Psych quizzes review

A violent patient is restrained. What is the nurse's first priority?

Ensure the patient's safety

A person who is speaking about a rival for a significant other's affection says in a gushy, syrupy voice, "What a lovely person. That's someone I simply adore." The individual is demonstrating:

Reaction formation (Reaction formation is an unconscious mechanism that keeps unacceptable feelings out of awareness by using the opposite behavior.)

A nurse is caring for a client in active alcohol withdrawals on a med-surg unit. The client is observed speaking in a loud voice, using profanity with clenched fists. Which of the following actions should the nurse take?

Request that other staff members remain close by.

The most therapeutic response a nurse could make to a student who begins to cry upon learning that a failing grade was received on a final exam is:

"Failing an exam is an upsetting thing to happen."

A patient who is experiencing moderate anxiety says, "I feel undone." An appropriate response for the nurse would be:

"I'm not sure I understand. Give me an example."

The nurse is caring for a Native American client who says, "I don't want you to touch me. I'll take care of myself." Which nursing response is most therapeutic?

"It sounds as though you want to take care of yourself. Let's work together so you can do things for yourself."

A client looks at a mirror and cries out, "I look like a bird. This is not my face." The nurse responds therapeutically by saying:

"That must be very distressing to you, your face does not look different to me."

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

"You seem upset. Tell me about it."

A client relates angrily to the nurse that his wife says he is selfish. Which response by the nurse would be most helpful?

"You sound angry - tell me more about what went on."

Two staff nurses applied for promotion to nurse manager. The nurse not promoted initially had feelings of loss but then became supportive of the new manager by helping make the transition smooth and encouraging others. Which term best describes this nurse's response?

Altruism (Altruism is the mechanism by which an individual deals with emotional conflict by meeting the needs of others and vicariously receiving gratification from the responses of others.)

Which patient behavior is a criterion for mechanical restraint?

Assaulting a staff person.

The child with autism spectrum disorder (ASD) has difficulty with trust. With this in mind, which of the following nursing actions would be most appropriate?

Avoid direct eye contact.

The principle on which nursing intervention should be predicated when a client's aggression quickly escalates is:

Begin with the least restrictive measure possible.

Calm Tension Reduction Agitated Anxious Agression

Calm → Nurse is professional; helpful; available , Agitated → Nurse takes a directive stance and provides short concise instructions., Tension Reduction → Nurse re-establishes therapeutic rapport; initiates debriefing., Anxious → Nurse uses active listening; allows for ventilation; supportive, informing; addresses immediate concerns and sources of fear, pain and frustration; offers alternatives., Aggression → Nurse is aware of physical distance; escape routs; physical intervention plan.

A person who feels unattractive repeatedly says, "Although I'm not beautiful, I am smart." This is an example of:

Compensation (Compensation is an unconscious process that allows an individual to make up for deficits in one area by excelling in another area to raise self-esteem.)

A patient is undergoing diagnostic tests. the patient says, "Nothing is wrong with me except a stubborn chest cold." the spouse reports that the patient smokes, coughs daily, and has lost 15 pounds and is easily fatigued. Which defense mechanism is the patient using?

Denial (Denial is an unconscious blocking of threatening or painful information or feelings. )

The first task in assessing violent behavior should be

Determination of the cause.

The medication protocol the nurse should use to provide immediate intervention for an angry psychotic client whose aggressive behavior continues to escalate despite verbal intervention is:

Haloperidol

The client says to the nurse "I am going to die, I wish my family would stop hoping for a cure! I get so angry when they carry on like this! After all, I'm the one who's dying." The most therapeutic response is:

Have you shared your feelings with your family?"

A client has, in the past, had a nursing diagnosis of ineffective coping related to impulsively acting out anger as evidenced by striking others. An appropriate plan for forestalling such incidents would be:

Helping a client identify incidents that trigger impulsive acting out.

A patient tells a nurse, "My new friend is the most perfect person one could imagine; kind, considerate, and good looking. I can't find a single flaw." This patient is demonstrating:

Idealization (idealization is an unconscious process that occurs when an individual attributes exaggerated positive qualities to another. )

The nurse is meeting a new client on the unit. Which action, by the nurse, is most effective in initiating the nurse-client relationship?

Introduce self and explain the purpose and the plan for the relationship

During the termination phase of the nurse-client relationship, the clinic nurse observes that the client continuously demonstrates bursts of anger. The most appropriate interpretation of the behavior is that the client...

Is displaying typical behaviors that can occur during termination.

The nurse is preparing the client for the termination phase of the nurse-client relationship. The nurse prepares to implement which nursing task is most appropriate for this phase?

Making appropriate referrals.

Mrs. F. has remained close to the nurse all day. When the nurse talked with other clients during dinner, Mrs. F. tried to regain the nurse's attention and began to shout, "You're just like my mother. You pay attention to everyone but me!" The best interpretation of this behavior is that...

Mrs. F. is demonstrating transference.

A supervisor assigns a worker a new project. The worker initially agrees but feels resentful. The next day when asked about the project, the worker says, "I've been working on other things." When asked 4 hours later, the worker says, "Someone else was using the copier, so I couldn't finish it." The worker's behavior demonstrates:

Passive aggression (A passive-aggressive person deals with emotional conflict by indirectly expressing aggression towards others. Compliance on the surface masks covert resistance. Resistance is expressed through procrastination, inefficiency, and stubbornness in response to assigned tasks. )

A client who was brought into the emergency room by EMS intoxicated, suddenly removes a knife from his coat pocket and threatens to kill himself or anyone who tries to stop him from leaving the room. A psychiatric emergency code is called and the client is safely disarmed and placed in restraints. the rationale for use of restraints was that the client:

Presented a clear and present danger to self and others.

Two staff nurses applied for a charge nurse position. After the promotion was announced, the nurse who was not promoted said, "The nurse manager had a headache the day I was interviewed." Which defense mechanism is evident?

Projection ( Projection is the hallmark of blaming, scapegoating, thinking prejudicially, and stigmatizing others.)

An individual experiences sexual dysfunction and blames it on a partner by calling the person unattractive and unromantic. Which defense mechanism is evident?

Rationalization (Rationalization involves unconsciously making excuses for one's behavior, inadequacies, or feelings.)

A client is admitted for psychiatric observation after being arrested for breaking windows in the home of his former girlfriend, who had refused to see him. His history reveals abuse as a child by a punitive father, torturing family pets, and one arrest for disorderly conduct. The nursing diagnosis that should be considered for development is:

Risk for other-directed violence

What is the team intervention techniques used in nonviolent crisis intervention?

TIP: Team, Isolate, Plan

The client on the mental health unit who should be assessed as being at highest risk for directing violent behavior towards others is...

The client who has paranoid delusions that she is being followed by members of the mafia

Two hours after a client lost control and required restraints and PRN medication, she is out of restraints, calm, and sitting in her room reading. The post-intervention debriefing process is initiated by the nurse and includes: Choose all that apply

The correct answers are: Helping the client identify the precipitating event., Reviewing possible alternative coping strategies., Reestablishing therapeutic communication and rapport with client.

An aggressive client was placed in four-point restraints and given an intramuscular dose of anxiolytic medication. Systematic assessment to guide interventions during the period of restraint should include: Choose all that apply

The correct answers are: Hydration, Vital signs, Nutritional needs, Elimination needs, Level of awareness, Range of Motion and comfort needs

The nurse directs the intervention team who must take an aggressive client to seclusion. Other clients have been removed from the area. Before approaching the client, the nurse should ensure that staff: Choose all that apply

The correct answers are: Remove jewelry, glasses, and harmful items from their persons., Select the person who will communicate with the client., Appoint a person to clear a pat and open, close or lock doors.

An effective nursing intervention for helping angry clients learn to manage anger without violence would be:

Using cognitive strategies to identify a thought that increases anger, find proof for or against the belief, and substitute reality-based thinking.

Which statement about aggression would serve as the rational for care planning using behavioral techniques? Aggression...

is motivated by rewards received for previous aggression.

Instumental- irritable- Fear driven -

→ The individual brings to the current situation, factors such as attitudes, beliefs, and behavioral tendencies which leads to aggression., Instrumental → The individual has learned from past experiences that aggression helps him to get what he wants., Irritable → The individual is chronically angry at the world. She may be looking for something to set her off. This client may have had boundaries that were violated and is trying to regain her self-worth., Fear Driven → The individual attacks others in an effort to avoid getting hurt.