Mental Health Chapters 5-9

The acronym QSEN refers to: a. Qualitative Standardized Excellence in Nursing. b. Quality and Safety Education for Nurses. c. Quantitative Effectiveness in Nursing. d. Quick Standards Essential for Nurses.

B: Quality and Safety Education for Nurses QSEN represents national initiatives centered on patient safety and quality. The primary goal of QSEN is to prepare future nurses with the knowledge, skills, and attitudes to increase the quality, care, and safety in the health care setting in which they work.

A newly admitted patient with major depressive disorder has lost 20 pounds over the past month and has suicidal ideation. The patient has taken an antidepressant medication for 1 week without remission of symptoms. Select the priority nursing diagnosis. a. Imbalanced nutrition: Less than body requirements b. Chronic low self-esteem c. Risk for suicide d. Hopelessness

C. Risk for Suicide

A multidisciplinary health care team meets 12 hours after an adolescent is hospitalized after a suicide attempt. Members of the team report their assessments. What outcome can be expected from this meeting? a. A treatment plan will be formulated. b. The health care provider will order neuroimaging studies. c. The team will request a court-appointed advocate for the patient. d. Assessment of the patients need for placement outside the home will be undertaken.

a. A treatment plan will be formulated. Treatment plans are formulated early in the course of treatment to streamline the treatment process and reduce costs. It is too early to determine the need for alternative post-discharge living arrangements. Neuroimaging is not indicated for this scenario.

A nurse performing an assessment interview for a patient with a substance abuse disorder decides to use a standardized rating scale. Which scales are appropriate? Select all that apply. a. Addiction Severity Index (ASI) b. Brief Drug Abuse Screen Test (B-DAST) c. Abnormal Involuntary Movement Scale (AIMS) d. Cognitive Capacity Screening Examination (CCSE) e. Recovery Attitude and Treatment Evaluator (RAATE)

a. Addiction Severity Index (ASI) b. Brief Drug Abuse Screen Test (B-DAST) e. Recovery Attitude and Treatment Evaluator (RAATE) The ASI, B-DAST, and RAATE are scales related to substance abuse. The AIMS assesses involuntary movements associated with antipsychotic medications. The CCSE assesses cognitive function.

When a nurse assesses an older adult patient, the patients answers seem vague or unrelated to the questions. The patient also leans forward and frowns, listening intently to the nurse. An appropriate question for the nurse to ask would be: a. Are you having difficulty hearing when I speak? b. How can I make this assessment interview easier for you? c. I notice you are frowning. Are you feeling annoyed with me? d. Youre having trouble focusing on what Im saying. What is distracting you?

a. Are you having difficulty hearing when I speak? The patients behaviors may indicate difficulty hearing. Identifying any physical need the patient may have at the onset of the interview and making accommodations are important considerations. By asking if the patient is annoyed, the nurse is jumping to conclusions. Asking how to make the interview easier for the patient may not elicit a concrete answer. Asking about distractions is a way of asking about auditory hallucinations, which is not appropriate because the nurse has observed that the patient seems to be listening intently.

Which action by a psychiatric nurse best supports a patients right to be treated with dignity and respect? a. Consistently addressing a patient by title and surname. b. Strongly encouraging a patient to participate in the unit milieu. c. Discussing a patients condition with another health care provider in the elevator. d. Informing a treatment team that a patient is too drowsy to participate in care planning.

a. Consistently addressing a patient by title and surname. A simple way of showing respect is to address the patient by title and surname rather than assuming that the patient would wish to be called by his or her first name. Discussing a patients condition with a health care provider in the elevator violates confidentiality. Informing a treatment team that the patient is too drowsy to participate in care planning violates patient autonomy. Encouraging a patient to participate in the unit milieu exemplifies beneficence and fidelity.

Which benefits are most associated with the use of telehealth? Select all that apply. a. Cost savings for patients b. Maximization of care management c. Access to services for patients in rural areas d. Prompt reimbursement by third-party payers e. Rapid development of trusting relationships with patients

a. Cost savings for patients b. Maximization of care management c. Access to services for patients in rural areas

A Mexican-American patient puts a picture of the Virgin Mary on the bedside table. Under which section of the assessment should the nurse document this behavior? a. Culture b. Ethnicity c. Verbal communication d. Nonverbal communication

a. Culture

A nurse assesses an older adult patient brought to the emergency department by a family member. The patient was wandering outside, saying, I cant find my way home. The patient is confused and unable to answer questions. Select the nurses best action. a. Document the patients mental status. Obtain other assessment data from the family member. b. Record the patients answers to questions on the nursing assessment form. c. Ask an advanced practice nurse to perform the assessment interview. d. Call for a mental health advocate to maintain the patients rights.

a. Document the patients mental status. Obtain other assessment data from the family member. When the patient (primary source) is unable to provide information, secondary sources should be used, in this case the family member. Later, more data may be obtained from other relatives or neighbors who are familiar with the patient. An advanced practice nurse is not needed for this assessment; it is within the scope of practice of the staff nurse. Calling a mental health advocate is unnecessary.

Which employers health plan is required to include parity provisions related to mental illnesses? a. Employer with more than 50 employees b. Cancer thrift shop staffed by volunteers c. Daycare center that employs 7 teachers d. Church that employs 15 people

a. Employer with more than 50 employees Under federal parity laws, companies with more than 50 employees may not limit annual or lifetime mental health benefits unless they also limit benefits for physical illnesses.

A nurse can best address factors of critical importance to successful community treatment for persons with mental illness by including assessments related to which of the following? Select all that apply. a. Housing adequacy and stability b. Income adequacy and stability c. Family and other support systems d. Early psychosocial development e. Substance abuse history and current use

a. Housing adequacy and stability b. Income adequacy and stability c. Family and other support systems e. Substance abuse history and current use Early psychosocial developmental history is less relevant to successful outcomes in the community than the assessments listed in the other options. If a patient is homeless or fears homelessness, focusing on other treatment issues is impossible. Sufficient income for basic needs and medication is necessary. Adequate support is a requisite to community placement. Substance abuse undermines medication effectiveness and interferes with community adjustment.

A patient tells the nurse at the clinic, I havent been taking my antidepressant medication as directed. I leave out the midday dose. I have lunch with friends and dont want them to ask me about the pills. Select the nurses most appropriate intervention. a. Investigate the possibility of once-daily dosing of the antidepressant. b. Suggest to the patient to take the medication when no one is watching. c. Explain how taking each dose of medication on time relates to health maintenance. d. Add the following nursing diagnosis to the plan of care: Ineffective therapeutic regimen management, related to lack of knowledge.

a. Investigate the possibility of once-daily dosing of the antidepressant. Investigating the possibility of once-daily dosing of the antidepressant has the highest potential for helping the patient achieve compliance. Many antidepressants can be administered by once-daily dosing, a plan that increases compliance. Explaining how taking each dose of medication on time relates to health maintenance is reasonable but would not achieve the goal; it does not address the issue of stigma. The self-conscious patient would not be comfortable doing this. A better nursing diagnosis would be related to social stigma. The question asks for an intervention, not analysis.

A nurse surveys the medical records for violations of patients rights. Which finding signals a violation? a. No treatment plan is present in record. b. Patient belongings are searched at admission. c. Physical restraint is used to prevent harm to self. d. Patient is placed on one-to-one continuous observation.

a. No treatment plan is present in record. The patient has the right to have a treatment plan. Inspecting a patients belongings is a safety measure. Patients have the right to a safe environment, including the right to be protected against impulses to harm self that occur as a result of a mental disorder.

While talking with a patient with severe depression, a nurse notices the patient is unable to maintain eye contact. The patients chin lowers to the chest while the patient looks at the floor. Which aspect of communication has the nurse assessed? a. Nonverbal communication b. A message filter c. A cultural barrier d. Social skills

a. Nonverbal communication

Which principle takes priority for the psychiatric inpatient staff when addressing behavioral crises? a. Resolve behavioral crises using the least restrictive intervention possible. b. Rights of the majority of patients supersede the rights of individual patients. c. Swift intervention is justified to maintain the integrity of the therapeutic milieu. d. Allow patients opportunities to regain control without intervention if the safety of other patients is not compromised.

a. Resolve behavioral crises using the least restrictive intervention possible. The rule of using the least restrictive treatment or intervention possible to achieve the desired outcome is the patients legal right. Planned interventions are nearly always preferable. Intervention may be necessary when the patient threatens harm to self.

Which technique will best communicate to a patient that the nurse is interested in listening? a. Restate a feeling or thought the patient has expressed. b. Ask a direct question, such as, Did you feel angry? c. Make a judgment about the patients problem. d. Say, I understand what youre saying.

a. Restate a feeling or thought the patient has expressed. Restating allows the patient to validate the nurses understanding of what has been communicated. Restating is an active listening technique.

A community member asks a nurse, People diagnosed with mental illnesses used to go to a state hospital. Why has that changed? Select the nurses accurate responses. Select all that apply. a. Science has made significant improvements in drugs for mental illness, so now many people may live in their communities. b. A better selection of less restrictive settings is now available in communities to care for individuals with mental illness. c. National rates of mental illness have declined significantly. The need for state institutions is actually no longer present. d. Most psychiatric institutions were closed because of serious violations of patients rights and unsafe conditions. e. Federal legislation and payment for treatment of mental illness have shifted the focus to community rather than institutional settings.

a. Science has made significant improvements in drugs for mental illness, so now many people may live in their communities. b. A better selection of less restrictive settings is now available in communities to care for individuals with mental illness. e. Federal legislation and payment for treatment of mental illness have shifted the focus to community rather than institutional settings.

A nurse at the mental health center prepares to administer a scheduled injection of haloperidol decanoate (Haldol depot) to a patient with schizophrenia. As the nurse swabs the site, the patient shouts, Stop! I dont want to take that medicine anymore. I hate the side effects. Select the nurses best initial action. a. Stop the medication administration procedure and say to the patient, Tell me more about the side effects youve been having. b. Say to the patient, Since Ive already drawn the medication in the syringe, Im required to give it, but lets talk to the doctor about skipping next months dose. c. Proceed with the injection but explain to the patient that other medications are available that may help reduce the unpleasant side effects. d. Notify other staff members to report to the room for a show of force and proceed with the injection, using restraint if necessary.

a. Stop the medication administration procedure and say to the patient, Tell me more about the side effects youve been having. Patients with mental illness retain their civil rights unless clear, cogent, and convincing evidence of dangerousness exists. The patient in this situation presents no evidence of being dangerous. The nurse, an as advocate and educator, should seek more information about the patients decision and should not force the medication.

When a female Mexican-American patient and a female nurse sit together, the patient often holds the nurses hand. The patient also links arms with the nurse when they walk. The nurse is uncomfortable with this behavior and thinks the patient is homosexual. Which alternative is a more accurate assessment? a. The patient is accustomed to touch during conversations, as are members of many Hispanic subcultures. b. The patient understands that touch makes the nurse uncomfortable and controls the relationship based on that factor. c. The patient is afraid of being alone. When touching the nurse, the patient is reassured and comforted. d. The nurse is homophobic.

a. The patient is accustomed to touch during conversations, as are members of many Hispanic subcultures.

Several nurses are concerned that agency policies related to restraint and seclusion are inadequate. Which statement about the relationship of substandard institutional policies and individual nursing practice should guide nursing practice? a. The policies do not absolve an individual nurse of the responsibility to practice according to the professional standards of nursing care. b. Agency policies are the legal standard by which a professional nurse must act and therefore override other standards of care. c. In an institution with substandard policies, the nurse has a responsibility to inform the supervisor and leave the premises. d. Interpretation of policies by the judicial system is rendered on an individual basis and therefore cannot be predicted.

a. The policies do not absolve an individual nurse of the responsibility to practice according to the professional standards of nursing care. Nurses are professionally bound to uphold the American Nurses Association (ANA) standards of practice, regardless of lesser standards established by a health care agency or state. Conversely, if the agency standards are higher than the ANA standards of practice, the agency standards must be upheld. The courts may seek to establish the standard of care through the use of expert witnesses when the issue is clouded.

The family of a patient whose insurance will not pay for continuing hospitalization considers transferring the patient to a public psychiatric hospital. The family expresses concern that the patient will never get any treatment. Which reply by the nurse would be most helpful? a. Under the law, treatment must be provided. Hospitalization without treatment violates patients rights. b. Thats a justifiable concern because the right to treatment extends only to the provision of food, shelter, and safety. c. Much will depend on other patients, because the right to treatment for a psychotic patient takes precedence over the right to treatment of a patient who is stable. d. All patients in public hospitals have the right to choose both a primary therapist and a primary nurse.

a. Under the law, treatment must be provided. Hospitalization without treatment violates patients rights. The right to medical and psychiatric treatment was conferred on all patients hospitalized in public mental hospitals with the enactment of the federal Hospitalization of Mentally Ill Act in 1964. Stating that the concern is justifiable supports the familys erroneous belief. The provisions mentioned in the third and fourth options are not part of this or any other statute governing psychiatric care.

Which statement shows a nurse has empathy for a patient who made a suicide attempt? a. You must have been very upset when you tried to hurt yourself. b. It makes me sad to see you going through such a difficult experience. c. If you tell me what is troubling you, I can help you solve your problems. d. Suicide is a drastic solution to a problem that may not be such a serious matter.

a. You must have been very upset when you tried to hurt yourself. Empathy permits the nurse to see an event from the patients perspective, understand the patients feelings, and communicate this to the patient. The incorrect responses are nurse centered (focusing on the nurses feelings rather than the patients), belittling, and sympathetic.

Which situations qualify as abandonment on the part of a nurse? (Select all that apply.) The nurse: a. allows a patient with acute mania to refuse hospitalization without taking further action. b. terminates employment without referring a seriously mentally ill for aftercare. c. calls police to bring a suicidal patient to the hospital after a suicide attempt. d. refers a patient with persistent paranoid schizophrenia to community treatment. e. asks another nurse to provide a patients care because of concerns about countertransference.

a. allows a patient with acute mania to refuse hospitalization without taking further action. b. terminates employment without referring a seriously mentally ill for aftercare. Abandonment arises when a nurse does not place a patient safely in the hands of another health professional before discontinuing treatment. Calling the police to bring a suicidal patient to the hospital after a suicide attempt and referring a patient with schizophrenia to community treatment both provide for patient safety. Asking another nurse to provide a patients care because of concerns about countertransference demonstrates self-awareness.

A patient being treated in an alcohol rehabilitation unit reveals to the nurse, I feel terrible guilt for sexually abusing my 6-year-old child before I was admitted. Based on state and federal law, the best action for the nurse to take is to: a. anonymously report the abuse by telephone to the local child abuse hotline. b. reply, Im glad you feel comfortable talking to me about it. c. respect the nurse-patient relationship of confidentiality. d. file a written report on the agency letterhead.

a. anonymously report the abuse by telephone to the local child abuse hotline. Laws regarding reporting child abuse discovered by a professional during a suspected abusers alcohol or drug treatment differ by state. Federal law supersedes state law and prohibits disclosure without a court order except in instances in which the report can be made anonymously or without identifying the abuser as a patient in an alcohol or drug treatment facility. Anonymously reporting the abuse by telephone to the local child abuse hotline meets federal criteria. Respecting nurse-patient confidentiality and replying Im glad you feel comfortable talking to me about it do not accomplish reporting. Filing a written report on agency letterhead violates federal law.

A nurse assesses an inpatient psychiatric unit, noting that exits are free from obstruction, no one is smoking, the janitors closet is locked, and all sharp objects are being used under staff supervision. These observations relate to: a. management of milieu safety. b. coordinating care of patients. c. management of the interpersonal climate. d. use of therapeutic intervention strategies.

a. management of milieu safety. Members of the nursing staff are responsible for all aspects of milieu management. The observations mentioned in this question directly relate to the safety of the unit. The other options, although part of the nurses concerns, are unrelated to the observations cited.

Planning for patients with mental illness is facilitated by understanding that inpatient hospitalization is generally reserved for patients who: a. present a clear danger to self or others. b. are noncompliant with medications at home. c. have no support systems in the community. d. develop new symptoms during the course of an illness.

a. present a clear danger to self or others. Hospitalization is justified when the patient is a danger to self or others, has dangerously decompensated, or needs intensive medical treatment. The incorrect options do not necessarily describe patients who require inpatient treatment.

A patient diagnosed with mental illness asks a psychiatric technician, Whats the matter with me? The technician replies, Your wing nuts need tightening. The nurse who overheard the exchange should take action based on: a. violation of the patients right to be treated with dignity and respect. b. the nurses obligation to report caregiver negligence. c. preventing defamation of the patients character. d. supervisory liability.

a. violation of the patients right to be treated with dignity and respect. Patients have the right to be treated with dignity and respect. Patients should never be made the butt of jokes about their illness. Patient emotional abuse has been demonstrated, not negligence. The technicians response was not clearly defamation. Patient abuse, not supervisory liability, is the issue.

Which nursing intervention demonstrates false imprisonment? a. A confused and combative patient says, Im getting out of here and no one can stop me. The nurse restrains this patient without a health care providers order and then promptly obtains an order. b. A patient has been irritating, seeking the attention of nurses most of the day. Now a nurse escorts the patient down the hall, saying, Stay in your room or youll be put in seclusion. c. An involuntarily hospitalized patient with suicidal ideation runs out of the psychiatric unit. A nurse rushes after the patient and convinces the patient to return to the unit. d. An involuntarily hospitalized patient with suicidal ideation attempts to leave the unit. A nurse calls the security team and uses established protocols to prevent the patient from leaving.

b. A patient has been irritating, seeking the attention of nurses most of the day. Now a nurse escorts the patient down the hall, saying, Stay in your room or youll be put in seclusion. False imprisonment involves holding a competent person against his or her will. Actual force is not a requirement of false imprisonment. The individual needs only to be placed in fear of imprisonment by someone who has the ability to carry out the threat. The patient in one distractor is not competent, and the nurse is acting beneficently. The patients in the other distractors have been admitted as involuntary patients and should not be allowed to leave without permission of the treatment team.

A patient is very suspicious and states, The FBI has me under surveillance. Which strategies should a nurse use when gathering initial assessment data about this patient? Select all that apply. a. Tell the patient that medication will help this type of thinking. b. Ask the patient, Tell me about the problem as you see it. c. Seek information about when the problem began. d. Tell the patient, Your ideas are not realistic. e. Reassure the patient, You are safe here.

b. Ask the patient, Tell me about the problem as you see it. c. Seek information about when the problem began. e. Reassure the patient, You are safe here. During the assessment interview, the nurse should listen attentively and accept the patients statements in a nonjudgmental way. Because the patient is suspicious and fearful, reassuring safety may be helpful, although trust is unlikely so early in the relationship. Saying that medication will help or telling the patient that the ideas are not realistic will undermine the development of trust between the nurse and patient.

A nurse asks a patient, If you had fever and vomiting for 3 days, what would you do? Which aspect of the mental status examination is the nurse assessing? a. Behavior b. Cognition c. Affect and mood d. Perceptual disturbances

b. Cognition Assessing cognition involves determining a patients judgment and decision-making capabilities. In this case, the nurse expects a response of Call my doctor if the patients cognition and judgment are intact. If the patient responds, I would stop eating, or I would just wait and see what happened, the nurse would conclude that judgment is impaired. The other options refer to other aspects of the examination.

A nurse assesses a confused older adult. The nurse experiences sadness and reflects, The patient is like one of my grandparents . . . so helpless. What feelings does the nurse describe? a. Transference b. Countertransference c. Catastrophic reaction d. Defensive coping reaction

b. Countertransference Countertransference is the nurses transference or response to a patient that is based on the nurses unconscious needs, conflicts, problems, or view of the world.

A patient cries as the nurse explores the patients relationship with a deceased parent. The patient says, I shouldn't be crying like this. It happened a long time ago. Which responses by the nurse will facilitate communication? Select all that apply. a. Why do you think you are so upset? b. I can see that you feel sad about this situation. c. The loss of your parent is very painful for you. d. Crying is a way of expressing the hurt youre experiencing. e. Lets talk about something else because this subject is upsetting you.

b. I can see that you feel sad about this situation. c. The loss of your parent is very painful for you. d. Crying is a way of expressing the hurt youre experiencing.

A voluntarily hospitalized patient tells the nurse, Get me the forms for discharge against medical advice so I can leave now. What is the nurses best initial response? a. I cant give you those forms without your health care providers knowledge. b. I will get them for you, but lets talk about your decision to leave treatment. c. Since you signed your consent for treatment, you may leave if you desire. d. Ill get the forms for you right now and bring them to your room.

b. I will get them for you, but lets talk about your decision to leave treatment. A patient who has been voluntarily admitted as a psychiatric inpatient has the right to demand and obtain release in most states. However, as a patient advocate, the nurse is responsible for weighing factors related to the patients wishes and best interests. By asking for information, the nurse may be able to help the patient reconsider the decision. The statement that discharge forms cannot be given without the health care providers knowledge is not true. Facilitating discharge without consent is not in the patients best interest before exploring the reason for the request.

A patient diagnosed with schizophrenia tells the nurse, The CIA is monitoring us through the fluorescent lights in this room. Be careful what you say. Which response by the nurse would be most therapeutic? a. Lets talk about something other than the CIA. b. It sounds like youre concerned about your privacy. c. The CIA is prohibited from operating in health care facilities. d. You have lost touch with reality, which is a symptom of your illness.

b. It sounds like youre concerned about your privacy. It is important not to challenge the patients beliefs, even if they are unrealistic. Challenging undermines the patients trust in the nurse. The nurse should try to understand the underlying feelings or thoughts the patients message conveys. The correct response uses the therapeutic technique of reflection.

A nurses neighbor asks, Why arent people with mental illness kept in state institutions anymore? What is the nurses best response? a. Many people are still in psychiatric institutions. Inpatient care is needed because many people who are mentally ill are violent. b. Less restrictive settings are now available to care for individuals with mental illness. c. Our nation has fewer persons with mental illness; therefore fewer hospital beds are needed. d. Psychiatric institutions are no longer popular as a consequence of negative stories in the press.

b. Less restrictive settings are now available to care for individuals with mental illness. The community is a less restrictive alternative than hospitals for the treatment of people with mental illness. The remaining options are incorrect and part of the stigma of mental illness.

A community mental health nurse has worked for 6 months to establish a relationship with a delusional, suspicious patient. The patient recently lost employment and stopped taking medications because of inadequate money. The patient says, Only a traitor would make me go to the hospital. Which solution is best? a. Arrange a bed in a local homeless shelter with nightly onsite supervision. b. Negotiate a way to provide medication so the patient can remain at home. c. Hospitalize the patient until the symptoms have stabilized. d. Seek inpatient hospitalization for up to 1 week.

b. Negotiate a way to provide medication so the patient can remain at home. Hospitalization may damage the nurse-patient relationship even if it provides an opportunity for rapid stabilization. If medication can be obtained and restarted, the patient can possibly be stabilized in the home setting, even if it takes a little longer. A homeless shelter is inappropriate and unnecessary. Hospitalization may be necessary later, but a less restrictive solution should be tried first because the patient is not dangerous.

A patient diagnosed with schizophrenia has been stable in the community. Today, the spouse reports the patient is expressing delusional thoughts. The patient says, Im willing to take my medicine, but I forgot to get my prescription refilled. Which outcome should the nurse add to the plan of care? a. Nurse will obtain prescription refills every 90 days and deliver them to the patient. b. Patients spouse will mark dates for prescription refills on the family calendar. c. Patient will report to the hospital for medication follow-up every week. d. Patient will call the nurse weekly to discuss medication-related issues.

b. Patients spouse will mark dates for prescription refills on the family calendar. The nurse should use the patients support system to meet patient needs whenever possible. Delivery of medication by the nurse should be unnecessary for the nurse to do if the patient or a significant other can be responsible. The patient may not need more intensive follow-up as long as he or she continues to take the medications as prescribed. No patient issues except failure to obtain medication refills were identified.

1. A nurse assesses a patient who reluctantly participates in activities, answers questions with minimal responses, and rarely makes eye contact. What information should be included when documenting the assessment? Select all that apply. a. Uncooperative patient b. Patients subjective responses c. Only data obtained from the patients verbal responses d. Description of the patients behavior during the interview e. Analysis of why the patient is unresponsive during the interview

b. Patients subjective responses d. Description of the patients behavior during the interview Both the content and process of the interview should be documented. Providing only the patients verbal responses creates a skewed picture of the patient. Writing that the patient is uncooperative is subjectively worded. An objective description of patient behavior is preferable. Analysis of the reasons for the patients behavior is speculation, which is inappropriate.

Which entry in the medical record best meets the requirement for problem-oriented charting? a. A: Pacing and muttering to self. P: Sensory perceptual alteration, related to internal auditory stimulation. I: Given fluphenazine (Prolixin) 2.5 mg at 0900, and went to room to lie down. E: Calmer by 0930. Returned to lounge to watch TV. b. S: States, I feel like Im ready to blow up. O: Pacing hall, mumbling to self. A: Auditory hallucinations. P: Offer haloperidol (Haldol) 2 mg. I: (Haldol) 2 mg at 0900. E: Returned to lounge at 0930 and quietly watched TV. c. Agitated behavior. D: Patient muttering to self as though answering an unseen person. A: Given haloperidol (Haldol) 2 mg and went to room to lie down. E: Patient calmer. Returned to lounge to watch TV. d. Pacing hall and muttering to self as though answering an unseen person. haloperidol (Haldol) 2 mg administered at 0900 with calming effect in 30 minutes. Stated, Im no longer bothered by the voices.

b. S: States, I feel like Im ready to blow up. O: Pacing hall, mumbling to self. A: Auditory hallucinations. P: Offer haloperidol (Haldol) 2 mg. I: (Haldol) 2 mg at 0900. E: Returned to lounge at 0930 and quietly watched TV. Problem-oriented documentation uses the first letter of key words to organize data: S for subjective data, O for objective data, A for assessment, P for plan, I for intervention, and E for evaluation. The distractors offer examples of PIE charting, focus documentation, and narrative documentation.

A community psychiatric nurse assesses that a patient diagnosed with a mood disorder is more depressed than on the previous visit a month ago; however, the patient says, I feel the same. Which intervention supports the nurses assessment while preserving the patients autonomy? a. Arrange for a short hospitalization. b. Schedule weekly clinic appointments. c. Refer the patient to the crisis intervention clinic. d. Call the family and ask them to observe the patient closely.

b. Schedule weekly clinic appointments. Scheduling clinic appointments at shorter intervals will give the opportunity for more frequent assessment of symptoms and allow the nurse to use early intervention. If the patient does not admit to having a crisis or problem, a referral would be useless. The remaining options may produce unreliable information, violate the patients privacy, and waste scarce resources.

During the first interview with a parent whose child died in a car accident, the nurse feels empathic and reaches out to take the patients hand. Select the correct analysis of the nurses behavior. a. It shows empathy and compassion. It will encourage the patient to continue to express feelings. b. The gesture is premature. The patients cultural and individual interpretation of touch is unknown. c. The patient will perceive the gesture as intrusive and overstepping boundaries. d. The action is inappropriate. Patients in a psychiatric setting should not be touched.

b. The gesture is premature. The patients cultural and individual interpretation of touch is unknown. Touch has various cultural and individual interpretations. Nurses should refrain from using touch until an assessment can be made regarding the way in which the patient will perceive touch. The other options present prematurely drawn conclusions.

A patient diagnosed with schizophrenia believes evil spirits are being summoned by a local minister and verbally threatens to bomb a local church. The psychiatrist notifies the minister. The psychiatrist has: a. released information without proper authorization. b. demonstrated the duty to warn and protect. c. violated the patients confidentiality. d. avoided charges of malpractice.

b. demonstrated the duty to warn and protect. The duty of a health care professional is to warn or notify an intended victim after a threat of harm has been made. Informing a potential victim of a threat is a legal responsibility of the health care professional and not considered a violation of confidentiality.

The patient says, My marriage is just great. My spouse and I usually agree on everything. The nurse observes the patients foot moving continuously as the patient twirls a shirt button. What conclusion can the nurse draw? The patients communication is: a. clear. b. mixed. c. precise. d. inadequate.

b. mixed.

After leaving work, a staff nurse realizes that documentation of the administration of a medication to a patient was omitted. This off-duty nurse telephones the unit and tells the nurse, Please document the administration of the medication I forgot to do. My password is alpha1. The nurse should: a. fulfill the request. b. refer the matter to the charge nurse to resolve. c. access the record and document the information. d. report the request to the patients health care provider.

b. refer the matter to the charge nurse to resolve. At most hospitals, termination is a possible penalty for unauthorized entry into a patient record. Referring the matter to the charge nurse will allow the observance of hospital policy while ensuring that documentation occurs. Making an exception and fulfilling the request places the on-duty staff nurse in jeopardy. Reporting the request to the patients health care provider would be unnecessary. Accessing the record and documenting the information would be unnecessary when the charge nurse can resolve the problem.

An African-American patient says to a Caucasian nurse, There's no sense talking. You wouldn't understand because you live in a white world. The nurses best action would be to: a. explain, Yes, I do understand. Everyone goes through the same experiences. b. say, Please give an example of something you think I wouldn't understand. c. reassure the patient that nurses interact with people from all cultures. d. change the subject to one that is less emotionally disturbing.

b. say, Please give an example of something you think I wouldn't understand.

In which situations does a nurse have a duty to intervene and report? Select all that apply. a. A peer is unable to write behavioral outcomes. b. A health care provider consults the Physicians Desk Reference. c. A peer tries to provide patient care in an alcohol-impaired state. d. A team member has violated the boundaries of a vulnerable patient. e. A patient refuses a medication prescribed by a licensed health care provider.

c. A peer tries to provide patient care in an alcohol-impaired state. d. A team member has violated the boundaries of a vulnerable patient. Both instances jeopardize patient safety. The nurse must practice within the Code of Ethics for Nurses. A peer being unable to write behavioral outcomes is a concern but can be informally resolved. A health care provider consulting the Physicians Desk Reference is acceptable practice.

To provide comprehensive care to patients, which competency is more important for a nurse who works in a community mental health center than a psychiatric nurse who works in an inpatient unit? a. Problem-solving skills b. Calm and caring manner c. Ability to cross service systems d. Knowledge of psychopharmacology

c. Ability to cross service systems A community mental health nurse must be able to work with schools, corrections facilities, shelters, health care providers, and employers. The mental health nurse working in an inpatient unit needs only to be able to work within the single setting. Problem-solving skills are needed by all nurses. Nurses in both settings must have knowledge of psychopharmacology.

A patient discloses several concerns and associated feelings. If the nurse wants to seek clarification, which comment would be appropriate? a. What are the common elements here? b. Tell me again about your experiences. c. Am I correct in understanding that? d. Tell me everything from the beginning.

c. Am I correct in understanding that?

A patient hurriedly tells the community mental health nurse, Everythings a disaster! I cant concentrate. My disability check didnt come. My roommate moved out, and I cant afford the rent. My therapist is moving away. I feel like Im coming apart. Which nursing diagnosis applies? a. Decisional conflict, related to challenges to personal values b. Spiritual distress, related to ethical implications of treatment regimen c. Anxiety, related to changes perceived as threatening to psychological equilibrium d. Impaired environmental interpretation syndrome, related to solving multiple problems affecting security needs

c. Anxiety, related to changes perceived as threatening to psychological equilibrium Subjective and objective data obtained by the nurse suggest the patient is experiencing anxiety caused by multiple threats to security needs. Data are not present to suggest Decisional conflict, Spiritual distress caused by ethical conflicts, or Impaired environmental interpretation syndrome.

A nurse works with a patient to establish outcomes. The nurse believes that one outcome suggested by the patient is not in the patients best interest. What is the nurses best action? a. Remain silent. b. Educate the patient that the outcome is not realistic. c. Explore with the patient possible consequences of the outcome. d. Formulate a more appropriate outcome without the patients input.

c. Explore with the patient possible consequences of the outcome.

Documentation in a patients chart shows, Throughout a 5-minute interaction, patient fidgeted and tapped left foot, periodically covered face with hands, and looked under chair while stating, I enjoy spending time with you. Which analysis is most accurate? a. Patient is giving positive feedback about the nurses communication techniques. b. Nurse is viewing the patients behavior through a cultural filter. c. Patients verbal and nonverbal messages are incongruent. d. Patient is demonstrating psychotic behaviors.

c. Patients verbal and nonverbal messages are incongruent.

A new staff nurse completes orientation to the psychiatric unit. This nurse will expect to ask an advanced practice nurse to perform which action for patients? a. Perform mental health assessment interviews. b. Establish therapeutic relationships. c. Prescribe psychotropic medications. d. Individualize nursing care plans.

c. Prescribe psychotropic medications.

Which principle should guide the nurse in determining the extent of silence to use during patient interview sessions? a. Nurses are responsible for breaking silences. b. Patients withdraw if silences are prolonged. c. Silence can provide meaningful moments for reflection. d. Silence helps patients know that what they said is understood.

c. Silence can provide meaningful moments for reflection.

A nurse volunteers for a committee that must revise the hospital policies and procedures for suicide precautions. Which resources would provide the best guidance? Select all that apply. a. Diagnostic and Statistical Manual of Mental Disorders (fifth edition) (DSM-5) b. States nurse practice act c. State and federal regulations that govern hospitals d. Summary of common practices of several local hospitals e. American Nurses Association Scope and Standards of Practice for PsychiatricMental Health Nursing

c. State and federal regulations that govern hospitals e. American Nurses Association Scope and Standards of Practice for PsychiatricMental Health Nursing Regulations regarding hospitals provide information about the minimal standard. The American Nurses Association (ANA) national standards focus on elevating practice by setting high standards for nursing practice. The DSM-5 and the states nurse practice act would not provide relevant information. A summary of common practices of several local hospitals cannot be guaranteed to be helpful because the customs may or may not comply with laws or best practices.

After several therapeutic encounters with a patient who recently attempted suicide, which occurrence should cause the nurse to consider the possibility of countertransference? a. The patients reactions toward the nurse seem realistic and appropriate. b. The patient states, Talking to you feels like talking to my parents. c. The nurse feels unusually happy when the patients mood begins to lift. d. The nurse develops a trusting relationship with the patient.

c. The nurse feels unusually happy when the patients mood begins to lift. Strong positive or negative reactions toward a patient or an overidentification with a patient signals possible countertransference. Nurses must carefully monitor their own feelings and reactions to detect countertransference and then seek supervision. Realistic and appropriate reactions from a patient toward a nurse are desirable. One incorrect response suggests transference. A trusting relationship with the patient is desirable.

What information is conveyed by nursing diagnoses? Select all that apply. a. Medical judgments about the disorder b. Goals and outcomes for the plan of care c. Unmet patient needs currently present d. Supporting data that validate the diagnoses e. Probable causes that will be targets for nursing interventions

c. Unmet patient needs currently present d. Supporting data that validate the diagnoses e. Probable causes that will be targets for nursing interventions

An adolescent asks a nurse conducting an assessment interview, Why should I tell you anything? You'll just tell my parents whatever you find out. Select the nurses best reply. a. That is not true. What you tell us is private and held in strict confidence. Your parents have no right to know. b. Yes, your parents may find out what you say, but it is important that they know about your problems. c. What you say about feelings is private, but some things, like suicidal thinking, must be reported to the treatment team. d. It sounds as though you are not really ready to work on your problems and make changes.

c. What you say about feelings is private, but some things, like suicidal thinking, must be reported to the treatment team. The patient has a right to know that most information will be held in confidence but that certain material must be reported or shared with the treatment team, such as threats of suicide, homicide, use of illegal drugs, or issues of abuse. The first response is not strictly true. The second response will not inspire the confidence of the patient. The fourth response is confrontational.

A patient tells the nurse, I dont think I will ever get out of here. Select the nurses most therapeutic response. a. Dont talk that way. Of course you will leave here! b. Keep up the good work and you certainly will. c. You dont think youre making progress? d. Everyone feels that way sometimes.

c. You dont think youre making progress? By asking if the patient does not believe that progress has been made, the nurse is reflecting by putting into words what the patient is hinting. By making communication more explicit, issues are easier to identify and resolve.

A patient is hospitalized for a reaction to a psychotropic medication and then is closely monitored for 24 hours. During a predischarge visit, the case manager learns the patient received a notice of eviction on the day of admission. The most appropriate intervention for the case manager is to: a. cancel the patients discharge from the hospital. b. contact the landlord who evicted the patient to discuss the situation. c. arrange a temporary place for the patient to stay until new housing can be arranged. d. document that the adverse medication reaction was feigned because the patient had nowhere to live.

c. arrange a temporary place for the patient to stay until new housing can be arranged. The case manager should intervene by arranging temporary shelter for the patient until suitable housing can be found. This is part of the coordination and delivery of services that falls under the case manager role. The other options are not viable alternatives.

A student nurse prepares to administer oral medications to a patient diagnosed with major depressive disorder, but the patient refuses the medication. The student nurse should: a. tell the patient, Ill get an unsatisfactory grade if I dont give you the medication. b. tell the patient, Refusing your medication is not permitted. You are required to take it. c. discuss the patients concerns about the medication, and report to the staff nurse. d. document the patients refusal of the medication without further comment.

c. discuss the patients concerns about the medication, and report to the staff nurse. The patient has the right to refuse medication in most cases. The patients reason for refusing should be ascertained, and the refusal should be reported to a unit nurse. Sometimes refusals are based on unpleasant side effects that can be ameliorated. Threats and manipulation are inappropriate. Medication refusal should be reported to permit appropriate intervention.

A patient should be considered for involuntary commitment for psychiatric care when he or she: a. is noncompliant with the treatment regimen. b. sells and distributes illegal drugs. c. threatens to harm self and others. d. fraudulently files for bankruptcy.

c. threatens to harm self and others. Involuntary commitment protects patients who are dangerous to themselves or others and cannot care for their own basic needs. Involuntary commitment also protects other individuals in society. The behaviors described in the other options are not sufficient to require involuntary hospitalization.

Which individual with a mental illness may need emergency or involuntary hospitalization for mental illness? The individual who: a. resumes using heroin while still taking methadone. b. reports hearing angels playing harps during thunderstorms. c. throws a heavy plate at a waiter at the direction of command hallucinations. d. does not show up for an outpatient appointment with the mental health nurse.

c. throws a heavy plate at a waiter at the direction of command hallucinations. Throwing a heavy plate is likely to harm the waiter and is evidence of being dangerous to others. This behavior meets the criteria for emergency or involuntary hospitalization for mental illness. The behaviors in the other options evidence mental illness but not dangerousness.

Two hospitalized patients fight when they are in the same room. During a team meeting, a nurse asserts that safety is of paramount importance and therefore the treatment plans should call for both patients to be secluded to prevent them from injuring each other. This assertion: a. reveals that the nurse values the principle of justice. b. reinforces the autonomy of the two patients. c. violates the civil rights of the two patients. d. represents the intentional tort of battery.

c. violates the civil rights of the two patients. Patients have a right to treatment in the least restrictive setting. Less restrictive measures should be tried first. Unnecessary seclusion may result in a charge of false imprisonment. Seclusion removes the patients autonomy. The principle by which the nurse is motivated is beneficence, not justice. The tort represented is false imprisonment, not battery.

Which scenario is an example of a tort? a. The primary nurse does not complete the plan of care for a patient within 24 hours of the patients admission. b. An advanced practice nurse recommends that a patient who is dangerous to self and others be voluntarily hospitalized. c. A patients admission status is changed from involuntary to voluntary after the patients hallucinations subside. d. A nurse gives an as-needed dose of an antipsychotic drug to a patient to prevent violence because a unit is short staffed.

d. A nurse gives an as-needed dose of an antipsychotic drug to a patient to prevent violence because a unit is short staffed. A tort is a civil wrong against a person that violates his or her rights. Giving unnecessary medication for the convenience of staff members controls behavior in a manner similar to secluding a patient; thus false imprisonment is a possible charge. The other options do not exemplify torts.

A nurse assessing a new patient asks, What is meant by the saying, You cant judge a book by its cover? Which aspect of cognition is the nurse assessing? a. Mood b. Attention c. Orientation d. Abstraction

d. Abstraction Patient interpretation of proverbial statements gives assessment information regarding the patients ability to abstract, which is an aspect of cognition. Mood, orientation, and attention span are assessed in other ways.

A community psychiatric nurse facilitates medication compliance for a patient by having the health care provider prescribe depot medications by injection every 3 weeks at the clinic. For this plan to be successful, which factor will be of critical importance? a. Attitude of significant others toward the patient b. Nutritional services in the patients neighborhood c. Level of trust between the patient and the nurse d. Availability of transportation to the clinic

d. Availability of transportation to the clinic The ability of the patient to get to the clinic is of paramount importance to the success of the plan. The depot medication relieves the patient of the necessity to take medication daily, but if he or she does not receive the injection at 3-week intervals, noncompliance will again be the issue. Attitude toward the patient, trusting relationships, and nutrition are important but not fundamental to this particular problem.

A patient says to the nurse, I dreamed I was stoned. When I woke up, I felt emotionally drained, as though I hadnt rested well. Which comment would be appropriate if the nurse seeks clarification? a. It sounds as though you were uncomfortable with the content of your dream. b. I understand what youre saying. Bad dreams leave me feeling tired, too. c. So, all in all, you feel as though you had a rather poor nights sleep? d. Can you give me an example of what you mean by stoned?

d. Can you give me an example of what you mean by stoned?

An adolescent hospitalized after a violent physical outburst tells the nurse, Im going to kill my father, but you cant tell anyone. Select the nurses best response. a. Youre right. Federal law requires me to keep that information private. b. Those kinds of thoughts will make your hospitalization longer. c. You really should share this thought with your psychiatrist. d. I am required to share information with the treatment team.

d. I am required to share information with the treatment team. Breach of nurse-patient confidentiality does not pose a legal dilemma for the nurse in this circumstance because a team approach to the delivery of psychiatric care presumes communication of patient information to other staff members to develop treatment plans and outcome criteria. The patient should know that the team may have to warn the father of the risk for harm.

Which statement made by a patient during an initial assessment interview should serve as the priority focus for the plan of care? a. I can always trust my family. b. It seems like I always have bad luck. c. You never know who will turn against you. d. I hear evil voices that tell me to do bad things.

d. I hear evil voices that tell me to do bad things. The statement regarding evil voices tells the nurse that the patient is experiencing auditory hallucinations. The other statements are vague and do not clearly identify the patients chief symptom.

A nurse interacts with a newly hospitalized patient. Select the nurses comment that applies the communication technique of offering self. a. I've also had traumatic life experiences. Maybe it would help if I told you about them. b. Why do you think you had so much difficulty adjusting to this change in your life? c. I hope you will feel better after getting accustomed to how this unit operates. d. Id like to sit with you for a while to help you get comfortable talking to me.

d. Id like to sit with you for a while to help you get comfortable talking to me. Offering self is a technique that should be used in the orientation phase of the nurse-patient relationship. Sitting with the patient, an example of offering self, helps build trust and conveys that the nurse cares about the patient.

n a team meeting a nurse says, Im concerned whether we are behaving ethically by using restraint to prevent one patient from self-mutilation while the care plan for another patient who has also self-mutilated calls for one-on-one supervision. Which ethical principle most clearly applies to this situation? a. Beneficence b. Autonomy c. Fidelity d. Justice

d. Justice The nurse is concerned about justice, that is, the fair treatment with the least restrictive methods for both patients. Beneficence means promoting the good of others. Autonomy is the right to make ones own decisions. Fidelity is the observance of loyalty and commitment to the patient.

A newly admitted patient who is acutely psychotic is a private patient of the senior psychiatrist. To whom does the psychiatric nurse who is assigned to this patient owe the duty of care? a. Health care provider b. Profession c. Hospital d. Patient

d. Patient Although the nurse is accountable to the health care provider, the agency, the patient, and the profession, the duty of care is owed to the patient.

Select the most appropriate label to complete this nursing diagnosis: ___________, related to feelings of shyness and poorly developed social skills as evidenced by watching television alone at home every evening. a. Deficient knowledge b. Ineffective coping c. Powerlessness d. Social isolation

d. Social isolation Nursing diagnoses are selected on the basis of the etiologic factors and assessment findings or evidence. In this instance, the evidence shows social isolation that is caused by shyness and poorly developed social skills.

A Filipino-American patient had this nursing diagnosis: Situational low self-esteem, related to poor social skills as evidenced by lack of eye contact. Interventions were used to raise the patients self-esteem; however, after 3 weeks, the patients eye contact did not improve. What is the most accurate analysis of this scenario? a. The patients eye contact should have been directly addressed by role-playing to increase comfort with eye contact. b. The nurse should not have independently embarked on assessment, diagnosis, and planning for this patient. c. The patients poor eye contact is indicative of anger and hostility that remain unaddressed. d. The nurse should have assessed the patients culture before making this diagnosis and plan.

d. The nurse should have assessed the patients culture before making this diagnosis and plan.

Which documentation of a patients behavior best demonstrates a nurses observations? a. Isolates self from others. Frequently fell asleep during group. Vital signs stable. b. Calmer and more cooperative. Participated actively in group. No evidence of psychotic thinking. c. Appeared to hallucinate. Patient frequently increased volume on television, causing conflict with others d. Wears four layers of clothing. States, I need protection from dangerous bacteria trying to penetrate my skin.

d. Wears four layers of clothing. States, I need protection from dangerous bacteria trying to penetrate my skin. The documentation states specific observations of the patients appearance and the exact statements made. The other options are vague or subjective statements and can be interpreted in different ways.

A Puerto RicanAmerican patient uses dramatic body language when describing emotional discomfort. Which analysis most likely explains the patients behavior? The patient: a. likely has a histrionic personality disorder. b. believes dramatic body language is sexually appealing. c. wishes to impress staff with the degree of emotional pain. d. belongs to a culture in which dramatic body language is the norm.

d. belongs to a culture in which dramatic body language is the norm.

Nursing behaviors associated with the implementation phase of the nursing process are concerned with: a. participating in the mutual identification of patient outcomes. b. gathering accurate and sufficient patient-centered data. c. comparing patient responses and expected outcomes. d. carrying out interventions and coordinating care.

d. carrying out interventions and coordinating care. Nursing behaviors relating to implementation include using available resources, performing interventions, finding alternatives when necessary, and coordinating care with other team members.

At one point in an assessment interview a nurse asks, How does your faith help you in stressful situations? This question would be asked during the assessment of: a. childhood growth and development. b. substance use and abuse. c. educational background. d. coping strategies.

d. coping strategies. When discussing coping strategies, the nurse might ask what the patient does when upset, what usually relieves stress, and to whom the patient goes to talk about problems. The question regarding whether the patients faith helps deal with stress fits well here. It would seem out of place if introduced during exploration of the other topics.

The relapse of a patient diagnosed with schizophrenia is related to medication noncompliance. The patient is hospitalized for 5 days, medication is restarted, and the patients thoughts are now more organized. The patients family members are upset and say, Its too soon for discharge. Hospitalization is needed for at least a month. The nurse should: a. call the psychiatrist to come explain the discharge rationale. b. explain that health insurance will not pay for a longer stay for the patient. c. call security to handle the disturbance and escort the family off the unit. d. explain that the patient will continue to improve if medication is taken regularly.

d. explain that the patient will continue to improve if medication is taken regularly. Patients no longer stay in the hospital until every vestige of a symptom disappears. The nurse must assume responsibility to advocate for the patients right to the least restrictive setting as soon as the symptoms are under control and for the right of citizens to control health care costs. The health care provider will use the same rationale. Shifting blame will not change the discharge. Calling security is unnecessary. The nurse can handle this matter.

A psychiatric nurse best implements the ethical principle of autonomy when he or she: a. intervenes when a self-mutilating patient attempts to harm self. b. stays with a patient who is demonstrating a high level of anxiety. c. suggests that two patients who are fighting be restricted to the unit. d. explores alternative solutions with a patient, who then makes a choice.

d. explores alternative solutions with a patient, who then makes a choice. Autonomy is the right to self-determination, that is, to make ones own decisions. When the nurse explores alternatives with the patient, the patient is better equipped to make an informed, autonomous decision. Staying with a highly anxious patient or intervening with a self-mutilating patient demonstrates beneficence and fidelity. Suggesting that two fighting patients be restricted to the unit demonstrates the principles of fidelity and justice.

The spouse of a patient who has delusions asks the nurse, Are there any circumstances under which the treatment team is justified in violating the patients right to confidentiality? The nurse must reply that confidentiality may be breached: a. under no circumstances. b. at the discretion of the psychiatrist. c. when questions are asked by law enforcement. d. if the patient threatens the life of another person.

d. if the patient threatens the life of another person. The duty to warn a person whose life has been threatened by a patient under psychiatric treatment overrides the patients right to confidentiality. The right to confidentiality is not suspended at the discretion of the therapist or for legal investigations.

The following patients are seen in the emergency department. The psychiatric unit has one bed available. Which patient should the admitting officer recommend for admission to the hospital? The patient who: a. is experiencing dry mouth and tremor related to side effects of haloperidol (Haldol). b. is experiencing anxiety and a sad mood after a separation from a spouse of 10 years. c. self-inflicted a superficial cut on the forearm after a family argument. d. is a single parent and hears voices saying, Smother your infant.

d. is a single parent and hears voices saying, Smother your infant. Admission to the hospital would be justified by the risk of patient danger to self or others. The other patients have issues that can be handled with less restrictive alternatives than hospitalization.

Which assessment finding for a patient living in the community requires priority intervention by the nurse? The patient: a. receives Social Security disability income plus a small check from a trust fund. b. lives in an apartment with two patients who attend day hospital programs. c. has a sibling who is interested and active in care planning. d. purchases and uses marijuana on a frequent basis.

d. purchases and uses marijuana on a frequent basis. Patients who regularly buy illegal substances often become medication noncompliant. Medication noncompliance, along with the disorganizing influence of illegal drugs on cellular brain function, promotes relapse. The remaining options do not suggest problems.

An example of a breach of a patients right to privacy occurs when a nurse: a. asks a family to share information about a patients prehospitalization behavior. b. discusses the patients history with other staff members during care planning. c. documents the patients daily behaviors during hospitalization. d. releases information to the patients employer without consent.

d. releases information to the patients employer without consent. The release of information without patient authorization violates the patients right to privacy. The other options are acceptable nursing practices.

A patient with major depressive disorder has lost 20 pounds in one month has chronic low self-esteem and a plan for suicide. The patient has taken an antidepressant medication for 1 week. Which nursing intervention is most directly related to this outcome: Patient will refrain from gestures and attempts to harm self? a. Implement suicide precautions. b. Frequently offer high-calorie snacks and fluids. c. Assist the patient to identify three personal strengths. d. Observe patient for therapeutic effects of antidepressant medication.

A. Implement suicide precautions

A nurse documents: Patient is mute, despite repeated efforts to elicit speech. Makes no eye contact. Is inattentive to staff. Gazes off to the side or looks upward rather than at the speaker. Which nursing diagnosis should be considered? a. Defensive coping b. Decisional conflict c. Risk for other-directed violence d. Impaired verbal communication

D. Impaired Verbal Communication

Before assessing a new patient, a nurse is told by another health care worker, I know that patient. No matter how hard we work, there isnt much improvement by the time of discharge. The nurses responsibility is to: a. document the other workers assessment of the patient. b. assess the patient based on data collected from all sources. c. validate the workers impression by contacting the patients significant other. d. discuss the workers impression with the patient during the assessment interview.

B. Assess the patient based on data collected by all sources Assessment should include data obtained from both the primary and reliable secondary sources. Biased assessments by others should be evaluated as objectively as possible by the nurse, keeping in mind the possible effects of countertransference.

After formulating the nursing diagnoses for a new patient, what is the next action a nurse should take? a. Design interventions to include in the plan of care. b. Determine the goals and outcome criteria. c. Implement the nursing plan of care. d. Complete the spiritual assessment.

B: Determine the goals and outcome criteria The third step of the nursing process is planning and outcome identification. Outcomes cannot be determined until the nursing assessment is complete and the nursing diagnoses have been formulated.

A patient begins a new program to assist with building social skills. In which part of the plan of care should a nurse record the item Encourage patient to attend one psychoeducational group daily? a. Assessment b. Analysis c. Planning d. Implementation e. Evaluation

D. Implementation Interventions are the nursing prescriptions to achieve the outcomes. Interventions should be specific.

A patients nursing diagnosis is Insomnia. The desired outcome is: Patient will sleep for a minimum of 5 hours nightly by October 31. On November 1, a review of the sleep data shows the patient sleeps an average of 4 hours nightly and takes a 2-hour afternoon nap. Which evaluation should be documented? a. Consistently demonstrated b. Often demonstrated c. Sometimes demonstrated d. Never demonstrated

D. Never demonstrated Although the patient is sleeping 6 hours daily, the total is not in one uninterrupted session at night. Therefore the outcome must be evaluated as never demonstrated.

A patient is having difficulty making a decision. The nurse has mixed feelings about whether to provide advice. Which principle usually applies? Giving advice: a. is rarely helpful. b. fosters independence. c. lifts the burden of personal decision making. d. helps the patient develop feelings of personal adequacy.

a. is rarely helpful.

A patient with severe depression states, God is punishing me for my past sins. What is the nurses best response? a. Why do you think that? b. You sound very upset about this. c. You believe God is punishing you for your sins? d. If you feel this way, you should talk to a member of your clergy.

b. You sound very upset about this.

A suspicious and socially isolated patient lives alone, eats one meal a day at a nearby shelter, and spends the remaining daily food allowance on cigarettes. Select the community psychiatric nurses best initial action. a. Report the situation to the manager of the shelter. b. Tell the patient, You must stop smoking to save money. c. Assess the patients weight; determine the foods and amounts eaten. d. Seek hospitalization for the patient while a new plan is being formulated.

c. Assess the patients weight; determine the foods and amounts eaten. Assessment of biopsychosocial needs and general ability to live in the community is called for before any action is taken. Both nutritional status and income adequacy are critical assessment parameters. A patient may be able to maintain adequate nutrition while eating only one meal a day. Nurses assess before taking action. Hospitalization may not be necessary.

When a new patient is hospitalized, a nurse takes the patient on a tour, explains the rules of the unit, and discusses the daily schedule. The nurse is engaged in: a. counseling. b. health teaching. c. milieu management. d. psychobiologic intervention.

c. milieu management. Milieu management provides a therapeutic environment in which the patient can feel comfortable and safe while engaging in activities that meet the patients physical and mental health needs. Counseling refers to activities designed to promote problem solving and enhanced coping and includes interviewing, crisis intervention, stress management, and conflict resolution. Health teaching involves identifying health educational needs and giving information about these needs. Psychobiologic interventions involve medication administration and monitoring response to medications.

A patient states, Im not worth anything. I have negative thoughts about myself. I feel anxious and shaky all the time. Sometimes I feel so sad that I want to go to sleep and never wake up. Which nursing intervention should have the highest priority? a. Self-esteembuilding activities b. Anxiety self-control measures c. Sleep enhancement activities d. Suicide precautions

d. Suicide precautions The nurse should place priority on monitoring and reinforcing suicide self-restraint because it relates directly and immediately to patient safety. Patient safety is always a priority concern. The nurse should monitor and reinforce all patient attempts to control anxiety, improve sleep patterns, and develop self-esteem while giving priority attention to suicide self-restraint.

A nurse cares for an older adult patient admitted for treatment of depression. The health care provider prescribes an antidepressant medication, but the dose is more than the usual adult dose. The nurse should: a. implement the order. b. consult a drug reference. c. give the usual geriatric dosage. d. hold the medication and consult the health care provider.

d. hold the medication and consult the health care provider. The dose of an antidepressant medication for older adult patients is often less than the usual adult dose. The nurse should withhold the medication and consult the health care provider who wrote the order. The nurses duty is to intervene and protect the patient. Consulting a drug reference is unnecessary because the nurse already knows the dose is excessive. Implementing the order is negligent. Giving the usual geriatric dose would be wrong; a nurse without prescriptive privileges cannot change the dose.

A patients nursing diagnosis is Insomnia. The desired outcome is: Patient will sleep for a minimum of 5 hours nightly by October 31. On November 1, a review of the sleep data shows the patient sleeps an average of 4 hours nightly and takes a 2-hour afternoon nap. What is the nurses next action? a. Continue the current plan without changes. b. Remove this nursing diagnosis from the plan of care. c. Write a new nursing diagnosis that better reflects the problem. d. Revise the outcome target date and interventions.

D. Revise the outcome target date and interventions

The relationship between a nurse and patient as it relates to status and power is best described by which term? a. Symmetric b. Complementary c. Incongruent d. Paralinguistic

b. Complementary When a difference in power exists, as between a student and teacher or between a nurse and patient, the relationship is said to be complementary. Symmetrical relationships exist between individuals of like or equal status. Incongruent and paralinguistic are not terms used to describe relationships.

Select the best outcome for a patient with this nursing diagnosis: Impaired social interaction, related to sociocultural dissonance as evidenced by stating, Although Id like to, I dont join in because I dont speak the language very well. The patient will: a. demonstrate improved social skills. b. express a desire to interact with others. c. become more independent in decision making. d. select and participate in one group activity per day.

d. select and participate in one group activity per day. The outcome describes social involvement on the part of the patient. Neither cooperation nor independence has been an issue. The patient has already expressed a desire to interact with others. Outcomes must be measurable. Two of the distractors are not measurable.

Which patient would a nurse refer to partial hospitalization? An individual who: a. spent yesterday in the 24-hour supervised crisis care center and continues to be actively suicidal. b. because of agoraphobia and panic episodes needs psychoeducation for relaxation therapy. c. has a therapeutic lithium level and reports regularly for blood tests and clinic follow-up. d. states, Im not sure I can avoid using alcohol when my spouse goes to work every morning.

d. states, Im not sure I can avoid using alcohol when my spouse goes to work every morning. This patient could profit from the structure and supervision provided by spending the day at the partial hospitalization program. During the evening, at night, and on weekends, the spouse could assume supervision responsibilities. The patient who is actively suicidal needs inpatient hospitalization. The patient in need of psychoeducation can be referred to home care. The patient who reports regularly for blood tests and clinical follow-up can continue on the same plan.