Exam 1
self-disclosure
Revealing personal information such as biographical information and personal experiences, ideas, thoughts and feelings about oneself.
Denial
Failure to acknowledge an unbearable condition failure to admit the reality of the situation ex: diabetic eating cake spending money freely when broke waiting for 3 days to seek help for abdominal pain
The nurse is assessing a school-aged child to determine underlying causes for socially inappropriate behavior. The nurse uses knowledge that which children are likely to have impaired impulse control? Select all that apply.
1. Children who belong to low-income families. 2. Children who belong to dysfunctional families. 3. Children who get inconsistent responses for their behavior.
Assessment of sensorium and intellectual processes includes which of the following?
1. Concentration 2. Memory 3. Orientation
Assessment of suicidal risk includes which of the following?
1. Intent to die 2. Method 3. Plan 4. Reason
A client who has a history of hostile behavior appears severely agitated. What interventions should the nurse perform to prevent harm to the client and others? Select all that apply.
1. Obtain orders for seclusion if needed. 2. Make arrangements for possible restraint. 3. Anticipate the use of sedatives. 4. Use a low calm voice
The nurse is planning treatment for a client with aggressive and psychotic behavior. What should be the immediate goals of treatment for this client? Select all that apply.
1. The client will not harm the self. 2. The client will demonstrate decreased acting out behavior. 3. The client will withhold from harming others or damaging the hospital property.
Intellectualization
- Separation of the emotions of a painful event or situation from the facts involved; acknowledging the facts but not the emotions - Person shows no emotional expression when discussing serious car accident
A person brings a parent to the clinic and tells the nurse that the parent has begun to act strangely in the past few days, with unprovoked outbursts of anger. After the incidents, the parent expresses remorse for the outburst. The person says, "I've never seen my parent act this way." Which question would be most appropriate for the nurse to ask next?
"Has your parent suffered any traumatic injury to the brain recently?"
The nurse is caring for a client with rheumatoid arthritis. Upon entering the client's room, the nurse finds that the client is very angry and is punching pillows to express the anger. What should be the nurse's response to this behavior? Select the best answer.
"I am here so we can talk about what is making you angry."
The nurse has entered a hospital client's room and asked the client if the client plans to attend the morning's scheduled group life-skills session. Which response should signal the presence of thought blocking to the nurse?
"I might. I'll give it some..."
A nurse is caring for a family whose older parent with dementia is living in their home. The nurse has instructed the family about how to decrease the parent's agitation. The nurse determines that the child of the parent has understood the instructions when stating:
"If I simplify our home environment, my parent may be less agitated."
The nurse is caring for a client with aggressive behavior. The client tells the nurse, "I am feeling extremely angry. I feel like breaking the windows in here." What would be the most appropriate response of the nurse?
"Let's go to the gym and exercise."
While interviewing a client, a nurse asks, "What do you do when you get angry?" Which client response would indicate to the nurse that the client engages in anger suppression?
"People say I withdraw and pout about the problem."
Sublimation
- Substituting a socially acceptable for an impulse that is unacceptable - Person who has quit smoking sucks on hard candy when the urge to smoke arises
Ego
- The balancing or mediating force between the id and the superego - Represents mature + adaptive behavior that allows a person to function successfully in the world - Freud believed that anxiety resulted from the ego's attempts o balance the impulsive instincts of the id with the stringent rules of the superego
During assessment of a client with schizophrenia, the nurse notes the client has ideas of reference. Which statement of the client would have led the nurse to conclude this?
"The news of the terrorist attack is directed to me. The terrorists are trying to warn me."
Which client statement indicates the most insight into his or her issue with auditory hallucinations?
"The voices aren't real but it's hard to ignore them."
Which question would be best for the nurse to ask in order to assess recent memory?
"What did you eat for breakfast today?"
The nurse is performing a psychosocial assessment of a client. Which questions should the nurse ask to assess the client's self-concept? Select all that apply.
"What do you do when you have a problem?" "How do you think you look today?"
When assessing orientation, the nurse completes the assessment by asking which questions? Select all that apply.
"What is your name?" "What day of the week is it?" "Can you tell me where you are?"
A new nurse asks the nurse manager about the best intervention to use when trying to de-escalate a potentially violent client. Which response would be most appropriate?
"What works best is what fits the client and the situation."
An adult client is pacing and yelling. Which is the best response by the nurse?
"When did these feelings begin?"
The nurse is preparing to assess a client's remote memory. Which questions would be most appropriate for the nurse to ask?
"When did you get your first job?"
A psychiatric-mental health nurse is teaching a class for a group of colleagues about anger, aggression, and violence. Which statement by the nurse would be most appropriate to include?
"Women experience anger as frequently as men do."
Identify five questions that the nurse would choose to ask this client initially. Give a rationale for the chosen questions.
1. What is the problem as the client sees it (to gain the client's perception of the situation)? 2. Has the client ever felt this way before (to determine if this is a new occurrence, or a recurrent one)? 3. Does the client have thoughts of harming herself or others (to determine safety)? 4. Has the client been drinking alcohol, using drugs, or taking medication (to assess client's ability to think clearly or if there is impairment)? 5. What kind of help does the client need (to see what kind of help the client wants, e.g., someone to listen, help to solve a specific problem, or as a referral)?
Under which circumstances can an expression of anger be considered a normal and healthy reaction? Select all that apply.
1. When facing an unjust situation. 2. When personal rights are not respected. 3. When realistic expectations are not met.
When the nurse asks, "How would you carry out this plan?" the nurse is questioning which component of a suicide assessment?
Access
The nurse is responsible for developing a therapeutic relationship with the client. There are many factors that enhance the nurse client relationship. What is the first step the nurse must take in order to prepare to accomplish this goal? A. Desire to form friendship B. Self-awareness C. Previous social skills D. Communication skills
B. self-awareness
Which sign of escalating behaviors, if displayed by a client, requires immediate intervention?
Banging the head against the wall
Discuss three trends of mental health care in the United States.
Cost containment and managed care, population diversity, and community-based care.
A client has lost emotional and physical control. The client is shouting, screaming, hitting others, and throwing objects. Which phase of the aggression cycle is this client expressing?
Crisis
In which phase of the aggression cycle can techniques of seclusion or restraint be used to deal with the aggression quickly?
Crisis
While talking with a schizophrenic client, the nurse observes that the client is looking straight ahead, maintains no eye contact, and moves facial muscles very little, even though the client is telling the nurse about a very emotional episode the client just experienced with a roommate. When describing the client's affect, the nurse documents it as what?
Flat
A nurse assesses a 29-year-old client in the outpatient mental health clinic. The nurse notes the client is speaking very quickly and jumping from topic to topic very rapidly. There is some connection between ideas, but they are difficult to follow. Which term most accurately describes this thought process?
Flight of ideas
Working phase-
Has 2 subphases 1) problem identification- client identifies the issues or concerns causing problems 2) Exploitation-nurse guides pt to examine feelings & responses to develop better coping skills & more positive self image- develops independence
Discuss ideas for increasing the number of people receiving treatment for mental illness.
Increased community-based clinics; increased screening for mental illness in primary care settings; screening identified high-risk populations; improved mental health parity in insurance coverage; increased services in jails, prisons, and other institutional settings.
What led you to come to the clinic?
Insight
Intimate relationship
Involves two people who are emotionally committed to each other
Antisocial personality disorders are assessed with which tool?
Milton Clinical Multiaxial Inventory (MCMI)
A client with schizophrenia has been brought to the hospital in an agitated state. In order for the nurse to perform the initial assessment, which approaches should the nurse use to manage the situation? Select all that apply.
Monitor facial expressions Monitor emotional responses Ensure availability of assistance
In general, how are you feeling?
Mood
The psychiatric nurse correctly identifies the client's form of communication as circumstantiality when the client does what?
Provides long, irrelevant explanations when asked why the client abuses alcohol.
During which phase of the aggression cycle does the client regain physical and emotional control?
Recovery
During which phase of the aggression cycle does the staff usually have a debriefing session?
Recovery
When asking a client to "tell me how having schizophrenia has affected your life," the nurse is assessing the client's capacity for what?
Reflective insight
A client has been admitted to the detoxification unit after binge drinking. Even though the client is not currently intoxicated, the client is combative and exhibits altered thought processes. Which nursing diagnosis would be the priority?
Risk for other-directed violence related to alcohol withdrawal
How would you describe yourself as a person?
Self-concept
A client tells the nurse that the client has strong urges to damage property as a result of feelings of hostility and anger. Which is an appropriate nursing action?
Take the client to the gym for exercise.
Roles of nurse in Therapuetic relationships
Teacher, caregiver, advocate
orientation phase
The beginning of the nurse-client relationship; begins when the nurse and client meet and ends when the client begins to identify problems to examine.
When the nurse is assessing whether or not the client's ideas are logical and make sense, the nurse is examining which of the following?
Thought process
Preconscious
Thoughts and emotions are not currently in the person's awareness but he or she can recall them with some effort such an adult remembering what he or she did, thought or felt as a child
The nurse is assessing a client who expresses extreme hostility toward the nurse. What may be the client's intentions? Select all that apply.
To intimidate the nurse To emotionally harm the nurse
A nurse is seeing a client for a weekly therapeutic session in an outpatient psychiatric clinic. The client discloses to the nurse that the client often has thoughts about killing a neighbor. What should be the nurse's first response?
Warn the client's neighbor and report to the authorities.
Preconceptions
Ways one person expects another to behave or speak- generally blocks formations of relationships
Which of the following is an example of an open-ended question?
What concerns you most about your health?
tort
a wrongful act that results in injury, loss, or damage
Values
abstract standards that give a person a sense of right and wrong and establish a code of conduct for living ex- hard work, honesty, sincerity, cleanliness, orderliness
causation
action that constitutes a breach of duty and was the direct cause of the loss, damage, or injury; in other words, the loss, damage, or injury would not have occurred if the nurse had acted in a reasonable, prudent manner
negligence
an unintentional tort that involves causing harm by failing to do what a reasonable and prudent person would do in similar circumstances
Phillippe Pinel or William Dukes
asylum as a safe refuge
standards of care
authoritative statements by professional organizations that describe the responsibilities for which nurses are accountable; the care that nurses provide to clients meets set expectations and is what any nurse in a similar situation would do
The client who believes everyone is out to get him or her is experiencing a(n)
delusion.
The nurse assesses a client with a history of bipolar disorder. The client tells the nurse that that an intelligence agency has surveillance equipment set up in the client's bathroom. The nurse is observing which thought process or content?
delusional thinking
Which client behavior would the nurse document as being an automatism?
drumming one's fingers on the table top
Mental health parity laws ensure
equality in insurance coverage for mental illness.
duty
existence of a legally recognized relationship, that is, physician to client, nurse to client
Linda Richards
first American psychiatric nurse
Humanism
focuses on a persons positive qualities, his or her capacity to change (human potential), and the promotion of self-esteem. Humanists do consider the persons past experiences but they direct more attention toward the present and future.
The client's belief that a news broadcast has special meaning for him or her is an example of
ideas of reference.
The nurse is assessing an adolescent in a psychiatric facility. The parent tells the nurse that the adolescent has intense sporadic anger episodes. The adolescent becomes angry for petty reasons and starts throwing objects at home. The adolescent also feels guilty and repents for the actions. Based on this history, the nurse would expect the client to be diagnosed with:
intermittent explosive disorder.
assault
involves any action that causes a person to fear being touched, without consent or authority, in a way that is offensive, insulting, or physically injurious
battery
involves harmful or unwarranted contact with a client; actual harm or injury may or may not have occurred
The nurse is performing a physical assessment on a 3-year-old client. During the assessment, the child starts screaming and kicking. The nurse suspects this child:
is acting out.
Managed care is designed to
maintain a balance between the quality and costs of health care.
Dorothea Dix
moral treatment of the mentally ill
The primary purpose of the Community Mental Health Center Act of 1963 was
moving patients to their home community for treatment.
A nurse is reading a journal article about anger and violence. Which would the nurse expect to see as being linked to excessive, outwardly directed anger?
myocardial infarction
The client tells the nurse "I never do anything right. I make a mess of everything. Ask anyone, they'll tell you the same thing." The nurse recognizes these statements as examples of
negative thinking.
Social relationships
primarily initiated for purpose of friendship
justice
refers to fairness, or treating all people fairly and equally without regard for social or economic status, race, sex, marital status, religion, ethnicity, or cultural beliefs
beneficence
refers to one's duty to benefit or to promote good for others
fidelity
refers to the obligation to honor commitments and contracts
transference
when a client unconsciously got feelings he or she has for significant others
The nurse is performing an assessment of a client with a psychiatric illness. The nurse has 10 cards with different inkblot shapes. Which test is the nurse about to perform?
The Rorschach Test
empathy
The ability to perceive the meaning and feelings of another person and to communicate that understanding to that person.
Fixation
- Immobilization of a portion of the personality resulting from unsuccessuful completion of tasks in the develpmental stage - Never learning to delay gratification - Lack of a clear sense of identity as an adult
Superego
- Is the part of a person's nature that reflects moral and ethical concepts, values, parental and social expectations; therefore it is in direct OPPOSITION to the id
Ego Defense Mechanisms
- Methods of attempting to protect the self and cope with basic drives or emotionally painful thoughts, feelings or events - Compensation, conversion, denial, displacement, dissociation, fixation, identification, intellectualization, introjection, projection, rationalization, reaction formation, regression, reporession, resistance + sublimation
Identification
- Modeling actions and opinions of influential others while searching for identity or aspiring to reach a personal, social or occupational goal - Nursing student becomes a critical care nurse because this is the specialty of an instructor she admires
Regression
- Moving back to a previous developmental stage to feel safe or have needs met - Five year old asks for a bottle when new baby brother is fed
Transference
- Occurs when the client displaces onto the therapist attitudes and feelings that the client originally experienced in other relationships - Automatic and unconscious in the theraputic relationship
Countertransference
- Occurs when the therapist displaces onto the client attitudes or feelings from his or her past
Compensation
- Overachievement in one area to offset real or perceived deficiencies in another area - Napoleon complex: diminutive man becoming emperor - Nurse with low self esteem working double shifts so her supervisor will like her
Introjection
- Accepting another person's attitudes, beliefs and values as one's own - Person who dislikes guns becomes an avid hunter, just like a best friend
Reaction formation
- Acting the opposite of what one thinks or feels - Woman who never wanted to have children becomes a supermom
Supppression
- Conscious exclusion of unaccceptable thoughts and feelings from conscious awareness - Student decides not to think about a parent's illness to study for a test
Dissociation
- Dealing wiht emotional conflict by a temporary alteration in consciousness or identity - Amnesia that prevents recall of yesterday's auto accident - Adult remembers nothing of childhood sexual abuse
Repression
- Excluding emotionally painful or anxiety provoking thoughts and feelings from conscious awareness - Woman has no memory of the mugging she suffered yesterday
Rationalization
- Excusing own behavior to aboid guilt, responsibility, conflict, anxiety or loss of self-respect - Student blames failure on teacher being mean
Undoing
- Exhibiting acceptable behavior to make up for or negate unacceptable behavior - Person who cheats on a spouse brings the spouse a bouquet of roses
Conversion
- Expression of an emotional conflict though the development of a PHYSICAL symptom, usually sensorimoter in nature - A teenager forbidden to see x rate movies is tempted to do so by friends + develops blindness and the teenager is unconcerned about the loss of sight
Psychoanalytic Theory
- Founded by Freud - Psychoanalytic theory supports the notion that all human behavior is caused and can be explained (deterinistic theory). - Personality composed of Id, Ego + Superego - Behavior motivated by subconscious thoughts + feelings
Id
- Part of one's nature that reflects basic or innate desires such as pleasure seeking behavior, aggression and sexual impulses - Seeks instant gratification, causes impulsive unthinking behavior and has no regard for rules of social convention
Substitution
- Replacing the desired gratification with one that is more readily available - Woman who would like to have her own children opens a day care center
Projection
- Unconscious blaming of an unacceptable inclinations or thoughts of an external object - Man who has though about same gender sexual relationship, but never had one, beats a man who is gay
Displacement
- Ventilation of intense feelings toward persons less threatening than the one who aroused those feelings - Person who is mad at the boss yells at his or her spouse
Which clients in the psychiatric inpatient unit should the nurse watch closely for risk of aggressive behavior? Select all that apply.
1. A client with a history of violence. 2. A client with history of being personally victimized. 3. A client with a history of substance abuse.
The nurse is caring for a client with aggression disorder. The client has an anger episode and is threatening other clients in the emergency room with a knife. What should be the approach of the nurse in this situation? Select all that apply.
1. The nurse should attempt to kick the knife out of the client's hand. 2. The nurse should call for outside assistance.
Freud's 5 Stages of Psychosocial Development
1.) Oral (birth - 18 months) 2.) Anal (18- 36 months) 3.) Phallic/Oedipal (3 - 5 years) 4.) Latency (5 - 11 years) 5.) Genital (11 - 13 years)
Piaget's 4 Stages of Cognitive Development
1.) Sensorimotor: birth to 2 years 2.) Preoperational: 2 - 6 years 3.) Concrete operations: 6 - 12 years 4.) Formal operations 12 - 15 years
Erikson's 8 Stages of Psychosocial Development
1.) Trust vs. Mistrust 2.) Automony vs. shame 3.) Initiative vs. guilt 4.) Industry vs. inferiority 5.) Identity vs. role confusion 6.) Intamacy vs. isolation 7.) Generative vs. stagnation 8.) Ego integrity vs. despair
A client has recovered from an episode of aggressive and hostile behavior. Which behaviors in the client indicate that the client is in the post-crisis stage of the aggression cycle? Select all that apply.
1.The client apologizes for the hostile behavior. 2. The client cries and is remorseful for the event. 3. The client remains withdrawn from others.
The nurse finds that a client with a history of aggressive behavior is restless, is pacing up and down in the hallway, and has clenched fists. The client also talks in a loud voice. Which intervention would be most appropriate at this point?
Immediately approach the client to engage in communication
Which personality trait is associated with aggressive behavior?
Impulsivity
The nurse working in a psychology clinic finds that suppression of anger is more common in women than in men. What is the possible explanation for such a finding? Choose the best answer.
Women are expected not to express so-called negative feelings like anger.
A nurse documents that "the client describes the recent breakup of a dating relationship with an emotionless tone and a flat facial expression." In which section of the mental status exam would the nurse have documented this statement?
Affect
A nurse suggests that the client explores new ideas about a particular problem and considers other possibilities to reflect:
A cognitive intervention.
The nurse is preparing to perform a psychosocial assessment of a client with schizophrenia. The client has a history of extreme aggression. What is the optimal setting for conducting an interview with the client?
A physician's intake room with other medical personnel nearby.
intimate relationship
A relationship involving two people who are emotionally committed to each other; both parties are concerned about having their individual needs met and helping each other to meet needs as well; the relationship may include sexual or emotional intimacy as well as sharing of mutual goals.
While conducting an interview with a psychiatric-mental health client, the nurse is observing the client's facial expressions and nonverbal cues. What are these physical manifestations known as?
Affect
Pam is a nursing student experiencing her first clinical rotation in a psychiatric unit her friends and family have told her that all mentally ill patients are dangerous. Because of their comments, Pam is feeling very anxious about having to talk to the patients on the unit. Which of the following terms is used to describe her feelings with regard to the psychiatric patients in general? A. Attitudes B. beliefs C. Values D. Self-awareness
A. Attitudes
Which of the following patterns of nursing knowledge is being utilized when the nurse remains of the client even though the nurses shift has ended? A. Ethical B. Personal knowing C. Aesthetic D. Empirical
A. Ethical
Hey client who suffers from depression is upset that her grandchildren seem to like concern for her. After some discussion with the nurse, the client began to realize that her communication with her children involves complaining and criticizing. The nurse assesses the clients emotional needs during this interview. What should you expect. The outcome will be of this particular working phase. A. Evaluation of mutually identified go B. discussions of the expectation of the relationship C. Discussion regarding termination of the relationship D. Assessment of the client needs
A. Evaluation of mutually identify goals
When is it appropriate for the nurse to introduce information regarding the termination of the relationship? A. An orientation phase B. right before the last meeting C. When the goals are being identified D. When the client is emotionally ready
A. Information regarding the termination phase should be introduced during the orientation phase
The nurses role is varied, and one area of the nursing role may supersede another role in importance at any given time during the nurse - client relationship. Which of the following roles is being exhibited when the nurse instruct the client about his medication regime? A. Teacher B. caregiver C. Parent surrogate D. Advocate
A. Teacher
The student nurses are practicing communication techniques with their clients in order to establish a therapeutic method of assessing; planning; implementing; and evaluating the client through the art of communication. Which of the following is true regarding the establishment of a therapeutic relationship? A. The nurse and the client agree about the areas to work on and evaluate the outcomes B. The nurse and the client enter into a mutual social relationship C. The client and the nurse are building a friendship D. A nurse focuses on his or her own needs
A. The nurse and the client agree about areas to work on and evaluate the outcomes
Therapeutic use of the milieu sets The town for the nurse - client relationship. Which phase of the nurse - client relationship provides the nurse with the opportunity to establish a professional therapeutic environment for the patient? A. Orientation B. resolution C. Termination D. Working
A. The orientation phase
One of the clients on the psychiatric unit has made comments to the nursing student that he finds her cute and wants to know more about her. Which of the following terms is applied to the situation when the client unconsciously shows the same types of feelings for the nurse that he or she has for a significant other? A. Transference B. Countertransference C. Exploitation D. Self-disclosure
A. Transference
Which phase of the nurse client relationship includes exploration of the clients feelings and participation in identifying his or her own problems? A. Working B. termination C. Orientation D. Beginning
A. Working
13. A nurse is performing a mental health assessment on an adult client. According to Maslow's hierarchy of needs, which client action would demonstrate the highest achievement in terms of mental health? 1. Maintaining a long-term, faithful, intimate relationship. 2. Achieving a sense of self-confidence. 3. Possessing a feeling of self-fulfillment and realizing full potential. 4. Developing a sense of purpose and the ability to direct activities.
ANS: 3 Rationale: The nurse should identify that the client who possesses a feeling of self-fulfillment and realizes his or her full potential has achieved self-actualization, the highest level on Maslow's hierarchy of needs.
15. A client diagnosed with schizophrenia receives fluphenazine decanoate (Prolixin Decanoate) from a home health nurse. The client refuses medication at one regularly scheduled home visit. Which nursing intervention is ethically appropriate? 1. Allow the client to decline the medication and document the decision. 2. Tell the client that if the medication is refused, hospitalization will occur. 3. Arrange with a relative to add the medication to the client's morning orange juice. 4. Call for help to hold the client down while the injection is administered.
ANS: 1 Rationale: It is ethically appropriate for the nurse to allow the client to decline the medication and provide accurate documentation. The client's right to refuse treatment should be upheld, unless the refusal puts the client or others in harm's way.
3. Without authorization, a nurse administers an extra dose of narcotic tranquilizer to an agitated client. The nurse's coworker observes this action but does nothing for fear of retaliation. What is the ethical interpretation of the coworker's lack of involvement? 1. Taking no action is still considered an unethical action by the coworker. 2. Taking no action releases the coworker from ethical responsibility. 3. Taking no action is advised when potential adverse consequences are foreseen. 4. Taking no action is acceptable, because the coworker is only a bystander.
ANS: 1 Rationale: The coworker's lack of involvement can be interpreted as an unethical action. The coworker is experiencing an ethical dilemma in which a decision needs to be made between two unfavorable alternatives. The coworker has a responsibility to report any observed unethical actions.
10. A psychiatric nurse working on an inpatient unit receives a call asking if an individual has been a client in the facility. Which nursing response reflects appropriate legal and ethical obligations? 1. The nurse refuses to give any information to the caller, citing rules of confidentiality. 2. The nurse hangs up on the caller. 3. The nurse confirms that the person has been at the facility but adds no additional information. 4. The nurse suggests that the caller speak to the client's therapist.
ANS: 1 Rationale: The most appropriate action by the nurse is to refuse to give any information to the caller. Admission to the facility would be considered protected health information (PHI) and should not be disclosed by the nurse without prior client consent.
4. Which client should the nurse anticipate to be most receptive to psychiatric treatment? 1. A Jewish, female social worker. 2. A Baptist, homeless male. 3. A Catholic, black male. 4. A Protestant, Swedish business executive.
ANS: 1 Rationale: The nurse should anticipate that the client of Jewish culture would place a high importance on preventative health care and would consider mental health as equally important as physical health. Women are also more likely to seek treatment for mental health problems than men.
5. A psychiatric nurse intern states, "This client's use of defense mechanisms should be eliminated." Which is a correct evaluation of this nurse's statement? 1. Defense mechanisms can be appropriate responses to stress and need not be eliminated. 2. Defense mechanisms are a maladaptive attempt of the ego to manage anxiety and should always be eliminated. 3. Defense mechanisms, used by individuals with weak ego integrity, should be discouraged and not eliminated. 4. Defense mechanisms cause disintegration of the ego and should be fostered and encouraged.
ANS: 1 Rationale: The nurse should determine that defense mechanisms can be appropriate during times of stress. The client with no defense mechanisms may have a lower tolerance for stress, thus leading to anxiety disorders. Defense mechanisms should be confronted when they impede the client from developing healthy coping skills.
3. A nurse is assessing a set of 15 year-old identical twins who respond very differently to stress. One twin becomes anxious and irritable, and the other withdraws and cries. How should the nurse explain these different stress responses to the parents? 1. Reactions to stress are relative rather than absolute. Individual responses to stress vary. 2. It is abnormal for identical twins to react differently to similar stressors. 3. Identical twins should share the same temperament and respond similarly to stress. 4. Environmental influences to stress weigh more heavily than genetic influences.
ANS: 1 Rationale: The nurse should explain to the parents that, although the twins have identical DNA, there are several other factors that affect reactions to stress. Mental health is a state of being that is relative to the individual client. Environmental influences and temperament can affect stress reactions.
11. A client requests information on several medications in order to make an informed choice about management of depression. A nurse should provide this information to facilitate which ethical principle? 1. Autonomy 2. Beneficence 3. Nonmaleficence 4. Justice
ANS: 1 Rationale: The nurse should provide the information to support the client's autonomy. A client who is capable of making independent choices should be permitted to do so. In instances when clients are incapable of making informed decisions, a legal guardian or representative would be asked to give consent.
14. A client who will be receiving electroconvulsive therapy (ECT) must provide informed consent. Which situation should cause a nurse to question the validity of the informed consent? 1. The client is paranoid. 2. The client is 87 years old. 3. The client incorrectly reports his or her spouse's name, date, and time of day. 4. The client relies on his or her spouse to interpret the information.
ANS: 3 Rationale: The nurse should question the validity of informed consent when the client incorrectly reports the spouse's name, date, and time of day. This indicates that this client is disoriented and may not be competent to make informed choices.
16. A nurse is assessing a client who appears to be experiencing some anxiety during questioning. Which symptoms might the client demonstrate that would indicate anxiety? (Select all that apply.) 1. Fidgeting 2. Laughing inappropriately 3. Palpitations 4. Nail biting 5. Limited attention span
ANS: 1, 2, 4 Rationale: The nurse should assess that fidgeting, laughing inappropriately, and nail biting are indicative of heightened stress levels. The client would not be diagnosed with mental illness unless there is significant impairment in other areas of daily functioning. Other indicators of more serious anxiety are restlessness, difficulty concentrating, muscle tension, and sleep disturbance.
19. After disturbing the peace, an aggressive, disoriented, unkempt, homeless individual is escorted to an emergency department. The client threatens suicide. Which of the following criteria would enable a physician to consider involuntary commitment? (Select all that apply.) 1. Being dangerous to others 2. Being homeless 3. Being disruptive to the community 4. Being gravely disabled and unable to meet basic needs 5. Being suicidal
ANS: 1, 4, 5 Rationale: The physician could consider involuntary commitment when a client is dangerous to others, gravely disabled, or is suicidal. If the physician determines that the client is mentally incompetent, consent should be obtained from the legal guardian or court-approved guardian or conservator. A hospital administrator may give permission for involuntary commitment when time does not permit court intervention.
5. Which is an example of an intentional tort? 1. A nurse fails to assess a client's obvious symptoms of neuroleptic malignant syndrome. 2. A nurse physically places an irritating client in four-point restraints. 3. A nurse makes a medication error and does not report the incident. 4. A nurse gives patient information to an unauthorized person.
ANS: 2 Rationale: A tort, which can be intentional or unintentional, is a violation of civil law in which an individual has been wronged. A nurse who intentionally physically places an irritating client in restraints has touched the client without consent and has committed an intentional tort.
2. During a hiring interview, which response by a nursing applicant should indicate that the applicant operates from an ethical egoism framework? 1. "I would want to be treated in a caring manner if I were mentally ill." 2. "This job will pay the bills, and the workload is light enough for me." 3. "I will be happy caring for the mentally ill. Working in med/surg kills my back." 4. "It is my duty in life to be a psychiatric nurse. It is the right thing to do."
ANS: 2 Rationale: The applicant's comment reflects the ethical egoism framework. This framework promotes the idea that decisions are made based on what is good for the individual and may not take the needs of others into account.
1. In response to a student's question regarding choosing a psychiatric specialty, a charge nurse states, "Mentally ill clients need special care. If I were in that position, I'd want a caring nurse also." From which ethical framework is the charge nurse operating? 1. Kantianism 2. Christian ethics 3. Ethical egoism 4. Utilitarianism
ANS: 2 Rationale: The charge nurse is operating from a Christian ethics framework. The imperative demand of Christian ethics is that all decisions about right and wrong should be centered in love for God and in treating others with the same respect and dignity with which we would expect to be treated. Kantianism states that decisions should be made based on moral law and that actions are bound by a sense of moral duty. Utilitarianism holds that decisions should be made focusing on the end result being happiness. Ethical egoism promotes the idea that what is right is good for the individual.
16. Which situation exemplifies both assault and battery? 1. The nurse becomes angry, calls the client offensive names, and withholds treatment. 2. The nurse threatens to "tie down" the client and then does so, against the client's wishes. 3. The nurse hides the client's clothes and medicates the client to prevent elopement. 4. The nurse restrains the client without just cause and communicates this to family.
ANS: 2 Rationale: The nurse in this situation has committed both the acts of assault and battery. Assault refers to an action that results in fear and apprehension that the person will be touched without consent. Battery is the touching of another person without consent.
9. Which nursing statement about the concept of neurosis is most accurate? 1. An individual experiencing neurosis is unaware that he or she is experiencing distress. 2. An individual experiencing neurosis feels helpless to change his or her situation. 3. An individual experiencing neurosis is aware of psychological causes of his or her behavior. 4. An individual experiencing neurosis has a loss of contact with reality.
ANS: 2 Rationale: The nurse should define the concept of neurosis with the following characteristics: The client feels helpless to change his or her situation, the client is aware that he or she is experiencing distress, the client is aware the behaviors are maladaptive, the client is unaware of the psychological causes of the distress, and the client experiences no loss of contact with reality.
2. At what point should the nurse determine that a client is at risk for developing a mental illness? 1. When thoughts, feelings, and behaviors are not reflective of the DSM 5 criteria. 2. When maladaptive responses to stress are coupled with interference in daily functioning. 3. When a client communicates significant distress. 4. When a client uses defense mechanisms as ego protection.
ANS: 2 Rationale: The nurse should determine that the client is at risk for mental illness when responses to stress are maladaptive and interfere with daily functioning. The DSM-5 indicates that in order to be diagnosed with a mental illness, daily functioning must be significantly impaired. The client's ability to communicate distress would be considered a positive attribute.
8. Which potential client should a nurse identify as a candidate for involuntarily commitment? 1. The client living under a bridge in a cardboard box 2. The client threatening to commit suicide 3. The client who never bathes and wears a wool hat in the summer 4. The client who eats waste out of a garbage can
ANS: 2 Rationale: The nurse should identify the client threatening to commit suicide as eligible for involuntary commitment. The suicidal client who refuses treatments is in danger and needs emergency treatment.
14. According to Maslow's hierarchy of needs, which situation on an in-patient psychiatric unit would require priority intervention by a nurse? 1. A client rudely complaining about limited visiting hours. 2. A client exhibiting aggressive behavior toward another client. 3. A client stating that no one cares. 4. A client verbalizing feelings of failure.
ANS: 2 Rationale: The nurse should immediately intervene when a client exhibits aggressive behavior toward another client. Safety and security are considered lower-level needs according to Maslow's hierarchy of needs and must be fulfilled before other higher-level needs can be met. Clients who complain, have feelings of failure, or state that no one cares are struggling with higher-level needs such as the need for love and belonging or the need for self-esteem.
10. Which nursing statement regarding the concept of psychosis is most accurate? 1. Individuals experiencing psychoses are aware that their behaviors are maladaptive. 2. Individuals experiencing psychoses experience little distress. 3. Individuals experiencing psychoses are aware of experiencing psychological problems. 4. Individuals experiencing psychoses are based in reality.
ANS: 2 Rationale: The nurse should understand that the client with psychosis experiences little distress owing to his or her lack of awareness of reality. The client with psychosis is unaware that his or her behavior is maladaptive or that he or she has a psychological problem.
4. Group therapy is strongly encouraged, but not mandatory, in an inpatient psychiatric unit. The unit manager's policy is that clients can make a choice about whether or not to attend group therapy. Which ethical principle does the unit manager's policy preserve? 1. Justice 2. Autonomy 3. Veracity 4. Beneficence
ANS: 2 Rationale: The unit manager's policy regarding voluntary client participation in group therapy preserves the ethical principle of autonomy. The principle of autonomy presumes that individuals are capable of making independent decisions for themselves and that health-care workers must respect these decisions.
15. How would a nurse best complete the new DSM-5 definition of a mental disorder? "A health condition characterized by significant dysfunction in an individual's cognitions, or behaviors that reflects a disturbance in the 1. psychosocial, biological, or developmental process underlying mental functioning." 2. psychological, cognitive, or developmental process underlying mental functioning." 3. psychological, biological, or developmental process underlying mental functioning." 4. psychological, biological, or psychosocial process underlying mental functioning."
ANS: 3 Rationale: "A health condition characterized by significant dysfunction in an individual's cognitions, or behaviors that reflects a disturbance in the psychological, biological, or developmental process underlying mental functioning", is the new DSM 5 definition of a mental disorder.
18. A brother calls to speak to his sister, who has been admitted to a psychiatric unit. The nurse connects him to the community phone, and the sister is summoned. Later the nurse realizes that the brother was not on the client's approved call list. What law has the nurse broken? 1. The National Alliance for the Mentally Ill Act 2. The Tarasoff Ruling 3. The Health Insurance Portability and Accountability Act 4. The Good Samaritan Law
ANS: 3 Rationale: The nurse has violated the Health Insurance Portability and Accountability Act (HIPAA) by revealing that the client had been admitted to the psychiatric unit. The nurse should not have provided any information without proper consent from the client.
6. During an intake assessment, a nurse asks both physiological and psychosocial questions. The client angrily responds, "I'm here for my heart, not my head problems." Which is the nurse's best response? 1. "It's just a routine part of our assessment. All clients are asked these same questions." 2. "Why are you concerned about these types of questions?" 3. "Psychological factors, like excessive stress, have been found to affect medical conditions." 4. "We can skip these questions, if you like. It isn't imperative that we complete this section."
ANS: 3 Rationale: The nurse should attempt to educate the client on the negative effects of excessive stress on medical conditions. It is not appropriate to skip physiological and psychosocial questions, as this would lead to an inaccurate assessment.
12. Devastated by a divorce from an abusive husband, a wife completes grief counseling. Which statement by the wife should indicate to a nurse that the client is in the acceptance stage of grief? 1. "If only we could have tried again, things might have worked out." 2. "I am so mad that the children and I had to put up with him as long as we did." 3. "Yes, it was a difficult relationship, but I think I have learned from the experience." 4. "I still don't have any appetite and continue to lose weight."
ANS: 3 Rationale: The nurse should evaluate that the client is in the acceptance stage of grief because during this stage of the grief process, the client would be able to focus on the reality of the loss and its meaning in relation to life.
7. An employee uses the defense mechanism of displacement when the boss openly disagrees with suggestions. What behavior would be expected from this employee? 1. The employee assertively confronts the boss. 2. The employee leaves the staff meeting to work out in the gym. 3. The employee criticizes a coworker. 4. The employee takes the boss out to lunch.
ANS: 3 Rationale: The nurse should expect that the client using the defense mechanism displacement would criticize a coworker after being confronted by the boss. Displacement refers to transferring feelings from one target to a neutral or less-threatening target.
8. A fourth-grade boy teases and makes jokes about a cute girl in his class. This behavior should be identified by a nurse as indicative of which defense mechanism? 1. Displacement 2. Projection 3. Reaction formation 4. Sublimation
ANS: 3 Rationale: The nurse should identify that the boy is using reaction formation as a defense mechanism. Reaction formation is the attempt to prevent undesirable thoughts from being expressed by expressing opposite thoughts or behaviors. Displacement refers to transferring feelings from one target to another. Rationalization refers to making excuses to justify behavior. Projection refers to the attribution of unacceptable feelings or behaviors to another person. Sublimation refers to channeling unacceptable drives or impulses into more constructive, acceptable activities.
13. Which situation reflects violation of the ethical principle of veracity? 1. A nurse discusses with a client another client's impending discharge. 2. A nurse refuses to give information to a physician who is not responsible for the client's care. 3. A nurse tricks a client into seclusion by asking the client to carry linen to the seclusion room. 4. A nurse does not treat all of the clients equally, regardless of illness severity.
ANS: 3 Rationale: The nurse who tricks a client into seclusion has violated the ethical principle of veracity. The principle of veracity refers to one's duty to always be truthful and not intentionally deceive or mislead clients.
9. A client diagnosed with schizophrenia refuses to take medication, citing the right of autonomy. Under which circumstance would a nurse have the right to medicate the client against the client's wishes? 1. A client makes inappropriate sexual innuendos to a staff member. 2. A client constantly demands attention from the nurse by begging, "Help me get better." 3. A client physically attacks another client after being confronted in group therapy. 4. A client refuses to bathe or perform hygienic activities.
ANS: 3 Rationale: The nurse would have the right to medicate a client against his or her wishes if the client physically attacks another client. This client poses a significant risk to safety and is incapable of making informed choices. The client's refusal to accept treatment can be challenged, because the client is endangering the safety of others.
11. When under stress, a client routinely uses alcohol to excess. Finding her drunk, her husband yells at the client about her chronic alcohol abuse. Which action alerts the nurse to the client's use of the defense mechanism of denial? 1. The client hides liquor bottles in a closet. 2. The client yells at her son for slouching in his chair. 3. The client burns dinner on purpose. 4. The client says to the spouse, "I don't drink too much!"
ANS: 4 Rationale: The client's statement "I don't drink too much!" alerts the nurse to the use of the defense mechanism of denial. The client is refusing to acknowledge the existence of a real situation and the feelings associated with it.
17. A geriatric client is confused and wandering in and out of every door. Which scenario reflects the least restrictive alternative for this client? 1. The client is placed in seclusion. 2. The client is placed in a geriatric chair with tray. 3. The client is placed in soft Posey restraints. 4. The client is monitored by an ankle bracelet.
ANS: 4 Rationale: The least-restrictive alternative for this client would be monitoring by an ankle bracelet. The client does not pose a direct dangerous threat to self or others, so neither physical restraints nor seclusion would be justified.
6. An involuntarily committed client is verbally abusive to the staff, repeatedly threatening to sue. The client records the full names and phone numbers of the staff. Which nursing action is most appropriate to decrease the possibility of a lawsuit? 1. Verbally redirect the client, and then refuse one-on-one interaction. 2. Involve the hospital's security division as soon as possible. 3. Notify the client that documenting personal staff information is against hospital policy. 4. Continue professional attempts to establish a positive working relationship with the client.
ANS: 4 Rationale: The most appropriate nursing action is to continue professional attempts to establish a positive working relationship with the client. The involuntarily committed client should be respected and has the right to assert grievances if rights are infringed.
1. A nurse is assessing a client who is experiencing occasional feelings of sadness because of the recent death of a beloved pet. The client's appetite, sleep patterns, and daily routine have not changed. How should the nurse interpret the client's behaviors? 1. The client's behaviors demonstrate mental illness in the form of depression. 2. The client's behaviors are extensive, which indicates the presence of mental illness. 3. The client's behaviors are not congruent with cultural norms. 4. The client's behaviors demonstrate no functional impairment, indicating no mental illness.
ANS: 4 Rationale: The nurse should assess that the client's daily functioning is not impaired. The client who experiences feelings of sadness after the loss of a pet is responding within normal expectations. Without significant impairment, the client's distress does not indicate a mental illness.
12. An inpatient psychiatric physician refuses to treat clients without insurance and prematurely discharges those whose insurance benefits have expired. Which ethical principle should a nurse determine has been violated based on these actions? 1. Autonomy 2. Beneficence 3. Nonmaleficence 4. Justice
ANS: 4 Rationale: The nurse should determine that the ethical principle of justice has been violated by the physician's actions. The principle of justice requires that individuals should be treated equally, regardless of race, sex, marital status, medical diagnosis, social standing, economic level, or religious belief.
7. Which statement should a nurse identify as correct regarding a client's right to refuse treatment? 1. Clients can refuse pharmacological but not psychological treatment. 2. Clients can refuse any treatment at any time. 3. Clients can refuse only electroconvulsive therapy (ECT). 4. Professionals can override treatment refusal by an actively suicidal or homicidal client.
ANS: 4 Rationale: The nurse should understand that health-care professionals could override treatment refusal when a client is actively suicidal or homicidal. A suicidal or homicidal client who refuses treatment may be in danger or a danger to others. This situation should be treated as an emergency, and treatment may be performed without informed consent.
1. A nurse wishes to teach alternative coping strategies to a patient who is experiencing severe anxiety. The nurse will first need to: a. Lower the patient's current anxiety level. b. Verify the patient's learning style. c. Create outcomes and a teaching plan. d. Assess how the patient uses defense mechanisms.
ANS: A A patient experiencing severe anxiety has a significantly narrowed perceptual field and difficulty attending to events in the environment. A patient experiencing severe anxiety will not learn readily. Determining preferred modes of learning, devising outcomes, and constructing teaching plans are relevant to the task but are not the priority measure. The nurse has already assessed the patient's anxiety level. Using defense mechanisms does not apply.
5. A patient with a high level of motor activity runs from chair to chair and cries, "They're coming! They're coming!" The patient is unable to follow staff direction or respond to verbal interventions. Which nursing diagnosis has the highest priority? a. Risk for injury b. Self-care deficit c. Disturbed energy field d. Disturbed thought processes
ANS: A A patient who is experiencing panic-level anxiety is at high risk for injury, related to an increase in non-goal-directed motor activity, distorted perceptions, and disordered thoughts. Existing data do not support the nursing diagnoses of Self-care deficit or Disturbed energy field. This patient has disturbed thought processes, but the risk for injury has a higher priority.
2. Which action by a psychiatric nurse best supports patients' rights to be treated with dignity and respect? a. Consistently addressing each patient by title and surname. b. Strongly encouraging a patient to participate in the unit milieu. c. Discussing a patient's 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.
ANS: A 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 patient's 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.
17. 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 the nurse's response? a. Altruism b. Sublimation c. Suppression d. Passive aggression
ANS: A 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. The nurse's reaction is conscious, not unconscious. No evidence of aggression is exhibited, and no evidence of conscious denial of the situation exists. Passive aggression occurs when an individual deals with emotional conflict by indirectly and unassertively expressing aggression toward others.
When completing a physical assessment of an individual's response to stress, the nurse should observe and inquire about what?
Appetite and sleep
35. A patient has a fear of public speaking. The nurse should be aware that social phobias are often treated with which type of medication? a. (beta)-blockers. b. Antipsychotic medications. c. Tricyclic antidepressant agents. d. Monoamine oxidase inhibitors.
ANS: A Beta-blockers, such as propranolol, are often effective in preventing symptoms of anxiety associated with social phobias. Neuroleptic medications are major tranquilizers and not useful in treating social phobias. Tricyclic antidepressants are rarely used because of their side effect profile. MAOIs are administered for depression and only by individuals who can observe the special diet required.
1. 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.
ANS: A 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.
28. Which statement is mostly likely to be made by a patient with agoraphobia? a. "Being afraid to go out seems ridiculous, but I can't go out the door." b. "I'm sure I'll get over not wanting to leave home soon. It takes time." c. "When I have a good incentive to go out, I can do it." d. "My family says they like it now that I stay home."
ANS: A Individuals who are agoraphobic generally acknowledge that the behavior is not constructive and that they do not really like it. Patients state they are unable to change the behavior. Patients with agoraphobia are not optimistic about change. Most families are dissatisfied when family members refuse to leave the house.
12. A patient in the emergency department exhibits disorganized behavior and incoherence after a friend suggested a homosexual encounter. In which room should the nurse place the patient? a. Interview room furnished with a desk and two chairs b. Small, empty storage room with no windows or furniture c. Room with an examining table, instrument cabinets, desk, and chair d. Nurse's office, furnished with chairs, files, magazines, and bookcases
ANS: A Individuals who are experiencing a severe-to-panic level of anxiety require a safe environment that is quiet, nonstimulating, structured, and simple. A room with a desk and two chairs provides simplicity, few objects with which the patient could cause self-harm, and a small floor space around which the patient can move. A small, empty storage room without windows or furniture would be like a jail cell. The nurse's office or a room with an examining table and instrument cabinets may be overstimulating and unsafe.
16. A patient tells the nurse at the clinic, "I haven't been taking my antidepressant medication as directed. I leave out the midday dose. I have lunch with friends and don't want them to ask me about the pills." Select the nurse's 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 nursing diagnosis—Ineffective therapeutic regimen management, related to lack of knowledge—to the plan of care.
ANS: A 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 etiologic statement would be related to social stigma. The question asks for an intervention, not analysis.
17. 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, "I'm glad you feel comfortable talking to me about it." c. respect nurse-patient relationship of confidentiality. d. file a written report on the agency letterhead.
ANS: A Laws regarding reporting child abuse discovered by a professional during a suspected abuser's 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, "I'm glad you feel comfortable talking to me about it" do not accomplish reporting. Filing a written report on agency letterhead violates federal law.
5. A nurse assesses an inpatient psychiatric unit, noting that exits are free from obstruction, no one is smoking, the janitor's 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
ANS: A 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 nurse's concerns, are unrelated to the observations cited.
10. Several nurses are concerned that agency policies related to restraint and seclusion practices 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.
ANS: A 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.
22. A patient with mental illness asks a psychiatric technician, "What's the matter with me?" The technician replies, "Your wing nuts need tightening." The patient looks bewildered and wanders off. The nurse who overheard the exchange should take action based on: a. violation of the patient's right to be treated with dignity and respect. b. the nurse's obligation to report caregiver negligence. c. preventing defamation of the patient's character. d. supervisory liability.
ANS: A 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 technician's response was not clearly defamation. Patient abuse, not supervisory liability, is the issue.
9. A nurse at the mental health center prepares to administer a scheduled injection of haloperidol decanoate (Haldol depot injection) to a patient with schizophrenia. As the nurse swabs the site, the patient shouts, "Stop, stop! I don't want to take that medicine anymore. I hate the side effects." Select the nurse's best initial action. a. Stop the medication administration procedure and say to the patient, "Tell me more about the side effects you've been having." b. Say to the patient, "Since I've already drawn the medication in the syringe, I'm required to give it, but let's talk to the doctor about skipping next month's 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.
ANS: A 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 patient's decision and should not force the medication.
20. An individual experiences sexual dysfunction and blames it on a partner by calling the person unattractive and unromantic. Which defense mechanism is evident? a. Rationalization b. Compensation c. Introjection d. Regression
ANS: A Rationalization involves unconsciously making excuses for one's behavior, inadequacies, or feelings. Regression involves the unconscious use of a behavior from an earlier stage of emotional development. Compensation involves making up for deficits in one area by excelling in another area. Introjection is an unconscious, intense identification with another person.
19. 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: a. Reaction formation b. Repression c. Projection d. Denial
ANS: A Reaction formation is an unconscious mechanism that keeps unacceptable feelings out of awareness by using the opposite behavior. Instead of expressing hatred for the other person, the individual gives praise. Denial operates unconsciously to allow an anxiety-producing idea, feeling, or situation to be ignored. Projection involves unconsciously disowning an unacceptable idea, feeling, or behavior by attributing it to another. Repression involves unconsciously placing an idea, feeling, or event out of awareness.
26. Which comment by a person who is experiencing severe anxiety indicates the possibility of obsessive-compulsive disorder? a. "I check where my car keys are eight times." b. "My legs often feel weak and spastic." c. "I'm embarrassed to go out in public." d. "I keep reliving the car accident."
ANS: A Recurring doubt (obsessive thinking) and the need to check (compulsive behavior) suggest obsessive-compulsive disorder. The repetitive behavior is designed to decrease anxiety but fails and must be repeated. The statement, "My legs feel weak most of the time," is more in keeping with a somatoform disorder. Being embarrassed to go out in public is associated with an avoidant personality disorder. Reliving a traumatic event is associated with posttraumatic stress disorder.
4. A patient with a high level of motor activity runs from chair to chair and cries, "They're coming! They're coming!" The patient does not follow the staff's directions or respond to verbal interventions. The initial nursing intervention of highest priority is to: a. provide for patient safety. b. increase environmental stimuli. c. respect the patient's personal space. d. encourage the clarification of feelings.
ANS: A Safety is of highest priority; the patient who is experiencing panic is at high risk for self-injury related to an increase in non-goal-directed motor activity, distorted perceptions, and disordered thoughts. The goal should be to decrease the environmental stimuli. Respecting the patient's personal space is a lower priority than safety. The clarification of feelings cannot take place until the level of anxiety is lowered.
22. A student says, "Before taking a test, I feel a heightened sense of awareness and restlessness." The nursing intervention most suitable for assisting the student is to: a. Explain that the symptoms are the result of mild anxiety, and discuss the helpful aspects. b. Advise the student to discuss this experience with a health care provider. c. Encourage the student to begin antioxidant vitamin supplements. d. Listen without comment.
ANS: A Teaching about the symptoms of anxiety, their relation to precipitating stressors, and, in this case, the positive effects of anxiety serves to reassure the patient. Advising the patient to discuss the experience with a health care provider implies that the patient has a serious problem. Listening without comment will do no harm but deprives the patient of health teaching. Antioxidant vitamin supplements are not useful in this scenario.
8. 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.
ANS: A The patient has the right to have a treatment plan. Inspecting a patient's 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.
15. 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. "That's 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."
ANS: A 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 family's erroneous belief. The provisions mentioned in the third and fourth options are not part of this or any other statute governing psychiatric care.
9. Which principle takes priority for the psychiatric inpatient staff when addressing behavioral crises? a. Resolve behavioral crises with 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 the opportunities to regain control without intervention if the safety of other patients is not compromised.
ANS: A The rule of using the least restrictive treatment or intervention possible to achieve the desired outcome is the patient's legal right. Planned interventions are nearly always preferable. Intervention may be necessary when the patient threatens harm to self.
25. A person who has been unable to leave home for more than a week because of severe anxiety says, "I know it does not make sense, but I just can't bring myself to leave my apartment alone." Which nursing intervention is appropriate? a. Teach the person to use positive self-talk. b. Assist the person to apply for disability benefits. c. Ask the person to explain why the fear is so disabling. d. Advise the person to accept the situation and use a companion.
ANS: A This intervention, a form of cognitive restructuring, replaces negative thoughts such as "I can't leave my apartment" with positive thoughts such as "I can control my anxiety." This technique helps the patient gain mastery over the symptoms. The other options reinforce the sick role.
3. 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 determined. 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 patient's need for placement outside the home will be undertaken.
ANS: A 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 postdischarge living arrangements. Neuroimaging is not indicated for this scenario.
20. Which employer's 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
ANS: A 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.
3. 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 patient's care because of concerns about countertransference.
ANS: A, B 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 patient's care because of concerns about countertransference demonstrates self-awareness.
17. _______________________ is a diffuse apprehension that is vague in nature and is associated with feelings of uncertainty and helplessness.
ANS: Anxiety Rationale: The definition of anxiety is a diffuse apprehension that is vague in nature and is associated with feelings of uncertainty and helplessness. Townsend considers this a core concept.
termination or resolution phase
The final stage in the nurse-client relationship; it begins when the client's problems are resolved and concludes when the relationship ends.
1. 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
ANS: A, B, C, E 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.
The nurse finds that the client is constantly rubbing the hands. Under which component of psychosocial assessment should the nurse document this finding?
The general assessment and motor behavior component
1. A child is placed in a foster home after being removed from parental contact because of abuse. The child is apprehensive and overreacts to environmental stimuli. The foster parents ask the nurse how to help the child. What should the nurse recommend? Select all that apply. a. Use a calm manner and low voice. b. Maintain simplicity in the environment. c. Avoid repetition in what is said to the child. d. Minimize opportunities for exercise and play. e. Explain and reinforce reality to avoid distortions.
ANS: A, B, E The child can be hypothesized to have moderate-to-severe trait (chronic) anxiety. A calm manner calms the child. A simple, structured, predictable environment is less anxiety provoking and reduces overreaction to stimuli. Calm, simple explanations that reinforce reality validate the environment. Repetition is often needed when the child is unable to concentrate because of elevated levels of anxiety. Opportunities for play and exercise should be provided as avenues to reduce anxiety. Physical movement helps channel and lower anxiety. Play also helps by allowing the child to act out concerns.
2. A community member asks a nurse, "People with mental illnesses used to go to a state hospital. Why has that changed?" Select the nurse's 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."
ANS: A, B, E The community is a less restrictive alternative than hospitals for the treatment of people with mental illness. Funding for treatment of mental illness remains largely inadequate but now focuses on community rather than institutional care. Antipsychotic medications improve more symptoms of mental illness; hence, management of psychiatric disorders has improved. Rates of mental illness have increased, not decreased. Hospitals were closed because funding shifted to the community. Conditions in institutions have improved.
2. A nurse plans health teaching for a patient with generalized anxiety disorder who takes lorazepam (Ativan). What information should be included? Select all that apply. a. Use caution when operating machinery. b. Allowed tyramine-free foods in diet. c. Understand the importance of caffeine restriction. d. Avoid alcohol and other sedatives. e. Take the medication on an empty stomach.
ANS: A, C, D Caffeine is a central nervous system stimulant that acts as an antagonist to the benzodiazepine lorazepam. Daily caffeine intake should be reduced to the amount contained in one cup of coffee. Benzodiazepines are sedatives, thus the importance of exercising caution when driving or using machinery and the importance of not using other central nervous system depressants such as alcohol or sedatives to avoid potentiation. Benzodiazepines do not require a special diet. Food will reduce gastric irritation from the medication.
14. A voluntarily hospitalized patient tells the nurse, "Get me the forms for discharge against medical advice so I can leave now." What is the nurse's best initial response? a. "I can't give you those forms without your health care provider's knowledge." b. "I will get them for you, but let's talk about your decision to leave treatment." c. "Since you signed your consent for treatment, you may leave if you desire." d. "I'll get the forms for you right now and bring them to your room."
ANS: B 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 patient's 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 provider's knowledge is not true. Facilitating discharge without consent is not in the patient's best interest before exploring the reason for the request.
10. A nurse encourages an anxious patient to talk about feelings and concerns. What is the rationale for this intervention? a. Offering hope allays and defuses the patient's anxiety. b. Concerns stated aloud become less overwhelming and help problem solving to begin. c. Anxiety is reduced by focusing on and validating what is occurring in the environment. d. Encouraging patients to explore alternatives increases the sense of control and lessens anxiety.
ANS: B All principles listed are valid, but the only rationale directly related to the intervention of assisting the patient to talk about feelings and concerns is the one that states that concerns spoken aloud become less overwhelming and help problem solving to begin.
21. 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 patient's health care provider.
ANS: B 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 patient's health care provider would be unnecessary. Accessing the record and documenting the information would be unnecessary when the charge nurse can resolve the problem.
30. A patient performs ritualistic hand washing. What should the nurse do to help the patient develop more effective coping strategies? a. Allow the patient to set a hand-washing schedule. b. Encourage the patient to participate in social activities. c. Encourage the patient to discuss hand-washing routines. d. Focus on the patient's symptoms rather than on the patient.
ANS: B Because patients with obsessive-compulsive disorder become overly involved in rituals, promoting involvement with other people and activities is necessary to improve the patient's coping strategies. Daily activities prevent the constant focus on anxiety and its symptoms. The other interventions focus on the compulsive symptom.
36. A patient tells the nurse, "I wanted my health care provider to prescribe diazepam (Valium) for my anxiety disorder, but buspirone (BuSpar) was prescribed instead. Why?" The nurse's reply should be based on the knowledge that buspirone: a. Does not produce blood dyscrasias. b. Does not cause dependence. c. Can be administered as needed. d. Is faster acting than diazepam.
ANS: B Buspirone is considered effective in the long-term management of anxiety because it is not habituating. Because it is long acting, buspirone is not valuable as an as-needed or as a fast-acting medication. The fact that buspirone does not produce blood dyscrasias is less relevant in the decision to prescribe buspirone.
7. Which nursing intervention demonstrates false imprisonment? a. A confused and combative patient says, "I'm getting out of here and no one can stop me." The nurse restrains this patient without a health care provider's 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 you'll 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.
ANS: B 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 distracter is not competent, and the nurse is acting beneficently. The patients in the other distracters have been admitted as involuntary patients and should not be allowed to leave without permission of the treatment team.
13. 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.
ANS: B 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.
16. A patient experiences an episode of severe anxiety. Of these medications in the patient's medical record, which is most appropriate to administer as an as-needed (prn) anxiolytic medication? a. buspirone (BuSpar) b. lorazepam (Ativan) c. amitriptyline (Elavil) d. desipramine (Norpramin)
ANS: B Lorazepam is a benzodiazepine medication used to treat anxiety; it may be administered as needed. Buspirone is long acting and not useful as an as-needed drug. Amitriptyline and desipramine are tricyclic antidepressants and considered second- or third-line agents.
8. A patient with a mass in the left upper lobe of the lung is scheduled for a biopsy. The patient has difficulty understanding the nurse's comments and asks, "What do you mean? What are they going to do?" Assessment findings include a tremulous voice, respirations at 28 breaths per minute, and a pulse rate at 110 beats per minute. What is the patient's level of anxiety? a. Mild b. Moderate c. Severe d. Panic
ANS: B Moderate anxiety causes the individual to grasp less information and reduces his or her problem-solving ability to a less-than-optimal level. Mild anxiety heightens attention and enhances problem-solving abilities. Severe anxiety causes great reduction in the perceptual field. Panic-level anxiety results in disorganized behavior.
9. A patient who is preparing for surgery has moderate anxiety and is unable to understand preoperative information. Which nursing intervention is appropriate? a. Reassure the patient that all nurses are skilled in providing postoperative care. b. Describe the procedure again in a calm manner using simple language. c. Tell the patient that the staff is prepared to promote recovery. d. Encourage the patient to express feelings to his or her family.
ANS: B Providing information in a calm, simple manner helps the patient grasp the important facts. Introducing extraneous topics as described in the remaining options will further scatter the patient's attention.
17. A community psychiatric nurse assesses that a patient 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 nurse's assessment while preserving the patient's 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.
ANS: B 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, this referral would be useless. The remaining options may produce unreliable information, violate the patient's privacy, and waste scarce resources.
6. A nurse's neighbor asks, "Why aren't people with mental illness kept in state institutions anymore?" What is the nurse's 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."
ANS: B 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.
20. A patient with paranoid 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 patient's confidentiality. d. avoided charges of malpractice.
ANS: B 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.
2. A patient approaches the nurse and impatiently blurts out, "You've got to help me! Something terrible is happening. My heart is pounding." The nurse responds, "It's almost time for visiting hours. Let's get your hair combed." Which approach has the nurse used? a. Distracting technique to lower anxiety b. Bringing up an irrelevant topic c. Responding to physical needs d. Addressing false cognitions
ANS: B The nurse has closed off patient-centered communication. The introduction of an irrelevant topic makes the nurse feel better. The nurse is uncomfortable dealing with the patient's severe anxiety.
12. A patient with schizophrenia has been stable in the community. Today, the spouse reports the patient is delusional and explosive. The patient says, "I'm 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. Patient's 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.
ANS: B The nurse should use the patient's 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.
10. 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 external manner c. Ability to cross service systems d. Knowledge of psychopharmacology
ANS: C 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.
11. 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 nurse's 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 patient's weight; determine the foods and amounts eaten. d. Seek hospitalization for the patient while a new plan is being formulated.
ANS: C 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.
27. When alprazolam (Xanax) is prescribed for acute anxiety, health teaching should include instructions to: a. Report drowsiness. b. Eat a tyramine-free diet. c. Avoid alcoholic beverages. d. Adjust dose and frequency based on anxiety level.
ANS: C Drinking alcohol or taking other anxiolytic medications along with the prescribed benzodiazepine should be avoided because depressant effects of both drugs will be potentiated. Tyramine-free diets are necessary only with monoamine oxidase inhibitors (MAOIs). Drowsiness is an expected effect and needs to be reported only if it is excessive. Patients should be taught not to deviate from the prescribed dose and schedule for administration.
31. For a patient experiencing panic, which nursing intervention should be first? a. Teach relaxation techniques. b. Administer an anxiolytic medication. c. Provide calm, brief, directive communication. d. Gather a show of force in preparation for gaining physical control.
ANS: C Calm, brief, directive verbal interaction can help the patient gain control of the overwhelming feelings and impulses related to anxiety. Patients experiencing panic-level anxiety are unable to focus on reality; thus learning relaxation techniques is virtually impossible. Administering an anxiolytic medication should be considered if providing calm, brief, directive communication is ineffective. Although the patient is disorganized, violence may not be imminent, ruling out the intervention of preparing for physical control until other less-restrictive measures are proven ineffective.
15. 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: a. denial. b. projection. c. idealization. d. compensation.
ANS: C Idealization is an unconscious process that occurs when an individual attributes exaggerated positive qualities to another. Denial is an unconscious process that calls for the nurse to ignore the existence of the situation. Projection operates unconsciously and results in blaming behavior. Compensation results in the nurse unconsciously attempting to make up for a perceived weakness by emphasizing a strong point.
3. A patient who is experiencing moderate anxiety says, "I feel undone." An appropriate response for the nurse would be: a. "Why do you suppose you are feeling anxious?" b. "What would you like me to do to help you?" c. "I'm not sure I understand. Give me an example." d. "You must get your feelings under control before we can continue."
ANS: C Increased anxiety results in scattered thoughts and an inability to articulate clearly. Clarification helps the patient identify his or her thoughts and feelings. Asking the patient why he or she feels anxious is nontherapeutic, and the patient will not likely have an answer. The patient may be unable to determine what he or she would like the nurse to do to help. Telling the patient to get his or her feelings under control is a directive the patient is probably unable to accomplish.
8. A patient should be considered for involuntary commitment for psychiatric care when he or she: a. is noncompliant with the treatment regimen. b. sold sells and distributes illegal drugs. c. threatens to harm self and others. d. fraudulently files for bankruptcy.
ANS: C 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.
29. A patient has the nursing diagnosis: Anxiety, related to __________, as evidenced by an inability to control compulsive cleaning. Which phrase correctly completes the etiologic portion of the diagnosis? a. Ensuring the health of household members b. Attempting to avoid interactions with others c. Having persistent thoughts about bacteria, germs, and dirt d. Needing approval for cleanliness from friends and family
ANS: C Many compulsive rituals accompany obsessive thoughts. The patient uses these rituals to relief anxiety. Unfortunately, the anxiety relief is short lived, and the patient must frequently repeat the ritual. The other options are unrelated to the dynamics of compulsive behavior.
3. 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.
ANS: C 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 patient's autonomy. The principle by which the nurse is motivated is beneficence, not justice. The tort represented is false imprisonment, not battery.
14. 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? a. Introjection b. Conversion c. Projection d. Splitting
ANS: C Projection is the hallmark of blaming, scapegoating, thinking prejudicially, and stigmatizing others. Conversion involves the unconscious transformation of anxiety into a physical symptom. Introjection involves intense, unconscious identification with another person. Splitting is the inability to integrate the positive and negative qualities of oneself or others into a cohesive image.
23. If a cruel and abusive person rationalizes this behavior, which comment is most characteristic of this person? a. "I don't know why it happens." b. "I have poor impulse control." c. "That person shouldn't have provoked me." d. "I'm really a coward who is afraid of being hurt."
ANS: C Rationalization consists of justifying one's unacceptable behavior by developing explanations that satisfy the teller and attempt to satisfy the listener. The abuser is suggesting that the abuse is not his or her fault; it would not have occurred except for the provocation by the other person.
18. A patient hurriedly tells the community mental health nurse, "Everything's a disaster! I can't concentrate. My disability check didn't come. My roommate moved out, and I can't afford the rent. My therapist is moving away. I feel like I'm 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
ANS: C 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, ethical conflicts around treatment causing Spiritual distress, or Impaired environmental interpretation syndrome.
32. Which finding indicates that a patient with moderate-to-severe anxiety has successfully lowered the anxiety level to mild? The patient: a. Asks, "What's the matter with me?" b. Stays in a room alone and paces rapidly. c. Can concentrate on what the nurse is saying. d. States, "I don't want anything to eat. My stomach is upset."
ANS: C The ability to concentrate and attend to reality is increased slightly in mild anxiety and decreased in moderate-, severe-, and panic-level anxiety. Patients with high levels of anxiety often ask, "What's the matter with me?" Staying in a room alone and pacing suggest moderate anxiety. Expressing a lack of hunger is not necessarily a criterion for evaluating anxiety.
2. 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 patient's discharge from the hospital. b. contact the landlord who evicted the patient to further 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.
ANS: C 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.
33. A patient tells the nurse, "I don't go to restaurants because people might laugh at the way I eat or I could spill food and be laughed at." The nurse assesses this behavior as consistent with: a. Acrophobia b. Agoraphobia c. Social phobia d. Posttraumatic stress disorder
ANS: C The fear of a potentially embarrassing situation represents a social phobia. Acrophobia is the fear of heights. Agoraphobia is the fear of a place in the environment. Posttraumatic stress disorder is associated with a major traumatic event.
7. A student nurse prepares to administer oral medications to a patient with major depression, but the patient refuses the medication. The student nurse should: a. tell the patient, "I'll get an unsatisfactory grade if I don't give you the medication." b. tell the patient, "Refusing your medication is not permitted. You are required to take it." c. explore the patient's concerns about the medication, and report to the staff nurse. d. document the patient's refusal of the medication without further comment.
ANS: C The patient has the right to refuse medication in most cases. The patient's 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.
13. A person has minor physical injuries after an automobile accident. The person is unable to focus and says, "I feel like something awful is going to happen." This person has nausea, dizziness, tachycardia, and hyperventilation. What is this person's level of anxiety? a. Mild b. Moderate c. Severe d. Panic
ANS: C The person whose anxiety is severe is unable to solve problems and may have a poor grasp of what is happening in the environment. Somatic symptoms such as those described are usually present. The individual with mild anxiety is only mildly uncomfortable and may even find his or her performance enhanced. The individual with moderate anxiety grasps less information about a situation and has some difficulty with problem solving. The individual in a panic level of anxiety demonstrates significantly disturbed behavior and may lose touch with reality.
16. 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.
ANS: C 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.
2. 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.
ANS: C, D 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.
During a conversation, the client states, "It's raining outside and raining in my heart. Did you know that St. Valentine used to visit jails? I've never been to jail." The nurse can correctly identify this thought process as what?
Flight of ideas
3. Which assessment questions are most appropriate to ask a patient with possible obsessive-compulsive disorder? Select all that apply. a. "Have you been a victim of a crime or seen someone badly injured or killed?" b. "Are there certain social situations that cause you to feel especially uncomfortable?" c. "Do you have to do things in a certain way to feel comfortable?" d. "Is it difficult to keep certain thoughts out of awareness?" e. "Do you do certain things over and over again?"
ANS: C, D, E The correct questions refer to obsessive thinking and compulsive behaviors. The incorrect responses are more pertinent to a patient with suspected posttraumatic stress disorder or with suspected social phobia.
1. 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 (fourth edition, text revision) (DSM-IV-TR) b. State's 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 Psychiatric-Mental Health Nursing Practice
ANS: C, E 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-IV-TR and the state's 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.
6. 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: a. acting out. b. projection. c. rationalization. d. passive aggression.
ANS: D A passive-aggressive person deals with emotional conflict by indirectly expressing aggression toward others. Compliance on the surface masks covert resistance. Resistance is expressed through procrastination, inefficiency, and stubbornness in response to assigned tasks.
5. 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 patient's admission. b. An advanced practice nurse recommends that a patient who is dangerous to self and others be voluntarily hospitalized. c. A patient's admission status is changed from involuntary to voluntary after the patient's hallucinations subside. d. A nurse gives an as-needed dose of an antipsychotic drug to a patient to prevent violent acting-out because a unit is short staffed.
ANS: D 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.
6. 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. experiencing dry mouth and tremor related to side effects of haloperidol (Haldol). b. experiencing anxiety and a sad mood after a separation from a spouse of 10 years. c. who self-inflicted a superficial cut on the forearm after a family argument. d. who is a single parent and hears voices saying, "Smother your infant."
ANS: D 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.
11. 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
ANS: D 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.
1. 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.
ANS: D Autonomy is the right to self-determination, that is, to make one's 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.
13. An adolescent hospitalized after a violent physical outburst tells the nurse, "I'm going to kill my father, but you can't tell anyone." Select the nurse's best response. a. "You're 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 obligated to share information with the treatment team."
ANS: D Breach of nurse-patient confidentiality does not pose a legal dilemma for nurses in these circumstances 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.
34. A patient checks and rechecks electrical cords related to an obsessive thought that the house may burn down. The nurse and patient explore the likelihood of an actual fire. The patient states that a house fire is not likely. This counseling demonstrates the principles of: a. Flooding b. Desensitization c. Relaxation technique d. Cognitive restructuring
ANS: D Cognitive restructuring involves the patient in testing automatic thoughts and drawing new conclusions. Desensitization involves a graduated exposure to a feared object. Relaxation training teaches the patient to produce the opposite of the stress response. Flooding exposes the patient to a large amount of undesirable stimuli in an effort to extinguish the anxiety response.
18. A person who feels unattractive repeatedly says, "Although I'm not beautiful, I am smart." This is an example of: a. Repression b. Devaluation c. Identification d. Compensation
ANS: D 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. Repression unconsciously puts an idea, event, or feeling out of awareness. Identification is an unconscious mechanism calling for an imitation of the mannerisms or behaviors of another. Devaluation occurs when the individual attributes negative qualities to self or to others.
7. 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, has lost 15 pounds, and is easily fatigued. Which defense mechanism is the patient using? a. Displacement b. Regression c. Projection d. Denial
ANS: D Denial is an unconscious blocking of threatening or painful information or feelings. Regression involves using behaviors appropriate at an earlier stage of psychosexual development. Displacement shifts feelings to a more neutral person or object. Projection attributes one's own unacceptable thoughts or feelings to another.
21. A student says, "Before taking a test, I feel a heightened sense of awareness and restlessness." The nurse can correctly assess the student's experience as: a. Culturally influenced b. Displacement c. Trait anxiety d. Mild anxiety
ANS: D Mild anxiety is rarely obstructive to the task at hand. It may be helpful to the patient because it promotes study and increases awareness of the nuances of questions. The incorrect responses have different symptoms.
A 20-year-old client who has a diagnosis of schizophrenia frequently experiences delusions of persecution. At the prompting of the client's mother, the nurse attempts to determine the character and severity of these delusions on a particular day. In doing so, the nurse is conducting what type of assessment?
Focused
4. The relapse of a patient with schizophrenia is related to medication noncompliance. The patient is hospitalized for 5 days, medication is restarted, and the patient's thoughts are now more organized. The patient's family members are upset and say, "It's too soon about the patient being scheduled 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.
ANS: D Patients no longer stay in the hospital until every vestige of a symptom disappears. The nurse must assume responsibility to advocate for the patient's 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.
15. Which assessment finding for a patient 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.
ANS: D 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.
11. Which assessment question would be most appropriate to ask a patient who has possible generalized anxiety disorder? a. "Have you been a victim of a crime or seen someone badly injured or killed?" b. "Do you feel especially uncomfortable in social situations involving people?" c. "Do you repeatedly do certain things over and over again?" d. "Do you find it difficult to control your worrying?"
ANS: D Patients with generalized anxiety disorder frequently engage in excessive worrying. They are less likely to engage in ritualistic behavior, fear social situations, or have been involved in a highly traumatic event.
14. 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 patient's neighborhood c. Level of trust between the patient and the nurse d. Availability of transportation to the clinic
ANS: D 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.
23. Which documentation of a patient's behavior best demonstrates a nurse's 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."
ANS: D The documentation states specific observations of the patient's appearance and the exact statements made. The other options are vague or subjective statements and can be interpreted in different ways.
19. A nurse cares for an older adult patient admitted for the 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.
ANS: D 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 nurse's 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.
18. 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 patient's 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.
ANS: D The duty to warn a person whose life has been threatened by a patient under psychiatric treatment overrides the patient's right to confidentiality. The right to confidentiality is not suspended at the discretion of the therapist or for legal investigations.
4. In a team meeting a nurse says, "I'm 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
ANS: D 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 one's own decisions. Fidelity is the observance of loyalty and commitment to the patient.
Therapeutic Relationship
Focuses on needs, experiences, feelings & ideas of the client ONLY.
Behaviorism
Focuses on observable behaviors and what one can do externally to bring about behavior changes.
12. An example of a breach of a patient's right to privacy occurs when a nurse: a. asks a family to share information about a patient's prehospitalization behavior. b. discusses the patient's history with other staff members during care planning. c. documents the patient's daily behaviors during hospitalization. d. releases information to the patient's employer without consent.
ANS: D The release of information without patient authorization violates the patient's right to privacy. The other options are acceptable nursing practices.
24. A patient with severe anxiety suddenly begins running and shouting, "I'm going to explode!" The nurse should: a. Ask, "I'm not sure what you mean. Give me an example." b. Chase after the patient, and give instructions to stop running. c. Capture the patient in a basket-hold to increase feelings of control. d. Assemble several staff members and state, "We will help you regain control."
ANS: D The safety needs of the patient and other patients are a priority. The patient is less likely to cause self-harm or hurt others when several staff members take responsibility for providing limits. The explanation given to the patient should be simple and neutral. Simply being told that others can help provide the control that has been lost may be sufficient to help the patient regain control. Running after the patient will increase the patient's anxiety. More than one staff member is needed to provide physical limits if they become necessary. Asking the patient to give an example is futile; a patient in panic processes information poorly.
19. 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, "I'm not sure I can avoid using alcohol when my spouse goes to work every morning."
ANS: D 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.
18. _______________________ is a subjective state of emotional, physical, and social responses to the loss of a valued entity.
ANS: Grief Rationale: The definition of grief is a subjective state of emotional, physical, and social responses to the loss of a valued entity. Townsend considers this a core concept.
21. A branch of philosophy that addresses methods for determining the rightness or wrongness of one's actions is defined as _______________________.
ANS: ethics Rationale: Ethics is a branch of philosophy that deals with systematic approaches to distinguishing right from wrong behavior. Bioethics is the term applied to these principles when they refer to concepts within the scope of medicine, nursing, and allied health.
20. A valid, legally recognized claim or entitlement, encompassing both freedom from government interference or discriminatory treatment and an entitlement to a benefit or a service is defined as a _______________________.
ANS: right Rationale: A right is a valid, legally recognized claim or entitlement, encompassing both freedom from government interference or discriminatory treatment and an entitlement to a benefit or a service. A right is absolute when there is no restriction whatsoever on the individual's entitlement.
Asking the client to complete serial sevens assesses what?
Ability to concentrate
values
Abstract standards that give a person a sense of right and wrong and establish a code of conduct for living
If the client provides a literal explanation of a proverb and cannot interpret its meaning, which thought process is lacking?
Abstract thinking
What does the saying "A rolling stone gathers no moss" mean to you?
Abstract thinking ability
When communicating with a client in the triggering phase of the aggression cycle, which intervention should the nurse include?
Allow the client to take a "time out" in a quiet area
Which describes a strong emotional response to a real or perceived provocation?
Anger
The nurse is teaching a group of clients in a juvenile detention center about anger management and the positive effects of anger, if handled appropriately. What advantages, as explained by the nurse, may be helpful to the clients? Select all that apply.
Anger helps to focus attention. Anger helps in decision making. Anger helps in resolving conflicts.
The primary goal of de-escalation is to resolve which that can happen on an inpatient unit?
Angry conflicts
aesthetic knowing
Art of nursing Although the pt shows outward signals now, the nurse has sensed previously the pt's jumpiness and subtle differences in the pt's demeanor and behavior.
Seclusion and restraint are nursing interventions to be used for an individual in which situation?
As a last resort
A client is being admitted to an inpatient setting. It is important for the nurse to first obtain which information about the client?
Assessment of history
Hospitals established by Dorothea Dix were designed to provide which of the following?
Asylum
A nurse is working in a psychiatric-mental health facility. The nurse observes a client pacing and punching the wall. Which measure can the nurse take for personal safety?
Avoid being alone with the client.
Acceptance
Avoiding judgements of the person no matter what the behavior, being clear without judgement the nurse allows client to feel intact while conveying certain behavior is unacceptable
acceptance
Avoiding judgments of the person, no matter what the behaviors. Nurse does not become upset or respond negatively to a pt outbursts, anger or acting out.
Even though the client has an active participant, the nurse me assume the role of the counselor and the facilitator to help the client examine problems and to gain insight on achieving solutions. Choose the option that describes his working phase of the nurse - client relationship. A. The nurse assist the client to have a more positive self image B. The client identifies issues or concerns C. The nurse assist the client to develop better coping skills D. The nurse guide the client to examine feelings
B. The client identifies issues or concerns
Neurobiologic factors are increasingly being explored as an explanation for aggressive behavior. Which is true?
Brain neuroimaging studies show that aggressive behavior is linked to damage of brain structures located in the limbic, frontal, and temporal lobes.
Which role of the nurse client relationship is being exhibited when the nurse informs the client and then supports him or her and whatever decision he or she makes? A. Caregiver B. advocate C. Parent surrogate D. Teacher
B. advocate
The following our terms used in the art of therapeutic communication between nurses and mental health clients. However which of the following is not considered a step in the values clarification process? A. Choosing B. assessing C. Acting D. Pricing
B. assessing
There were seven student nurses on the psychiatric unit. Mr. P. with a client admitted the diagnosis of paranoid schizophrenia. He had not spoken to anyone in the previous three days of his stay. The students were assigned to engage the clients and therapeutic conversation. Which of the following relationships would be a factor that would encourage Mr. P. To communicate with the student nurses? A. Intimacy B. genuine interest C. Unclear boundaries D. Abuse of power
B. genuine interest
The student nurses are taught that they should have an unconditional and non-judge mental attitude and the relationship with mental health clients. The students are expected to call the client by name and spend time with the client. These actions are examples of which of the following? A. Value B. positive regard C. Empathy D. Excepting
B. positive regard
The mental health psychiatric nurse uses therapeutic use of self while interacting with mentally L clients. So if disclosure is one technique used to convey support, educate clients, and demonstrate any clients anxiety is normal and that many people deal with stress and problems in their own lives. Which of the following actions will the nurse use the technique of self-disclosure? A. To shift the focus from the client to the nurse B. to meet therapeutic goals C. To meet personal goals D. To initiate conversation
B. to meet therapeutic goals
The nursing only establish a therapeutic relationship with the client when he or she believes that the nurse will be consistent in words and actions and can't be relied upon to do what here she says. Which of the following is gained when the nurse successfully establishes this type of relationship with the client? A. Empathy B. Trust C. Genuine interest D. Congruence
B. trust
Orientation
Begins when a client meet and ends when the client begins to identify problems to examine Nurse establishes roles, purpose of meeting, & parameters of subsequent meetings; identifies the clients problems and clarifies expectations. Nurse begins to build trust and understanding
Termination (resolution phase)
Begins when problems are resolved and it ends when relationships are ended.
Therapeutic use of Self
By developing self awareness the nurse can use aspects of their own personality, experience, values, feelings, coping skills, perceptions to establish relationships with clients.
When the mental health nurse asks the client, "Do you recall what month and year this is?" the nurse is assessing which part of the mental status examination?
Orientation
Phases of a therapeutic relationship
Orientation Working Termination
The student nurses are talking about a client on the psychiatric unit he looks like the actor George Clooney. During the hours spent with the client, one of the students become physically attracted to him. Which of the following terms describes the relationship that has occurred when the nurse response the client based on personal unconscious needs and conflicts? A. Self-disclosure B. transference C. Countertransference D. Exploitation
C. Countertransference
During which phase of the therapeutic relationship doesn't become the nurses responsibility to define the boundaries of the nurse client relationship? A. Working B. problem identification C. Orientation D. Termination
C. Orientation
Which term is used to describe an activity used to release anger?
Catharsis
Which must be addressed to establish a trusting working relationship before proceeding with the assessment?
Client's feelings and perceptions
The nurse is preparing a psychosocial assessment for use with clients with various mental health conditions. For which group of clients should the nurse include mostly closed-ended questions?
Clients with adult attention deficit hyperactivity disorder
The nurse performs an assessment of a client who presents with symptoms of mental illness for the first time. Which is the nurse's priority?
Collect comprehensive data
A nurse is assessing a hospitalized client who is hearing voices due to psychosis. The client is easily distracted, and this is creating a barrier to completing the assessment. What is the most effective way for the nurse to proceed?
Complete the assessment in several short interactions.
A nurse is assessing a Haitian client. The caregiver of the client tells the nurse that the client is having an episode of Bouffée delirante. What symptoms would the nurse expect to find in this client? Select all that apply.
Confusion Hallucinations Extreme aggression
The nurse is caring for a client who has recently developed psychomotor retardation. Based on this information, which behavior would the nurse expect to see in this client?
Slowness of body movements
The nurse is looking to assess the client's ability to concentrate. Which task should the nurse ask the client to perform
Spell "America" backward.
Self-awareness is an important concept in the psychiatric - mental health nursing. The nurses must always be aware of their feelings regarding the clients behaviors. Which of the following would be a barrier to the nurse client relationship? A. Trust B. Empathy C. Excepting D. Abuse of power
D. Abuse of power
Which situation is likely to have the least influence on the a child's ability to develop socially appropriate behaviors?
Spending time in foster care
The students in the concepts and theories course I talked to nursing is better than art and a science. Which pattering of knowing is derived from the art of nursing? A. Ethical B. personal knowing C. Empirical D. Aesthetic
D. Aesthetic is Derived from the art of nursing
Which of the following behaviors occurs when the nurses voice or body language it's consistent with the words he or she speaks A. Empathy B. Genuine interest C. Trust D. Congruence
D. Congruence
Kaplan's social model of behavior supports the theory that social behavior is culturally biased. Behavior that is excepted in one culture may not be excepted by another culture. Which of the following types of behavior are not accepted as part of the nurse - client relationship and the United States? A. Social B. therapeutic C. Professional D. Intimate
D. Intimate
Mr. Lopez, a client, as the preconceived stereotypical idea that all male nurses are homosexual and refuses to have Samuel, a male nurse, take care of him. Samuel has a preconceived stereotypical notion that all Hispanic men you switchblades, so he is relieved that Mr. Lopez has refused to work with him. Which of the following is an accurate statement regarding a preconception? A. It enables the nurse to get an accurate picture of the clients problems B. it allows people to get to know one another C. It provides the nurse at the opportunity to develop a therapeutic relationship with the client D. Is a way of person expects another to behave
D. The way the person expects another to behave
The nurse - client relationships that are formed in a clinical setting are formed for the purpose of helping the client to return to a more healthy state of wellness. Therefore the term used in this type of relationship is classified by the nurse as which type of relationship? A. Social B. intimate C. Friendly D. Therapeutic
D. Therapeutic
A client visits the clinic and tells the nurse that no matter how difficult the client's child acts, the client simply cannot express any anger. The nurse should plan to assess the client for symptoms of which mental health condition?
Depression
A nurse is preparing a presentation for a group of staff nurses on anger. When describing maladaptive anger, which psychiatric condition would the nurse identify as being linked to this anger?
Depression
A nurse is beginning the process of providing therapy to a client with anger management problems. When implementing this therapy, which should occur first to promote optimal effectiveness?
Development of a therapeutic relationship
While working in a psychiatric-mental health facility, the nurse notices a client pacing back and forth and becoming increasingly agitated. Which is a critical step in communicating with the client to prevent the escalation of aggressive behavior?
Discover the source of the distress.
patterns of knowing
Empirical knowing - science of nursing Personal knowing - life experience Ethical knowing - moral knowledge of nursing Aesthetic knowing - art of nursing
Patterns of knowing
Empirical, personal, ethical. aesthetic
Which staff behaviors are most likely to trigger clients who are predisposed to aggressive or violent behavior?
Engaging in disputes over medication, supplies, or rules on the unit
Which is the most effective way in which the nurse can assess the progress of a client's mental status based on the expected outcome of the therapeutic plan?
Evaluation
A nurse has been asked to complete a mental status examination of a psychiatric-mental health client. Which is a necessary component of this assessment?
Evaluation of insight and judgment
Provide three different concerns nursing students might have as they begin psychiatric nursing clinical experiences.
Examples of fears include saying the wrong thing, not knowing what to do, being rejected by clients, handling bizarre or inappropriate behavior, maintaining physical safety, and seeing a friend or acquaintance as a client.
A nurse assesses a newly admitted client on the unit. When assessing the client in detail about his/her past medical history, it is important for the nurse to also explore which information about the client?
Experience of health problems and health professionals
A nurse is leading an anger management group in the inpatient program. A client says, "I'm feeling really tense, and I'm fidgety today." What is the nurse's most appropriate response to the client's comment?
Explore what is underlying the client's physical and emotional state
The nurse is caring for a client with depression. The client has an anger episode. What are the possible behaviors expected in this client during and immediately following the episode? Select all that apply.
Expresses anger verbally. Feels guilty for inappropriate anger reaction.
Assessment data about the client's speech patterns are categorized in which of the following areas?
General appearance and motor behavior
attitudes
General feeling or a frame of reference around which a person organizes knowledge about the world.
Attitudes
General feelings or a frame of reference around which a person organizes knowledge about the world
How should the nurse approach the crying client? What should the nurse say and do?
Give positive feedback for coming to the clinic to get help. 1. Tell her it is all right to cry. 2. Tell the client that the nurse will sit with her until she's ready to talk. 3. Validate the client's feelings (i.e., "I can see you're very upset").
The nurse is assessing a client who is aggressive. Which safety measures must the nurse ensure are in place prior to continuing the assessment? Select all that apply.
Give the client plenty of space. Sit in an open area Request the presence of additional staff.
Which term is used to describe an emotion expressed through verbal abuse and violation of rules or norms?
Hostility
A psychiatric-mental health client informs the nurse that a tornado that hit a neighboring town was the client's fault because the client dislikes a neighbor. This disturbance of thought content is known as what?
Ideas of reference
Beliefs
Ideas that one holds to be true
beliefs
Ideas that one holds to be true. All old people are hard of hearing.
working phase
In the therapeutic relationship, the phase where issues are addressed, problems identifies, and solutions explored; nurse and client work to accomplish goals; contains Peplau's phases of problem identification and exploitation.
State nurse practice act
Include legal responsibility to report boundary violations and unethical conduct on the part of other health-care providers
A mental health nurse is caring for a client with schizophrenia. The nurse observes the client laughing about the recent death of the client's father. The nurse would correctly document this mood as what?
Incongruent
A psychiatric-mental health nurse is feeling highly anxious before conducting an interview with a client. The nurse's experience of anxiety will impact the client assessment in which way?
It will be detrimental to the interaction by decreasing the nurse's focus and attention.
If you were lost downtown, what would you do?
Judgment
personal knowing
Life experience Pt's face shows the panic
A client with psychosis who was recently admitted to a psychiatric unit says to the nurse, "The car is red. Are you ready for lunch? My head is hurting. Dogs bark loud." The client is exhibiting which type of speech?
Loose associations
As the nurse is conducting an interview with a client with a diagnosis of schizophrenia, the client states, "Bunnies are cute as a button, buttons are on my shirt, shirts can be bought in a store." Which is a term used to describe this thought process?
Loose associations
A client with aggressive behavior shows no psychotic symptoms. Which medication should the nurse expect to be ordered for this client?
Lorazepam
A nurse must assess for characteristics that are predictive of violent behavior. Research suggests violent behavior is influenced by possession of which attribute?
Low self-esteem
Ethical knowing
Moral knowledge of nursing Although the nurse's shift has ended, he or she remains with the pt.
A nurse is conducting an interview with a psychiatric-mental health client and notices the client is using made-up words. This is known as what?
Neologisms
Positive Regard
Nurse who appreciates the clients as a unique worth-while human being can respect the client regardless of his or her behavior, background, lifestyle and IMPLIES RESPECT - Calling pt by name, spending time with them, and listening + responding to pt all imply positive regard
therapeutic use of self
Nurses us themselves as a therapeutic tool to establish the therapeutic relationship with clients and help clients grow, change, and heal.
When determining a client's potential for aggression and violence prior to engaging in a detailed psychosocial assessment, which would be most important for the nurse to do?
Obtain a thorough client history
transference
Occurs when the client displaces onto the therapist attitudes and feelings that the client originally experiences in other relationships; it is common for the client to unconsciously transfer to the nurse feelings he or she has for significant others.
countertransference
Occurs when the therapist displaces onto the client attitudes or feeling from his or her past; process that can occur when the nurse responds to the client based on personal, unconscious needs and conflicts.
Congruence
Occurs when words and actions match
congruence
Occurs when words and actions match
Can you tell me today's date? (time)
Orientation
Can you tell me where you are? (place)
Orientation
Can you tell me your name? (person)
Orientation
A nurse's response to aggressive behavior on the unit is influenced by the which ability of the nurse?
Own awareness and reaction to aggression
problem identification
Part of the working phase of the nurse-client situation, when the client identifies the issues or concerns causing problems.
A nurse must assess a client's thought process and content to identify risk for aggression. The assessment of the client's thought process and content would allow the nurse to identify what?
Perceptions and delusions
exploitation
Phase of nurse-client relationship, identified by Peplau, when the nurse guides the client to examine feelings and responses and to develop better coping skills and more positive self-image; this encourages behavior change an develops independence; part of the working phase.
When assessing a client who has been referred to the outpatient mental health clinic with symptoms of depression, the psychiatric nurse should closely observe the client's affect and which assessment component?
Physical appearance
In which phase of the aggression cycle is the client removed from restraint or seclusion as soon as he or she meets the behavioral criteria?
Postcrisis
Which would not be included as a purpose of the psychosocial assessment?
Previous compliance with treatment regimen
The nurse is assessing a group of clients on an inpatient psychiatric unit. The nurse determines that a client most likely to be violent has what?
Previous episodes of rage
social relationship
Primarily initiated for the purpose of friendship, socialization, companionship, or accomplishment of a task
Self-awareness
Process of developing an understanding of one's own values, beliefs, thoughts, feelings, attitudes, motivations, prejudice, strengths and limitations & how these qualities affect others - allows nurse to understand responses and reactions of clients when interacting with them
The nurse has been working on anger management with the client. The client yells during dinner, "Give me that salt shaker!" What is the best nursing intervention at this time?
Remind the client about communication skills discussed earlier
To assess the client's ability to concentrate, the nurse would instruct the client to do which of the following?
Repeat the days of the week backward.
Confidentiality
Respecting clients right to keep private any information about his or her mental and physical health related to care
confidentialty
Respecting the client's right to keep private any information about his or her mental and physical health and related care.
Self-Disclosure
Revealing personal information such as biographical info, personal ideas thoughts and feelings about one self to clients
empirical knowing
Science of nursing Pt with panic disorder begins to have an attack. Panic attack will raise pulse rate.
A client is diagnosed with intermittent explosive disorder. The nurse understands that this disorder is associated with which neurotransmitter?
Serotonin
The nurse is caring for a client hospitalized in an inpatient psychiatric setting for a history of violent behaviors and delusions. The nurse should instruct the client's family that aggression has been linked to low levels of which bodily chemical?
Serotonin
An aggressive client is holding a weapon and threatening to harm other clients in the unit. How should the nurse handle this situation?
Shield oneself with a pillow
Aggression control can be measured by the nurse's observation of a client's ability to do what?
Show an increased tolerance for frustration
During an assessment, which would be the most important question topic?
Suicidal ideation
An aggressive client gets hold of a glass piece and prevents anyone from entering the room. What interventions should the nurse perform to ensure safety of the client, staff, and other clients? Select all that apply.
Summon help from others Leave the area immediately Shift other clients to a safe place
The nurse is counseling a client couple who are trying to reconcile and hold their marriage together. During therapy the wife states, "He makes me so mad when he spends all his weekend time with his friends instead of us. He makes me want to hurt him back." Using concepts from assertiveness training and effective communication techniques, the nurse implements which intervention after hearing the wife's remarks?
Teach the client to make "I" statements.
If the client decided to leave the clinic before the assessment formally began, what would the nurse need to do?
Tell the client that the nurse needs to know if the client is safe (from suicidal ideas or self-harm urges). If the client is safe, she can leave the clinic. If she is not safe, the nurse must ask her to stay or must call emergency services (911) if necessary.
The nurse is performing an assessment of a client with psychiatric illness. The nurse documents that the client has a restricted affect. Which behavior of the client is indicative of restricted affect? Choose the best answer.
The client displays only one type of facial expression.
A nurse is assessing a Korean client. The caregiver of the client tells the nurse that the client had been diagnosed with Hwa-Byung by their local health care provider. What should the nurse interpret from this?
The client had health-related issues due to suppression of anger.
What, if any, assumptions might the nurse make about this client and her situation?
The client is in crisis. The client is seeking help/treatment. The client is not currently stable.
Of the following clinical information, which one would be the most important in determining whether the client would be diagnosed with a mental disorder?
The client is unable to continue school work and has been sitting on the client's bed for 3 days.
A client with a history of angry outbursts that have caused interpersonal and work problems has been in counseling for several months. The nurse judges the plan of care to be effective when which outcome is met?
The client uses adaptive coping to manage anger impulses.
During a mental status exam, what conclusion should the nurse draw when the client is able to complete fewer than half of tasks accurately?
The client's cognitive deficit is significant
The nurse has been asked to identify a location to conduct an interview with a psychiatric-mental health client. Which is an essential consideration when choosing a location?
The client's right to privacy
duty to warn
The exception to the client's right to confidentiality; when healthcare providers are legally obligated to warn another person who is the target of the threats or plan by the client, even if the threats were discussed during therapy sessions otherwise protected by confidentiality.
The nurse is assessing an older adult client with lower back pain. In the course of assessment, the nurse learns that the client lost a spouse 10 weeks ago. The client laughs inappropriately and states, "My spouse just up and left me!" Which is the nurse's best response?
The nurse should recognize the incongruity between content and behavior and find ways of exploring further.
Conscious
The perceptons, thoughts + eotions that exist in the person's awareness, such as being aware of happy feelings or thinking about a loved one
self-awareness
The process by which a person gains recognition of his or her own feelings, beliefs, and attitudes; the process of developing an understanding of one's own values, beliefs, thoughts, feelings, attitudes, motivations, prejudices, strengths, and limitations and how these qualities affect others.
advocacy
The process of acting in the client's behalf when he or she can not do so.
Unconscious
The realm of thoughts and feelings that motivate a person even though he or she is totally unaware of them - Includes most defense mechanisms and some instinctual drives or motivations
preconception
The way one person expects another to behave or speak; often a roadblock to the formation of an authentic relationship
Hildegard Peplau is best known for her writing about which of the following?
Therapeutic nurse-client relationship
genuine interest
Truly paying attention to the client, caring about what he or she is saying; only possible when the nurse is comfortable with himself or herself and aware of his or her strengths and limitations.
Parts to therapeutic relationships
Trust, genuine interest, acceptance, positive regard, self-awareness, and therapeutic use of self
To defuse a critical situation, the nurse can use the therapeutic communication techniques for which reason?
Try to clarify what has upset the client
The nurse is explaining the importance of expressing anger to a client. What should the nurse mention as the possible physical complications associated with suppressing anger? Select all that apply.
Ulcers Coronary artery disease Migraine headaches
positive regard
Unconditional nonjudgmental attitude that implies respect.
A nurse is considering using restraint and seclusion for a client who is acting out. Which is the primary guideline for the use of restraint and seclusion?
Use should be limited to emergencies in which the risk of a client physically harming self, staff, or others is imminent.
Attending
Verbal or non-verbal communication techniques to make client aware that they have full attn
unknowing
When the nurse admits she does not know the client or the client's subjective world; this opens the way for a truly authentic encounter; the nurse in a ste of unknowing is open to seeing and hearing the client's views without imposing any of his or her values or viewpoints.
Which of the following is an example of a closed-ended question?
Where are you employed?
ethics
a branch of philosophy that deals with values of human conduct related to the rightness or wrongness of actions and to the goodness and badness of the motives and ends of such actions
ethical dilemma
a situation in which ethical principles conflict or when there is no one clear course of action in a given situation
utilitarianism
a theory that bases ethical decisions on the "greatest good for the greatest number"; primary consideration is on the outcome of the decision
deontology
a theory that says ethical decisions should be based on whether or not an action is morally right with no regard for the result or consequences
malpractice
a type of negligence that refers specifically to professionals such as nurses and physicians
Existentialism
belief that behavioral deviations result when a person is out of touch with himself or herself or the environment. lack of self-awareness coupled with harsh self criticism, prevents the person from participating in satisfying relationships.
Emil Kraepelin
classification of mental disorders according to symptoms
When assessing a client's potential for aggression and violence, which would the nurse identify as the most important predictor?
client's history
A group of nurses is reviewing information about maladaptive anger. The nurses demonstrate a need for additional study when they identify which physical condition as being linked to suppressed anger?
coronary heart disease
The nurse is orienting a new staff member in an inpatient mental health unit when a client begins to act in a violent manner. The nurse should explain to the new staff member that some clients use violence and aggression to ...
have their needs met.
How should the nurse describe the mood and affect of a client who has a mask-like facial expression but states, "I'm really happy."
incongruent
When considering where to conduct a psychosocial assessment, the nurse can effectively interview which client in the unit's conference room?
the anxious client
injury or damage
the client suffered some type of loss, damage, or injury
restraint
the direct application of physical force to a person, without his or her permission, to restrict his or her freedom of movement
veracity
the duty to be honest or truthful
duty to warn
the exception to the client's right to confidentiality; when health-care providers are legally obligated to warn another person who is the target of the threats or plan by the client, even if the threats were discussed during therapy sessions otherwise protected by confidentiality
seclusion
the involuntary confinement of a person in a specially constructed, locked room equipped with a security window or camera for direct visual monitoring
breach of duty
the nurse (or physician) failed to conform to standards of care, thereby breaching or failing the existing duty; the nurse did not act as a reasonable, prudent nurse would have acted in similar circumstances
autonomy
the person's right to self-determination and independence
nonmaleficence
the requirement to do no harm to others either intentionally or unintentionally
false imprisonment
the unjustifiable detention of a client, such as the inappropriate use of restraint or seclusion
Hildegard Peplau
therapeutic nurse-client relationship
least restrictive environment
treatment appropriate to meet the client's needs with only necessary or required restrictions
