Foundations of Psychiatric Nursing - PassPoint

A client on an inpatient psychiatric unit refuses to take a medication that has been prescribed. What finding would be the priority before requiring the client to take the medication?

the client's degree of danger to self or others

Which outcome developed by the health care team is appropriate for a client diagnosed with pedophilia?

verbalizing appropriate methods to meet sexual needs upon discharge

A client is admitted to the behavioral health unit for treatment of pedophilia and tells the nurse that the client doesn't want to talk about sexual behaviors. Which response from the nurse is most appropriate?

"I know this must be difficult for you."

The nurse on the acute inpatient psychiatric unit is determining which clients on the unit should be placed in the rooms closest to the nurse's station to facilitate frequent observation. In which order does the nurse prioritize the clients? Place the clients in order from the highest priority for being in a room close to the nursing station to the lowest priority. All options must be used.

1. A client with depression who has just been admitted due to a suicide attempt 2. A client with a delusional disorder who is disoriented to both place and time 4. A client with conduct and borderline personality disorders who acts out impulsively 5. A client with bipolar disorder who is experiencing an episode of hypomania 3. A client with an anxiety disorder who performs frequent compulsive rituals

The nurse is caring for five clients. Which client does the nurse identify who requires screening for suicidal ideation? Select all that apply.

A 19-year-old male who moved across the country to begin college A 28-year-old female with bipolar disorder who was recently married A 36-year-old female who gave birth 6 months ago to her first child A 44-year-old male who recently lost his job due to being furloughed A 52-year-old female whose daughter experienced an unplanned pregnancy

The nurse educator is presenting an in-service on unhealthy boundaries. The educator will discuss how unhealthy personal boundaries are a product of dysfunctional families and a lack of positive role models. Which factor should the educator include that indicates unhealthy boundaries may also be a result of?

Abuse and neglect

The nurse documents, "The client described her husband's abuse in an emotionless tone and with a flat facial expression." When reviewing the documentation, the nurse recognizes this statement is describing which aspect of the client's disposition?

Affect

The nurse is caring for a client who continually has paranoid thoughts. How should the nurse interact with this client?

Approach him or her in a nonthreatening way.

A client confides to a nurse, "I have urges and desires to have sex with children." What should the nurse's most appropriate response be?

Ask the client, "Have you ever acted on these desires?"

A client tells the nurse she has never had an orgasm and her partner is upset that he can't meet her needs. Which nursing intervention is most appropriate?

Assess the couple's perception of the problem.

The nurse is assigned to care for a client of Japanese descent who is having a surgical procedure. While talking with the client, the nurse is aware that the client is not maintaining eye contact. Which intervention should be performed at this time?

Be aware that this is a cultural norm and continue talking.

During a mental status examination, a client may be asked to explain such proverbs as "Don't cry over spilled milk." What about the client's ability to think is being assessed by the health care practitioner?

Client's ability to think abstractly

The nurse collecting data on a client asks the client the meaning of the proverb "People in glass houses shouldn't throw stones." What is the nurse assessing by asking this question?

Concept formation

A client in an acute care setting tells the nurse, "I don't think I can face going home tomorrow." The nurse replies, "Do you want to talk more about it?" The nurse is using which technique?

Exploring

A client doesn't make eye contact with the nurse during an interview. The nurse suspects that the client's behavior has a cultural basis. What should the nurse do first?

Observe how the client and his family and friends interact with each other and with other staff members.

During an initial assessment, a client reports the following behaviors: social inhibition, hypersensitivity to negative evaluation, fear of criticism, and social ineptitude. A review of the collected data leads the nurse to suspect which personality disorder?

Paranoid

The nurse observes two clients playing basketball during exercise activity. The clients are engaged in aggressive communication and begin to fight. Which nursing intervention is most appropriate?

Remove the clients to separate areas and set limits

A client with borderline personality disorder dramatically expresses feelings about each nurse on the staff, stating that only one nurse is understanding and trustworthy — the nurse the client is talking to at the time. The nurse realizes this client is demonstrating which type of behavior?

Splitting

The terms "judgment" and "insight" are sometimes used incorrectly. How would the nurse appropriately define insight?

The ability to understand the nature of one's problem or situation

A caregiver is suspected of neglect and abuse. What warning signals should the nurse document and report? Select all that apply.

The caregiver does not allow the client to speak for him or herself, have visitors, or be alone with others. The caregiver places blame on the client for his or her illness or limitations. The caregiver has alcohol on his or her breath and acts as though he or she is impaired.

Mental health laws in each state specify when restraints can be used and which type of restraints are allowed. Most laws stipulate which information regarding the use of restraints?

Use if the client poses a present danger to himself or others

A client on the inpatient psychiatric unit is agitated, pacing, and speaking loudly. The nurse explains to the client the desire to avoid the use of seclusion if it can be done so safely. What assessment finding(s) should the nurse indicate support the decision to forgo seclusion? Select all that apply.

You can verbalize your feelings and concerns rationally." "You do not make any verbal threats to others." "We can see that you have decreased muscle tension."

The school nurse is assisting with the performance of screening for children with possible autistic spectrum disorder (ASD). Which child does the nurse determine is at greatest risk for this disorder?

a child that has a sibling with ASD

A nurse is conducting a sexual awareness group of known pedophiles. What will the nurse highlight as the primary focus of this group?

cognitive restructuring

A client on the psychiatric unit who is charged with child abuse does not speak to the staff when approached. Which response by the nurse would be most appropriate?

"Admission to a psychiatric unit can be very difficult."

A client comes to the clinic for right shoulder pain. The nurse observes bruises resembling fingerprints on several areas of the right arm and bruising on the back. The client has a history of similar injuries in the past. What questions would be important for the nurse to ask? Select all that apply.

"Are you in a relationship that makes you afraid or unsafe?" "People in relationships argue. What happens when you and your partner argue?" "If you are in danger now, would you like help in locating a shelter?"

A 22-year-old male client diagnosed with antisocial personality disorder asks the nurse if he can have an additional smoke break because he's anxious. Which of the following responses would be best?

"Clients are permitted to smoke at designated times. You'll have to follow the rules."

The nurse in a psychiatric unit has formed a therapeutic relationship with a client with a borderline personality disorder. When the client is readmitted to the unit for a suicide attempt, the nurse exclaims to another staff nurse, "Why? Everything was going well. How could they do this to me?" What response by the staff nurse reflects an understanding of the client's borderline disorder?

"Clients with borderline disorder act out to relieve anxiety, and something must have provoked a great deal of anxiety."

The nurse is having a conversation with a depressed client. The client states, "Do you think I should tell my family how I feel?" What is the most therapeutic response by the nurse?

"Do you think you should tell your family?"

On admission to the inpatient psychiatric unit, a client's facial expression indicates severe panic. The client repeatedly states, "I know the police are going to shoot me. They found out that I'm the child of the devil." What is the nurse's best response to initiate a therapeutic relationship with the client?

"Hello, my name is ___. I'm a nurse, and I'll care for you when I'm on duty. Should I call you ___, or do you prefer something else?"

The nurse is preparing to discharge a client with depression from inpatient care. The client tells the nurse, "You helped me more than anyone else in this place. I am hoping you will still be there to help me once I am discharged." How should the nurse respond?

"I am glad you found our work together productive. I am confident you will continue to improve with the support of the outpatient program team."

A client being released from restraints says, "I'll never get that angry and lose it again. Those restraints were the worst things that ever happened to me." Which response by the nurse is most appropriate?

"I'd like to talk with you about your experience."

A client is admitted to a mental health unit with a diagnosis of depression and is participating in group sessions. The client asks a nurse if they are married or in a romantic relationship. What is the best response by the nurse to maintain a therapeutic relationship?

"I'm curious about your question but I want to know how you are feeling today."

A client on short-term mental health disability leave undergoes required psychiatric evaluation and counseling. The client requests that their evaluation and counseling records be emailed to the client's Human Resources representative. How should the nurse respond?

"It's best not to e-mail your personal records because doing so might jeopardize your right to privacy."

An obese client has returned to the unit after receiving electroconvulsive therapy (ECT). A nurse requests assistance in moving the client from the stretcher to the bed. Which direction should the nurse give to a nurse who volunteers to help?

"Obtain the sliding board or two other people to assist us."

A newly hired nurse is assigned to a mental health clinic and is unfamiliar with mental health nursing. The nurse asks another nurse what is the goal of crisis intervention. What is the best response by the nurse?

"The goal is psychological resolution of the immediate crisis."

A client is brought to the crisis center by family members after giving away all of the family's possessions. When gathering data from the client, which statement would lead the nurse to suspect possible suicidal ideation?

"There's no hope. I feel like going to sleep and never waking up."

An older adult client has been admitted to the acute care unit with new-onset delirium. What statement made by the caregiver should be relayed to the healthcare provider?

"When I was toileting the client, the urine had a very strong odor."

The caregiver of an adolescent reports the teen will only dress in clothing associated with the opposite sex. The caregiver asks the nurse if treatment is needed for a psychiatric disorder. Which response from the nurse would be most appropriate?

"With what gender does your teen say they identify?"

The nurse is caring for a client with a social anxiety disorder who has difficulty sharing with the treatment team. The nurse believes using self-disclosure may assist the therapeutic relationship. Which approach to self-disclosure is most appropriate for the nurse to use?

"Would you like to hear how I cope when I feel anxious in new social situations?"

An agitated client demands to see her chart so she can read what has been written about her. Which statement is the nurse's best response to the client?

"You have the right to see your chart. Please discuss this with your primary care provider."

An agitated client demands to see the chart to read what has been written about the client. Which statement is the nurse's best response to the client?

"You have the right to see your chart. Please discuss your wish with your physician."

A client on an inpatient psychiatric unit has been taking a tricyclic antidepressant (TCA) without satisfactory results, so the health care provider changes the medication to a monoamine oxidase inhibitor (MAOI). Prior to administering the medication, what should the nurse be sure to check?

Adequate time has elapsed between discontinuing the first medication and beginning the second.

In group therapy, a client angrily speaks up and responds to a peer, "You're always whining, and I'm getting tired of listening to you! Here is the world's smallest violin playing for you." Which of the following roles is the client playing?

Aggressor

A client with ulcerative colitis has recently had a colostomy and is anxious. The client reports to the nurse, "I don't think I can ever have a sexual relationship now that I have this." Which response by the nurse would be most appropriate?

Allow the client to express concerns.

A nurse is caring for a client with antisocial personality disorder. The client states to the nurse, "When I leave here, I want to take you on a date. You have been the best nurse in this place." What is the best response by the nurse?

Demonstrate a nonjudgmental attitude. Institute safety precautions as needed according to facility protocol. Encourage the client to identify feelings.

A nurse is obtaining data for a client admitted to the clinic with a paraphilic disorder. Which interventions best demonstrate the appropriate care of this client? Select all that apply.

Demonstrate a nonjudgmental attitude. Institute safety precautions as needed according to facility protocol. Encourage the client to identify feelings.

A client with long-term body-focused repetitive behaviors including trichotillomania (hair pulling) finds support through an online website. The client begins to attend local meetings and realizes that a nurse from the clinic also attends. When approached outside of these meetings, how should the nurse respond?

Discuss this to define the relationship.

A parent is discussing his or her 12-year old child with the nurse at the clinic and tells the nurse that the child is having trouble at school being bullied and coming home and picking on a younger sibling. What does the nurse recognize this ego defense mechanism as?

Displacement

The nurse-client relationship progresses through phases. At which time should the nurse introduce information about the end of the nurse-client relationship?

During the orientation phase

A hospitalized client becomes angry and belligerent toward a nurse after speaking on the phone with the parent. The nurse learns that the parent cannot visit as expected. Which interventions might the nurse use to help the client deal with the displaced anger? Select all that apply.

Explore the client's unmet needs. Invite the client to a quiet place to talk. Assist the client in identifying alternate ways of approaching the problem.

The nurse is performing an assessment on a newly admitted client. She asks the client to remember three words: apple, house, and umbrella. Then she asks the client, "What are the three words I want you to remember?" What is the nurse assessing?

Immediate recall

An 8-year-old girl and her 5-year-old sister tell the school nurse that their mother frequently yells and spits in their faces when she is mad at them. The nurse hesitates to intervene because she knows the family personally. Which action by the nurse is appropriate?

Report the information to child protective services.

When presenting a lecture on anxiety, which term would a nursing instructor use that refers to the primary unconscious defense mechanism which keeps intense anxiety-producing situations out of a person's conscious awareness?

Repression

A nurse in a psychiatric care unit finds that a client with psychosis has become violent and has struck another client in the unit. What action should the nurse take in this case?

Restrain the client, as they are harmful to the other clients.

As the nurse arrives to visit a family 2 days after release from the hospital, she hears shouting and swearing between the mother and father and several loud crashes, just as she is going to knock on the door. What action by the nurse is the most appropriate?

Return to the car and call the police.

Assertive behavior involves which of the following elements?

Standing up for your rights while respecting the rights of others

A client is admitted to an inpatient psychiatric unit. After data collection and admission procedures are completed, the nurse states, "I'll try to be available to talk with you when needed and will spend time with you each morning from 10:00 until 10:30 in a specific corner of the dayroom." The nurse is communicating these planned nursing interventions for which main rationale?

To establish a trusting relationship

The nurse is caring for a group of clients on the inpatient psychiatric unit. Which client(s) will the nurse identify as being at high risk for violent behavior? Select all that apply.

a client with antisocial personality disorder and paranoid delusions a client with post-traumatic stress disorder who lacks insight and is impulsive a client who is in the manic phase of bipolar disorder and has dementia

A recently engaged 22-year-old woman loses her fiancé in a drunken driving accident. She complains of difficulty eating, sleeping, and working. Her reaction is considered:

a crisis caused by traumatic stress.

A client is in the emergency department after being sexually assaulted by a stranger. Which nursing intervention has priority?

assisting in identifying family or friends who could provide immediate support

A client is brought to the emergency department after being sexually assaulted by a rival gang member. The nurse observes that the client appears relaxed and is calmly talking to a relative. The nurse determines that the client may be using which defense mechanism?

denial

A client is transferred from the emergency department to the locked psychiatric unit after attempting suicide by taking 200 acetaminophen tablets. The client is now awake and alert but refuses to speak with the nurse. In this situation, the nurse's first priority is to:

ensure safety by initiating suicide precautions

A nurse is using drawing, puppetry, and other forms of play therapy while caring for a terminally ill, school-age child. What is the primary nursing goal of play therapy for this child?

expression of feelings that the child cannot articulate

An appropriate way for the nurse to set limits for a newly admitted client who puts out cigarettes on the floor of the room designated for smoking is to:

hand the client an ashtray and state that he must use it or he won't be allowed to smoke.

A client with antisocial personality disorder smokes where it's prohibited and refuses to follow other unit and facility rules. The client gets others to do his laundry and other personal chores, splits the staff, and will work only with certain nurses. The plan of care for this client should focus primarily on:

isolating the client to decrease contact with easily manipulated clients.

A client refuses his evening dose of haloperidol then becomes extremely agitated in the day room while other clients are watching television. He begins cursing and throwing furniture. The nurse's first action is to:

remove all other clients from the day room.

A client refuses the evening dose of haloperidol and then becomes extremely agitated in the day room while other clients are watching television. The client begins cursing and throwing furniture. The nurse's first action is to:

remove all other clients from the day room.

A nurse is assisting with the development of a plan of care for a client who has undergone electroconvulsive therapy (ECT). Which intervention would most likely be included?

reorienting the client to time and place

A client is receiving electroconvulsive therapy (ECT) for the treatment of severe depression. Immediately after ECT, what is the nurse's priority focus for assessment?

respiratory rate and oxygen saturation

The basis for building a strong, therapeutic nurse-client relationship begins with a nurse's:

self-awareness and understanding.

A manager observes a nurse interacting with clients on a psychiatric unit. Which nursing action(s) would cause the manager to intervene? Select all that apply.

talking with a client about personal issues such as the nurse's recent divorce spending more time than necessary with a client and showing favoritism asking a client to meet for lunch outside the hospital setting posting a picture of the nurse and client on social media