyone ages. Other classmates have had more problems than you." -"Do you think you are the only person who has aged and faced difficulties in life?" -"I think you are doing well in the face of the numerous problems you have endured."
"Do you think you are the only person who has aged and faced difficulties in life?"
Over the past 2 months a patient made eight suicide attempts with increasing lethality. The health care provider informs the patient and family that electroconvulsive therapy (ECT) is needed. The family whispers to the nurse, "Isn't this a dangerous treatment?" How should the nurse reply? -"Our facility has an excellent record of safety associated with use of electroconvulsive therapy." -"Your family member will eventually be successful with suicide if aggressive measures are not promptly taken." -"Yes, there are hazards with electroconvulsive therapy. You should discuss these concerns with the health care provider." -"Electroconvulsive therapy is very effective when urgent help is needed. Your family member was carefully evaluated for possible risks."
"Electroconvulsive therapy is very effective when urgent help is needed. Your family member was carefully evaluated for possible risks."
The nurse assesses a new patient suspected of having schizotypal personality disorder. Which assessment question is this patient most likely to answer affirmatively? -"Do some types of situations frighten you?" -"Do you often have episodes of prolonged crying?" -"Has anyone in your family ever been diagnosed with a mental illness?" -"Is it ever very important for you to do everything correctly?"
"Has anyone in your family ever been diagnosed with a mental illness?"
A nurse assesses a 78-year old patient who lives alone at home and is beginning three new prescriptions. Which question by the nurse will best provide for the patient's safety? -"How do you store your medications at home?" -"What is your usual bowel elimination pattern?" -"Who usually helps you with your medications?" -"How much alcohol do you drink on a normal day?"
"How much alcohol do you drink on a normal day?"
In a hostile voice, a patient experiencing mania yells at the nurse: "You will listen to me and not interrupt. I have some really important stuff to say. I'm tired of you nurses and doctors acting like you have all the answers." To facilitate effective communication, which initial response should the nurse provide? -"You are our patient, so we always listen to you." -"I can talk to you better if you use a calm voice." -"It's our job to help you get through this manic episode." -"Patients have an important role in treatment planning."
"I can talk to you better if you use a calm voice."
A patient diagnosed with dissociative identity disorder is hospitalized on an acute care psychiatric unit after a suicide attempt. During a team meeting, which staff nurse's comment should prompt the nursing supervisor to intervene? -"I have never taken care of a patient diagnosed with this disorder." -"I think this patient was misdiagnosed and probably has schizophrenia." -"I find myself more fascinated and engaged with this patient than others." -"I recently read an autobiographical book about someone with this problem."
"I find myself more fascinated and engaged with this patient than others."
Considering Maslow's pyramid, which comment indicates an individual is motivated by one of the higher levels of need? -"Even though I'm 40 years old, I have returned to college so I can get a better job." -"I help my community by volunteering at a thrift shop that raises money for the poor." -"I recently applied for public assistance in order to feed my family, but I hope it's not forever." -"My children tell me I'm a good parent. I feel happy being part of a family that appreciates me."
"I help my community by volunteering at a thrift shop that raises money for the poor."
The nurse assessed an elderly person who was abused by the caregiver. Afterward, which internal dialogue should prompt the nurse to seek guidance? -"Sometimes I get so discouraged and frustrated with my job." -"It's incredible that anyone could hurt a child or elderly person." -"The abuser was probably a victim of abuse at some point in life." -"I hope the abused gets victimized so they know what it feels like."
"I hope the abused gets victimized so they know what it feels like."
The school nurse assesses four adolescents who appear to have a healthy weight. Which comment would lead the nurse to explore further for an eating disorder? -"I usually try to exercise 30 minutes a day." -"I know everything in my life will be better once I lose 15 more pounds." -"I forgot my lunch today, so I will only be eating an apple." -"I know I shouldn't eat potato chips, but I just love them."
"I know everything in my life will be better once I lose 15 more pounds."
Four adult patients describe frightening events that resulted in panic levels of anxiety/fear. Which patient's report most clearly indicates a reasonable fear response? -"I saw a large spider crawling along my kitchen wall." -"I was at the mall when a gunman began firing an assault weapon." -"I was at home when a storm with heavy thunder and lightening lasted over an hour." -"I was trapped in an elevator that stopped between floors when the power went out."
"I was at the mall when a gunman began firing an assault weapon."
A female nurse is appointed to a committee with seven men. At the beginning of the meeting, the chairman asks the nurse to be the secretary. The nurse responds, "No. You're just asking me to be secretary because I'm the only woman here." Which response would have been more effective? -"There are others more qualified than I am to be secretary." -"I would be glad to perform another role for our committee." -"I'm probably overreacting, but I find your request offensive." -"Thank you for asking, but your request is sexually discriminatory."
"I would be glad to perform another role for our committee."
A patient diagnosed with bipolar disorder lives in the community and is showing early signs of mania. The patient says, "I need to go visit my daughter, but she lives across the country. I put some requests on the Internet to get a ride. I'm sure someone will take me." What is the nurse's most therapeutic response? -"I'm concerned about your safety when meeting or riding with strangers." -"Have you asked friends and family to donate money for your airfare?" -"You are not likely to get a ride. Let's consider some other strategies." -"Have you asked your daughter if she wants you to come for a visit?"
"I'm concerned about your safety when meeting or riding with strangers."
A nurse assesses four adolescents diagnosed with various eating disorders. Which comment would the nurse expect from the adolescent diagnosed with anorexia nervosa? -"I look good because whenever I overeat, I purge myself." -"I love sweets. I make myself throw up so I can eat more." -"I've lost 60 pounds, but I'm still a size 2. I want to be a size 0." -"I've hidden my eating disorder from everyone, even my parents."
"I've lost 60 pounds, but I'm still a size 2. I want to be a size 0."
An 85-year-old woman says to the nurse, "I raised three children, but now two of them barely speak to me. I did not do a good job of instilling a family spirit." Which response should the nurse provide? -"Do you think this situation is likely to change?" -"If you could relive this earlier years, what would you do differently?" -"There's no guidebook for parenting. Your children have made their own choices." -"Your children are likely to regret their behavior. I hope you can find it in your heart to forgive them."
"If you could relive this earlier years, what would you do differently?"
A victim of reported sexual assault tells the nurse, "This was entirely my fault. I should never have gone to that party alone." Which response by the nurse is the most therapeutic? -"This was a frightening experience for you." -"What do you think you should have done differently?" -"Would you like to tell me more about what happened?" -"It sounds like you're blaming yourself for the assailant's behavior."
"It sounds like you're blaming yourself for the assailant's behavior."
A patient tells the nurse, "I was raped 8 years ago but never told anyone. Nevertheless, the memories haunt me every day. I should be over it by now." Which comment should the nurse offer next? -"It sounds like you're judging yourself for continuing to struggle with your reaction." -"Rape is criminal behavior. You should have reported the incident to law enforcement." -"Are you ready to engage in counseling to deal with your reactions to this experience?" -"Although it is important to learn from such life events, it's even more important to out things in the past."
"It sounds like you're judging yourself for continuing to struggle with your reaction."
An emergency department nurse prepares to discharge a victim of reported rape. Which comment by the victim indicates that the nurse's teaching was effective? -"I should bathe frequently over the next week." -"I am required to follow up with law enforcement." -"It's important for me to follow up with counseling." -"I should delay any sexual activity for at least 3 months."
"It's important for me to follow up with counseling."
A patient experiencing depression says to the nurse, "My health care provider said I need 'talk' therapy, but I think I need a prescription for an antidepressant medication. What should I do?" Select the nurse's best response. -"Which antidepressant medication do you think would be helpful?" -"There are different types of talk therapy. Most patients find it beneficial." -"Let's consider some ways to address your concerns with your health care provider." -"Are you willing to give 'talk therapy' a try before starting an antidepressant medication?"
"Let's consider some ways to address your concerns with your health care provider."
A patient at a general medical clinic tells the nurse, "I have so many ailments that I need to see six different doctors. None of them has discovered what is really wrong with me." Which comment should the nurse offer next? -"Let's review all the medications you currently take." -"Tell me about allergic reactions you've had to medication." -"Selecting one primary care provider would be better for you." -"I'm not sure I understand how you can afford these expenses."
"Let's review all the medications you currently take."
A nurse leads a milieu meeting in an outpatient program for adults diagnosed with serious mental illness. Four patients complain that another patient is "always begging us for money." Which comment by the nurse is therapeutic? -"If you can afford to help each other, it is reasonable to do so." -"Let's review what we have learned about being assertive with others." -"No one needs to bring money to our program. Lunch is provided at no charge." -"Let's show understanding of each other. Money management is a problem for everyone."
"Let's review what we have learned about being assertive with others."
A patient has been disruptive to the therapeutic milieu for 2 days. A certified nursing assistant says to the nurse, "We need to seclude this patient because this behavior is upsetting everyone on the unit." Considering patients' rights, how should the nurse respond? -"Seclusion is not part of this patient's plan of care." -"Let's think of some new ways to help this patient be less disruptive." -"Thank you for that suggestion. I will discuss it with the health care provider." -Disruptive behavior is expected with mental illness. We must respond therapeutically."
"Let's think of some new ways to help this patient be less disruptive."
An 84-year old tells the nurse, "I do four or five number puzzles every day to keep my brain healthy and sharp." When considering a holistic approach to maintaining mental health, the nurse should respond: -"It is more important for you to have physical activity every day." -"Let's think of some other activities we can add to your daily routine." -"Repetition of the same activity is not helpful for keeping your brain healthy." -"There are some herbal preparations that will also help keep your brain sharp."
"Let's think of some other activities we can add to your daily routine."
The nurse interviews the parent of a 7-year-old child diagnosed with moderate autism spectrum disorder. Which comment from the parent best describes autistic behavior? -"My child occasionally has temper tantrums." -"Sometimes my child wakes up with nightmares." -"My child swings for hours on our backyard gym set." -"Toilet training was more difficult for this child than my other children."
"My child swings for hours on our backyard gym set."
The parent of an adolescent recently diagnosed with schizophrenia says to the nurse, "This is entirely my fault. I should have spent more time with my child when he was a toddler." Which response by the nurse is correct? -"Schizophrenia is genetically transmitted, so it was not in your control." -"Your child's disorder is more likely the result of an undetected head injury." -"Environmental toxins are directly implicated in the origins of schizophrenia." -"Lack of prenatal care causes schizophrenia rather than early childhood events."
"Schizophrenia is genetically transmitted, so it was not in your control."
Shortly after hospitalization, an adolescent diagnosed with anorexia nervosa says to the nurse, "Being fat is the worse thing in the world. I hope it never happens to me." Which response by the nurse is appropriate? -"You need to gain weight to become healthier." -"Your world would not change if you gained a few pounds." -"Tell me how your world would be different if you were fat." -"Your attractiveness is not defined by a number on the scale."
"Tell me how your world would be different if you were fat."
The nurse asks an 87-year-old, "How are you doing?" The patient replies, "I have good days and bad days." Select the nurse's therapeutic response. -"How is your sleep?" -"Tell me more about that." -"Are you feeling depressed?" -"We expect that from people your age."
"Tell me more about that."
A nursing student arrives late for a clinical experience and is not wearing the correct attire. When the instructor privately criticizes the behavior, the student responds, "I'm always the one who gets caught. You're going to cause me to fail." Select the instructors best response. -"Other students get caught as well." -"I am not trying to cause you to fail. I am here to help you." -"I am sorry you feel that way. I try to treat all my students equally." -"The requirements for this experience were discussed during our orientation."
"The requirements for this experience were discussed during our orientation."
A nurse in an outpatient medical clinic talks to a patient with a long history of malingering and doctor-shopping. The patient continues to express complaints of multiple problems. Select the nurse's best comment to the patient. -"The treatment team believes you would benefit more from seeing a mental health professional." -"The treatment team discussed your case and wants to begin a special case management program for you." -"Because you take a number of medications, it would be safer to have them all filled out at the same pharmacy." -"Diagnostic testing has shown no medical problems, and you are using more than your fair share of health care services."
"The treatment team discussed your case and wants to begin a special case management program for you."
A family member asks the nurse, "I know my uncle's Alzheimer's disease has progressed, but is there any medication that can help him now?" Which response by the nurse is correct? -"I'm sorry, but there are no medications that help with severe Alzheimer's disease." -"Alzheimers disease sometimes stabilizes. Let's hope that happens in this situation." -"There are a few medications that may help. Let's discuss it with the health care provider." -"It sounds like you're having difficulty accepting that your uncle's disease is irreversible. Would you like to talk about those feelings?"
"There are a few medications that may help. Let's discuss it with the health care provider."
An emergency department nurse assesses a child with a fractured ulna. The nurse also observes yellow and purple bruises across the child's back and shoulders. Which comment by the parents should prompt the nurse to consider making a report to Child Protective Services? -"We do not believe in immunization of our children." -"This child is always creating problems for the family." -"Our child would rather play alone than with other children." -"We homeschool our children in order to include religious education."
"This child is always creating problems for the family."
A nurse teaches a patient with alcoholism disorder about a new prescription for naltrexone (ReVia, Vivitrol). Which comment by the patient indicates the teaching was effective? -"This medicine will stop my cravings for alcohol." -"I should take this medication only when I feel cravings to drink alcohol." -"This medicine is one part of a bigger treatment plan to help me stay sober." -"I should not use products that contain alcohol, such as cough medicine and aftershave lotion."
"This medicine is one part of a bigger treatment plan to help me stay sober."
A community mental health nurse talks with a 6-year-old child whose divorced parents have shared custody. Which initial question will best help the nurse explore the child's perceptions of home life? -"Is your life different from your friends' lives?" -"Are you happiest at your mother's or your father's house?" -"Do you find it hard to move back and forth between two homes?" -"What are some of the good and bad things about living in two places?"
"What are some of the good and bad things about living in two places?"
Which comment by a patient diagnosed with bipolar disorder best indicates the patient is experiencing mania? -"I have been sleeping about 6 hours each night." -"Yesterday I made 487 posts on my social network page." -"I am having dreams about my father's death 8 years ago." -"My appetite is so robust that I've gained 4 pounds in the past 2 weeks."
"Yesterday I made 487 posts on my social network page."
An emergency department nurse talks with a newly admitted victim of reported rape. Which communication should the nurse offer to comfort this patient? -"You are safe now. I will stay with you in this private room." -"Would you like your friend to stay with you during your examination?" -"You made a good decision to come to the hospital after you were raped." -"What questions do you have about your examination by the sexual assault nurse examiner?"
"You are safe now. I will stay with you in this private room."
After a power outage, a facility must serve a dinner of sandwiches and fruit to patients. Which comment is most likely from a patient diagnosed with a narcissistic personality disorder? -"These sandwiches are probably contaminated with bacteria." -"I suppose it's the best we can hope for under these circumstances." -"You should have ordered a to-go meal from a local restaurant for me." -"I would rather wait to eat until the dietary department can prepare a meal."
"You should have ordered a to-go meal from a local restaurant for me."
A patient was diagnosed with bipolar disorder many years ago. The patient tells the nurse, "When I have a manic episode, there's always a feeling of gloom behind it, and I know I will soon be totally depressed." What is the nurse's best response? -"Most patients diagnosed with bipolar disorder report the same types of feelings." -"Feelings of gloom associated with depression result from serotonin dysregulation." -"If you take your medication as it is prescribed, you will not have those experiences." -"Your comment indicates that you have an understanding of and insight about your disorder."
"Your comment indicates that you have an understanding of and insight about your disorder."
The nurse cares for a hospitalized adolescent diagnosed with major depressive disorder. The health care provider prescribes a low-dose antidepressant. In consideration of published warnings about the use of antidepressant medications in younger patients, which action(s) should the nurse empty? SATA -Notify the facility's patient advocate about the new prescription. -Teach the adolescent about Black Box warnings associated with antidepressant medications. -Monitor the adolescent closely for evidence of adverse effects, particularly suicidal thinking or behavior. -Remind the health care provider about warnings associated with the use of antidepressants in children and adolescents.
-Teach the adolescent about Black Box warnings associated with antidepressant medications. -Monitor the adolescent closely for evidence of adverse effects, particularly suicidal thinking or behavior.
A university football coach invites the campus nurse to talk to the team about healthy relationships in the community. Which topic has priority for the nurse to include? -Appropriate behavior with intimate partners -University resources for counseling and support -The importance of role modeling for children and teens -Public recognition of children with life-threatening illnesses
Appropriate behavior with intimate partners
Which scenario presents the highest risk for a pregnancy resulting in offspring with an intellectual development disability (IDD)? -18-year-old mother who received no prenatal care -32-year-old woman diagnosed with anorexia nervosa -26-year-old father with a history of episodic alcohol abuse -38-year-old father diagnosed with generalized anxiety disorder
32-year-old woman diagnosed with anorexia nervosa
Which scenario presents the most risk factors for suicide? -64-year-old black female whose husband died 3 months ago -72-year-old white female scheduled for hip replacement in 2 weeks -82-year-old widowed white male recently diagnosed with pancreatic cancer -92-year-old black male who recently moved into the home of his adult children
82-year-old widowed white male recently diagnosed with pancreatic cancer
Which newly hospitalized patient should the nurse monitor closely for development of delirium? -A 48-year-old who usually drinks a six-pack of beer daily -A 68-year-old who takes aspirin 650 mg twice daily for arthritic pain -A 72-year-old who says, "I have a glass of wine every evening to stimulate my appetite." -A 78-year-old diabetic whose blood glucose levels are consistently greater than 250 mg/dL
A 48-year-old who usually drinks a six-pack of beer daily
Which patient is likely to achieve maximum benefit from cognitive-behavioral therapy (CBT)? -Older adult diagnosed with stage 3 Alzheimers disease -Adult diagnosed with schizophrenia and experiencing delusions -Adult experiencing feelings of failure after losing the fourth job in 2 years -School-age child diagnosed with attention-deficit/hyperactivity disorder (ADHD)
Adult experiencing feelings of failure after losing the fourth job in 2 years
In a staff meeting at an inpatient mental health facility for individuals, the administrator announces that psychiatric technicians will now be supervised by the milieu director rather than by nurses. What is the nurse's best action? -Confer with colleagues about their opinions regarding the proposed change. -Volunteer to participate on a committee charged with defining the job responsibilities of unlicensed assistive personnel. -Ask the administrator to delay implementation of this change until the decision can be reviewed by an interdisciplinary team. -Advise the administrator of regulations in the state nurse practice act regarding supervision of unlicensed assistive personnel.
Advise the administrator of regulations in the state nurse practice act regarding supervision of unlicensed assistive personnel.
A mental health nurse assesses a patient diagnosed with an antisocial personality disorder. Which comorbid problem is most important for the nurse to include in the assessment? -Generalized anxiety -Alcohol or substance use disorder -Compulsions and phobias -Dysfunctional sleep patterns
Alcohol or substance use disorder
Select the best example of altruism. -After recovering from a gunshot wound, a police officer attends a local support group. -After recovering from open-heart surgery, an individual plays tennis three times a week. -An individual who received a liver transplant volunteers at a local organ procurement agency. -An individual with a long-standing fear of animals volunteers at a community animal shelter.
An individual who received a liver transplant volunteers at a local organ procurement agency.
A nurse working in the county jail assess four new inmates. The nurse should direct officers to place which inmate under suicide watch? -An inmate charged with breaking and entering -An inmate charged with criminal solicitation (prostitution) -An inmate charged with a lewd and lascivious act perpetrated on a minor -An inmate charged with assault and battery of an elderly patient
An inmate charged with a lewd and lascivious act perpetrated on a minor
A person shoplifts merchandise from a community cancer thrift shop. When confronted, the person replies, "All this stuff was donated, so I can take it." This comment suggests features of which personality disorder? -Antisocial -Histrionic -Borderline -Schizotypal
Antisocial
A patient diagnosed with schizophrenia complains to the nurse about persistent feelings of restlessness and says, "I feel like I need to move all the time." What is the nurse's next action? -Add an activity group to the patient's plan of care. -Assess the patient for other extrapyramidal symptoms. -Perform a full mental status evaluation of the patient. -Educate the patient about the psychomotor agitation associated with schizophrenia.
Assess the patient for other extrapyramidal symptoms.
A patient diagnosed with schizophrenia says, "I hear the voices every day. They always say bad things about me." Which action by the nurse has the highest priority? -Assess the patient for suicidal thinking and plans. -Review the patient's medication regimen and adherence. -Educate the patient about symptoms associated with schizophrenia. -Suggest distracters for the patient to use when auditory hallucinations occur.
Assess the patient for suicidal thinking and plans.
A veteran of the war in Afghanistan tells the nurse, "Every day, something happens that makes me feel like I'm still there. My family has grown impatient with me. They say it's time for me to move on from that time in my life but I can't." What is the nurse's first priority? -Assess the veteran for suicide risk. -Refer the veteran for specialized mental health services. -Assess the veteran for evidence of traumatic brain injury. -Refer the veteran's family to a posttraumatic stress disorder group.
Assess the veteran for suicide risk.
A patient is hospitalized with a diagnosis of anorexia nervosa. The nurse reviews the patient's laboratory results, as follows: Sodium 143 mEq/L Potassium 3.1 mEq/L Chloride 102 mEq/L Magnesium 2.2 mEq/L Calcium 8.4 mg/dL Phosphate 3.0 mg/dL The nurse should take which action next? -Measure the patient's body temperature. -Inspect the patient's skin and sclera for jaundice. -Assess the patient's mucous membranes for erosion. -Auscultate the patient's heart rate, rhythm, and sounds.
Auscultate the patient's heart rate, rhythm, and sounds.
A distraught 8-year-old girl tells the nurse, "I had a horrible nightmare and was so scared. I tried to get in bed with my parents, but they said 'No.' I think I could have gone back to sleep if I had been with them." Which family dynamic is likely the basis of this child's comment? -Boundaries in the family are rigid. -The family has poor differentiation of roles. -The girl is enmeshed in part of a family's triangle. -Generational boundaries in the family are diffuse.
Boundaries in the family are rigid.
A nurse plans a group meeting for adult patients in a therapeutic milieu. Which topic should the nurse include? -Coping with grief and loss -The importance of hand washing -Strategies for money management -Staffing shortages expected over the next 3 days
The importance of hand washing
An experienced nurse in a major medical center requests a transfer from a general medical unit to an acute care psychiatric unit. Which organizational feature would best support the nurse's successful transition? -Assignment to medication administration for the first 6 months -Working with a seasoned mental health technician for the first month -Co-assignment with a knowledgeable psychiatric nurse for an extended orientation -Staff development activities focused on developing therapeutic communication skills
Co-assignment with a knowledgeable psychiatric nurse for an extended orientation
A patient smiles broadly at the nurse and says, "Look at my clean teeth. I brushed them with scouring powder because the label said, 'It brightens and whitens everything.'" Which term should the nurse include when documenting this encounter? -Circumstantiality -Concrete thinking -Poverty of speech -Associative looseness
Concrete thinking
A colleague tells the nurse, "I have not been able to sleep for the past 3 days. I feel like a robot." What is the nurse's best action? -Direct the colleague to leave the facility immediately. -Observe the colleague closely for evidence of impaired practice. -Offer to administer medications to patients assigned to the colleague. -Confer with the supervisor about the nurse's ability to safely deliver care.
Confer with the supervisor about the nurse's ability to safely deliver care.
A patient has a long history of bipolar disorder with frequent episodes of mania secondary to stopping prescribed medications. The patient says, "I will use my whole check next month to buy lottery tickets. Winning will solve my money problems." Select the nurse's best action. -Educate the patient about the low odds of winning the lottery. -Present reality by saying to the patient, "That is not a good use of your money." -Confer with the treatment team about appointing a legal guardian for the patient. -Tell the patient, "If you buy lottery tickets, your money will run out before the end of the month."
Confer with the treatment team about appointing a legal guardian for the patient.
An 8-year-old tells a parent, "I like to scare kids at school by showing them pictures of clowns. Some kids are terrified." How should the nurse counsel the parents regarding this behavior? -Recommend family therapy for the child, siblings, and parents. -Suggest the parents enroll the child in an anger management program. -Educate both parents about bullying, including possible origins and long-term effects. -Teach the parents about the developmental phase and tasks for an 8-year-old child.
Educate both parents about bullying, including possible origins and long-term effects.
A day-shift nurse contacts a nurse scheduled for the night shift at home and says, "Our unit is full, and there are eight patients in the emergency department waiting for a bed." The night-shift nurse replies, "Thanks for telling me. I am calling in sick." Which type of problem is evident by the night-shift nurse's reply? -Ethical problem of fidelity -Legal problem of negligence -Legal problem of intentional tort -Violation of the patients' right to treatment
Ethical problem of fidelity
A mature, professional couple plans a large wedding in a city that is 100 miles from their home. Which response is most likely to be associated with this experience? -Distress -Eustress -Acute stress -Depersonalization
Eustress
Which disorder would the nurse suspect when a person takes their child from doctor to doctor and from hospital to hospital with a variety of intentionally induced symptoms? -Illness anxiety disorder -Functional neurological disorder -Factitious disorder imposed by another -Rumination disorder
Factitious disorder imposed by another
A 28-year-old second-grade teacher is diagnosed with major depressive disorder. She grew up in Texas but moved to Alaska 10 years ago to separate from an abusive mother. Her father died by suicide when she was 12 years old. Which combination of factors in this scenario best demonstrates the stress-diathesis model? -Cold climate coupled with history of abuse -Current age of 28 coupled with family history of depression -Family history of mental illness coupled with history of abuse -Female gender coupled with the stressful profession of teaching
Family history of mental illness coupled with history of abuse
As Election Day nears, a psychiatric nurse studies the position statements of various candidates for federal offices. Which candidate's commentary would the nurse interpret as supportive of services for persons diagnosed with mental illness? -Full parity insurance coverage for mental illness -Coverage for biologically based mental illnesses -Reimbursement for initial treatment of addictions -Managed care oversight for mental illness services
Full parity insurance coverage for mental illness
A nurse plans a psychoeducational group about physical health in an outpatient program for patients diagnosed with serious mental illness. Which topic has priority? -Heart-healthy living -Living with diabetes -ABCDEs of skin cancer -Breast and testicular self-examination
Heart-healthy living
A person diagnosed with serious mental illness has been homeless for 8 years and says, "I don't have any money because I've never had a job. I can't afford a place to live." Which intervention should the outpatient mental health nurse add to the plan of care? -Requisition of the patient's legal record of arrests and convictions. -Help the patient to apply for Supplemental Security Income (SSI). -Assist the patient to apply for Social Security Disability Income (SSDI). -Seek to have the patient adjudicated non composition mantis (incompetent).
Help the patient to apply for Supplemental Security Income (SSI).
A patient who had a stroke 3 days ago tearfully tells the nurse, "What's the use in living? I'm no good to anybody like this." Which action should the nurse employ first when caring for a patient demonstrating hopelessness? -Implement the institutional protocol for suicide risk. -Support the patient to clarify and express feelings of grief. -Educate the patient about the success of stroke rehabilitation. -Offer the patient an opportunity to confer with the pastoral counselor.
Implement the institutional protocol for suicide risk.
A nurse plans care for a patient diagnosed with borderline personality disorder. Which patient problem is most likely to apply to this patient? -Ineffective relationships related to frequent splitting -Social isolation related to fear of embarrassment or rejection -Ineffective impulse control related to violence as evidenced by cruelty to animals -Disturbed thought processes related to recurrent suspiciousness of people and situations
Ineffective relationships related to frequent splitting
An emergency department nurse assesses a women suspected of being abused by an intimate partner. Which assessment finding most clearly confirms the suspicion? -Leathery facial tone -Injuries in a bikini pattern -Reluctance to be examined -Lack of eye contact with the nurse
Injuries in a bikini pattern
A young adult tells the nurse, "I have a new prescription for medical marijuana. I use it several times a day for my frequent muscle spasms." What information should the nurse provide first to this patient? -Guidance that the prescription should not be shared with peers -Directions to weigh self once a week and maintain a log of the results -Instructions about safety issues associated with driving or operating machinery -Information about the potential for amotivational syndrome and memory problems
Instructions about safety issues associated with driving or operating machinery
A patient in the emergency department was seen for the third time in a month with complaints of tremors and paresthesia in the lower extremities. Neurological functional disorder was diagnosed. While preparing for discharge, the patient says, "Now I'm having chest pain, but it's probably nothing." How should the nurse respond? -Assess the patient's most current laboratory values. -Interrupt the discharge and arrange additional medical evaluation of the patient. -Remind the patient, "The diagnostic tests showed you did not have a medical problem." -Tell the patient, "Being in the emergency department for a long time can be very distressing."
Interrupt the discharge and arrange additional medical evaluation of the patient.
A nurse working in an acute care unit for adolescents diagnosed with mental illness says, "Our patients have so much energy. We need some physical activities for them." In recognition of needs for safety and exercise, which activity could the treatment team approve? -Badminton tournament -Competitive soccer matches -Intramural basketball games -Line dancing to popular music
Line dancing to popular music
The nurse at a local clinic reviews phoned-in requests from patients for prescription refills. As the nurse confers with the health care provider about which prescription refill requests should be authorized, which refill request should be considered first? -Codeine 10 mg PO q4h PRN for an adult with a persistent cough -Hydroxyzine (Vistaril) 25 mg PO TID PRN for an adult who experiences uncomfortable muscle spams -Lorazepam (Ativan) 1 mg PO BID for an adult who has taken it daily for 3 years for episodes of anxiety -Lomotil 2 mg PO q6h PRN for an adult experiencing severe diarrhea
Lorazepam (Ativan) 1 mg PO BID for an adult who has taken it daily for 3 years for episodes of anxiety
A woman in a relationship characterized by a long history of battering and abuse tells the nurse, "We've had a rough time lately. I admit it: He beat me last night but then said he was sorry." Which event would the nurse expect to occur next in this relationship? -Another beating by the abusive partner -Love, gifts, and praise from the abusive partner -A brief period during which the partners ignore each other -The abusive partner leaving the relationship for a short time
Love, gifts, and praise from the abusive partner
The nurse admits a patient experiencing hallucinations and delusional thinking to an inpatient mental health unit. The plan of care will require that which service occurs first? -Social history -Psychiatric history -Medical assessment -Psychological evaluation
Medical assessment
Three days after beginning a new regime of haloperidol (Haldol), the nurse observes that a hospitalized patient is drooling, has stiff and extended extremities, and has skin that is hot and damp to the touch. The patient has difficulty responding verbally to the nurse. Which is the nurse's correct analysis and action in this situation? -A seizure is occurring; place the patient in a lateral recumbent position and monitor. -Serotonin symptom has developed; place an intravenous line and rapidly infuse D5 1/2 normal saline (NS). -Neuroleptic malignant syndrome has developed; prepare the patient for immediate transfer to a medical unit. -A acute dystonic reaction is occurring; promptly administer an intramuscular injection of diphenhydramine (Benadryl).
Neuroleptic malignant syndrome has developed; prepare the patient for immediate transfer to a medical unit.
A disaster relief nurse has just arrived to help efforts after a tornado that destroys a town. Which approach would be the most appropriate when talking with survivors? -Provide active listening. -Help the survivors generate possible solutions. -Help the survivors develop self-awareness to understand their stress response. -Offer firm, short, simple statements and instructions.
Offer firm, short, simple statements and instructions.
A patient diagnosed with major depressive disorder was hospitalized for 2 weeks on an acute psychiatric unit. One day after discharge, the patient completed suicide. Recognizing likely reactions among staff, which action should the nursing supervisor implement first? -Assess each staff member individually for suicide intent and/or plans. -Provide a private setting for staff members to talk about feelings associated with the event. -Remind staff members that suicide is a risk for the patient population and that they are not at fault. -Invite a guest speaker to conduct an educational session for staff members about suicide risk factors.
Provide a private setting for staff members to talk about feelings associated with the event.
Friends invite an adult diagnosed with type 2 diabetes to go on a mountain hike. The adult replies, "I can't go because I don't have any hiking shoes." Unconsciously, this person is concerned about difficulty with blood glucose management during strenuous activity. Which defense mechanism is evident? -Displacement -Rationalization -Passive aggression -Reaction formation
Rationalization
A patient has been identified as having somatoform disorder. Which of the following should the nurse do when interacting with the patient? -Ignore feelings to avoid promoting progression of symptoms. -Redirect conversation away from feelings but show interest toward the patient. -Encourage the use of benzodiazepines on a consistent basis to reduce anxiety. -Suggest the patient direct all questions to the nurse and not the medical provider.
Redirect conversation away from feelings but show interest toward the patient.
A single adult says to the nurse, "Both of my parents died several years ago, and my only sibling committed suicide 2 weeks ago. I feel so alone." After determining that the adult has no suicidal ideation, the nurse should: -Explore the adult's feelings of survivors guilt. -Assess the adult's cultural beliefs and spirituality. -Refer the adult for cognitive-behavioral therapy (CBT). -Refer the adult to a self-help group for suicide survivors.
Refer the adult to a self-help group for suicide survivors.
A patient diagnosed with major depressive disorder tells the community mental health nurse, "I usually spend all day watching television. If there's nothing good to watch, I just sleep or think about my problems." What is the nurses best action? -Refer the patient to counseling with a recreational therapist. -Ask the patient, "What kinds of program do you like to watch?" -Suggest to the patient, "Are there some friends you could call instead?" -Advise the patient, "Watching television and thinking about problems makes depression worse."
Refer the patient to counseling with a recreational therapist.
An adult required a heart transplant 5 years ago. Multiple medical complications followed, resulting in persistent irritability, depression, and insomnia. The adult's spouse says, "I've walked on eggshells for five years, never knowing when something else will go wrong." What is the nurse's priority intervention regarding the spouse? -Explore the spouse's feelings, showing care and compassion. -Encourage the spouse to attend a community support group. -Teach stress reduction and relaxation techniques to the spouse. -Refer the spouse to the primary care provider for health assessment.
Refer the spouse to the primary care provider for health assessment.
An outpatient nurse has lunch with a group of patients diagnosed with severe mental illness. The nurse observes an obese adult ask a malnourished adult, "If you aren't going to eat your apple, will you give it to me?" What is the nurse's best action? -Remind both adults that sharing food with each other is not permitted. -Remind the malnourished adult of treatment goals related to weight gain. -Reseat the patients at two separate tables for the remainder of the meal. -Overlook the remark. Both adults are permitted to make their own decisions.
Remind the malnourished adult of treatment goals related to weight gain.
An adult diagnosed with stage 2 Alzheimer's disease begins a new prescription for rivastigmine (Exelon). Which nursing diagnosis has the highest priority to add to the plan of care? -Risk for constipation -Impaired perception -Impaired oral mucous membrane -Risk for impaired nutritional status
Risk for impaired nutritional status
A 92-year-old lives alone, but family members assist with transportation and home maintenance. This adult tells the nurse, "They mean well, but sometimes my family treats me like a child." What is the nurse's best action? -Encourage the adult to overlook these behaviors from family members. -Role-play with the adult ways to share these feelings with family members. -Contact family members privately and educate them about the harmful effects of ageism. -Reinforce family members' good intentions and say, "It's fortunate your family is so helpful."
Role-play with the adult ways to share these feelings with family members.
A patient tells the nurse, "No matter what I do, I feel like there's always a dark cloud following me." Select the nurse's initial action. -Assess the patient's current sleep and eating patterns -Explain to the patient, "Everyone fells down from time to time." -Suggest alternative activities for times when the patient feels depressed. -Say to the patient, "Tell me more about what you mean by 'a dark cloud.'"
Say to the patient, "Tell me more about what you mean by 'a dark cloud.'"
A nurse's sibling happily says, "I want to introduce you to my fiancé. We're getting married in 6 months." The nurse has encountered the fiancé in a clinical setting and is aware of the fiancé's diagnosis of schizophrenia. What is the nurse's best response? -In private, tell the sibling about the fiancé's diagnosis. -Encourage the sibling to postpone the wedding for at least a year. -Ask the fiancé, "Have you told my sibling about your mental illness?" -Say to the sibling and fiancé, "I hope you will be very happy together."
Say to the sibling and fiancé, "I hope you will be very happy together."
A nurse plans to lead a group in a residential facility for kindergarten-age, abused children. Which strategy should the nurse incorporate? -Building a house using blocks -Telling a story about a child who felt sad -Drawing pictures of fun activities at a park -Reading and discussing a book about abused children
Telling a story about a child who felt sad
A woman experienced a double mastectomy yesterday. Now she cheerfully says to the nurse, "I didn't need those things anyway. No more wet T-shirt contests for me!" How should the nurse interpret this comment? -The patient is realistically accepting her loss. -The comment is sarcastic, which may reflect anger. -The patient is experiencing a distorted body image. -The comment suggests guilt regarding prior behavior.
The comment is sarcastic, which may reflect anger.
A college student has been experiencing significant stress associated with academic demands. Last month, the students began attending yoga sessions three times a week. Which outcome indicates this activity has been successful? -The student reports improved feelings of well-being. -The student increases the use of caffeine to enhance concentration. -The students reports, "Now I am sleeping about 10 hours every day." -The student says, "I withdrew from two courses to reduce my academic load."
The student reports improved feelings of well-being.
While interacting with a 62-year-old adult diagnosed with progressive neurocognitive disorder, the nurse observes that the adult has slow responses and difficulty finding the right words. What is the nurse's best initial action? -Suggest words that the adult may be trying to remember. -Ask the adult, "Are you having problems saying what you mean?" -Use silence to allow the adult an opportunity to compose responses. -Discontinue the interaction to prevent further frustration for the adult.
Use silence to allow the adult an opportunity to compose responses.