EVOLVE PSYCH

Which statements describe a mentally healthy person? Select all that apply. 1 One who accepts aging 2 One who engages available strengths 3 One who maintains minimum autonomy 4 One who sustains positive relationships 5 One who engages available weaknesses

1 2 4

4. 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

ANS: 3 Rationale: The priority nursing diagnosis for this client is risk for self-directed violence R/T hopelessness. Nurses should prioritize diagnoses and outcomes based on potential safety risk to the client or others.

6. An involuntarily committed client when offered a dinner tray pushes it off the bedside table onto the floor. Which nursing intervention should 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 and a show of solidarity, set firm limits on the behavior.

ANS: 4 Rationale: The most appropriate nursing intervention is to set firm limits on the behavior. Pushing food onto the floor should not warrant forced medication. This intervention may be too restrictive, considering the behavior. Exploring the source of anger may be more appropriate once the client has resolved the current emotion or in a therapeutic group setting. Ignoring the act may further upset the client and is not a method of teaching appropriate behavior.

Before effectively responding to a sexually abused victim on the phone, it is essential that the nurse in the rape crisis center do what? 1 Get the client's full name and address. 2 Call for assistance from the psychiatrist. 3 Know some myths and facts about sexual assault. 4 Be aware of any personal bias about sexual assault

Be aware of any personal bias about sexual assault -If nurses are unaware of their biases about sexual assault, they will be unprepared to evaluate objectively and meet the client's needs. Getting the client's full name and address may interrupt communication; information can be solicited later. The nurse should be able to help this client without assistance. Although knowing some myths and facts about sexual assault may be important, it is not the priority

A nurse encourages a client to join a self-help group after being discharged from a mental health facility. What is the purpose of having people work in a group? 1 Support 2 Confrontation 3 Psychotherapy 4 Self-awarenes

Support

A nurse is caring for a client who is experiencing a crisis. Which nervous system is primarily responsible for the clinical manifestations that the nurse is likely to identify? 1 Central nervous system 2 Peripheral nervous system 3 Sympathetic nervous system 4 Parasympathetic nervous system

Sympathetic nervous system

The nurse understands that a primary gain is distinguished from a secondary gain. What is the main function of a primary gain? 1 Reduce anxiety 2 Gain benefits from others 3 Fulfill unconscious desires 4 Control unacceptable impulses

reduce anxiety -A primary gain is always the reduction of anxiety. Gaining benefits from others is related to a secondary gain. Fulfillment of unconscious desires is unrelated to primary gains. Control of unacceptable impulses is unrelated to primary gains.

A young adult sustained a spinal cord injury at the level of T5 a week ago and is now incontinent of feces. When the nurse tries to give a bath and change the linens, the client says, "Leave me alone. It's worse having you change me than it is to lie in this mess." What is the best response by the nurse? 1 "Do you want me to get someone else to change you?" 2 "You shouldn't be embarrassed; this is part of my job." 3 "I'll be back in a little while; why don't you rest until then?" 4 "While I'm bathing you I'll start teaching you about bowel training."

-"While I'm bathing you I'll start teaching you about bowel training." A matter-of-fact approach eases embarrassment and then focuses on a method of helping the client regain control. The response "Do you want me to get someone else to change you?" ignores the issue, and with it the nurse is abandoning responsibility. The response "You shouldn't be embarrassed; this is part of my job" lacks empathy and does not offer hope for improvement. The response "I'll be back in a little while; why don't you rest until then?" cuts off communication and ignores the client's need to be changed.

A nurse facilitating a support group of widows and widowers recalls that research indicates that the probability of a spouse having a pathological or morbid grief response will be greater in what case? 1 The couple had an ambivalent relationship. 2 The cause of the spouse's death was suicide. 3 The relationship between the spouses was satisfying. 4 There was a long preparatory grief period before a spouse's death.

-The survivors of a suicide feel more guilt and bitterness and go through a longer grieving process, and therefore the chances of a pathological grief response are increased. An ambivalent relationship between the spouses may result in a difficult grief response because of guilty feelings but should not cause a morbid grief response. Research documents that the more satisfying the relationship, the more likely that the mourner will establish a new relationship. With a preparatory grief period a person may have the opportunity to work through a part of the grief process before the death and have a shorter mourning period after the death.

Before discharge of an anxious client, the nurse should teach the family that anxiety can be recognized as what? 1 A totally unique feeling 2 Fears specifically related to the total environment 3 Consciously motivated actions, thoughts, and wishes 4 A pattern of emotional and behavioral responses to stress

A pattern of emotional and behavioral responses to stress -Anxiety is a human response consisting of both physical and emotional changes that everyone experiences when faced with stressful situations. Anxiety is experienced to a greater or lesser degree by every person. The fear may be related to a specific aspect of the environment rather than the total environment. Anxiety does not operate from the conscious level.

A client is admitted to a mental health facility because of maladaptive coping behavior. How can the nurse best help the client develop healthier coping mechanisms? 1 By providing a stress-free environment 2 By promoting interpersonal relationships with peers 3 By allowing the client to assume responsibility for decisions 4 By setting realistic limits on the client's maladaptive behavior

By setting realistic limits on the client's maladaptive behavior -Setting realistic limits on the client's maladaptive behavior provides structure that promotes learning acceptable behavior. No environment is stress free. The client may not be ready for relationships with peers or responsibility for decisions at this time.

An older adult who lives alone tells a nurse at the community health center, "I really don't need anyone to talk to. The TV is my best friend." What defense mechanism does the nurse identify? 1 Denial 2 Projection 3 Sublimation 4 Displacement

Denial

What can the nurse do to help an older adult successfully complete Erikson's major task of this stage? 1 Invest creative energy in promoting social welfare. 2 Develop a sense of satisfaction when considering past achievements. 3 Develop deep and lasting relationships with other people or institutions. 4 Recapture opportunities that the client did not take or those that were not fulfilled.

Develop a sense of satisfaction when considering past achievements.

A nurse is conducting a group therapy session. Why is a group setting especially conducive to therapy? 1 It provides a new learning environment. 2 It decreases the focus on the individual. 3 It fosters one-on-one personal relationships. 4 It confronts individual members with their shortcomings.

It provides a new learning environment. -The group setting provides an individual with the opportunity to learn that others share the same problems and needs. The group also provides a safe arena in which new, healthier, more meaningful methods of relating to others can be explored. The focus is still on the individual, but more on the individual's learning how to relate to others. Groups promote interaction among many people rather than one-on-one relationships. Confronting individual members with their shortcomings may happen from time to time, with support given to the individual by the group, but it is not a main function of the group.

The wife of a client who is dying tells the nurse that although she wants to visit her husband daily, she can visit only twice a week because she works and has to take care of the house and their cat and dog. What defense mechanism does the nurse conclude that the client's wife is using? 1 Projection 2 Sublimation 3 Compensation 4 Rationalization

Rationalzation

A client who had to be cut out of a car after a motor vehicle collision has no visible physical effects from the ordeal. The client responds to the emergency department nurse's questions factually in a soft voice with a composed manner. What may this behavior indicate about the client? 1 The client is controlling the expression of feelings. 2 The client has repressed the details of the accident. 3 The client has blocked out the events of the last few hours. 4 The client is experiencing the reorganization phase of the trauma experience.

The client is controlling the expression of feelings. -The ability to respond to questions in a composed manner indicates that the client is using intellectualization and withholding feelings to maintain emotional control. The fact that the client is answering questions regarding the incident does not indicate repression or blocking out the accident. Reorganization is a long-term process that starts several days or weeks after the trauma.

After a child's visit to a healthcare provider, the parent tells the nurse, "I'm so upset! The doctor prescribed an antidepressant!" What is the best response by the nurse? 1 "Tell me more about what's bothering you." 2 "Weren't you told why your child needs an antidepressant?" 3 "You need to speak with the healthcare provider about your concerns." 4 "Are you sure it's an antidepressant and not a drug for attention deficit disorder?"

"Tell me more about what's bothering you."

A young adult sustained a spinal cord injury at the level of T5 a week ago and is now incontinent of feces. When the nurse tries to give a bath and change the linens, the client says, "Leave me alone. It's worse having you change me than it is to lie in this mess." What is the best response by the nurse? 1 "Do you want me to get someone else to change you?" 2 "You shouldn't be embarrassed; this is part of my job." 3 "I'll be back in a little while; why don't you rest until then?" 4 "While I'm bathing you I'll start teaching you about bowel training."

"While I'm bathing you I'll start teaching you about bowel training." -A matter-of-fact approach eases embarrassment and then focuses on a method of helping the client regain control. The response "Do you want me to get someone else to change you?" ignores the issue, and with it the nurse is abandoning responsibility. The response "You shouldn't be embarrassed; this is part of my job" lacks empathy and does not offer hope for improvement. The response "I'll be back in a little while; why don't you rest until then?" cuts off communication and ignores the client's need to be changed.

A psychiatric nurse understands that a situational crisis usually resolves within what timeframe? 1 1 to 4 days 2 2 to 3 weeks 3 1 to 2 months 4 2 to 6 months

1 to 2 months -A situational crisis is a sudden, unexpected event with which the individual is unable to cope using past coping behaviors; 1 to 2 months provides an opportunity for the individual to learn new coping behaviors. Two to 6 months is longer than the expected period within which a crisis should be resolved. One to 4 days and 2 to 3 weeks are both periods that are too short for the individual to develop new, successful coping mechanisms.

A woman is admitted to the emergency department with trauma that indicates possible abuse. List in priority order the appropriate nursing interventions. 1. Gathering a more in-depth history 2. Providing information about safe houses 3. Assisting in the treatment of the client's physical injuries 4. Encouraging the client to express her feelings

1. Assisting in the treatment of the client's physical injuries Correct 2. Gathering a more in-depth history Correct 3. Encouraging the client to express her feelings Correct 4. Providing information about safe houses

A nurse is planning care for a group of hospitalized children. Which age group does the nurse anticipate will have the most problem with separation anxiety? 1 5 to 11 years 2 12 to 18 years 3 6 to 30 months 4 36 to 59 months

6 to 30 months -Infants and toddlers ages 6 to 30 months experience separation anxiety; it is this age group's major life stressor and is most traumatic to the child and parent. Adolescents when hospitalized are often ambivalent about whether they want their parents with them. Peer group separation may pose more anxiety for the adolescent. The school-aged child is more accustomed to periods of separation from parents. Separation anxiety occurs in preschool and young school-aged children, but it is less obvious and less serious than it is in the toddler.

14. Which of the following nursing statements and/or questions represent appropriate communication to assess an individual in crisis? (Select all that apply.) 1. "Tell me what happened." 2. "What 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."

ANS: 1, 2, 3 Rationale: In the assessment phase, the nurse should gather information regarding the precipitating stressor and the resulting crisis. Focusing on the current problem and selecting functional coping strategies would not occur until after a complete assessment.

15. Which of the following interventions should 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.

ANS: 1, 2, 4 Rationale: The nurse should determine that, when working with an inpatient client with difficulty expressing anger appropriately, it is important to maintain a calm demeanor, clearly define the consequences, and set limits on the behavior. The use of therapeutic touch may not be appropriate and could increase the client's anger. Teaching would not be appropriate when a client is agitated.

7. A college student who was nearly raped while 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 your 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."

ANS: 4 Rationale: The nurse should evaluate that the client who has developed adaptive coping strategies has achieved the goals of crisis intervention. The final phase of crisis intervention involves evaluating the outcome of the crisis intervention and anticipatory planning.

What is the best initial approach to take with a self-accusatory, guilt-ridden client? 1 Contradict the client's persecutory delusions. 2 Accept the client's statements as the client's beliefs. 3 Medicate the client when these thoughts are expressed. 4 Redirect the client whenever a negative topic is mentioned.

Accept the client's statements as the client's beliefs. -The nurse must accept the client's statement and beliefs as real to the client to develop trust and move into a therapeutic relationship. Clients cannot be argued out of delusions. Medication should not be the initial approach. Redirecting the client's conversation whenever negative topics are brought up may make the client believe that these thoughts and feelings are being ignored.

A single mother of two children who recently lost her job because her company is downsizing comes to the emergency department. The woman does not know what to do and is in crisis. The most critical factor for the nurse to determine during crisis intervention is the client's what? 1 Developmental history 2 Available situational supports 3 Underlying unconscious conflict 4 Willingness to restructure the personality

Available situational supports -Personal internal strengths and supportive individuals are critical to the development of a crisis intervention plan; they must be explored with the client. Although developmental history information may be helpful, it is not essential; factors concerning the current situation are paramount. Identifying unconscious conflicts takes a long time and is inappropriate for crisis intervention. Willingness to restructure the personality is a goal of psychotherapy, not crisis intervention.

A client with a diagnosis of major depression tells a nurse, "No matter what I do, everything turns out bad." The nurse recognizes this as an example of what? 1 Using a cognitive distortion 2 Seeking sympathy from the nurse 3 Regressing to an earlier developmental level 4 Avoiding responsibility for previous behavior

Avoiding responsibility for previous behavior -The client is using the cognitive distortions of overgeneralization and pessimism. Negative events are magnified and become the focus, whereas contrary positive experiences are minimized and ignored. With the focus on the negative events, the depressive mood is reinforced. There are no data to support the conclusion that the client is seeking sympathy, regressing, or avoiding responsibility.

Several clients are to be admitted to the mental health unit. How can the nurse manager establish an environment that is conducive to psychologic safety? 1 By assigning no more than two clients to a room 2 By not permitting significant others to visit initially 3 By emphasizing that there are realistic rules that must be followed 4 By allowing interaction with other clients only during group therapy

By emphasizing that there are realistic rules that must be followed -Realistic limits and controls provide a degree of security that adds to the client's emotional safety by limiting choices, reducing the need for self-regulation, and decreasing the need for decision-making. The status of clients, not their number, influences psychologic safety. Whether to permit significant others to visit initially is individualized; some significant others can be supportive. Allowing interaction with other clients only when in group is unrealistic; clients interact with other clients in a variety of settings.

A married woman is brought to the emergency department of a local hospital. Her eyes are swollen shut, and she has a bruise on her neck. She reports that she is being beaten by her husband. How does the nurse expect the husband to behave when he arrives at the emergency department? 1 Fearful 2 Confused 3 Charming 4 Indifferent

Charming -Abusers are often extremely charming to mask their abusive tendencies and convince the abused mate and others that change is possible. After an abusive episode there is often a "honeymoon" period because the tensions of the abuser have been released. Abusers mask their fears by becoming angry and aggressive. Abusers are not confused; they are manipulative of others. Abusers are rarely indifferent; they tend to be opinionated and demanding.

A nurse has just completed a mental status examination on a newly admitted psychiatric client and returns to the nurses' station to document the results. The nurse reflects on the client's drawn-out explanation of the reason for the admission and concludes that excessive detail was given before the client eventually answered the questions. What mental process does the nurse identify? 1 Flight of ideas 2 Circumstantiality 3 Thought blocking 4 Tangential thinking

Circumstantiality -In a circumstantial thought process, excessive and unnecessary detail, usually relevant to the question, ultimately gives way to an answer. Flight of ideas is rapid shifting from one topic to another and fragmentation of ideas. Thought blocking is a sudden stoppage of the train of thought or in the middle of the sentence. Tangential thinking is similar to circumstantial thought processes, but the person never answers the question or returns to the central point of the conversation.

In an attempt to remain objective and support a client during a crisis, the nurse uses imagination and determination to project the self into the client's emotions. What is this technique known as? 1 Empathy 2 Sympathy 3 Projection 4 Acceptance

Empathy -Empathy is the projection of self into another's emotions to share the emotions and the other's state of mind; this technique helps the nurse understand the meaning and significance of the experience to the client. Sympathy is a shared expression of sorrow over a real or imagined loss. Projection is an unconscious defense mechanism, not a therapeutic technique. Acceptance does not require the nurse to project the self into the client's emotions; rather, it involves accepting the client and the emotions

What is it imperative for a mental health nurse to prevent clients from doing? 1 Breaking contracts 2 Using delusional thinking 3 Harming themselves or others 4 Engaging further in hallucinatory thoughts or behaviors

Harming themselves or others

When a newly admitted client with paranoid ideation tells the nurse about people coming through the doors to commit murder, what should the nurse do? 1 Ignore the client's stories. 2 Listen to what the client is saying. 3 Explain that no one can get through the door. 4 Ask for an explanation of where the information was obtained.

Listening to what the client is saying demonstrates that the nurse believes that what the client has to say is important; it also encourages verbalization of feelings. Ignoring the client's stories may increase the client's feelings of worthlessness and persecution. Explaining that no one can get through the door will accomplish little; a paranoid individual cannot be talked out of his or her feelings. These are feelings, not information, and they cannot always be explained; asking where the information came from forces the client to further develop the delusional system.

What does a psychiatric nurse identify as the primary purpose of the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5)? 1 Facilitate communication between researchers and clinicians. 2 Aid in teaching psychopathology to mental health professionals. 3 Assist in collecting accurate public health statistics through the use of diagnostic codes. 4 Provide a classification of types of mental disorders and guidelines to aid in making a diagnosis.

Provide a classification of types of mental disorders and guidelines to aid in making a diagnosis. -The prime purpose of the DSM-5 is to serve the clinician as a guide in identifying a client's mental health or psychiatric diagnosis. Although the DSM-5 is useful in facilitating communication, the teaching of psychopathology, and the collection of accurate public health statistics, none of these are the primary purpose of this publication.

A nurse is conducting the sixth and final session of crisis intervention with a client in a community health center. Evaluation demonstrates that the client has not yet resolved her crisis issues. What is the most acceptable intervention by the nurse? 1 Discharging the client on time whether or not the crisis has been fully resolved 2 Agreeing to continue the treatment until the client feels that the crisis has been resolved 3 Providing the client with additional information and referral regarding other community resources 4 Focusing on the client's underlying personality conflicts in preparation for referral to long-term therapy

Providing the client with additional information and referral regarding other community resources -The client needs continued assistance to facilitate resolution of unresolved conflicts and problems. Discharging the client on time whether or not the crisis has been fully resolved is unethical; referral for ongoing therapy is warranted in this situation. If immediate issues have not been resolved during crisis intervention, further therapy is an appropriate option. Focusing on underlying personality conflicts is not the objective of crisis intervention and should be left to the therapist who undertakes long-term therapy with the client. Topics

Which of the following interventions will assist in creating and maintaining a therapeutic environment on an acute care mental health unit? Select all that apply. 1 Reorienting clients to the rules of the unit whenever necessary 2 Providing a posted schedule of unit activities 3 Monitoring each client for the potential of aggressive behavior 4 Assuring the clients that they will have unlimited access to the telephone 5 Encouraging the clients to take an active role in planning the unit's activities

Reorienting clients to the rules of the unit whenever necessary Providing a posted schedule of unit activities Monitoring each client for the potential of aggressive behavior Encouraging the clients to take an active role in planning the unit's activities -Safety, structure, balance, and limit setting are elements that the nurse addresses when providing a therapeutic milieu. Privileges, such as telephone access, cannot be assured, because they are earned and often are factors that are affected by the client's needs and behaviors

An older client whose family has been visiting the client in the psychiatric unit is visibly angry and says to the nurse, "My daughter-in-law says they can't take me home until the doctor lets me go. She doesn't understand how important this is to me; she's not from our culture." What should the nurse do? 1 Ignore the statement for the present. 2 Say, "You feel she doesn't want you at home." 3 Reflect on the client's feelings about the cultural differences. 4 Respond, "The doctor is the one who makes decisions about discharge."

Say, "You feel she doesn't want you at home." -Identifying and accepting feelings help to open lines of communication. Ignoring the statement for the present does not allow the client to explore feelings with an accepting person. Reflecting on the client's feelings about the cultural differences focuses on only one aspect of the statement; it does not allow exploration of feelings. Explaining that the health care provider makes the decisions about discharge avoids the real issue.

After caring for a terminally ill client for several weeks, a nurse becomes increasingly aware of a need for a respite from this assignment. What is the best initial action by the nurse? 1 Requesting a few days' vacation time 2 Seeking support from colleagues on the unit 3 Withdrawing emotional involvement with the client 4 Staying with the client while trying to work through the feelings

Seeking support from colleagues on the unit

What is the most appropriate intervention for the nurse to implement after finding a disturbed client in bed in the fetal position? 1 Sitting down in a chair by the client and saying, "I'm here to spend time with you." 2 Touching the client gently on the shoulder and saying, "I'm going to sit with you for a while." 3 Going to the client and saying, "I'll be waiting for you in the community room, so please get up and join me." 4 Leaving the client alone because the behavior demonstrates that the client has regressed too far to benefit from talking with the nurse

Sitting down in a chair by the client and saying, "I'm here to spend time with you." -"I'm here to spend time with you" accepts the client at the client's current level and allows the client to set the pace of the relationship. Touching the client may be misinterpreted and may precipitate an aggressive response. Going to the client and saying, "I'll be waiting for you in the community room, so please get up and join me," asks the client to reach out to the nurse; in the therapeutic relationship, the nurse must reach out to the client. Even if the client is too withdrawn to respond, the nurse's physical presence can be reassuring, so leaving the client alone is not the most appropriate choice.

During a nursing assessment, a nurse notes that a client has begun to create new words. What term does the nurse use to document this finding? Correct1 Neologism 2 Perseveration 3 Pressured speech 4 Tangential speech

Tangential speech -Neologism is the invention of new words with meanings understood only by the client. Perseveration is repetitive verbalizations or motions. Pressured speech is rapid speech with an urgent quality. Tangential speech is a tendency to digress from the original subject.

While assessing an older adult in the emergency department the nurse notes that the client is upset. The nurse asks what is wrong, and the client describes the current situation and then offers information that goes further and further off the topic. What pattern of communication does this conversation reflect? 1 Perseveration 2 Thought blocking 3 Overcompensation 4 Tangential thinking

Tangential thinking -In tangential thinking the person never answers the question or returns to the central point of the conversation. It often is seen in people with dementia. Perseveration is the repetitive expression of a single idea in response to different questions; it is found most often in clients with cognitive impairments and those experiencing catatonia. Thought blocking is a sudden stoppage of the spontaneous flow of speaking for no apparent external reason; it is seen most often in clients who are experiencing auditory hallucinations. Overcompensation, also known as reaction formation, is a defense mechanism, not a pattern of communication

What is the most important information for a nurse to teach to prevent relapse in a client with a psychiatric illness? 1 The need to develop a close support system 2 The need to create a stress-free environment 3 The need to refrain from activities that cause anxiety 4 The need to follow the prescribed medication regimen

The need to follow the prescribed medication regimen -Following the prescribed medication regimen is important because side effects and denial of illness may cause clients to stop taking their medications; this is a common cause of relapse or recurrence of symptoms. Although a close support system is beneficial, it may not always be possible to achieve. It is impossible to create a stress-free environment; clients need to learn better ways to cope with stress. Refraining from any activity that may cause anxiety is too restrictive.

What is most important for a nurse to do when initially helping clients resolve a crisis situation? 1 Encourage socialization. 2 Meet dependency needs. 3 Support coping behaviors. 4 Involve them in a therapy group

support coping behaviors -In a crisis situation, the individual frequently just needs support to regroup and re-establish the ability to cope. Socialization is part of recovery; this is not done during the initial stage of a crisis. Meeting dependency needs is not possible or realistic. Involving clients in a therapy group may have the effect of increasing anxiety, thereby making the crisis situation worse