420 Exam 1

How would a nurse prioritize nursing diagnoses? 1.By the established goal of care 2.By the life-threatening potential 3.By the physician's priority of care 4.By the client's preference

2.By the life-threatening potential

Which data in the history would the nurse expect to find in a client diagnosed with substance-induced psychotic disorder? 1.Had delirium 2.Had less severe withdrawal symptoms 3.Has an opioid use disorder 4.Has a fluid and electrolyte imbalance

3.Has an opioid use disorder The prominent hallucinations and delusions associated with substance-induced or medication-induced disorder are found to be directly attributable to substance intoxication or withdrawal, like opioid use disorder.

During a hiring interview, which response by a nursing applicant would indicate that the applicant operates from an ethical egoism framework? 1."I would want to be treated in a caring manner if I were mentally ill." 2."This job will pay the bills, and the workload is light enough for me." 3."I will be happy caring for the mentally ill. Working in med/surg kills my back." 4."It is my duty in life to be a psychiatric nurse. It is the right thing to do."

"This job will pay the bills, and the workload is light enough for me." The applicant's comment reflects the ethical egoism framework. This framework promotes the idea that decisions are made based on what is good for the individual and may not take the needs of others into account.

A client is brought to an emergency department by police after threatening to jump off a bridge several hours ago. To assess for suicide potential, which question would a nurse ask first? 1."Are you currently thinking about harming yourself?" 2."Why do you want to harm yourself?" 3."Have you thought about the consequences of your actions?" 4."Who is your emergency contact person?"

1."Are you currently thinking about harming yourself?"

Which nursing statements or questions represent appropriate communication to assess an individual in crisis? (Select all that apply.) 1."Tell me what happened." 2."Which coping methods have you used, and did they work?" 3."Describe to me what your life was like before this happened." 4."Let's focus on the current problem." 5."I'll assist you in selecting functional coping strategies."

1."Tell me what happened." 2."Which coping methods have you used, and did they work?" 3."Describe to me what your life was like before this happened."

Which situation exemplifies both assault and battery? 1.The nurse becomes angry, calls the client offensive names, and withholds treatment. 2.The nurse threatens to "tie down" the client and then does so, against the client's wishes. 3.The nurse hides the client's clothes and medicates the client to prevent elopement. 4.The nurse restrains the client without just cause and communicates this to family.

2.The nurse threatens to "tie down" the client and then does so, against the client's wishes.

Which action would the nurse take to establish a trusting relationship with a client diagnosed with schizophrenia spectrum disorder? 1.Establish personal contact with family members 2.Be reliable, honest, and consistent during interactions 3.Share limited personal information 4.Sit close to the client to establish rapport

2.Be reliable, honest, and consistent during interactions The nurse can enhance the establishment of a trusting relationship with a client diagnosed with schizophrenia spectrum disorder by being reliable, honest, and consistent during interactions. The nurse should also convey acceptance of the client's needs and maintain a calm attitude.

A wife brings her husband to an emergency department (ED) after an attempt to hang himself. He is a full-time student and works 8 hours at night to support his family. He states, "I can't function any longer under all this stress." Which type of crisis is the client experiencing? 1.Maturational/developmental crisis 2.Psychiatric emergency crisis 3.Anticipated life transition crisis 4.Traumatic stress crisi

2.Psychiatric emergency crisis

Which individuals are communicating a message? (Select all that apply.) 1.A mother spanking her son for playing with matches 2.A teenage boy isolating himself and playing loud music 3.A biker sporting an eagle tattoo on his biceps 4.A teenage girl writing, "No one understands me" 5.A father checking for new email on a regular basis

1.A mother spanking her son for playing with matches 2.A teenage boy isolating himself and playing loud music 3.A biker sporting an eagle tattoo on his biceps 4.A teenage girl writing, "No one understands me"

A client requests information on several medications in order to make an informed choice about management of depression. A nurse would provide this information to facilitate which ethical principle? 1.Autonomy 2.Beneficence 3.Nonmaleficence 4.Justice

1.Autonomy

The unit manager's policy is that clients can make a choice about whether or not to attend group therapy in an inpatient psychiatric unit. Which ethical principle does the unit manager's policy preserve? 1.Justice 2.Autonomy 3.Veracity 4.Beneficence

2.Autonomy The unit manager's policy regarding voluntary client participation in group therapy preserves the ethical principle of autonomy. The principle of autonomy presumes that individuals are capable of making independent decisions for themselves and that health-care workers must respect these decisions.

The nurse is caring for a client with schizophrenia spectrum disorder who is experiencing a flat affect, paranoid delusions, anhedonia, anergia, neologisms, and echolalia. Which statement correctly differentiates the client's positive and negative symptoms of schizophrenia? 1.Paranoid delusions, anhedonia, and anergia are positive symptoms of schizophrenia. 2.Paranoid delusions, neologisms, and echolalia are positive symptoms of schizophrenia. 3.Paranoid delusions, anergia, and echolalia are negative symptoms of schizophrenia. 4.Paranoid delusions, flat affect, and anhedonia are negative symptoms of schizophrenia.

2.Paranoid delusions, neologisms, and echolalia are positive symptoms of schizophrenia. The nurse should recognize that positive symptoms of schizophrenia include, but are not limited to, paranoid delusions, neologisms, and echolalia.

An inpatient psychiatric physician refuses to treat clients without insurance and prematurely discharges those whose insurance benefits have expired. Which ethical principle would a nurse determine has been violated based on these actions? 1.Autonomy 2.Beneficence 3.Nonmaleficence 4.Justice

4.Justice

Which type of touch is described as functional-professional? 1.A nurse performing an assessment 2.Shaking the hand of an acquaintance 3.A child laying their head on the mother's lap 4.Hugging a good friend and former coworker good-bye

1.A nurse performing an assessment A nurse performing an assessment is an example of functional-professional touch; it is used to accomplish a task.

Which statement is most accurate regarding the assessment of clients diagnosed with psychiatric problems? 1.Medical history is of little significance and can be eliminated from the nursing assessment. 2.Assessment provides a holistic view of the client, including biopsychosocial aspects. 3.Comprehensive assessments can be performed only by advanced practice nurses. 4.Psychosocial evaluations are gained by subjective reports rather than objective observations.

2.Assessment provides a holistic view of the client, including biopsychosocial aspects.

The nurse maintains a client's confidentiality, addresses the client appropriately, and does not discriminate based on gender, age, race, or religion. Which guiding principle of recovery has this nurse employed? 1.Recovery is culturally based and influenced. 2.Recovery is based on respect. 3.Recovery involves individual, family, and community strengths and responsibility. 4.Recovery is person-driven

2.Recovery is based on respect. Maintaining confidentiality, addressing the client appropriately, and not discriminating based on individual characteristics reflect a recovery based on respect.

An inpatient client with a known history of violence suddenly begins to pace. Which additional client behavior would alert a nurse to escalating anger and aggression? 1.The client requests prn medications. 2.The client has a tense facial expression. 3.The client refuses to eat lunch. 4.The client sits in group with back to peers.

2.The client has a tense facial expression.

Parents ask a nurse how they should reply when their son, diagnosed with schizophrenia spectrum disorder, tells them that voices command him to harm others. Which nursing response is appropriate? 1."Tell him to stop discussing the voices." 2."Ignore what he is saying, while attempting to discover the underlying cause." 3."Focus on the feelings generated by the hallucinations and present reality." 4."Present objective evidence that the voices are not real."

3."Focus on the feelings generated by the hallucinations and present reality." The most appropriate response by the nurse is to instruct the parents to focus on the feelings generated by the hallucinations and present reality. The parents should accept that their child is experiencing the hallucination but should not reinforce this unreal sensory perception.

Which client statement would a nurse identify as a typical response to stress most often experienced in the working phase of the nurse-client relationship? 1."I can't bear the thought of leaving here and failing." 2."I might have a hard time working with you because you remind me of my mother." 3."I really don't want to talk any more about my childhood abuse." 4."I'm not sure that I can count on you to protect my confidentiality."

3."I really don't want to talk any more about my childhood abuse." The nurse should identify that the client statement, "I really don't want to talk any more about my childhood abuse," reflects that the client is in the working phase of the nurse-client relationship. The working phase includes overcoming resistance behaviors on the part of the client as the level of anxiety rises in response to discussion of painful issues.

An instructor is correcting a nursing student's clinical worksheet. Which instructor statement is the best example of effective feedback? 1."Why did you use the client's name on your clinical worksheet?" 2."You were very careless to refer to your client by name on your clinical worksheet." 3."Surely you didn't do this deliberately, but you breached confidentiality by using names." 4."It is disappointing that after being told you're still using client names on your worksheet."

3."Surely you didn't do this deliberately, but you breached confidentiality by using names." The instructor's statement, "Surely you didn't do this deliberately, but you breeched confidentiality by using names," is an example of effective feedback. Feedback is method of communication for helping others consider a modification of behavior.

A client diagnosed with schizophrenia refuses to take medication, citing the right of autonomy. Under which circumstance would a nurse have the right to medicate the client against the client's wishes? 1.A client makes inappropriate sexual innuendos to a staff member. 2.A client constantly demands attention from the nurse by begging, "Help me get better." 3.A client physically attacks another client after being confronted in group therapy. 4.A client refuses to bathe or perform hygienic activities.

3.A client physically attacks another client after being confronted in group therapy. The nurse would have the right to medicate a client against his or her wishes if the client physically attacks another client. This client poses a significant risk to safety and is incapable of making informed choices. The client's refusal to accept treatment can be challenged, because the client is endangering the safety of others.

The psychiatrist prescribes haloperidol (Haldol) 50 mg bid, benztropine (Cogentin) 1 mg prn, and zolpidem (Ambien) 10 mg at bedtime for a client with schizophrenia spectrum disorder. Which client behavior would warrant the nurse to administer benztropine? 1.Tactile hallucinations 2.Tardive dyskinesia 3.Muscle rigidity 4.Reports of hearing disturbing voices

3.Muscle rigidity An anticholinergic medication such as benztropine would be used to treat the extrapyramidal symptom of muscle rigidity. Tardive dyskinesia, a potentially irreversible condition, would warrant the discontinuation of an antipsychotic medication such as haloperidol. Valbenazine (Ingrezza) can be given for tardive dyskinesia.

A college student, who was nearly raped while out jogging, completes a series of appointments with a rape crisis nurse. At the final session, which client statement most clearly suggests that the goals of crisis intervention have been met? 1."You've really been helpful. Can I count on you for continued support?" 2."I work out in the college gym rather than jogging outdoors." 3."I'm really glad I didn't go home. It would have been hard to come back." 4."I carry mace when I jog. It makes me feel safe and secure."

4."I carry mace when I jog. It makes me feel safe and secure."

An involuntarily committed client is verbally abusive to the staff, repeatedly threatening to sue. The client records the full names of the staff. Which nursing action is most appropriate to decrease the possibility of a lawsuit? 1.Verbally redirect the client and then refuse one-on-one interaction. 2.Involve the hospital's security division as soon as possible. 3.Notify the client that documenting personal staff information is against hospital policy. 4.Continue professional attempts to establish a positive working relationship with the client.

4.Continue professional attempts to establish a positive working relationship with the client. The most appropriate nursing action is to continue professional attempts to establish a positive working relationship with the client.

On which task would a nurse place highest priority during the working phase of relationship development? 1.Establishing a contract for intervention 2.Examining feelings about working with a particular client 3.Establishing a plan for continuing aftercare 4.Promoting the client's insight and perception of reality

4.Promoting the client's insight and perception of reality The nurse should place priority on promoting the client's insight and perception of reality during the working phase of relationship development.

Which student statement indicates that further teaching is needed regarding the guiding principles of the recovery model? 1."Recovery occurs via many pathways." 2."Recovery emerges from strong religious affiliations." 3."Recovery is supported by peers and allies." 4."Recovery is culturally based and influenced."

2."Recovery emerges from strong religious affiliations." Recovery emerges from hope but affiliation with any particular religion would have little bearing on the recovery process.

A client diagnosed with alcohol abuse disorder is referred to a residential care facility after discharge. According to SAMHSA, which dimension of recovery is supporting this client? 1.Health 2.Home 3.Purpose 4.Community

2.Home SAMHSA describes the dimension of home as a stable and safe place to live. The residential care facility will provide this for the client.

A geriatric client is confused and wandering in and out of every door of a care facility. Which scenario reflects the least restrictive alternative for this client? 1.The client is placed in seclusion. 2.The client is placed in a geriatric chair with tray. 3.The client is placed in soft Posey restraints. 4.The client is monitored by an ankle bracelet.

4.The client is monitored by an ankle bracelet.

Which of the following are behavior assessment categories in the Broset Violence Checklist? (Select all that apply.) 1.Confusion 2.Paranoia 3.Boisterousness 4.Panic 5.Irritability

1.Confusion 3.Boisterousness 5.Irritability

A new mother is concerned about her ability to perform her parental role. She is quite anxious and ambivalent about leaving the postpartum unit. To offer effective client care, a nurse would note that this type of crisis is precipitated by 1.Unexpected external stressors. 2.Preexisting psychopathology. 3.An acute response to an external situational stressor. 4.Normal life-cycle transitions that overwhelm the client.

4.Normal life-cycle transitions that overwhelm the client.

An adolescent diagnosed with schizophrenia spectrum disorder experiences command hallucinations to harm others. The client's parents ask a nurse, "Where do the voices come from?" Which response should the nurse make? 1."Your child has a chemical imbalance of the brain, which leads to altered perceptions." 2."Your child's hallucinations are caused by medication interactions." 3."Your child has too little serotonin in the brain, causing delusions and hallucinations." 4."Your child's abnormal hormonal changes have precipitated auditory hallucination

1."Your child has a chemical imbalance of the brain, which leads to altered perceptions." The nurse should explain that a chemical imbalance of the brain leads to altered perceptions. The current position on the dopamine hypothesis is that positive symptoms (like command hallucinations) may be related to increased numbers of dopamine receptors in the brain causing an imbalance.

A psychiatrist who embraces the Psychological Recovery Model tells the nurse that a client is in the Growth stage. Which would the nurse expect to find when assessing this client? 1.A client who feels confident about achieving goals in life. 2.A client who recognizes the need to set goals in life. 3.A client who is willing to take risks to re-establish a sense of self. 4.A client who sets realistic goals and pursues recovery at his or her pace

1.A client who feels confident about achieving goals in life. In Stage 5 (Growth) of the Psychological Recovery Model, the client achieves the growth outcome of the psychological recovery process. This outcome involves a strong, positive sense of self and identity and confidence in managing illnesses. This answer choice indicates the Growth stage.

The client diagnosed with schizophrenia refuses medication at one regularly scheduled home visit from a home-health nurse. Which nursing intervention is ethically appropriate? 1.Allow the client to decline and document 2.Tell the client that if the medication is refused, hospitalization will occur. 3.Arrange with a relative to add the medication to the client's morning orange juice. 4.Call for help to hold the client down while the injection is administered.

1.Allow the client to decline and document

9 The following outcome was developed for a client: "Client will list five personal strengths by the end of day one." Which correctly written nursing diagnostic statement most likely generated the development of this outcome? 1.Altered self-esteem R/T years of emotional abuse AEB self-deprecating statements 2.Self-care deficit R/T altered thought process 3.Disturbed body image R/T major depressive disorder AEB mood rating of 2/10 4.Risk for disturbed self-concept R/T hopelessness AEB suicide attempt

1.Altered self-esteem R/T years of emotional abuse AEB self-deprecating statements

After disturbing the peace, an aggressive, disoriented, unkempt, homeless individual is escorted to an emergency department. The client threatens suicide. Which of the following criteria would enable this client to be considered for involuntary commitment? (Select all that apply.) 1.Being dangerous to others 2.Being homeless 3.Being disruptive to the community 4.Being gravely disabled and unable to meet basic needs 5.Being suicidal

1.Being dangerous to others 4.Being gravely disabled and unable to meet basic needs 5.Being suicidal

Which is the most essential task for a nurse to accomplish prior to forming a therapeutic relationship with a client? 1.Clarify personal attitudes, values, and beliefs. 2.Obtain thorough assessment data. 3.Determine the client's length of stay. 4.Establish personal goals for the interaction.

1.Clarify personal attitudes, values, and beliefs. The most essential task for a nurse to accomplish prior to forming a therapeutic relationship with a client is to clarify personal attitudes, values, and beliefs. Understanding one's own attitudes, values, and beliefs is called self-awareness.

The diagnosis of catatonic disorder due to another medical condition is made when the client's medical history, physical examination, or laboratory findings provide evidence that symptoms are directly attributed to which conditions? (Select all that apply.) 1.Epilepsy 2.Hypothyroidism 3.Hyperadrenalism 4.Encephalitis 5.Hyperaphia

1.Epilepsy 2.Hypothyroidism 4.Encephalitis 5.Hyperaphia Types of medical conditions that have been associated with catatonic disorder include neurological conditions such as epilepsy. The diagnosis of catatonic disorder due to another medical condition is made when the symptomatology is evidenced from medical history, physical examination, or laboratory findings to be directly attributable to the physiological consequences of a general medical condition.

Which modalities should a nurse recognize as integral parts of a treatment program when planning care for clients diagnosed with schizophrenia spectrum disorder? (Select all that apply.) 1.Group therapy 2.Medication management 3.Deterrent therapy 4.Supportive family therapy 5.Social skills training

1.Group therapy 2.Medication management 4.Supportive family therapy 5.Social skills training

Which of the following has SAMHSA described as major dimensions of support for a life of recovery? (Select all that apply) 1.Health 2.Community 3.Home 4.Religion 5.Purpose

1.Health 2.Community 3.Home 5.Purpose SAMHSA suggests that four major dimensions support a life in recovery: health, home, purpose, and community.

Which of the following interventions would a nurse use when caring for an inpatient client who expresses anger inappropriately? (Select all that apply.) 1.Maintain a calm demeanor. 2.Clearly delineate the consequences of the behavior. 3.Use therapeutic touch to convey empathy. 4.Set limits on the behavior. 5.Teach the client to avoid "I" statements related to expression of feelings.

1.Maintain a calm demeanor. 2.Clearly delineate the consequences of the behavior. 3.Use therapeutic touch to convey empathy. 4.Set limits on the behavior.

A client diagnosed with obsessive-compulsive disorder states, "I really think my relationship with my family will improve because of this treatment. My relationship with my kids is going to be a lot better from now on." Which guiding principle of recovery has assisted this client? 1.Recovery emerges from hope. 2.Recovery is person-driven. 3.Recovery occurs via many pathways. 4.Recovery is holistic.

1.Recovery emerges from hope. This client is expressing hope for a better future as a motivator for recovery

Which therapeutic communication technique is being used in the following nurse-client interaction? Client: "My father spanked me often." Nurse: "Your father was a harsh disciplinarian." 1.Restating 2.Offering general leads 3.Focusing 4.Accepting

1.Restating The nurse is using the therapeutic communication technique of restating. Restating involves repeating the main idea of what the client has said. It allows the client to know whether the statement has been understood and provides an opportunity to continue.

The client diagnosed with schizophrenia spectrum disorder is prescribed an antipsychotic. Which client symptoms, related to the side effects of this medication, should prompt a nurse to intervene immediately? 1.Sore throat and malaise 2.Light-colored urine and bradycardia 3.Anosognosia and avolition 4.Dry mouth and urinary retention

1.Sore throat and malaise The nurse should intervene immediately if the client experiences signs of an infectious process—such as a sore throat, fever, and malaise—when taking antipsychotic drugs.

Which client action would a nurse expect during the working phase of the nurse-client relationship? 1.The client gains insight and incorporates alternative behaviors. 2.The client establishes rapport with the nurse and mutually develops treatment goals. 3.The client explores feelings related to reentering the community. 4.The client explores personal strengths and weaknesses that impact behavioral choices.

1.The client gains insight and incorporates alternative behaviors. The nurse should expect that the client will gain insight and incorporate alternative behaviors during the working phase of the nurse-client relationship.

The following NANDA-I nursing diagnostic stem was developed for a client on an inpatient unit: Risk for injury. Which assessment data most likely led to the development of this problem statement? 1.The client is receiving ECT and is diagnosed with Parkinsonism. 2.The client has a history of four suicide attempts in adolescence. 3.The client expresses hopelessness and helplessness and isolates self. 4.The client has disorganized thought processes and delusional thinking.

1.The client is receiving ECT and is diagnosed with Parkinsonism.

A nurse applies extra physical restraints to a client who yells obscenities and threatens harm to the nurse. The nurse's coworker observes this action and feels that this is an inappropriate use of restraints, but fears of retaliation if action is taken against the nurse in question. Which is true about this scenario? 1.The coworker may experience a great deal of emotion. 2.The nurse values the client's autonomy. 3.The coworker is exhibiting beneficence. 4.The client values justice.

1.The coworker may experience a great deal of emotion. This scenario represents an ethical dilemma. Ethical dilemmas may cause a great deal of emotion because no clear right or wrong answer may present itself.

The nurse is answering a phone call in which the person is asking if a client has recently been admitted to a psychiatric facility. Which nursing response reflects appropriate legal and ethical obligations? 1.The nurse refuses to give any information to the caller, citing rules of confidentiality. 2.The nurse immediately hangs up on the caller. 3.The nurse confirms that the person has been at the facility but adds no additional information. 4.The nurse suggests that the caller speak to the client's therapist.

1.The nurse refuses to give any information to the caller, citing rules of confide The most appropriate action by the nurse is to refuse to give any information to the caller.

A nursing instructor is teaching about components of the recovery process that led to the development of the Psychological Recovery Model. Which student statement indicates that further teaching is needed? 1."A client has a better chance of recovery if he or she truly believes that recovery can occur." 2."If a client is willing to give the responsibility of treatment to the health-care team, they are likely to recover." 3."A client who has a positive sense of self and a positive identity is likely to recover." 4."A client has a better chance of recovery if he or she has purpose and meaning in life."

2."If a client is willing to give the responsibility of treatment to the health-care team, they are likely to recover." In examining a number of studies, Andresen and associates identified four components that were consistently evident in the recovery process. These components are hope, responsibility, self and identity, and meaning and purpose. Under responsibility, this model tasks the client, not the health-care team, with taking responsibility for his or her life and well-being.

Which student statement indicates that further teaching is needed regarding recovery as it applies to mental illness? 1."The goal of recovery is improved health and wellness." 2."The goal of recovery is expedient, comprehensive behavioral change." 3."The goal of recovery is the ability to live a self-directed life." 4."The goal of recovery is the ability to reach full potential."

2."The goal of recovery is expedient, comprehensive behavioral change." Change in recovery is not an expedient process. It occurs incrementally over time.

A despondent client who has recently lost her husband of 30 years tearfully states, "I'll feel a lot better if I sell my house and move away." Which nursing response is most appropriate? 1."I'm confident you know what's best for you." 2."This may not be the best time for you to make such an important decision." 3."Your children will be terribly disappointed." 4."Tell me why you want to make this change."

2."This may not be the best time for you to make such an important decision."

A client diagnosed with posttraumatic stress disorder related to a rape is admitted to an inpatient psychiatric unit for evaluation and medication stabilization. Which therapeutic communication technique might a nurse use that is an example of "broad openings"? 1."What occurred prior to the rape, and when did you go to the emergency department?" 2."What would you like to talk about?" 3."I notice you seem uncomfortable discussing this." 4."How can we help you feel safe during your stay here?"

2."What would you like to talk about?" The nurse's statement, "What would you like to talk about?" is an example of the therapeutic communication technique of a broad opening. Using broad openings allows the client to take the initiative in introducing the topic and emphasizes the importance of the client's role in the interaction.

A mother rescues two of her four children from a house fire. The other two children die in the house fire. In an emergency department, she cries, "I should have gone back in to get them. I should have died, not them." What is the nurse's best response? 1."The smoke was too thick. You couldn't have gone back in." 2."You're experiencing feelings of guilt, because you weren't able to save your children." 3."Focus on the fact that you could have lost all four of your children." 4."It's best if you try not to think about what happened. Try to move on."

2."You're experiencing feelings of guilt, because you weren't able to save your children." The best response by the nurse is, "You're experiencing feelings of guilt, because you weren't able to save your children." This response uses the therapeutic communication technique of restating what the client has said. This lets the client know whether an expressed statement has been understood or if clarification is necessary.

In response to a student's question regarding choosing a psychiatric specialty, a charge nurse states, "Mentally ill clients need to feel compassion and care. If I were in that position, I'd want a caring nurse also." From which ethical framework is the charge nurse operating? 1.Kantianism 2.Christian ethics 3.Ethical egoism 4.Utilitarianism

2.Christian ethics The charge nurse is most likely operating from a Christian ethics framework. The imperative demand of Christian ethics is that all decisions about right and wrong should be centered in love for God and in treating others with the same respect and dignity with which we would expect to be treated.

Which is the priority focus of recovery models? 1.Empowerment of the health-care team to bring their expertise to decision-making 2.Empowerment of the client to make decisions related to individual health care 3.Empowerment of the family system to provide supportive care 4.Empowerment of the physician to provide appropriate treatment

2.Empowerment of the client to make decisions related to individual health care The basic concept of a recovery model is empowerment of the client. The recovery model is designed to allow clients primary control over decisions about their own care.

Which of the following characteristics should be included in a therapeutic nurse-client relationship? (Select all that apply.) 1.Meeting the psychological needs of the nurse and the client 2.Ensuring therapeutic termination 3.Promoting client insight into problematic behavior 4.Collaborating to set appropriate goals 5.Meeting both the physical and psychological needs of the client

2.Ensuring therapeutic termination 3.Promoting client insight into problematic behavior 4.Collaborating to set appropriate goals 5.Meeting both the physical and psychological needs of the client

The nurse has just met a new client and is beginning to get to know to the client. Which would be the priority nursing action during this phase of the nurse-client relationship? 1.Acknowledge the client's actions and generate alternative behaviors. 2.Establish rapport and develop treatment goals. 3.Attempt to find alternative placement for the client. 4.Explore how thoughts and feelings about this client may adversely impact nursing care.

2.Establish rapport and develop treatment goals. The priority nursing action during the orientation phase of the nurse-client relationship should be to establish rapport and develop treatment goals. Rapport implies feelings on the part of both the nurse and the client, based on respect, acceptance, a sense of trust, and a nonjudgmental attitude. It is the essential foundation of the nurse-client relationship.

The nurse is building a therapeutic relationship with a client. During their interaction, the nurse feels the individual is not always honest or open during their interactions. Which characteristic would a nurse identify as missing? 1.Respect 2.Genuineness 3.Sympathy 4.Rapport

2.Genuineness When an individual is seen as dishonest or not open, the nurse should identify that genuineness is missing in the relationship. Genuineness refers to the nurse's ability to be open and honest and maintain congruence between what is felt and what is communicated. When a nurse fails to bring genuineness to the relationship, trust cannot be established.

Which client assessment finding would alert the nurse to question a diagnosis of brief psychotic disorder? 1.Has impaired reality testing for a 24-hour period. 2.Has auditory hallucinations for the past 3 hours. 3.Has bizarre behavior for 1 day. 4.Has confusion for 3 weeks

2.Has auditory hallucinations for the past 3 hours. This disorder is identified by the sudden onset of psychotic symptoms that may or may not be preceded by a severe psychosocial stressor. These symptoms last at least 1 day but less than 1 month and there is an eventual full return to the premorbid level of functioning.

Which describes the primary purpose of a registered nurse gathering client information? 1.It enables the nurse to modify behaviors related to personality disorders. 2.It enables the nurse to make sound clinical judgments and plan appropriate care. 3.It enables the nurse to prescribe the appropriate medications. 4.It enables the nurse to assign the appropriate Axis I diagnosis.

2.It enables the nurse to make sound clinical judgments and plan appropriate care.

A client with schizophrenia spectrum disorder presents with bizarre behaviors and delusions. Which nursing action should be prioritized to maintain this client's safety? 1.Monitor for medication nonadherence. 2.Note escalating behaviors immediately. 3.Interpret attempts at communication. 4.Assess triggers for bizarre, inappropriate behaviors

2.Note escalating behaviors immediately. The nurse should note escalating behaviors immediately, to maintain this client's safety. Early intervention may prevent an aggressive response and keep the client and others safe.

A nurse maintains an uncrossed arm and leg posture when communicating with a client. This nonverbal behavior is reflective of which letter of the SOLER acronym for active listening? 1.S 2.O 3.L 4.E

2.O The nurse should identify that maintaining an uncrossed arm and leg posture is nonverbal behavior that reflects the O in the active-listening acronym SOLER: observing an open posture.

Which potential client would a nurse identify as a candidate for involuntary commitment? 1.The client living under a bridge 2.The client threatening to commit suicide 3.The client who never bathes and wears a wool hat in the summer 4.The client who eats waste out of a garbage can

2.The client threatening to commit suicide The nurse should identify the client threatening to commit suicide as eligible for involuntary commitment. The suicidal client who refuses treatments is in danger and needs emergency treatment.

Which function is exclusive to the advanced practice psychiatric nurse? 1.Teaching about the side effects of neuroleptic medications 2.Using psychotherapy to improve mental health status 3.Using milieu therapy to structure a therapeutic environment 4.Providing case management to coordinate continuity of health services

2.Using psychotherapy to improve mental health status

A client exhibiting dependent behaviors says, "Do you think I should move out of my parents' house and get a job?" Which nursing response is most appropriate? 1."It would be best to do that in order to increase independence." 2."Why would you want to leave a secure home?" 3."Let's discuss and explore all of your options." 4."I'm afraid you would feel very guilty leaving your parents."

3."Let's discuss and explore all of your options." The most appropriate response by the nurse is, "Let's discuss and explore all of your options." In this example, the nurse is encouraging the client to formulate ideas and decide independently the appropriate course of action.

The aging client takes an antipsychotic for schizophrenia spectrum disorder and a beta-adrenergic blocking agent for hypertension. Based on an understanding of the combined side effects of these drugs, which statement by a nurse is most appropriate? 1."Make sure you concentrate on taking slow, deep, cleansing breaths." 2."Watch your diet and try to engage in some regular physical activity." 3."Rise slowly when you change position from lying to sitting or sitting to standing." 4."Wear sunscreen and try to avoid midday sun exposure."

3."Rise slowly when you change position from lying to sitting or sitting to standing." The most appropriate statement by the nurse is to instruct the client to rise slowly when changing positions. Antipsychotic medications and beta blockers cause a decrease in blood pressure. When given in combination, the additive effect of these drugs places the client at risk for developing orthostatic hypotension.

A client diagnosed with schizophrenia spectrum disorder states, "Can't you hear him? It's the devil. He's telling me I'm going to hell." Which is the most appropriate nursing response? 1."Did you take your medicine this morning?" 2."You are not going to hell. You are a good person." 3."The voices must sound scary, but I do not hear any voices." 4."The devil only talks to people who are receptive to his influence."

3."The voices must sound scary, but I do not hear any voices." The most appropriate nursing response is to reassure the client while not reinforcing the hallucination. Reminding the client that "the voices" are not real will prevent validation of the hallucination. It is also important for the nurse to connect with the client's fears and inner feelings.

Which response by the instructor most accurately answers the student's question regarding how to best develop nursing outcomes for clients? 1."You can use NIC, a standardized reference for nursing outcomes." 2."Look at your client's problems and set a realistic, achievable goal." 3."With client collaboration, outcomes would be based on client problems." 4."Copy your standard outcomes from a nursing care plan textbook."

3."With client collaboration, outcomes would be based on client problems."

Which is an example of offering a "general lead" when interviewing a newly admitted psychiatric client? 1."Do you know why you are here?" 2."Are you feeling depressed or anxious?" 3."Yes, I see. Go on." 4."Can you order the specific events that led to your admission?"

3."Yes, I see. Go on." The nurse's statement, "Yes, I see. Go on," is an example of a general lead. Offering general leads encourages the client to continue sharing information.

____ 13. Which situation reflects a violation of the ethical principle of veracity? 1.A nurse discusses with a client another client's impending discharge. 2.A nurse refuses to give information to a physician who is not responsible for the client's care. 3.A nurse tricks a client into seclusion by asking the client to carry linen to the seclusion room. 4.A nurse does not treat all of the clients equally, regardless of illness severity.

3.A nurse tricks a client into seclusion by asking the client to carry linen to the seclusion room.

The client in an inpatient unit expresses doubt in the importance of the treatments. The nurse provides the client with copies of all documents related to the plan of care in order to reveal the significance of the treatments. This nurse is employing which commitment in the Tidal Model of Recovery? 1.Know that change is constant 2.Reveal personal wisdom 3.Be transparent 4.Give the gift of time

3.Be transparent The nurse is indicating the commitment to be transparent. The nurse is providing the client with all documents related to the plan of care, which will help the teambuilding process.

Which characteristics of accurately developed client outcomes would a nurse identify? (Select all that apply.) 1.Client outcomes are specifically formulated by nurses. 2.Client outcomes are not restricted by time frames. 3.Client outcomes are specific and measurable. 4.Client outcomes are realistically based on client capability. 5.Client outcomes are formally approved by the psychiatrist.

3.Client outcomes are specific and measurable. 4.Client outcomes are realistically based on client capability.

The client diagnosed with schizophrenia spectrum disorder tells the nurse, "I'm sad that the voice is telling me to stop seeing my psychiatrist." Which symptom is the client exhibiting? 1.Magical thinking 2.Persecutory delusions 3.Command hallucinations 4.Altered thought processes

3.Command hallucinations The nurse should determine that the client is exhibiting command hallucinations. Clients with command hallucinations could potentially be physically, emotionally, and/or sexually harmful to others or to self.

Which therapeutic communication technique is being used in the following nurse-client interaction? Client: "When I am anxious, the only thing that calms me down is alcohol." Nurse: "Other than drinking, what alternatives have you explored to decrease anxiety?" 1.Encouraging comparison 2.Making observations 3.Formulating a plan of action 4.Giving recognition

3.Formulating a plan of action The nurse is using the therapeutic communication technique of formulating a plan of action to help the client explore alternatives to drinking. The use of this technique may serve to prevent anger or anxiety from escalating.

Which nursing action would be identified with Stage IV of Roberts' Seven-stage Crisis Intervention Model? 1.Collaboratively implement an action plan. 2.Help the client identify the major problems or crisis precipitants. 3.Help the client deal with feelings and emotions. 4.Collaboratively generate and explore alternatives.

3.Help the client deal with feelings and emotions.

A client diagnosed with schizoaffective disorder is admitted for social skills training. Which information should be included in the nurse's teaching? 1.The side effects of medications 2.Deep breathing techniques to decrease stress 3.How to make eye contact when communicating 4.Behaviors needed to be a leader

3.How to make eye contact when communicating The nurse should plan to teach the client how to make eye contact when communicating. Social skills, such as making eye contact, can assist clients to communicate needs and to establish relationships.

Which statement regarding nursing interventions would a nurse identify as accurate? 1.Nursing interventions are independent from the treatment team's goals. 2.Nursing interventions are solely directed by written physician orders. 3.Nursing interventions are comprehensive and reflect current clinical nursing practice 4.Nursing interventions are standardized by policies and procedures.

3.Nursing interventions are comprehensive and reflect current clinical nursing practice

A high school student has learned that she cannot graduate. Her boyfriend will be attending a college out of state that she planned to attend. She is admitted to a psychiatric unit after overdosing on Tylenol. Which is the priority nursing diagnosis for this client? 1.Ineffective coping R/T situational crisis AEB powerlessness 2.Anxiety R/T fear of failure 3.Risk for self-directed violence R/T hopelessness 4.Risk for low self-esteem R/T loss events AEB suicidal ideations

3.Risk for self-directed violence R/T hopelessness

The client diagnosed with schizophrenia spectrum disorder tells a nurse about voices commanding him to kill his ex-spouse. Which nursing diagnosis is priority for this client? 1.Disturbed sensory perception 2.Altered thought processes 3.Risk for violence: directed toward others 4.Risk for injury

3.Risk for violence: directed toward others The nurse should prioritize the diagnosis risk for violence: directed toward others. A client who hears voices commanding him to kill someone is at risk for other-directed violence. Other risk factors for violence include aggressive body language, verbal aggression, catatonic excitement, and rage reactions.

A brother calls to speak to his sister, who has been admitted to a psychiatric unit. The nurse connects him to the community phone, and the sister is summoned. Later the nurse realizes that the brother was not on the client's approved call list. What law has the nurse broken? 1.The National Alliance for the Mentally Ill Act 2.The Tarasoff Ruling 3.The Health Insurance Portability and Accountability Act 4.The Good Samaritan Law

3.The Health Insurance Portability and Accountability Act

A client who will be receiving electroconvulsive therapy (ECT) must provide informed consent. Which situation would cause a nurse to question the validity of the informed consent? 1.The client is paranoid. 2.The client is 87 years old. 3.The client incorrectly reports his or her spouse's name, date, and time of day. 4.The deaf client relies on his or her spouse to interpret the information

3.The client incorrectly reports his or her spouse's name, date, and time of day.

The nurse is caring for a client who lost a child in a car accident. The client states she does not want to go on living. Which nursing statement conveys empathy for the client? 1."This situation is very sad, but time is a great healer." 2."You are sad, but you must be strong for your other children." 3."Once you cry it all out, things will seem so much better." 4."It must be horrible to lose a child, and I'll stay with you until your husband arrives."

4."It must be horrible to lose a child, and I'll stay with you until your husband arrives." The nurse's response, "It must be horrible to lose a child, and I'll stay with you until your husband arrives," conveys empathy to the client. Empathy is the ability to see the situation from the client's point of view. Empathy is considered to be one of the most important characteristics of the therapeutic relationship.

A newly admitted client, diagnosed with obsessive-compulsive disorder (OCD), washes his hands continually. This behavior prevents unit activity attendance. Which nursing statement best addresses this situation? 1."Everyone diagnosed with OCD needs to control their ritualistic behaviors." 2."It is important for you to discontinue these ritualistic behaviors." 3."Why are you asking for help if you won't participate in unit therapy?" 4."Let's figure out a way for you to attend unit activities and still wash your hands."

4."Let's figure out a way for you to attend unit activities and still wash your hands." The most appropriate statement by the nurse is, "Let's figure out a way for you to attend unit activities and still wash your hands." This statement reflects the therapeutic communication technique of formulating a plan of action. The nurse attempts to work with the client to develop a plan without damaging the therapeutic relationship.

Which situation exemplifies the basic concept of a recovery model? 1.The client's family is encouraged to make decisions in order to facilitate discharge. 2.A social worker, discovering the client's income, changes the client's discharge placement. 3.A psychiatrist prescribes an antipsychotic drug based on observed symptoms. 4.A client diagnosed with schizophrenia schedules follow-up appointments and group therapy.

4.A client diagnosed with schizophrenia schedules follow-up appointments and group therapy. The basic concept of a recovery model is empowerment of the client. The recovery model is designed to allow clients primary control over decisions about their own care.

The nurse asks the client with schizophrenia spectrum disorder, "Do you receive special messages from certain sources, such as the television or radio?" The nurse is assessing which potential symptom of this disorder? 1.Loose associations 2.Paranoid delusions 3.Magical thinking 4.Delusions of reference

4.Delusions of reference The nurse is assessing for the potential symptom of delusions of reference. A client who believes he or she receives messages through the radio or TV is experiencing delusions of reference. These delusions involve the client interpreting events within the environment as being directed toward himself or herself. Clients with delusions of reference believe that others are trying to send them messages in various ways, or they must break a code to receive a message.

Which describes the rationale for holding a debriefing session with clients and staff after a take-down intervention has taken place in an inpatient unit? 1.Reinforce unit rules with the client population. 2.Create protocols for the future release of tensions associated with anger. 3.Process client feelings and alleviate fears of undeserved seclusion and restraint. 4.Discuss the situation that led to inappropriate expressions of anger.

4.Discuss the situation that led to inappropriate expressions of anger.

The nurse is caring for an older male client who states, "You remind me so much of my late wife." During subsequent encounters with the client, he expresses overwhelming feelings of affection toward the nurse and states "I don't know what I would do if you weren't my nurse. No one cares for me like you do." How should the nurse respond? 1.Promote safety and immediately terminate the relationship with the client. 2.Encourage the client to ignore these thoughts and feelings. 3.Immediately reassign the client to another staff member. 4.Help the client to clarify the meaning of the relationship.

4.Help the client to clarify the meaning of the relationship. The nurse should respond to the client's transference by clarifying the meaning of the nurse-client relationship based on the present situation. Transference occurs when the client unconsciously displaces feelings about a person from the past toward the nurse.

Which statement would a nurse identify as correct regarding a client's right to refuse treatment? 1.Clients can refuse pharmacological but not psychological treatment. 2.Clients can refuse any treatment at any time. 3.Clients can refuse only electroconvulsive therapy (ECT). 4.Professionals can override treatment refusal by an actively suicidal or homicidal client.

4.Professionals can override treatment refusal by an actively suicidal or homicidal client. The nurse should understand that health-care professionals can override treatment refusal when a client is actively suicidal or homicidal. A suicidal or homicidal client who refuses treatment may be in danger or a danger to others. This situation should be treated as an emergency, and treatment may be performed without informed consent.

Which nursing intervention would be most appropriate when caring for an agitated, suspicious client diagnosed with schizophrenia spectrum disorder? 1.Supply neon lights and soft music. 2.Maintain continual eye contact throughout the interview. 3.Use therapeutic touch to increase trust and rapport. 4.Provide personal space to respect the client's boundarieS

4.Provide personal space to respect the client's boundarieS The most appropriate nursing intervention is to provide personal space to respect the client's boundaries. Providing personal space may serve to reduce anxiety and thus reduce the client's risk for violence. The nurse should observe the client while carrying out routine tasks.

A client experiences an exacerbation of psychiatric symptoms to the point of threatening self-harm. Which action step of the Wellness Recovery Action Plan (WRAP) model would be employed, and which action reflects this step? 1.Step 3: Triggers that cause distress or discomfort are listed. 2.Step 4: Signs indicating relapse are identified and plans for responding are developed. 3.Step 5: A specific plan to help with symptoms is formulated. 4.Step 6: Following client-designed plan, caregivers now become decision-makers.

4.Step 6: Following client-designed plan, caregivers now become decision-makers. In step 6 (Crisis Planning) of the WRAP Model, clients can no longer care for themselves, make independent decisions, or keep themselves safe. Caregivers take an active role in this step on behalf of the client and implement the plan that the client has previously developed. The client's threats of self-harm indicate that the client can no longer maintain his or her own safety.

A client comes to a psychiatric clinic experiencing sudden extreme fatigue, decreased sleep, and decreased appetite. The client works 12 hours a day and rates anxiety as 8/10 on a numeric scale. Which long-term outcome is realistic in addressing this client's crisis? 1.The client will change his type-A personality traits to more adaptive ones within one week. 2.The client will list five positive self-attributes. 3.The client will examine how childhood events led to his overachieving orientation. 4.The client will return to previous adaptive levels of functioning by week six

4.The client will return to previous adaptive levels of functioning by week six

A nurse says to a client, "Things will look better tomorrow after a good night's sleep." This is an example of which communication technique? 1.The therapeutic technique of giving advice 2.The therapeutic technique of defending 3.The nontherapeutic technique of presenting reality 4.The nontherapeutic technique of giving reassurance

4.The nontherapeutic technique of giving reassurance The nurse's statement, "Things will look better tomorrow after a good night's sleep," is an example of the nontherapeutic communication technique of giving reassurance. Giving reassurance indicates to the client that there is no cause for anxiety, thereby devaluing the client's feelings.

An involuntarily committed client purposely pushes a dinner tray off the bedside table onto the floor. Which nursing intervention would a nurse implement to address this behavior? 1.Initiate forced medication protocol. 2.Help the client to explore the source of anger. 3.Ignore the act to avoid reinforcing the behavior. 4.With staff support, set firm limits on the behavior.

4.With staff support, set firm limits on the behavior.

Which is an example of an intentional tort? 1.A nurse fails to assess a client's obvious symptoms of neuroleptic malignant syndrome. 2.A nurse physically places an irritating client in four-point restraints. 3.A nurse makes a medication error and does not report the incident. 4.A nurse gives patient information to an unauthorized person.

A nurse physically places an irritating client in four-point restraints. A tort, which can be intentional or unintentional, is a violation of civil law in which an individual has been wronged. A nurse who intentionally physically places an irritating client in restraints has touched the client without consent and has committed an intentional tort.