PSY. 1

Which are the purposes of a thorough mental health nursing assessment? SATA: Establish a rapport between the nurse and the patient

1. Assess for risk factors affecting the safety of the patient or others 2. Establish a rapport between the nurse and the patient 3. Allow the nurse the chance to provide counseling to the patient 4.Formulate a plan of care

A nurse is planning for multiple clients whose culture and religion may pose a potential conflict with the dominant American Healthcare system. SATA:

1.spouse of terminally ill Hispanic who refused to allow MD to tell client . 2.Jehovah's Witness who will not accept blood 3. Orthodox sikh who refuses to cut his beard 4. Amish client who wants her community to pray before surgery

A nurse is caring for several clients who are attending community-based mental health programs. Which of the following clients should the nurse plan to visit first?

A client who says he is hearing a voice that tells him he's not worthy of living anymore

.The amygdala:

Alzheimers

A client with lung cancer says "i wish I had never smoked". Which is the nurse's best response?

Are you concerned about your diagnosis?

The statement that best describes psychiatric nursing is:

Area of practice employing a purposeful use of self in response to mental health problems and psychiatric disorder

A non-English speaking patient has an interpreter to assist with the admission interview. The nurse should:

Ask questions directly to patient

The nurse knows that sublimation is a defense mechanism that helps the individual:

Channel unacceptable impulses into socially approved behavior

n the process of development the individual strives to maintain and protect the self. the nurse understands that this usually is accomplished through the use of:

Defense mechanism

A patient undergoing a diagnostic test says, "nothing is wrong with me except a stubborn chest cold" the spouse reports the patient smokes, coughs daily, lost 15 lb, and is easily fatigued. Which defense mechanism is the patient using?

Denial

For most nurses the most difficult part of the nurse client relationship is:

Developing an awareness of self and the professional role in the relationship

cancer patient decided to discontinue treatment nurse should

Encourage the patient to tell their family or doctor

Nurse working with a pregnant 16 year old who drinks 4 to 6 alcoholic drinks 3 to 4 times per week in the clinic. Based on the current development stage, what should the nurse's initial focus of care be?

Establish a trusting relationship

The nurse is assessing an elderly client diagnosed with diabetes and COPD whose spouse died 3 weeks ago. Which of the following should the nurse address first?

Expressed thoughts of being "better off dead"

Nurses use which question to assess judgment

Fever, vomiting for three days, what would you do ?

Which behavior in a 30 year old would not be appropriate to his developmental level?

Frequently calls his brother to check in

The nurse is conducting a mini mental status exam documents what characteristics in general appearance section

Gromming

While the nurse is performing an admission assessment, decline keeps turning his head to the side of listening carefully. Which of the following is the client most likely experiencing?

Hallucinations

A patient with a history of alcoholism is made for depression. Which is therapeutic?

Have you ever felt guilty about drinking?

A client says to the nurse, " I don't know what to do. I can't decide if I should tell my son to move out unless he stops drinking. what do you think I should do?" the nurse replies:

I can help you look at the positive and negatives, so that you can make the decision

When the family asks a nurse for reassurance about a client's condition, which of the following is an appropriate response?

I understand that you are concerned, what concerns you specifically?

The nurse instructor explains that the " id" is part of the self that says:

I want what I want

mental status exam

Includes patient's appearance Orientation Disorganized thinking Any suicidal ideology

An MRI of the schizophrenic brain will show:

Increase in ventricles and cortical atrophy

A 20 year old client's behavior reflects the clients need for:

Independence

A college student comes to the health room to complain of anxiety. The campus nurse replies:

Let's talk about what's going on

The temporal lobe:

Organize words and emotions

Acute mental health nurse, client needs supervision being discharged and wife works all day what would be most appropriate care

Partial hospitalization

The stage of development most often concerned with "good me- bad me" is:

Phallic stage

.In piaget's cognitive development the stage of egocentrism is:

Preoperational

When conducting a mini mental status exam the nurse should test for short term memory by asking the client too:

Restate 3 random words

A newly admitted client is very paranoid and fearful. Which of the following aspects of the therapeutic milieu are most important in the first days of treatment?

Safety and structured activities

.During a prenatal clinic visit the client states that her mother told her to restrict salt intake. The nurse's best response:

Salt is needed for water balance

In kohlberg's moral development the second level is:

Satisfying one's own needs

.Which neurotransmitter is correct?

Serotonin is decreased in depression

A nurse understands that milieu therapy can be helpful for a client with antisocial personality disorder because it:

Sets limits on unacceptable behavior

The client having a colostomy is concerned about the odor. The nurse replies:

Tell me more about what you are thinking

Two second graders have a fight and are brought to the health office. How should the nurse respond?

Tell me what happen

Psychoneuroimmunology is:

The effect of stress and toxins on psych disorder

Which response is most therapeutic when talking to a paranoid patient?

The men you see are the housekeepers for all unit

Synapses are:

The spaces between neurons

A client is suspicious and expresses a fear of sharing and asking for help. Which stage of erikson's development is being described?

Trust vs mistrust

Involuntary admission requires

Two psychiatrist

A client reports becoming physically ill with frequent crying spells on the anniversary of the spouse's death the last 5 years. The nurse should conclude that the client is experiencing:

Uncomplicated grief

A nurse is caring for a group of clients. Which of the clients should a nurse consider for a referral to an assertive Community treatment (actt) group?

a client who lives at home keeps forgetting to come in for his monthly antipsychotic

Which of the following is an example of a client who requires emergency admission to a mental health facility?

a client with psychosis who fought the homeless man with the metal rod

A client is admitted to the hospital for constant hand-washing rituals. the act of hand-washing is considered:

a compulsion

During an admission interview the client states that he believes that the news reporter on TVs talking about events that happened to the client. this is an example of:

a delusion

A nurse surveys medical records. Which finding signals a violation of patient rights?

a patient was not allowed to have visitors

A client is admitted with a bad history of assaults against others. The unit is short-staffed and the nurse decides to place the client in seclusion as a preventative action. this is considered:

a tort

A nurse is planning an educational program for school-age children on accidental poisoning. Which developmental task is most important for the nurse to consider with this group?

adherence to group rules

When assessing an anxious patient, the nurse should use which communication technique?

ask open-ended questions

A nurse is caring for a patient from another culture. Which would be appropriate?

ask the client a family, a Healer or cleric should be included in the decision-making process

.Which is the nurse's primary goal of seclusion for a client exhibiting violent behavior?

assure the safety of the client and others

A client states to the hospice nurse," if I could just live until my grandson's wedding in 2 months." which stage a grief is indicated:

bargaining

A nursing colleague tells you that the staff is being unfair to a client and that she is the only one who can understand what the client has been through. this is an example of:

boundary blurring/ countertransference

A Chinese American male who had surgery two days ago grimaces. the nurses intervention is based on the knowledge that Chinese culture expects:

clients will exert self-control at all times

Elements to prove negligence

duty

.Hildegard peplau nurse client relationship is best promoted by which nursing intervention:

focusing on communication with the client

A select example of primary prevention:

helping school-age children identify and describe normal emotions

A Latino American client is admitted in an aggravated, disheveled state to the psych ER. When developing an individual, culturally sensitive care plan, the nurse gives priority to:

inclusion of family in the client's care plan.

The criteria for admission to an inpatient psychiatry unit is that the patient:

is in imminent danger of harming himself or others, all the patient cannot properly care for his basic needs and cannot protect himself from harm

A patient says that he is forgetful and might have Alzheimer's:

let's talk about what's happening

Countertransference

nurse has feelings for patient

Which of the following is a barrier to communication?

offering advice

In psychiatric nursing, the most important to the nurse brings to the helping relationship is:

oneself and the desire to help

A client tells you he's worried that his medication is not working you respond:

please tell me about your medication concerns

An inpatient hospitalization for persons with mental illness is generally reserved for patients who:

present a clear danger to self or others

Most important of maslow's needs in psychiatric care

safety

A nurse instructor is teaching a new student about establishing therapeutic relationships with mental ill clients. What intervention should be used to establish this relationship?

sit with the client in silence

A nurse overhears a young person saying "I'm having a senior moment because I forgot...." How should the nurse interpret?

stereotypical reference to older adults that can be termed ageism

A patient is scared that she will lose her job. the nurse responds:

tell me about what's been going on/what has happen that is worrying you

A client tells you a student nurse that he has been hoarding his pills in his drawer instead of swallowing them. He asks you to keep this confidential. you should:

tell the client that this must be reported to the staff because it's concerns safety

A nurse is working on promotion of healthy coping skills with older adult clients who had all previously been hospitalized for severe depression and are now in a residential care facility. the nurse should recognize that this is an example of which of the following?

tertiary prevention

An Arabic female client rarely makes eye contact with a male nurse when questioned. What is the most likely explanation for this behavior?

the client is showing respect

A client has been involuntarily committed to the hospital because he has been assessed as being dangerous to himself and others. The client has lost which of the following rights?

the right to leave the hospital against medical advice (AMA)

Clinical pathway

time frame, expected timeframe for client outcomes

A 7 year old who has lived in foster homes since birth. What developments was he unlikely to have completed as an infant:

trust vs. mistrust

The patient thinks his roommate wants to kill him. Your response:

you must be afraid let's discuss this

A teen patient has difficulty sleeping and the nurse responds:

you sound worried, do you want to talk about it?