NURS 307 Test 2 review

A client is admitted to the mental health unit with a diagnosis of schizophrenia. A nursing diagnosis (analyze cues, prioritize hypotheses) formulated for the client is Altered Thought Processes, secondary to paranoia. In formulating a plan (generate solutions) of care with the health care team, the nurse includes instruction to the staff to: Select one: A. Avoid laughing or whispering in front of the client B. Increase socialization of the client with peers C. Have the client sign a release of information to appropriate parties so that assessment data will only be shared with necessary persons D. Begin to educate the client about social supports in the community

a

A nurse has prepared a client education plan for James that is designed to help him cope with his psychiatric illness. One content component is use of community supports. The nurse can consider the education related to this component successful when James: Select one: a. Accesses community programs independently b. Describes his medication regime c. Verbalizes his level of stress related to use of community resources d. Recognizes the characteristics of his diagnosis

a

A strategy for helping a client with schizophrenia to manage the relapses that are so likely with this illness is to: Select one: a. Teach the client and family about behaviors that indicate impending relapse b. Schedule appointments for periodic blood tests to determine serum medication levels c. Have the client attend group therapy d. Mandate that the client continue taking medication daily

a

Four individuals have given the following information about their suicide plans. Which plan would indicate the highest risk for the client? Select one: A. Plans to jump from a 100-foot-high railroad bridge located outside of his hometown in a deserted area late at night. B. Plans to take an overdose of codeine while her husband is out bowling with his friends. C. Plans to close the doors and windows of her kitchen and turn on the gas oven without lighting it. D. Plans to cut her wrists in the bathroom while her husband reads the evening paper in the living room.

a

Jasmine is an RN working with Candice, a survivor of domestic violence in the emergency department. The client has bruises of differing stages and the left side of her face is very swollen, her eye is swollen so she cannot open it and her mouth is swollen making it hard for her to speak clearly. Jasmine sits next to Candice's bed as she completes her assessment. Candice makes statements during the conversation such as "I know you won't believe me" and "a person like me deserves to get this." Jasmine tells Candice "I believe you and am here to help you. Coming in tonight took courage and strength; let's use that strength to consider next steps." What element of a partnership in the professional relationship is Jasmine focusing on most? a. Building on client's identified strengths b. Forming the client's dependency on the nurse c. Agreed upon roles for client and nurse d. Clear communication between client and nurse

a

Marcos tells the nurse, "I can't go to community meeting. When I get in that room with all those people, they can hear my thoughts." The nurse can correctly assess (recognize cues) this symptom as: Select one: a. Thought broadcasting b. Loose associations c. Concrete thinking d. Auditory hallucinations

a

Miss J. is a psychotic client who is delusional and has auditory hallucinations. The best approach when the nurse needs to take an oral temperature with an electronic thermometer would be: Select one: a. "Please sit here. I need to take your temperature. I'll put the thermometer under your tongue and hold it there for a few seconds." b. "I hope I can count on you to sit still while I take your temperature." c. "I need your vital signs. Put this in your mouth now, please." d. "There is nothing at all to be afraid of. This will tell us if you have a have a fever. It will be all over in just a few seconds."

a

On assessment of a child, a nurse notes that the child's genitals are swollen. The nurse suspects that the child is being sexually abused. Which action by the nurse is most appropriate? Select one: a. Report the case as suspected abuse b. Refer the family to appropriate support groups c. Share the child's physical findings with the RN on the next shift d. Assist the family in identifying resources and support systems

a

Paul, a person with schizophrenia, reveals to the nurse that voices have told him he is in danger. He is safe only if he stays in the room and wears the same clothes. He goes on, "They're so loud they frighten me. Do you hear them?" The nurse's best initial response would be: Select one: A. "Paul, I know these voices are very real to you, but I don't hear them." B. "Don't worry. You're safe in the hospital. I won't let anything happen to you." C. "Tell me more about the voices. Are they men or women? How many are there?" D. "You need to get out of your room and get your mind occupied so you don't hear the voices."

a

Sam is a 17-year-old young man who you saw in a community clinic. Sam tells you during the nursing history that "I often wish that I were dead. I play with different ways to do it in my head. During the night, I think about it the most." In order to assess Sam's current suicide potential, the nurse's best course of action would be: Select one: A. Ask Sam if he is thinking of killing himself B. Observe Sam for scars on his wrists or other signs of previous attempts C. Ask Sam's parents about any history of suicidal attempts or threats by Sam D. Ascertain if there is a family history of suicide

a

Sam is a 17-year-old young man who you saw in a community clinic. Sam tells you during the nursing history that "I often wish that I were dead. I play with different ways to do it in my head. During the night, I think about it the most." Which of the following is the most appropriate nursing intervention (action) for Sam Select one: A. Encourage Sam to seek out staff when he feels like he might harm himself B. Allow Sam lengthy periods of solitude and privacy for the purpose of reflection on his situation C. Ask several of Sam's peers to watch him D. Share with Sam the unit's rules, regulations, and policies related to suicidal behaviors

a

Susan, a 15-year-old high school student, made some superficial slashes on her wrists and then called her best friend and told her what she had done. Susan is admitted to an inpatient adolescent unit. She begins to look much better after less than a day on the unit. The nurse is alert for: Select one: A. Increased suicide risk B. An impending complication C. The need to begin discharge planning D. Side effects of her medication

a

Which referral is the top priority for the nurse to make for a wife who has been severely beaten by her husband, has no relatives or friends in the community, is afraid to return home, has no financial resources of her own, and has no job skills? Select one: a. Women's shelter b. Vocational counseling c. Law enforcement d. Community food pantry

a

A short-term goal (generate solutions) for Richard, a withdrawn, isolated client with schizophrenia is, "The client will: Select one: a. talk about feelings of withdrawal in group." b. consistently interact with one assigned nurse." c. define major barriers to communication." d. participate in all therapeutic activities."

b

An insurance agent who is sitting in his office after returning from a physical examination in which he was pronounced "in good health" suddenly experiences a feeling of terror. His heart pounds, he feels as though he cannot breathe, and he cannot focus on what is being said to him. Several earlier episodes and fear of their repetition had prompted the visit to the doctor. This experience can be assessed (recognize cues) as a possible: Select one: a. Dissociative reaction b. Panic attack c. Phobic reaction d. Obsessive-compulsive crisis

b

C, a battered wife, tells the nurse her husband abuses her most often when he is intoxicated, just like his father beat him and his mother. She also states he's always apologetic and remorseful after an incident. She has considered leaving home with her two children, but has not been able to bring herself to actually leave. In working with C, which goal (generate solutions) would be inappropriate to set for accomplishment within one week? Select one: a. Client will name two community resources she can contact b. Client's husband will seek counseling. c. Client will name a person she can call in case of further abuse d. Client will name a safe-house for battered women she can go to any time of the day or night

b

Riley is a 26-year-old female and has been diagnosed with dissociative identity disorder (DID) following a traumatic event. Riley's mother asks you "does this mean my daughter is now crazy?" Your best response would be: a. "People with dissociative disorders are out of touch with reality, so in that way, your daughter is now mentally ill. Don't worry. Treatment is available." b. "Riley is dealing with her anxiety associated with the trauma by separating herself from it. With treatment she can get back to her previous level of functioning." c. "Riley will most likely need long term intensive inpatient treatment to deal with her traumatic memories as well as to work through her delusions." d. "Most mental health providers are skeptical about dissociative disorders and aren't sure they truly exist. Riley may be making up her symptoms as a cry for help."

b

The nurse teaches C to snap a rubber band on her wrist whenever an obsessive thought enters her mind. This technique, designed to interrupt obsessive thinking, can be identified as: Select one: a. Flooding b. Thought stopping c. Implosion d. Desensitization

b

The nursing diagnosis (analyze cues, prioritize hypotheses) most likely to be used for a person who has a diagnosis of Schizophrenia with some paranoid symptoms is: Select one: a. Fear of being alone related to altered gustatory perceptions b. Social isolation related to impaired ability to trust c. Impaired mobility related to catatonic symptoms d. Impaired memory related to poor information processing associated with brain

b

A client with an anxiety disorder is considering cognitive therapy. The client says to the nurse, "How does this treatment work?" The nurse makes which statement to the client? Select one: a. "This type of treatment will help you relax and develop new coping skills." b. "This type of treatment helps you examine how your past life has contributed to your problems." c. "This type of treatment helps you examine how your thoughts contribute to your anxiety." d. "This type of treatment helps you confront your fears by gradually exposing you to them."

c

A nursing intervention (action) that would not serve to empower a client with schizophrenia is to: Select one: a. Support the client's efforts to cope with the stigma of mental illness b. Adapt teaching to the client level of understanding c. Avoid use of the term schizophrenia with the client d. Educate the client about the symptoms of relapse

c

A patient diagnosed with schizophrenia approaches the nurse and says, "I'm cold. Ice cream is cold. Freezers keep ice cream cold." This speech pattern can be assessed (recognize cues) as: Select one: a. Hyperverbosity b. Expressing delusions c. Loose associations d. Circumstantiality

c

C, a battered wife, tells the nurse her husband abuses her most often when he is intoxicated, just like his father beat him and his mother. She also states he's always apologetic and remorseful after an incident. She has considered leaving home with her two children, but has not been able to bring herself to actually leave. C cites being brought up to believe "you stay together, no matter what happens." What nursing diagnosis would be the highest priority for C? Select one: a. Disturbed sleep pattern related to problems in the home b. Impaired social interaction related to husband's abusive behavior c. Risk for injury related to husband's physical abuse when intoxicated d. Deficient knowledge of community resources related to lack of readiness to learn

c

Conversion disorder is described as an absence of a neurological diagnosis that manifests in neurological symptoms. Channeling of emotions, conflicts, and stressors into physical symptoms is thought to be the cause of conversion disorder. Which statement is true? a. Symptoms can be turned off and on depending on the patient's choice. b. People with conversion disorder are extremely upset about often dramatic symptoms. c. Symptoms may include non-epileptic psychogenic seizures, paralysis, or blindness. d. An organic cause is usually found in most cases of conversion disorder.

c

For the client whose nursing diagnosis (analyze cues, prioritize hypotheses) is powerlessness related to inability to control compulsive cleaning, the nurse recognizes that the client uses the cleaning to: Select one: a. ensure the health of household members b. gain a feeling of orderliness c. temporarily reduce anxiety d. receive affirmation from friends and family

c

In tertiary mental health protection, Nurse G. is more likely to work with a client with a psychiatric disorder: Select one: a. With the assumption that the professional knows best b. From the position of requiring the client to be compliant c. In a decision-making partnership d. By using one's education to authoritatively prescribe interventions

c

N tells the nurse he cannot go out on a date because he might have to eat something in front of others. He reveals that he is afraid that someone will laugh at the way he eats or that he will spill food and embarrass himself. The nurse can assess (recognize cues) this behavior as being consistent with: Select one: a. Post-traumatic stress disorder b. Agoraphobia c. Social phobia d. Specific phobia

c

Sam is a 17-year-old young man who you saw in a community clinic. Sam tells you during the nursing history that "I often wish that I were dead. I play with different ways to do it in my head. During the night, I think about it the most." Sam's statement is an example of a: Select one: A. Suicide plan B. Suicide threat C. Suicide ideation D. Suicide attempt

c

Susan, a 15-year-old high school student, made some superficial slashes on her wrists and then called her best friend and told her what she had done. This behavior is most indicative of which of the psychodynamics of suicide? Select one: A. Hopelessness, helplessness B. Aggression C. Ambivalence D. Guilt

c

When a client asks what causes his ongoing struggle with anxiety, the nurse should reply that research gives evidence to support the theory that anxiety disorders have their etiology in: Select one: a. Unemployment and poverty b.Genetic-biological factors c. All choices are correct d. Developmental fixations

c

When working with a client with post-traumatic stress disorder who has frequent flashbacks as well as persistent symptoms of arousal, the LEAST effective nursing intervention (action) would be to: Select one: a. Discuss possible meanings of the event b. Teach effective stress management techniques c. Encourage repression of memories associated with the traumatic event d. Explain that physical symptoms are related to the psychological state

c

Which data gathered from the assessment (recognize cues) of a family with a schizophrenic member for purposes of discharge planning would you want to follow up on? Select one: a. The client's family has adequate financial resources b. The client enjoys spending time with his "eccentric" brother. c. The client becomes anxious when family members are hostile and critical of one another. d. The client's family lives in a suburban area.

c

Y has generalized anxiety disorder, but is otherwise healthy. He is receiving buspirone daily. Which topic for health teaching is LEAST important to address? Select one: a. The importance of daily aerobic exercise b. Avoidance of foods and drinks containing caffeine c. How to prevent occurrence of flashbacks d. Effects and side effects of buspirone

c

You are caring for Benjamin, a 42-year-old patient diagnosed with somatic symptom disorder. When interacting with you, Benjamin continues to focus on his severe headaches. In planning care for Benjamin, which of the following interventions would be appropriate. a. Improve reality testing by telling Benjamin that you do not believe that the headaches are real. b. Educate Benjamin on alternative therapies to deal with pain. c. After a limited discussion of physical concerns, shift focus to his feelings and effective coping skills. d. Call for a family meeting with Benjamin in attendance to confront Benjamin regarding his diagnosis.

c

A 21-year-old woman diagnosed with dissociative identity disorder is admitted to the psychiatric unit for crisis treatment. Which of the following would be the highest priority nursing intervention (action)? Select one: a. Encourage description of the client's various alters/identities b. Focus on the causes of the diagnosis of DID c. Explore the history of the client's DID d. Provide a safe environment that focuses on the here and now

d

An ER nurse is performing an assessment on a 7 year old child with a fractured arm. The child is hesitant to answer questions that the nurse is asking and consistently looks at his parents in a fearful manner. The nurse suspects physical abuse and continues with the assessment procedures. Which of the following assessment data (recognize cues) would assist in verifying the suspicion of physical abuse? Select one: a. Lacerations in the anal area b. Poor hygiene c. Soiled clothing d. Multiple circular burns on arms and legs

d

C, a battered wife, tells the nurse her husband abuses her most often when he is intoxicated, just like his father had beaten him and his mother. She also states he's always apologetic and remorseful after an incident. She has considered leaving home with her two children, but has not been able to bring herself to actually leave. What stage in the cycle of violence prevents C from leaving her husband? Select one: a. The tension-building stage b. The recovery stage c. The acute battering stage d. The honeymoon stage

d

Family members who are in the ER awaiting the outcome of a suicide attempt are very tearful. Which statement by the nurse would be most therapeutic to the family at this time? Select one: A. "Don't worry - you have nothing to feel guilty about." B. "Everything possible is being done. We have great staff here. This is an excellent hospital." C. "Let me check to see what the rule is about visitors coming back into the treatment area." D. "This must be very overwhelming for you."

d

M is a single woman who works from 3 to 11 p.m. as an aide in a nursing home. One night after getting off the bus on the way home to her apartment, she was grabbed from behind by a man who put a gun to her head. The attacker warned her not to scream or he would, "blow your head off." He put tape over her mouth, tied her hands, forced her into the car, and took her to an isolated spot and raped her. A park maintenance man found her. When M was found she was dazed and crying. What other behaviors would the nurse expect of M as a part of the acute phase of the rape-trauma syndrome? Select one: a. Flashbacks and dreams b. Increased motor activity c. Fears and phobias d. Fear, shock, and disbelief

d

M is a single woman who works from 3 to 11 p.m. as an aide in a nursing home. One night after getting off the bus on the way home to her apartment, she was grabbed from behind by a man who put a gun to her head. The attacker warned her not to scream or he would, "blow your head off." He put tape over her mouth, tied her hands, forced her into the car, and took her to an isolated spot and raped her. A park maintenance man found her. The diagnosis for M is Rape-trauma syndrome. What would be a short-term goal (generate solutions) for M that could realistically be achieved by the time M leaves the emergency room? M will state that: Select one: a. She feels safe and relaxed. b. The memory of the rape is less vivid and less frightening. c. Her physical symptoms of pain and discomfort are completely gone. d. She agrees to keep the follow-up appointment with the rape victim advocate.

d

Miss A., a severely withdrawn client with schizophrenia, allows herself to be escorted to the dayroom. However, she does not speak. The most therapeutic nursing intervention (action) in response to this behavior would be to: Select one: A. Have her sit with a group of clients who will encourage her to talk B. Ignore her silence and talk about superficial topics such as the weather C. Point out that by not speaking she makes those about her feel uncomfortable D. Plan time with her even though she does not verbally communicate with the nurse

d

Sam is a 17-year-old young man who you saw in a community clinic. Sam tells you during the nursing history that "I often wish that I were dead. I play with different ways to do it in my head. During the night, I think about it the most." Two days after admission to the unit, Sam is found by a staff member as he is trying to hang himself from the shower bar in the bathroom. Later Sam says of his attempted suicide, "I had to do it, I just couldn't take it anymore." The best reply for the nurse is: Select one: A. "Well it's done now. Let's figure out what you can do from here on in." B. "You really didn't have to do it - there are other solutions." C. "Why did you feel that you had no other alternatives?" D. "Sounds as though things were overwhelming for you. What is it that you couldn't take?"

d

T. tells the nurse at the anxiety disorders clinic that he experiences palpitations, difficulty breathing, and a sense of overwhelming dread whenever he goes out of his home. This problem began after he was beaten and robbed on his way to work. He has been unable to go to his office for over a month. T. asks the nurse, "Don't you agree that not being able to go out is pretty stupid?" The most therapeutic reply from among those listed below is: Select one: a. "No, of course I don't think it's stupid." b. "I guess some people might say that being housebound is pretty strange." c. "Why do you use the term 'stupid'?" d. "You feel stupid because you're afraid to leave home?"

d

The goal of a mental health nurse working in tertiary health protection would be to help clients: Select one: a. Incorporate their illness as a central aspect of their identity b. Learn to accept their limitations c. Cope with their inevitable periodic hospitalizations d. Return to the highest level of functioning

d

The new nurse tells her mentor, "I admitted a client today who has several bizarre delusions. I wanted to tell him that his ideas and conclusions are simply not logical. What do you think will happen if I do?" The best reply for the mentor would be, Select one: A. "I think you'll give him something to think about." B. "He'll probably incorporate you into the delusions as a persecutor." C. "It would be better to go along with his thinking initially to gain his cooperation." D. "Don't point out discrepancies just yet. Your first priority is to develop trust by using empathetic responses."

d

What response would be most helpful for the telephone hotline counselor to make when a caller states, "I'm considering committing suicide"? Select one: A. "I'm glad you called. There's nothing to worry about now. We'll handle this together." B. "Don't do anything foolish to hurt yourself. We need to talk about the things you have to live for." C. "I think you should admit yourself to the hospital to get help sorting out your problems." D. "Your calling is a very positive action. I'm glad you made the decision to call."

d

When an outpatient on Nurse W's caseload is hospitalized in the psychiatric inpatient unit, Nurse W. will begin tertiary mental health protection by: Select one: a. Reviewing the client's former treatment plan for mistakes b. Focusing on the client's present deficits c. Considering lowering expectations when the client is discharged d. Identifying and reinforcing client strengths

d

When the nurse diagnoses (analyzes) that a client is experiencing panic-level anxiety, an intervention (action) that should be immediately implemented is to: Select one: a. Place the client in four-point restraints b. Gather a show of force c. Teach relaxation techniques d. Reduce stimuli

d

Which of the following is an example of instrumental violence? a. A spouse (perpetrator) feels wife (victim) is intentionally trying to irritate him by not preparing meals. Perpetrator reaches a point of intolerance and throws pots and pans in kitchen while yelling at the victim. One of the pots hits the victim in the head causing bleeding b. Marta is pregnant with her first child. Justin, her partner has made a number of remarks about her appearance "getting fat." Justin comes home one evening late after having several alcoholic drinks; it is evident to Marta that he is in a "bad mood". When Marta asks him why he's so late he tells her it's not her business and strikes her. c. Emilio is a father of five children and Jennifer, his wife, is pregnant with a sixth child. One evening, Emilio's stressful job and the noisy, chaotic home environment lead him to an outburst which results in slapping the two oldest children and telling them to "get out." d. Within a dating relationship, Steve feels his partner Suzanne is involved in another relationship with Antonio. Steve plans an attack targeting Antonio in an effort to frighten him into ending the relationship with Suzanne.

d

Which of the following would be an appropriate tertiary health protection intervention (take action) when working with a survivor of rape? a.Treat physical injuries and offer treatment for exposure to STI's (sexually transmitted infections) b. Speak to a group the survivor is a part of on the topic of safety when walking or jogging to prevent an attack c. Meet with local law enforcement and public safety officers to collaborate on rape-prevention strategies in the community d. Re-establish healthy sleeping, eating and activity patterns

d