Psychiatric Nursing

A nurse in an in-patient setting formulates an outcome for a client who has a nursing diagnosis of altered social interaction R/T paranoid thinking AEB aggressive behaviors. Which initial correctly written outcome would the nurse expect the client to achieve? - The client will list two triggers to angry outbursts by day two of hospitalization.

"The client will list two triggers to angry outbursts by day 2 of hospitalization" is the initial outcome that best relates to the nursing diagnosis of altered social interaction R/T paranoid thinking AEB hostile and aggressive behaviors toward fellow clients. The recognition of triggers must come before being able to implement other strategies to help with altered social interactions. Because this outcome includes a time frame and is specific (two triggers) it is measurable. The test taker must remember that all outcomes must be client centered, be specific to the client problem addressed, and contain a time frame to be measurable. The more specific the outcome, the easier it is to evaluate. The keywor "initial" makes answer 3 correct instead of 4.

On an in-patient psychiatric unit, a client who is anxious and distressed states. "God has abandoned me." Which nursing action would initiate collaboration with the member of the mental health-care team who can assist this client with this assessed problem? - Consult with the chaplin and describe the client's concerns.

- The chaplain provides spiritual counseling. Experiencing anger at God or a higher power can indicate spiritual distress that can be addressed by the chaplain. The test taker should review the roles of the members of the health-care team in a psychiatric setting and how the nurse would collaborate with each team member.

A client diagnosed with schizophrenia is about to be discharged and is facing the stressor of acquiring independent employment. Using a behavioral approach, which nursing intervention is most appropriate in meeting this client's needs? - Role-playing a job interview with the client.

- A client with a thought disorder would need assistance in practicing what to say and do during a job interview. The nurse is functioning in the role of "role player" as assistance is given to this client to meet immediate needs. Role-playing is a behavioral technique. When answering a questions related to the role of the nurse, the test taker should ensure that examples chosen reflect the role that is most appropriate in meeting described client needs. The workds "behavioral approach" also should be considered when deciding on an answer choice.

A welder who recently lost his leg in a work-related accident is being admitted to an in-patient psychiatric unit. The client states, "I'm worried because I can't support my family anymore!" Which nursing diagnosis is most reflective of this client's presenting problem? - Ineffective role performance R/T loss of job.

- A defining characteristic of the nursing diagnosis of ineffective role performance is a change in physical capacity to resume a role. The client presented has had a change in body image that affects his ability to perform his role as welder and provider for his family. Test taker must use only the situtaion and client data presented in the question to formulate an appropriate nursing diagnosis and must not read into the question any daya that are not presented.

In the emergency department, the nurse assesses a client who is aggressive and experiencing auditory hallucinations. The client states, "The CIA is plotting to kill me." To which mental health setting would the nurse expect this client to be admitted? - Short-term, in-patient, locked unit.

- A short-term, in patient, locked unit would be most appropriate for this client. This setting provides containment and structure for clients who are at risk for harming themselves or others. Understanding the types of care available to mentally ill clients and the types of clients these various settings serve assists the test taker in answering this question.

When the nurse creates an environment to facilitate healing, the nurse's actions are based on which of the following assumptions? Select all that apply. - A therapeutic relationship can be a healing experience. - Group settings can support ego strengths. - Treatment plans can be formulated by observing social behaviors.

- A therapeutic relationship is characterized by rapport, genuineness, and respect and can be a healing experience. - Group processes provide learning experiences and support a client's ego strengths. - During group processes and interactions, staff members can observe social behaviors, and this can determine client needs. Treatment plans can be customized to meet these needs. Reviewing the nurse's actions that assist in creating an environment that facilitates healing assists the test taker in determining the correct answer to this question. Understanding the meaning of counterttansference eliminates option 5.

Which of the following actions reflect the nurse's role of advocate in an in-patient psychiatric setting? Select all that apply. - The nurse speaks on behalf of a mentally ill client to ensure adequate access to needed mental health services. - The nurse talks with the treatment team to support a shy client's request for less-sedating medications

- Advocacy is an essential role of the psychiatric nurse. Often, mentally ill clients cannot identify their personal problems or communicate their needs effectively. A nurse advocate stands alongside clients and empowers them to have a voice when they are weak and vulnerable. - Advocay is an essential role for the psychiatric nurse. A nurse advocate stands alongside of, and empowers, clients to have a voice when they are weak and vulnerable. Understanding the interventions used by the nurse in a psychiatric setting when assuming various roles assists the test taker in categorizing the behaviors presented in the question correctly.

A client diagnosed with bipolar disorder has a nursing diagnosis of sleep pattern disturbance. Which intervention should the nurse implement initially? - Assess normal sleep patterns.

- Assessment of normal sleep patterns is what the nurse does initially so that a comparison can be made with current sleep patterns and an accurate assessment leading to appropriate interventions can be determined. Note the word "initially" in the question, which determines the correct answer. When answering questions that require an "initial" response, it is helpful for the test taker to consider the steps of the nursing process. Assessment is the first step of the nursing process.

Which of the folloing was the reason for the establishment of large hospitals or asylums that addressed the care of the mentally ill? - Mental illness was perceived as incurable. - Clients with mental illness were perceived as a threat to self and others. - Dorothea Dix saw a need for humane care for the mentally ill.

- Because there was no treatment for mental illness before 1840, it was perceived as incurable and there was a need to provide continuous supervision in hospitals or asylums. - Clients with mental illness were thought to be violent toward themselves and others, and a "reasonable" solution to care was to remove them from contract with the general population and observe them continuously in hospitals or asylums. - Dorothea Dix advocated for humane treatment for the mentally ill, and this led to the establishment of many hospitals devoted to their care. Reviewing the history of mental health care assists the test taker in inderstanding how care was delivered in the past.

Which is a nursing intervention that would promote the development of trust in the nurse-client relationship? - Simply and clearly providing reasons for policies and procedures.

- By being given simple and clear reasons for policies and procedures, the client can count on consistency from the nurse in the implementation of these policies and procedures. This consistency promotes the development of trust in the nurse-client realtionship. Although all of these answers are positive interventions toward clients, not all relate directly to the devolpment of trust. Trust is the ability to feel confidence toward a person and must be earned.

On an in-patient psychiatric unit, a client diagnosed with borderline personality disorder is challenging other clients and splitting staff. Which response by the nurse relfects the nurse's role of milieu manager? Ongoing assessment, diagnosis, outcome identification, planning, implementation, and evaluation of the environment are necessary for the successful management of a therapeutic milieu. - Setting strict limits and communicating these limits to all staff members.

- By setting strict limits on inappropriate or unacceptable behaviors, the nurse functions in the role of the milieu manager. The safety of the milieu is always the highest priority. The environment of the milieu should be constrcted to provide many opportunities for personal growth and social interaction to build interpersonal skills. To assist in correctly choosing the actions of the nurse that reflect the role of milieu manager, the test taker should review this role and its components.

Which is a nursing intervention to establish trust with a client who is experiencing concrete thinking? - Being consistent in adhering to unit guidelines.

- Concrete thinking focuses thought processes on specifics rather than eventual outcomes. Being consistent in adhering to unit guidelines is one way to establish trust with a client who is experiencing concrete thinking. The test taker must consider the client's problem (concrete thinking) and the establishment of trust when answering this question.

A cleint diagnosed with a personality disorder has a nursing diagnosis of impaired social interaction. Which is a correctly written short-term outcome related to this diagnosis? - The client will discuss with the nurse behaviors that wouold impede the development of satisfactory interpersonal relationships by day 2 of hospitalization.

- Discussing with the nurse behaviors that would impede the development of satisfactory interpersonal relationships is a short-term goal for impaired social interaction. This outcome is correctly written, is measurable, and has a time frame. Test takers must ensure that the outcome is related to the nursing diagnosis presented in the question. When choosing a short-term outcome, the test taker should look for something that is realistic to expect the client to achieve during hospitalization. Test takers also must ensure that any outcome is written so that it has a time frame and is measurable.

Number the following nursing interventions as the would proceed through the phases of the nurs-client relationship. 1. Examine personal bias. 2. Formulate nursing diagnoses. 3. Promote client's insight. 4. Plan for continued care.

- First, in the pre-orientation phase of the nurse-client realationship, the nurse would examine any personal biases. - Second, in the orientation phase, the nurse would fromulate nursing diagnostic statements. - Third, in the working phase, the nuse would attempt to promote client insight. - Fourth, in the termination phase, the nurse would plan for continued client care. The test taker must be aware of the nursing actions that occur in the various phases of the nurs-client relationship.

Which action of a mental health nurse case manager reflects the activity of service planning? - Holding a care conference for a client who is having difficulty returning to school.

- Holding a care conference for a client who is having difficulty returning to school reflects the activity of service planning. A service care plan is devised with client participation and should include mutually agreed on goals, specific actions directed toward goal achievement, and selection of essential resources and services. Reviewing examples of case management activities, such as identification and outreach, assessment, service planning, linkage with needed services, monitoring service delivery, and advocacy, assists the test taker in recognizing nursing actions that reflect these activities.

A client on an in-patient psychiatric unit has a nursing diagnosis of nonadherence R/T antipsychotic medications. In which role is the nurse functioning when checking for "cheeking"? "Cheeking" is when the client hides medication between the cheek and gum. Complete inspection of the mouth, with potential use of a tongue blade, is neccessary to discover cheeking. Another way to ensure that the client has swallowed medications is to talk to the client for a few minutes after medication administration. During this time, the medication would begin to dissolve if cheeking has occured. - Medication manager.

- In the role of medication manager, the nurse has the resonsibility of ensuring that clients are given the correct medication, in the correct dosage, by the correct route, and at the correct time, and that correct documentation occurs. By checking for "cheeking," the nurse is fulfilling this role. The test taker must look at the nursing action presented in the question. In what role is the nurse functioning when performing this action?

On an in-patient psychiatric unit, which of the following actions exemplify the nurse's role of teacher? Select all that apply. - The nurse presents information to help the client and family members to understand the effects of mental illness. - The nurse holds a group to discuss medication side effects.

- In the role of teacher, the nurse assists the client and family members in coping with the effects of mental illness. Helping the client to understand his or her illness, its signs and symptoms, the medications and potential side effects, and various coping techniques all are interventions of the nurse functiong in the role of teacher. - In the role of the teacher, the nurse assists the client to understand treatments, including medication actions and their side effects. Holding this teaching group is an intervention that reflects the nurse's role of teacher. To assist the test taker in distinguishing the various roles of the nurse, he or she should consider clinical examples that reflect these roles.

Which of the following assessment information would be evaluated as objective data? - Clinical Institute Withdrawal Assessement (CIWA) score of 10. - Client's mood rating of 5 on a 10-point scale.

- Objective data include scores of rating scales developed to quantify data. A CIWA score rates symptoms of alcohol withdrawal. - Objective data include scores of rating scales developed to quantify data. A mood scale has a client objectively rate his or her mood from 0 to 10 scale. These scales take the subjective data of mood and presents it as objective data. The test taker must understand that the measurement of objective data is based on an accepted standard or scale and may require the use of a measurement tool.

A nursing student has a special feeling toward a client that is based on acceptance, warmth, and a nonjudgmental attitude. The student is experirncing which charateristic that enhances the achievement of the nurse-client relationship? - Rapport.

- Rapport is the primary task in relationship development. Rapport implies special feelings on the part of the nurse and the client. All other conditions necessary to establish the nurse-client relationship are based on the ability to connect and establish rapport. The test taker should review that characteristics that enhance the establishment of the nurse-client relationship: rapport, trust, respect, genuineness, and empathy.

An 85- year-old client has become agitated and physically aggressive after having a stroke with right-sided weakness. The client is started on risperidone (Risperdal) PO 0.5 mg qhs. Which is a priority nursing diagnosis for this client? - Risk for falls R/T right-sided weakness and sedation from risperidon (Risperdal).

- Risk for falls R/T right-sided weakness and sedation from risperidone (Risperdal) is the priority diagnosis for this client. A fall would endanger this client, and safety issues always take priority. When evaluating what is being asked for in the question, the test taker should factor in common side effects of medications that the client s receiving. Safety is always prioritized.

A client states, "My wife is unfaithful. I think I am not worth anything." Which of the following describes this assessment information? Select all that apply. Statements by clients are considered subjective data. - This is subjective information or a "chief complaint." - This information needs objective measurement by a mood rating scale.

- Subjective data are reported by the client and significant others in their own words. An example of this is the "chief complaint," which is expressed by the client during the intake interview. - Subjective data are data expressed in the client's own words and can be made objective by the use of a mood scale measurement tool. Mood or anxiety scales objectively measure subjective data. The test taker must understand that subjective data consist of the client's perception of his or her health problems. Objective data are observations or measurements made by the data collector.

An in-patient psychiatric client recently diagnosed with bipolar disorder has been prescribed lithium carbonate (Lithium). When the nurse is functioning in the role of teacher, which of the following nursing interventions is (are) appropriate? Select all that apply. - Teaching the benifits of taking this medication as prescribed. - Teaching signs and symptoms of lithium toxicity. - Teaching dietary and fluid intake considerations. - Teaching reportable side effects.

- Teaching the benefits of taking this medication and the improtance of adherence is an appropriate teaching intervention by the nurse. Knowledge deficit with regard to medication effects and adherence would affect the course of the client's recovery. Affective motivation should be promoted during teaching sessions. - Teaching signs an dsymptoms of lithium toxicity is important so that the client will know when to report these potentially life-threatening side effects. - Teaching dietary and fluid intake information is important to prevent imbalances in lithium levels. - Teaching reportable side effects is important for the client to avoid adverse effects of the medication. The test taker should recognize that teaching the nerochemical action of a medication to a client is not beneficial and may confuse the recently diagnosed client. It is more important toteach practical imformation concerning the client's medications.

Which nursing intervention within the community is aimed at reducing the residual defects that are associated with severe or chronic mental illness? - Referring clients for various aftercare services such as day treatment programs.

- Tertiary prevention is aimed at reducing the residual defects that are associated with severe or chronic mental illness. Providing aftercare services, such as day treatment programs, is one way to accomplish this. Reviewing the functions of the nurse at all levels of community mental health prevention helps the test taker to distinguish interventions in each prevention category.

A client on an in-patient psychiatric unit exhibits traits of borderline personality disorder. Which action by the nurse would initiate collaboration with the member of the mental health-care team who can best confirm this diagnosis? Personality testing must be done initially to diagnose a client with a personality disorder. This testing is administered by a psychologist. - Colaborate with the clinical psychologist to prepare the client for personality testing.

- The clinical psychologist selects, administers, and interprets psychological tests. Clients with personality disorder traits need personality testing such as the Minnesota Multiphasic Personality Inventory (MMPI) to confirm a personality disorder diagnoisis. The test taker must know that the primary function of the psychologist in an in-patient setting is testing. The psychologist performs personality inventiories and IQ testing

The nurse uses the clock face assessment test to obatain which assessment data? -Early signs of neurocognitive disorder.

- The clock face assessmetn is a sensitive way to assess early signs of neurocognitive disorder. The client is asked to place numbers appropriately on a clock face. The test taker should be aware of the purpose of various assessment tools, including the clock face assessment.

A client with a long history of alcohol use disorder has been diagnosed with Wernicke-Korakoff syndrome. With which member of the mental health-care team would the nurse collaborate to meet this client's discribed need? - The dietitian to help the client increase consumption of thiamine-rich foods.

- The dietitan can help the client to increase the intake of thiamine-rich foods. Thiamine deficiency is the cause of Wernicke-Koraskoff syndrome. The test taker needs to recognize the signs, symptoms, and cause of Wernicke-Korsakoff syndrome.

Which is the goal for the orientation phase of the nurse-client relationship? - Establish trust.

- The establishment of trust is the goal of the orientation phase. During this phase, a contract is established with the client. The test taker must recognize that creating an enviroment for the stablishment of trust and rapport is the first task and goal of the orientation phase of the nurse-client relationship. Reviewing the phases of the nurse-client relationship-pre-orientation, orientation, working, and termination-assists in answering this question.

A resource person's function is to give specific answers to specific questions, as a counselor's function is to: - Listen as a client reviews feelings related to difficulties experienced in life.

- The nurse functioning as a couselor uses interpersonal communication techniques to assist clients in learning to adapt to difficulties or changes in life experiences. These techniques allow the experiences to be integrated with, rather than dissociated from, other experiences in life. An anology is a comparison. Test takers should look at what is being compared and choose an answer that provides information that reflects a similar comparison.

A client with a long history of alcohol use disorder comes to the out-patient clinic after losing a job and driver's license because of a driving under the influence (DUI) infraction. With which member of the mental health-care team would the nurse collaborate to meet this client's described need? - The occupational therapist for retraining and job placement.

- The occupational therapist in a mental health setting focuses on rehabilitation and vocational training to assist clients in becoming productive. The occupational therapist uses manual and creative techniques to elicit desired interpersonal and intrapsychic responses. The occupational therapist helps the client with job training and employment placement, which is the direct problem described in the question. The test taker shoud review the roles of the members of the health-care team in a psychiatric setting and how the nurse would collaborate with each team member.

On an in-patient psychiatric unit, a client states, "I want to learn better ways to handle my anger," This interaction is most likely to occur in which phase of the nurse-client relationship? - Orientation (intoductory) phase.

- The orientation (introductory) phase involves creating an environment that establishes trust and rapport. Another task of this phase includes establishing a contract for interventions that details the expectations and responsibilities of the nurse and the client. In this example, the client has built the needed trust and rapport wtih the nurse. The client now feels comfortable and ready to acknowledge the problem and contract for intervention. GOAl: Establish trust and formulate constract for intervention. The test taker must read this question completely. What makes this answer "orientation phase" is that the question presents a client who is willing to work with the nurse. If the question described the actual intervention of teaching adaptive ways to handle the client's aggression, the answer would be "working phase."

On an in-patient psychiatric unit, the nurse explores feelings about potentially working with a women who has allowed her husband to abuse her and her children physically and verbally. This interaction would occur in which phase of the nurse-client relationship? - Pre-interaction phase.

- The pre-interaction phase involves preparation for the first encounter with the client, such as reading previous medical records and exploring feelings regarding working with that particular client. In this examle, the nurse obtains information about the client for initial assessment. This also allows the nurse to become aware of any personal biases about the client. GOAL: Explore self-perception. The test taker must understand that self-assessment is a major intervention that occurs in the pre-interaction phase of the nurse-client relationship. The nurse must be self-aware of any feelings or personal history that might affect the nurse's feelings toward the client.

The nurse is interviewing a client admitted to an in-patient psychiatric unit with a diagnosis of depressive disorder. Which is the primary goal in the assessment phase of the nursing process for this client? - To collect and organize information.

- The primary goal in the assessment phase of the interview is to collect and organize data, which would be used to identify and prioritize the client's problems. The test taker should write the steps of the nursing process next to the goals presented. Which goal reflects the assessment phase?

on an in-patient psychiatric unit, the goals of therapy have been met, but the client cries and states, "I have to keep coming back to therapy to handle my anger better." This interaction occurs in which phase of the nurse-client relationship? - Termination phase.

- The termination phase occurs when progress has been made toward attainment of mutually set goals, a plan for continuing cae is mutually estabished, and feelings about termination are recognized and explored. In this example, the nurse must establish the reality of separation and resist repeated delays by the client because of dependency needs. GOAL: Evaluate goal attainment and ensure therapeutic closure. The question states that the goals of therapy have been met. This information indicates a description of the termination phase of the nurse-client relationship. The test taker also should recognize the client statement as as indicative of feelings experienced during termination.

The nurse helps a client practice various techniques of assertive communication and gives positive feedback for improvement of passive-aggressive interactions. This intervention would occur in which phase of the nurse-client relationship? - Working phase.

- The working phase includes promoting the client's insight and perception of reality, problem-solving, overcoming resistant behaviors, and continuoously evaluating progress toward goal attainment. In this example, the client works toward better communication and is guided and encouraged with positive feedback from the nurse. GOAL: Promote client change The tes taker should review the phases of the nurse-client relationship and think of examples of behaviors and interactions that occur in each phase.

In a psychiatric in-patient setting, the nurse observes an adolecscent client's peers calling the client names. In this context, which statement by the nurse exemplifies the concept of empathy? - "I cansee that your upset. Tell me how you feel."

- This empathetic statement appreciates the client's feelings and objectively communicates concern for the client. The test taker must distinguish between empathy and sympathy. Empathy is an objective process werein an individual is able to see beyond outward behavior and sense accurately another's inner experience. Sympathy is a subjective process wherein an individual actually experiences the emotions felt by the client.

Which of the following are examples of primary prevention in a community mental health setting? Select all that apply - Teaching physical and psychosocial effects of stress to elementary school students. - Teaching a class on child-rearing skills for a group of new parents.

- This is an example of primary prevention, which is focused on educational programs to help prevent the incidence of mental illness. - This is an example of primary prevention, which is focused on educational programs to help prevent the incidence of mental illness. Understanding the public health model that describes primary, secondary, and tertiary prevention assist the test taker in answering this question correctly.

The nurse reviews a client's record in preparation for client care. This action is one of the tasks that occur in a phase of the nurse-client relationship. What is the purpose of this phase? - Understanding the client's diagnosis and evaluating the nurse's attittudes.

- Understanding the signs and symptoms of the client's diagnosis and evaluating the nurse's attitudes toward the client are the purposes of the pre-orientation phase of the nurse-client relationship. The test taker first must determine the stage of the nurse-client relationship in which the nurse reviews a client's record in preparation for the client care. When the test taker has determinded the stage, the next step is to remember the purpose of this stage.

Which qualifications are appropriate to the scope of practice of the psychiatric/mental health registered nurse generalist? -The nurse generalist is qualified to implement crisis intervention.

-Part of the professional responsibilities of the psychiatric/mental health registered nurse generalist is crisis intervention. The test taker must be familiar with the scope of practice of various educational levels of the registered nurse and the roles and responsibilities within this scope.

Which is the overall, priority goal of in-patient psychiatric treatment? - Stabilization and return to the community.

-Stabilization and return to the community is the overall priority goal of in-patient psychiatric treatment. Understanding the current trends in the delivery of mental health care is in the community and in-patient settings assists the test taker in answering this question correctly. Note the keywords, "priority" and "in-patient," which determine the correct answer to this question.

Which statement by the nurse expresses respect for the client? - "Mr. Hawkins, because of you aggressive behavior you cannot atten the outing."

-The nurse conveys a respectful attitude toward this client by forcusing on the client's dysfunctional behaviors and not labeling the client as dysfunctional. The nurse also addresses the clietn by name and title ("Mr. Hawkins"). The test taker needs to understand that to show respect is to believe in the dignity and worth of an individual regardless of his or her unacceptable behavior.