Chapter 27

A patient is pacing the hall near the nurses' station, swearing loudly. An appropriate initial intervention for the nurse would be to address the patient by name and say:

"I'd like to talk with you about how you're feeling right now."

An adult patient assaulted another patient and was then restrained. One hour later, which statement by the restrained patient requires the nurse's immediate attention?

"My fingers are tingly."

The spouse of a patient diagnosed with schizophrenia says, "I don't understand how events from childhood have anything to do with this disabling illness." Which response by the nurse will best help the spouse understand the cause of this disorder?

"Research shows that this condition more likely has a biological basis."

Select the best response for the nurse to a question from another health professional regarding the difference between a diagnosis in DSM-V and a nursing diagnosis.

"The DSM-V diagnosis guides medical treatment, whereas the nursing diagnosis offers a framework for identifying interventions for issues a patient is experiencing."

After an assault by a patient, a nurse has difficulty sleeping, startles easily, and is preoccupied with the incident. The nurse said, "That patient should not be allowed to get away with that behavior." Which response poses the greatest barrier to the nurse's ability to provide therapeutic care?

A wish for revenge

A patient in the emergency department says, "Voices say someone is stalking me. They want to kill me because I developed a cure for cancer. I have a knife and will stab anyone who is a threat." Which aspects of the patient's mental health have the greatest and most immediate concern to the nurse? (Select all that apply.)

Appraisal of reality Control over behavior Healthy self-concept

Which belief will best support a nurse's efforts to provide patient advocacy during a multidisciplinary patient care planning session?

Assessment findings in mental illness reflect a person's cultural patterns.

Which is an effective nursing intervention to assist an angry patient learn to manage anger without violence?

Help a patient identify a thought that produces anger, evaluate the validity of the belief, and substitute reality-based thinking.

Which component of treatment of mental illness is specifically recognized by Quality and Safety Education for Nurses (QSEN)?

Care is centered on the patient.

A nurse is part of a multidisciplinary team working with groups of depressed patients. One group of patients receives supportive interventions and antidepressant medication. The other group receives only medication. The team measures outcomes for each group. Which type of study is evident?

Clinical epidemiology

Which assessment finding presents the greatest risk for violent behavior directed at others?

History of spousal abuse

A patient's relationships are intense and unstable. The patient initially idealizes the significant other and then devalues him or her, resulting in frequent feelings of emptiness. This patient will benefit from interventions to develop which aspect of mental health?

Fulfilling relationships

A category 5 tornado occurred in a community of 400 people. Many homes and businesses were destroyed. In the 2 years following the disaster, 140 individuals were diagnosed with posttraumatic stress disorder (PTSD). Which term best applies to these newly diagnosed cases?

Incidence

Which clinical scenario predicts the highest risk for directing violent behavior toward others?

Paranoid delusions of being followed by alien monsters

The staff development coordinator plans to teach use of physical management techniques for use when patients become assaultive. Which topic should the coordinator emphasize?

Practice and teamwork

Which nursing intervention below is part of the scope of an advanced practice psychiatric/mental health nurse rather than a basic level registered nurse?

Psychotherapy

A patient was arrested for breaking windows in the home of a former domestic partner. The patient's history also reveals childhood abuse by a punitive parent, torturing family pets, and an arrest for disorderly conduct. Which nursing diagnosis has priority?

Risk for other-directed violence

Which findings are signs of a person who is mentally healthy? (Select all that apply.)

Says, "I have some weaknesses, but I feel I'm important to my family and friends." Considers past experiences when deciding about the future. Experiences feelings of conflict related to changing jobs.

Which behavior best demonstrates aggression?

Stomping away from the nurses' station, going to the hallway, and grabbing a tray from the meal cart.

An experienced nurse says to a new graduate, "When you've practiced as long as I have, you automatically know how to take care of patients experiencing psychosis." Which factors should the new graduate consider when analyzing this comment? (Select all that apply.)

The experienced nurse may have lost sight of patients' individuality, which may compromise the integrity of practice. New research findings should be integrated continuously into a nurse's practice to provide the most effective care.

A confused older adult patient in a skilled nursing facility was asleep when unlicensed assistive personnel (UAP) entered the room quietly and touched the bed to see if it was wet. The patient awakened and hit the UAP in the face. Which statement best explains the patient's action?

The patient interpreted the UAP's behavior as potentially harmful.

An intramuscular dose of antipsychotic medication needs to be administered to a patient who is becoming increasingly more aggressive and refused to leave the day room. The nurse should enter the day room

accompanied by three staff members and say, "Please come to your room so I can give you some medication that will help you regain control."

A patient sat in silence for 20 minutes after a therapy appointment, appearing tense and vigilant. The patient abruptly stood, paced back and forth, clenched and unclenched fists, and then stopped and stared in the face of a staff member. The patient is

exhibiting clues to potential aggression.

A patient who was responding to auditory hallucinations earlier in the morning now approaches the nurse shaking a fist and shouts, "Back off!" and then goes to the dayroom. While following the patient into the dayroom, the nurse should

make sure there is adequate physical space between the nurse and patient.

An emergency code was called after a patient pulled a knife from a pocket and threatened, "I will kill anyone who tries to get near me." The patient was safely disarmed and placed in seclusion. Justification for use of seclusion was that the patient

presented a clear and present danger to others.

A patient with multi-infarct dementia lashes out and kicks at people who walk past in the hall of a skilled nursing facility. Intervention by the nurse should begin by

saying to the patient, "This is a safe place."