Mental Health Final Practice Questions

(11) A nurse cares for patients taking various medications, including buspirone (BuSpar), haloperidol (Haldol), carbamazepine (Tegretol), trazodone (Desyrel), and phenelzine (Nardil). The nurse will order a special diet for the patient who takes: a. buspirone. b. haloperidol. c. carbamazepine. d. trazodone. e. phenelzine.

Patients taking phenelzine, an MAO inhibitor, must be on a low tyramine diet to prevent hypertensive crisis. e. phenelzine. Acronym for MAOI drugs: "Take Pride in Shanghai" Tranylcypromine, Phenelzine, Isocarboxazid and Selegiline.

(31) As a nurse assesses an elderly patient, answers seem vague or unrelated to the questions. The patient also leans forward and frowns, listening intently to the nurse. An appropriate question for the nurse to ask would be: a. "Are you having difficulty hearing when I speak?" b. "I notice you frowning. Are you feeling annoyed with me?" c. "How can I make this assessment interview easier for you?" d. "You're having trouble focusing on what I'm saying. What is distracting you?"

a. "Are you having difficulty hearing when I speak?" The patient's behaviors may indicate difficulty hearing. Identifying any physical need the patient may have at the onset of the interview and making accommodations are important considerations.

(106) A patient with serious mental illness who has just moved into a homeless shelter tells the nurse that his "life just got out of control." He says he could not depend on others, so he kept to himself. Then he added, "I am like a leaf at the mercy of the wind." The nurse adds the nursing diagnosis of Powerlessness to his care plan. Which entry in his chart best suggests that the treatment plan is helping with this diagnosis? a. "Spent the day applying for positions at four local fast food places." b. "Playing chess with peer, went for walk earlier, no paranoia noted." c. "Hygiene adequate, no body odor noted, washed clothes on his own." d. "Patient reports that he has made friends with a peer at the group home."

a. "Spent the day applying for positions at four local fast food places." A desired outcome would be "decreased powerlessness" or "empowerment achieved," and indicators for those outcomes could include anything that suggests the patient is initiating goal-directed activities or feeling empowered. Applying for positions suggests that he feels empowered and capable. The other observations document decreased withdrawal (interacting), improved self-care (hygiene), and socialization (made friends).

(91) A 45-year-old married woman who works full time in a factory has recently been absent for 3-day periods on several occasions. Each time, she returned to work wearing dark glasses. Facial and body bruises were apparent. Her supervisor became suspicious that she was a victim of battering and referred her to the occupational health nurse. Which initial inquiry would be most important for the nurse to make? a. "Tell me what has happened to you." b. "Did your husband beat you?" c. "Why do you let this happen?" d. "What can you do to prevent this?"

a. "Tell me what has happened to you." Obtaining the victim's explanation and perception of what is happening is the most important initial focus of assessment. If the explanation does not match the injuries or the victim minimizes the injury, abuse should be suspected. Asking if her husband beat her seeks desired assessment information but in a blunt manner likely to interfere with trust and put the patient on the defensive. "Why do you let this happen?" and "What can you do to prevent this?" both imply that the patient is to blame for allowing or failing to stop the abuse.

(114) Family members ask the nurse, "What can we say when our loved one says, 'Death is coming soon?'" To promote communication, which response could the nurse suggest for family members? a. "We feel sad when we think about life without you." b. "We have not given up on getting you well." c. "We think you will be around for a long time yet." d. "Let's talk about the good memories we have."

a. "We feel sad when we think about life without you." The correct response is emotionally honest. It allows the family opportunities to express emotions, address issues in the relationship, and say farewell. The distracters are evasive.

(103) The nurse should complete the Geriatric Depression Scale as part of the assessment if an elderly patient answers which question affirmatively? a. "Would you say your mood is often low?" b. "Are you having any trouble with your memory?" c. "Have you noticed an increase in your alcohol use?" d. "Do you often experience moderate to severe pain?"

a. "Would you say your mood is often low?" Feeling low may be a symptom of depression. Low moods occurring with regularity should signal the need for further assessment for other symptoms of depression. The other options do not focus on mood.

(120) A patient states she has taken megadoses of vitamin E for 3 months to improve her circulation but thinks she feels somewhat worse. Which action should the nurse take first? a. Assess the patient for symptoms and signs of toxicity from excess vitamin exposure. b. Note that research has not shown that vitamin megadoses produce any benefits. c. Explain to the patient that megadoses may actually be harmful and advise caution. d. Assess for signs of circulatory impairment to determine whether improvement has occurred.

a. Assess the patient for symptoms and signs of toxicity from excess vitamin exposure. Megadoses of many vitamins, especially when taken over long periods, may produce dangerous side effects or toxicity. The priority for the nurse is to assess for signs of any dangerous consequences of the patient's use of such a regimen. Secondary interventions would include patient education about research findings related to the practice, along with any benefits and undesired effects associated with the practice. The patient should also be assessed for cardiovascular concerns by a health care provider.

(16) Select the example of tertiary prevention. a. Helping a person with serious and persistent mental illness learn to manage money. b. Restraining a psychotic patient who has become aggressive and assaultive. c. Teaching school-age children about the dangers of drugs and alcohol. d. Genetic counseling with a young couple expecting their first child.

a. Helping a person with serious and persistent mental illness learn to manage money. Tertiary prevention involves services that address residual impairments, with a goal of improved independent functioning. Restraint is a secondary prevention. Genetic counseling and teaching school-age children about substance abuse and dependence are examples of primary prevention.

(54) A nurse has been counseling a patient with generalized anxiety disorder to increase the patient's anxiety self-control. The patient has identified several stressful situations that cause physical and psychological manifestations of anxiety. Which indicator should the nurse monitor relative to the Nursing Outcomes Classification outcome of anxiety self-control? a. Plans coping strategies for stressful situations b. Identifies situations that precipitate hostility c. Refrains from destroying property d. Identifies alternatives to aggression

a. Plans coping strategies for stressful situations Plans coping strategies is directly related to having identified situations that precipitate anxiety and represents a necessary step in achieving anxiety self-control. The other options are indicators of progress in aggression self-control.

(75) Which intervention would be appropriate for a patient with a nursing diagnosis of Ineffective coping as evidenced by manipulation of others? a. Refer patient requests and questions about care to the primary nurse. b. Provide negative reinforcement for any acting-out behavior. c. Ignore rather than confront inappropriate interpersonal behavior. d. Encourage the patient to discuss feelings of fear and inferiority.

a. Refer patient requests and questions about care to the primary nurse Manipulative patients frequently make requests of many different staff, hoping one will give in. Having one decision maker provides consistency and prevents playing one staff member against another. Positive reinforcement of appropriate behaviors is more effective than negative reinforcement. Ignoring behavior can in some cases help extinguish the behavior, but more typically, manipulative behavior responds better to judicious use of confrontation. Antisocial patients suppress or conceal such feelings if present and would be very unlikely to admit to them, let alone discuss them.

(61) A patient with mania has not eaten or slept for 3 days. Which nursing diagnosis has priority? a. Risk for injury b. Ineffective coping c. Ineffective management of therapeutic regime d. Imbalanced nutrition, less than body requirements

a. Risk for injury Although each of the nursing diagnoses listed may apply for a patient having a manic episode, the priority lies with the patient's physiological safety. Hyperactivity and poor judgment put the patient at high risk for injury

(99) A parent with schizophrenia and 10-year-old child live in a homeless shelter. The child has adapted to shelter life and formed a relationship with a supportive volunteer. The child says, "My three best friends and I got an A on our school science project." Which assessment applies? a. The child displays resilience. b. Risk factors for substance abuse are evident. c. The child is at risk for posttraumatic stress disorder. d. The child uses intellectualization to deal with problems.

a. The child displays resilience. Resiliency enables a child to handle the stresses of a difficult childhood. Resilient children can adapt to changes in the environment, take advantage of nurturing relationships with adults other than parents, distance themselves from emotional chaos occurring within the family, and learn and use problem-solving skills. The other options are not supported by data given in the scenario.

(80) Which of these statements about suicide is accurate? a. The majority of persons who attempt suicide have given overt or covert indications of their intentions to others. b. A background in health care has a protective effect, leading to a lower rate of suicide among physicians and nurses than in the general public. c. Most persons with previous suicide attempts survived because they did not truly intend to die; they are at lower risk than those making their first attempt. d. Use of a low-lethality means or likelihood of being discovered in time to prevent death are merely suicide gestures, not genuine attempts.

a. The majority of persons who attempt suicide have given overt or covert indications of their intentions to others. Most persons who later attempt suicide have given some indication of being at risk, of having ideation or intent related to suicide. The suicide rate among physicians and nurses is higher than in the general population; their special knowledge of pharmacology and physiology can make attempts more likely to be lethal. Most people who complete suicide have made at least one previous attempt, and a history of prior attempts is one of the strongest predictors of future risk. Some attempts may appear unlikely to have succeeded from the outset, because the means was one of low lethality (e.g., choking oneself with socks wrapped around the neck) or because circumstances would have led to their being rescued before harm resulted (e.g., an attempt initiated in front of witnesses). Many tend to interpret such unlikely-to-succeed attempts as meaning that the person "wasn't really serious about suicide," that it was a (so-called) suicide gesture. In fact, often a depressed or psychotic person simply is too cognitively impaired to plan well to succeed at suicide. Further, identifying a serious attempt as "a gesture" (not serious) can increase the risk of suicide if it is perceived as a challenge or if the person feels they or their attempt are being ridiculed or not taken seriously. The person may respond by intensifying efforts and may succeed in a subsequent attempt.

(105) A selective serotonin reuptake inhibitor is prescribed for an elderly patient with depression. Nursing assessment should include careful collection of information regarding: a. other prescribed medications and over-the-counter products used. b. evidence of pseudoparkinsonism or tardive dyskinesia. c. history of psoriasis and any other skin disorders. d. history of diarrhea and electrolyte imbalances.

a. other prescribed medications and over-the-counter products used. Drug interactions, both prescription and over-the-counter, can be problematic for the geriatric patient taking an SSRI. Careful collection of information is important. The distracters do not pose problems with SSRI drugs.

(17) A patient with schizophrenia has been stable in the community for 6 weeks. Today the patient's spouse calls the nurse to report the patient's thinking is disorganized. The nurse makes a home visit and learns the patient is willing to take medication but forgot to have the prescription refilled. The nurse arranges a refill. Select the best outcome to add to the plan of care. a. The patient's spouse will mark dates for prescription refills on the family calendar. b. The nurse will obtain prescription refills every 90 days and deliver to the patient. c. The patient will call the nurse weekly to discuss medication-related issues. d. The patient will report to the clinic for medication follow-up every week.

a. The patient's spouse will mark dates for prescription refills on the family calendar. 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 patient or a significant other can be responsible. The patient may not need more intensive follow-up as long as medication is taken as prescribed. No patient issues except failure to obtain medication refill were identified.

(47) A patient who asked for and was refused a pass to leave the unit left the nurse's station and went to his room, where he slammed his closet door several times while looking for a sweater. This behavior is an example of __________ use of __________ . a. adaptive use of displacement b. maladaptive use of sublimation c. adaptive use of repression d. maladaptive use of reaction formation

a. adaptive use of displacement Displacement unconsciously transfers emotions associated with a person, object, or situation to another less threatening person, object, or situation. The patient slammed doors instead of discharging his feelings of anger against the individual who refused to give him the pass. Such behavior is adaptive in that it prevented aggression toward the source of his frustration. Sublimation is the unconscious process of substituting constructive activity for unacceptable impulses and by definition is an adaptive mechanism. Slamming of closet doors cannot be considered a constructive activity. Repression involves the unconscious blocking or exclusion of unacceptable thoughts or urges. In this case, the unacceptable impulses (to strike the nurse) are not blocked but redirected (displaced) instead. Reaction formation keeps unacceptable feelings or behaviors out of awareness by substituting the opposite feeling or behavior; reaction formation here would have involved the patient behaving protectively toward the nurse.

(4) A 4-year-old grabs toys from siblings and says, "I want that now!" The siblings cry, and the child's parent becomes upset with the behavior. Using Freudian theory, the nurse can interpret this behavior as a product of impulses originating in the: a. id. b. ego. c. superego. d. preconscious.

a. id. The id operates on the pleasure principle, seeking immediate gratification of impulses. The ego acts as a mediator of behavior and weighs the consequences of the action, perhaps determining that taking the toy is not worth the mother's wrath. The superego would oppose the impulsive behavior as "not nice." The preconscious is a level of awareness.

(51) A patient who has been unable to leave his home for more than a month because of symptoms of severe anxiety tells the nurse, "I know it's probably crazy, but I just can't bring myself to leave my apartment alone." An appropriate nursing intervention for the nurse to include in the initial nursing care plan is: a. teach the patient to replace negative self-talk with positive. b. encourage the patient to attend an agoraphobia support group. c. point out the irrationality of the patient's fears of leaving home. d. support the use of medication and be patient until they work.

a. teach the patient to replace negative self-talk with positive. This intervention, a form of cognitive restructuring, replaces negative thoughts such as "I can't leave my apartment" with positive thoughts such as "I am scared but I know that I am safe despite my fear, and if I do my deep breathing I can control my anxiety." This technique helps the patient gain mastery over his symptoms. A person unable to leave his home would be unable to access support groups or other treatment in the community. Pointing out the irrationality of his fears would be unproductive, since the patient is already aware of their irrationality. This awareness alone is not enough to change the fear. Medications play an important role, but there are many other actions the patient can take to improve coping, and the medications alone are not likely to be as effective as they would be if combined with other efforts to decrease anxiety and enhance coping.

(15) At age 19, an individual developed a serious mental illness. Symptoms continued for 2 years despite treatment, and the individual is unable to work. For which resource should this individual apply? a. Social Security Disability Insurance b. Veterans Administration benefits c. Supplemental Security Income d. Welfare

c. Supplemental Security Income Supplemental Security Income is for disabled persons who have economic need but who have not worked long enough to be eligible for Social Security Disability Insurance. The stem does not indicate the individual is a veteran. Welfare is a nonspecific term

(110) A man with severe mental illness dies suddenly at the age of 52. He had been living successfully in the community for 5 years without a hospitalization and worked for the past 6 months in the first job he had held for more than 20 years. His family is in shock, having been caught completely by surprise by his death, and asks why this has happened. Which of the following responses accurately reflects the research on mortality and serious mental illness and best addresses the family's question? a. "A certain number of people die young from undetected diseases, and it's just one of those sad things that happens sometimes to unlucky people." b. "Mentally ill people tend to die much younger than others, perhaps because they do not take as good care of their health, or smoke more, or are overweight." c. "We will have to wait for the autopsy to see for sure what happened. He had had some medical problems, but we were not expecting this." d. "We are all surprised. He had been doing so well, and he sees the nurse every other week; all we knew was wrong was that he was overweight."

b. "Mentally ill people tend to die much younger than others, perhaps because they do not take as good care of their health, or smoke more, or are overweight." The family is in distress; because they do not understand his death, they are less able to accept it and are seeking specific information to help them understand what has happened. Persons with severe mental illness die an average of 28 years before their peers without such illnesses. This may be a result of health care practitioners attributing their somatic complaints to their mental illness, to being unable to recognize or report symptoms indicating an impending health crisis, to not being able to afford or access health care, to poor health care practices, or to symptoms such as apathy and impaired judgment that lead them to choose unhealthy lifestyles. Medications can contribute to cardiac dysrhythmias, obesity, sedentary lifestyles, and diabetes. Finally, mentally ill persons have higher rates of smoking and substance abuse than the general population. Therefore, the most accurate answer indicates that seriously mentally ill people are at much higher risk of premature death for a variety of reasons. Staff who understand this would not have been surprised that such a patient died prematurely, and they would not attribute his death to random, undetected medical problems that are found in the general population. Although it is true that the cause of death will not be reliably established until the autopsy, this response fails to address the family's need for information

(83) A patient who has been depressed for the past several months presents in the clinic stating, "I'm at the end of my rope." Which of the following inquiries would be most effective to use for assessing suicide risk? a. "You seem very depressed and stressed. What is that like for you? What sort of feelings are you having when you say that?" b. "Tell me more about what you mean when you say you're at the end of your rope—are you thinking about killing yourself?" c. "Tell me about your family history. Do you have relatives or ancestors who suffered from depression?" d. "Tell me about your depression and being at the end of your rope; what are you thinking and feeling?"

b. "Tell me more about what you mean when you say you're at the end of your rope—are you thinking about killing yourself?" Although broad openings are valuable for eliciting information about a patient's concerns, when the nurse is seeking information about suicide risk, it is important to be candid, specific, and direct. This candidness shows you are concerned and is likely to elicit a more candid response from the patient. Similarly, the more specific the question, the more specific the answer.

(21) A depressed patient believes in traditional remedies but agrees to take an antidepressant medication. The patient tells the nurse, "I will also treat my symptoms with my own healing practices." Select the nurse's most important response. a. "You agreed to take this prescription. You must avoid herbal remedies." b. "What herbs and special foods do you plan to use?" c. "Will your treatment include yoga or meditation?" d."Will you do special breathing exercises?"

b. "What herbs and special foods do you plan to use?" The nurse needs to make sure that any herbs the patient may take are not harmful when taken in conjunction with the prescribed antidepressants. Patients adhere to their own belief systems, so admonishing the patient not to take herbals will not be effective.

(115) Which event is most likely to precipitate grief across a community? a. A local bank is robbed twice in a single month b. An adolescent shoots the principal of a local high school c. The elderly pastor of the town's largest church dies of heart failure d. Concrete pilings crumble in a bridge important to movement of local traffic

b. An adolescent shoots the principal of a local high school The correct response identifies an event likely to be perceived as a public tragedy. The distracters are occurrences that are more commonplace. They may precipitate concern but not grief.

(102) A 75-year-old patient comes to the clinic reporting frequent headaches. As the nurse begins the interaction, which action is most important? a. Complete a neurological assessment. b. Ask if the patient can hear clearly as the nurse speaks. c. Suggest that the patient lie down in a darkened room for a few minutes. d. Administer medication to relieve the patient's pain before continuing the assessment.

b. Ask if the patient can hear clearly as the nurse speaks. Before proceeding with any further assessment, the nurse should assess the patient's ability to hear questions. Impaired hearing could lead to inaccurate answers.

(19) A Native American patient describes difficulty learning as a child, living on a reservation, and being sent away to a Native American boarding school. The patient began using alcohol as a teenager to escape feelings of isolation but stopped 10 years ago when gastritis developed. The patient now says, "I feel stupid and good for nothing. I don't help my people." Which nursing diagnosis applies? a. Risk for other-directed violence b. Chronic low self-esteem c. Deficient knowledge d. Nonadherence

b. Chronic low self-esteem The patient has given several indications of chronic low self-esteem. Forming a positive self-image is often difficult for Native American individuals because these indigenous people must blend together both American and Native American worldviews. No defining characteristics are present for the other nursing diagnoses.

(3) A nurse is part of a multidisciplinary team working with groups of depressed patients. Half the patients receive supportive interventions and antidepressant medication. The other half receives only medication. The team measures outcomes for each group. Which type of study is evident? a. Prevalence b. Clinical epidemiology c. Descriptive epidemiology d. Experimental epidemiology

b. Clinical epidemiology Clinical epidemiology is a broad field that addresses what happens to people with illnesses seen by providers of clinical care. This study is concerned with the effectiveness of various interventions. Prevalence refers to numbers of new cases. Descriptive epidemiology provides estimates of the rates of disorders in a general population and its subgroups. Experimental epidemiology tests presumed assumptions between a risk factor and a disorder.

(65) Which nursing diagnosis is a priority for both a patient with depression and one with acute mania? a. Deficient diversional activity b. Disturbed sleep pattern c. Fluid volume excess d. Defensive coping

b. Disturbed sleep pattern Physical needs of patients with mood disorders include sleep disturbances. This possible problem should be monitored consistently. While the other diagnoses may apply, sleep problems are the priority.

(64) A patient with acute mania has exhausted staff by noon after joking, manipulating, and insulting all morning. Staff members feel defensive and fatigued. Select the best action. a. Call the health care provider to evaluate the patient. b. Hold a staff meeting to discuss consistency and limit-setting approaches. c. Seclude the patient, and then call the health care provider to write an order. d. Explain to the patient that the behavior is unacceptable. Ask the patient to be more cooperative.

b. Hold a staff meeting to discuss consistency and limit-setting approaches. When staff members are at their wits' end, the patient has succeeded in keeping the environment unsettled and avoided outside controls on behavior. Staff meetings can help minimize staff splitting and feelings of anger, helplessness, confusion, and frustration.

(55) A nurse is counseling a patient with an anxiety disorder by using cognitive therapy strategies. She gives the patient a homework assignment to keep a diary in which he records the symptoms of anxiety he experiences and the events that transpired just before the onset of symptoms. What is the rationale for this strategy? a. Keep the patient intellectually occupied to prevent dwelling on physiological phenomena. b. Link symptoms with precipitating events, which provides a basis for discussion and reframing. c. Anxiety gives rise to automatic, negative thoughts that must be identified and analyzed. d. Show the patient that certain events are the likely cause of his anxiety and should be avoided.

b. Link symptoms with precipitating events, which provides a basis for discussion and reframing. Reframing one's distorted thoughts is necessary for change. It permits the patient to see situations in a new way and move away from the use of automatic, negative thinking. The other options do not reflect cognitive theories of anxiety causation or treatment.

(66) A patient with mania dances around the unit, seldom sits or sleeps, and monopolizes conversations. Which nursing intervention will best assist the patient with energy conservation? a. Monitor physiological functioning. b. Provide a subdued environment. c. Observe for mood changes. d. Supervise personal hygiene.

b. Provide a subdued environment. All the options are reasonable interventions with a patient with acute mania, but the correct answer directly relates to the outcome of energy conservation. A subdued environment decreases stimulation, which will help balance activity and rest.

(63) During a manic episode, a patient is hyperactive, restless, and disorganized. The patient goes to the dining room and begins to throw food and dishes. Verbal intervention is ineffective. The patient's behavior poses a substantial risk of harm to others. Staff escorts the patient to the patient's room to dine alone. What is the rationale for this action? a. Prevent other patients from observing the behavior. b. Reduce environmental stimuli that negatively affect the patient. c. Protect the patient's biological integrity until medication takes effect. d. Reinforce limit setting, enabling the patient to learn to follow unit rules.

b. Reduce environmental stimuli that negatively affect the patient. Removing the patient from a crowded dining room will reduce overwhelming environmental stimuli affecting an extremely distractible individual.

(72) A patient is noted to be bending over backward in the group room. A peer asks what he is doing, and he replies, "People say they are bending over backwards to help me, so I am bending over backwards to help myself." This is an example of: a. abstract thinking. b. concrete thinking. c. impaired reality testing. d. boundary impairment.

b. concrete thinking. Abstract thinking is the ability to think in a nonliteral way and is essential for tasks such as understanding symbolism and abstract concepts such as love or time. Concrete thinking is the absence of abstract thinking, or literal thinking, and is seen here in the patient's interpreting the expression literally and actually bending over to help himself. Impaired reality testing is an inability to figure out whether a perception or thought is based in reality. Boundary impairment is difficulty telling where one's self begins or ends or how one is distinct from others or one's surroundings.

(93) The nurse at the clinic is interviewing a patient who offers a number of vague somatic complaints that might not ordinarily prompt a visit to a caregiver: fatigue, back pain, headaches, and sleep disturbance. The patient seems tense, and after having spoken of the symptoms, seems reluctant to provide more information and is in a hurry to leave. The nurse can best serve the patient by: a. asking if the patient has ever had psychiatric counseling. b. completing a structured abuse assessment protocol. c. exploring the possibility of patient social isolation. d. asking the patient to disrobe to check for signs of abuse.

b. completing a structured abuse assessment protocol. In this situation, the nurse should consider the possibility that the patient is a victim of domestic violence or possibly other abuse. Although the patient is reluctant to discuss issues, completing a screening as part of the health assessment might open the door to discussing possible abuse more openly. Asking about psychiatric care could imply the nurse suspects mental illness, which would likely be perceived as offensive and in turn decrease trust in the nurse. The data do not suggest that isolation is a likely issue. Disrobing will seem inappropriate and threatening to the patient, probably be met with refusal, interfere with trust, and impede the remainder of the nursing assessment.

(119) The nurse therapist assessing a family system perceives the family to be poorly differentiated and determines that family members have little sense of individuality. A desirable outcome is that members will: a. distinguish who is at fault for the family's dysfunction. b. develop their own values and beliefs instead of simply adopting those of others. c. become comfortable adhering to family norms and rules. d. integrate more effectively with other social systems.

b. develop their own values and beliefs instead of simply adopting those of others. Differentiation refers to the ability of the individual to establish a unique identity and still remain emotionally connected to the family of origin. Part of this process involves determining for oneself what one wishes to believe and value, rather than simply maintaining the values and beliefs of the other family members. Assigning fault for a family's dysfunction is rarely therapeutic (and rarely the fault of a single person). Adhering more strongly to the family's values would decrease differentiation, not increase it. Integrating effectively with social systems such as schools is desirable but is not pertinent to differentiation.

(62) The nursing diagnosis for a patient with mania is Imbalanced nutrition: less than body requirements related to caloric intake insufficient to balance with hyperactivity as evidenced by 5 lb weight loss in 4 days. Select the most appropriate outcome. The patient will: a. reduce hyperactivity within 1 week. b. drink four high-calorie, high-protein supplements per day. c. consistently wear appropriate attire for age and sex within 1 week. d. display consistently nonviolent behavior toward others within 1 week.

b. drink four high-calorie, high-protein supplements per day. Outcomes should be measurable. High-calorie, high-protein food supplements will provide the additional calories needed to offset the patient's hyperactivity. Nursing interventions are directed toward the etiology. The other outcomes are related to other nursing diagnoses that might be established for a patient with mania.

(104) A 79-year-old white male tells a nurse, "I have felt very sad lately. I do not have much to live for. My family and friends are all dead, and my own health is failing." The nurse should analyze this comment as: a. normal pessimism of the elderly. b. evidence of suicide risk. c. a cry for sympathy. d. normal grieving.

b. evidence of suicide risk The patient describes loss of significant others, economic security, and health. He describes mood alteration and voices the thought that he has little to live for. Combined with his age, sex, and single status, each is a risk factor for suicide. Elderly white males have the highest risk for completed suicide.

(56) When working with a patient with posttraumatic stress disorder who has frequent flashbacks as well as persistent symptoms of arousal, effective nursing interventions would include: a. encouraging repression of memories associated with the traumatic event. b. explaining that physical symptoms are related to the psychological state. c. triggering flashbacks as a way to help the patient learn to cope with them. d. supporting "numbing" as a temporary way to manage intolerable feelings.

b. explaining that physical symptoms are related to the psychological state. Persons with posttraumatic stress disorder often experience somatic symptoms or sympathetic nervous system arousal that can be confusing and distressing. Explaining that these are the body's responses to psychological trauma helps the patient understand how such symptoms are part of the illness and something that will respond to treatment. This decreases powerlessness over the symptoms and helps instill a sense of hope, reinforcing his participation in treatment. It also helps the patient to understand how relaxation, breathing exercises, and imagery can be helpful in symptom reduction. The goal of treatment for posttraumatic stress disorder is to come to terms with the event rather than repress it, so repression of memories and use of "numbing" are targeted for reduction rather than promoted. Triggering flashbacks would increase patient distress and is not necessary to recovery.

(71) A patient with schizophrenia has received typical (first-generation) antipsychotics for a year. His hallucinations are less intrusive, but he remains apathetic, has poverty of thought, cannot work, and is socially isolated. To address these symptoms, the nurse might consult the prescribing health care provider to suggest a change to: a. haloperidol (Haldol). b. olanzapine (Zyprexa). c. diphenhydramine (Benadryl). d. chlorpromazine (Thorazine).

b. olanzapine (Zyprexa). Olanzapine is an atypical (second-generation) antipsychotic that targets both positive and negative symptoms of schizophrenia. Haldol and Thorazine are typical antipsychotics of the same class as the patient's present medication and are effective primarily on positive symptoms. Benadryl is an antihistamine and has no antipsychotic properties.

(67) A salesman has had difficulty holding a job because he accuses co-workers of conspiring to take his sales. Today, he argued with several office mates and threatened to kill one of them. The police were called, and he was brought to the mental health center for evaluation. He has had previous admissions to the unit for stabilization of paranoid schizophrenia. When the nurse meets him, he points at staff in the nursing station and states loudly, "They're all plotting to destroy me. Isn't that true?" Which would be the most appropriate response? a. "No, that is not true. People here are trying to help you if you will let them." b. "Let's think about it: what reason would people have to want to destroy you?" c. "Thinking that people want to destroy you must be very frightening." d. "That doesn't make sense; staff are health care workers, not murderers."

c. "Thinking that people want to destroy you must be very frightening." The patient is expressing paranoid delusions. By definition, a delusion is a persistent irrational belief held despite evidence to the contrary. Therefore, stating that his belief is untrue will not make sense to him and may reinforce his belief that people are set against him. Similarly, because the delusion is believed firmly regardless of the evidence, providing more evidence that the belief is wrong or guiding the patient to look at the evidence are unlikely to be helpful and may reinforce his delusion. The most therapeutic response is the one which focuses on the feeling associated with the belief rather than the belief itself. It conveys empathy and interest in the patient's concerns, helping to build trust in the staff and giving him an opportunity to work through the fear he is experiencing.

(87) A cognitively impaired patient who has been a widow for 30 years is frantically trying to leave the unit, saying, "I have to go home to start dinner before my husband comes home from work." To intervene with validation therapy, the nurse should say: a. "Please, you must come away from the door." b. "Mrs. Smith, you have been a widow for many years." c. "You want to go home to get your husband's dinner." d. "I think your husband said he is going to eat out tonight."

c. "You want to go home to get your husband's dinner." Validation therapy meets the patient "where she or he is at the moment" and acknowledges the patient's perspectives on what she is experiencing. It does not seek to redirect, reorient, or probe. The other options do not validate patient feelings. Saying that her husband has other plans adds further to the patient's distorted view of reality.

(14) A patient was hospitalized for a reaction to a psychotropic medication. A new medication was prescribed, and the patient was monitored for 24 hours. During pre-discharge planning, the case manager learned that the patient received a notice of eviction on the day of admission. Select the most appropriate action for the case manager. 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. Determine whether the adverse medication reaction was artificial, because the patient had nowhere to live.

c. Arrange a temporary place for the patient to stay until new housing can be arranged. The case manager should intervene by arranging temporary shelter for the patient until an apartment can be found. This is part of the coordination and deliver of services that falls under the case manager role. None of the other options is a viable alternative.

(5) A patient says, "I never know the answers," and "My opinion doesn't count." The nurse correctly assesses that this patient had difficulty resolving which psychosocial crisis? a. Initiative versus guilt b. Trust versus mistrust c. Autonomy versus shame and doubt d. Generativity versus self-absorption

c. Autonomy versus shame and doubt These statements show severe self-doubt, indicating that the crisis of gaining control over the environment was not successfully met. Unsuccessful resolution of the crisis of initiative versus guilt results in feelings of guilt. Unsuccessful resolution of the crisis of trust versus mistrust results in poor interpersonal relationships and suspicion of others. Unsuccessful resolution of the crisis of generativity versus self-absorption results in self-absorption that limits the ability to grow as a person.

(57) A student in the Mood Disorders Clinic states that everything he does is wrong and that nothing he tries ever works. Although he has never failed an exam, he believes he will fail the next one. Based on evidence-based research, which of the following interventions would best address a presentation of this type? a. Psychoanalytic therapy b. Desensitization therapy c. Cognitive-behavioral therapy d. Alternative and complementary therapies

c. Cognitive-behavioral therapy Cognitive-behavioral therapy attempts to alter the patient's dysfunctional beliefs by identifying automatic and/or distorted thinking and then questioning it. This is then followed by rewording or reframing the thought in a more realistic manner. The patient is also taught the connection between thoughts and mood. Research shows that cognitive-behavioral therapy involves the formation of new connections between nerve cells in the brain and is at least as effective as medication. Evidence does not support similar effectiveness for the other psychotherapeutic modalities mentioned.

(60) A patient being treated for depression has been taking 300 mg amitriptyline (Elavil) daily for nearly a year. She calls her case manager at the mental health clinic, stating she stopped taking her antidepressant 2 days ago and has developed something like the "flu," with cold sweats, nausea, a rapid heartbeat, terrible nightmares when she sleeps, but no other symptoms. How should the nurse respond? a. Advise her to go to the nearest emergency department for an evaluation. b. Tell her to take two aspirin, drink plenty of fluids, and call her family doctor. c. Explain it may be withdrawal; tell her to take one Elavil and contact her doctor. d. Direct her to take the medicine every other day for 2 weeks, then stop.

c. Explain it may be withdrawal; tell her to take one Elavil and contact her doctor. The patient has symptoms associated with abrupt withdrawal of the tricyclic antidepressant. Taking a dose of the drug will ameliorate the symptoms, and discussing her plans with the physician will allow her to discuss the advisability of going off the medication and to be given a gradual withdrawal schedule if discontinuation is the decision. This situation is not a medical emergency, so the ER is not indicated. The situation is not "normal"; she is likely experiencing withdrawal and is also at risk of worsening or triggering her depression if she stops her medication, so the decision should be made in collaboration with a mental health professional. Aspirin would have no benefit in this situation. Taking the medication every other day would reduce the drug levels she is exposed to, but not in a gradual way; tapering the dosage gradually is needed instead.

(7) Operant conditioning is part of the treatment plan to encourage speech in a child who is nearly mute. Which technique applies? a. Encourage the child to observe others talking. b. Include the child in small group activities. c. Give the child a small treat for speaking. d. Teach the child relaxation techniques.

c. Give the child a small treat for speaking. Operant conditioning involves giving positive reinforcement for a desired behavior. Treats are rewards and reinforce speech through positive reinforcement. PTS: 1 DIF: Cognitive Level: Application REF: Text Pages: 32-33 TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

(44) A patient who had been complaining of intolerable stress at work has demonstrated the ability to use progressive muscle relaxation and deep breathing techniques. He will return to the clinic for follow-up evaluation in 2 weeks. Which data will best suggest that the patient is successfully using these techniques to cope more effectively with stress? a. The patient's wife reports that he spends more time sitting quietly at home. b. He reports that his appetite, mood, and energy levels are all good. c. His systolic blood pressure has gone from the 140s to the 120s (mm Hg). d. He reports that he feels better and that things are not bothering him as much.

c. His systolic blood pressure has gone from the 140s to the 120s (mm Hg). Objective measures tend to be the most reliable means of gauging progress. In this case, the patient's elevated blood pressure, an indication of the body's physiological response to stress, has diminished. The wife's observations regarding his activity level are subjective, and his sitting quietly could reflect his having given up rather than improved. Appetite, mood, and energy levels are also subjective reports that do not necessarily reflect physiological changes from stress and may not reflect improved coping with stress. The patient's report that he feels better and is not bothered as much by his circumstances could also reflect resignation rather than improvement.

(98)A 15-year-old was referred to the mental health clinic by juvenile court after an arrest for vandalism and assault on a teacher. The teen tells the nurse, "I hate my parents. They focus all attention on my brother, who is perfect in their eyes." Which nursing diagnosis applies? a. Chronic low self-esteem related to feelings of guilt, as evidenced by believing a brother is the parental favorite b. Hopelessness related to feeling unloved by parents, as evidenced by assaulting a teacher c. Ineffective coping related to seeking parental attention, as evidenced by acting out d. Disturbed personal identity related to acting out, as evidenced by vandalism

c. Ineffective coping related to seeking parental attention, as evidenced by acting out The patient demonstrates an inability to problem solve by using adaptive behaviors to meet life's demands and roles. The defining characteristics are not present for the other nursing diagnoses listed. The patient has not indicated hopelessness, low self-esteem, or disturbed personal identity.

(109) A man with severe mental illness has difficulty with boredom, feels that attending the day program does not challenge him, and wishes to earn money. Which of the following options would be most appropriate for addressing these issues? a. Involve him in volunteer work at the consumer-run clubhouse program at the mental health center. b. Help the patient apply for services at the state's Bureau of Vocational Rehabilitation. c. Rapidly pace him in a competitive job of his choosing, accompanied by a coach on the job site. d. First involve the patient in prevocational training, then in employment in a sheltered workshop.

c. Rapidly pace him in a competitive job of his choosing, accompanied by a coach on the job site The option associated with the greatest likelihood of achieving successful, sustained competitive employment is the supported employment model, which involves rapidly placing the patient in a competitive employment position, accompanied by on-site job coaching and support that coordinates with the employer to provide needed support and on-the-job training. Contrasted to volunteer work, competitive employment would be more challenging and provide income. Placing the patient in the job first, then giving individualized training and coaching support in the field describes the supported employment model that is now an evidence-based practice. Research has not supported the Bureau of Vocational Rehabilitation model, which involves prevocational training followed by sheltered employment before moving on to competitive employment. Clubhouse programs are helpful for many patients but do not have as high a success rate for achieving competitive employment.

(42) A patient reports that financial problems are stressing his marriage. Today he heard rumors about impending cutbacks at work, and he fears he will be laid off. He is wringing his hands, has a pulse rate of 112/minute, respirations are 26/minute, and his blood pressure is 166/88 instead of being in his usual 110-120/76-84 range. Which nursing intervention or recommendation should be used first? a. Go to sleep 30 to 60 minutes earlier each night to increase rest. b. Relax by spending more time playing with his pet dog. c. Slow and deepen breathing via use of a positive, repeated word. d. Consider that a new job might be better than his present one.

c. Slow and deepen breathing via use of a positive, repeated word. The patient is responding to stress with increased arousal of the sympathetic nervous system, as evident in his elevated vital signs. These will have a negative effect on his health and increase his perception of being anxious and stressed. Stimulating the parasympathetic nervous system (i.e., Benson's relaxation response) will counter the sympathetic nervous system's arousal, normalizing these vital-sign changes and reducing the physiological demands stress is placing on his body. Other options do not address his physiological response pattern as directly or immediately.

(68) A patient with schizophrenia refuses to take his medication because he believes he is not ill. What phenomenon most likely underlies this presentation? a. The patient is unable to face having an illness and is in denial. b. Stigma causes the patient to refuse to admit his mental illness. c. The illness itself is preventing the patient from realizing he is ill. d. Command hallucinations are instructing him to deny the illness.

c. The illness itself is preventing the patient from realizing he is ill. When a person with schizophrenia denies having the disorder, the most common reason for this is that the neurological changes that cause the illness also interfere with the person's ability to recognize that he is ill, a condition called anosognosia. Although a person with mental illness may experience denial, stigma, or command hallucinations, these are not the most common reasons for a lack of insight.

(46) A patient reports that nothing is wrong with him except a chest cold he's had for a couple weeks and "hasn't been able to shake off." His wife is very worried and says he smokes, coughs a lot, has lost 15 pounds, and is easily fatigued. Which of the following statements best describes this situation? a. The patient is using suppression to cope adaptively. b. The patient is using suppression to cope maladaptively. c. The patient is using denial to cope adaptively. d. The patient is using denial to cope maladaptively.

c. The patient is using denial to cope adaptively. Denial is an unconscious blocking of threatening or painful information or emotions and can be used adaptively to help a person cope with an overwhelming circumstance for a short period of time until more effective methods of coping can be utilized.

(39) Documentation in a patient's record shows: During 5-minute interaction, patient fidgeted, tapped foot, periodically covered face with hands, looked under chair. Stated, "I enjoy spending time with you." Which assessment is most accurate? a. The patient gave positive feedback about the nurse's communication techniques. b. The nurse is viewing the patient's behavior through a cultural filter. c. The patient's verbal and nonverbal messages were incongruent. d. Psychotic thought processes are likely.

c. The patient's verbal and nonverbal messages were incongruent. When a verbal message is not reinforced with nonverbal behavior, the message is confusing and incongruent. Some clinicians call it a "mixed message." Positive feedback is not evident. A cultural filter determines what we will pay attention to and what we will ignore, which is not relevant to the situation presented. Data are insufficient to draw the conclusion that the patient is psychotic.

(95) A nurse works with an adolescent who is moody and withdrawn because the teen's parents are divorcing. Establishing a therapeutic alliance is a priority because: a. focusing on the strengths of an individual increases the individual's self-esteem. b. the adolescent should express feelings and not keep them internalized. c. acceptance and trust convey feelings of security to the adolescent. d. therapeutic activities provide an outlet for tension.

c. acceptance and trust convey feelings of security to the adolescent. Trust is frequently an issue because the child or adolescent may never have had a trusting relationship with an adult. In this patient's situation, the trust she once had in her parents has been shattered, robbing her of feelings of security. Only the key relates to the therapeutic alliance.

(96) A 15-year-old is referred to the mental health clinic by juvenile court after an arrest for vandalism and running away from home six times. The teen has been physically abusive to the mother and defiant to the father. The adolescent's problem is most consistent with criteria for: a. attention-deficit hyperactivity disorder. b. adolescent depression. c. conduct disorder. d. autistic disorder.

c. conduct disorder. Conduct disorders are manifested by a persistent pattern of behavior in which the rights of others and age-appropriate societal norms are violated. The patient's clinical manifestations do not coincide with criteria of the other disorders.

A cognitive strategy a nurse could use to assist a very dependent patient would be to help the patient: a. reveal dream content. b. take prescribed medications. c. examine thoughts about being autonomous. d. role model ways to ask for help from others.

c. examine thoughts about being autonomous Cognitive theory suggests that one's thought processes are the basis of emotions and behavior. Changing faulty learning makes the development of new adaptive behaviors possible. Revealing dream content would be used in psychoanalytical therapy. Taking prescribed medications is an intervention associated with biological therapy. A dependent patient needs to develop independence.

(77) The nurse who assesses a patient previously diagnosed as having paranoid personality disorder is most likely to describe the patient as: a. superficially charming. b. intense and impulsive. c. guarded and distant. d. friendly and open.

c. guarded and distant. Patients with paranoid personality disorder are mistrustful of others. They expect to be exploited or wronged by others and are wary; as a result, they remain apart from others to increase their sense of security. Patients with antisocial personality disorder may display superficial charm, but paranoid persons usually seem cold and aloof and would not seem friendly or open. Patients with borderline personality disorder are intense and impulsive, whereas patients with paranoid personality disorder tend to be controlled and superficial.

(108) A patient with severe mental illness who lives independently in an apartment and attends a psychosocial rehabilitation program 4 days a week presents at the emergency department seeking admission to the inpatient psychiatric unit. The mental status examination reveals no acute symptoms of psychiatric disorder. Her chief complaint is that she has no money to pay her rent or refill her antipsychotic medication prescription. The best action for the emergency department nurse would be to: a. arrange for a short in-patient admission and begin discharge planning. b. send the patient to a homeless shelter until housing can be arranged. c. involve the patient's case manager to provide crisis intervention. d. explain that one must have more psychiatric symptoms to be admitted.

c. involve the patient's case manager to provide crisis intervention. Impaired stress tolerance and problem-solving abilities can cause persons with SMI to experience relatively minor stressors as crises. This patient has run out of money, and this has overwhelmed her ability to cope, resulting in a crisis for which crisis intervention would be an appropriate response. Inpatient care is not clinically indicated, nor is the patient homeless (although she may fear she is). Telling the patient that she is not symptomatic enough to be admitted may prompt malingering.

A patient is hospitalized for severe depression. Of the medications listed below, the nurse can expect to provide the patient with teaching about: a. chlordiazepoxide (Librium) b. clozapine (Clozaril) c. sertraline (Zoloft) d. tacrine (Cognex)

c. sertraline (Zoloft) Sertraline (Zoloft) is an SSRI. This antidepressant blocks the reuptake of serotonin, with few anticholinergic and sedating side effects. Clozapine is an antipsychotic. Chlordiazepoxide is an anxiolytic. Tacrine treats Alzheimer's disease.

(85) A severely depressed patient who has been on suicide precautions tells the nurse, "I am feeling a lot better, so you can stop watching me. I have taken too much of your time already." The best response for the nurse to make would be: a. "I wonder what this sudden change is all about. Care to elaborate?" b. "I am glad you are feeling better. The team will consider what you have said." c. "You should not try to direct your plan for care. Leave that to the team." d. "Because we are concerned about your safety, we will continue with our plan."

d. "Because we are concerned about your safety, we will continue with our plan." When a patient seeks to have precautions lifted by professing to feel better, the patient may be seeking greater freedom in which to attempt suicide. Changing the treatment plan requires careful evaluation of outcome indicators by staff. Asking the patient to elaborate could yield further evaluation data but would not reliably address suicide risk. Taking the patient's comment at face value neglects the fact that people can seek to conceal their plans in order to increase their chances of success. Asking the patient to "leave that to the team" conveys a parental attitude that would discourage the patient from participating in his treatment.

(41) The daughter of a severely depressed patient asks the nurse "What do you think about the relationship between depression and physical illness? Since my mother has been grieving over my father's death, she has had colds, shingles, and the flu, and she's usually not one to get sick." The answer that best reflects the current thinking about psychoimmunology is: a. "It is probably a coincidence. Not much evidence is available that emotions like grieving make one prone to physical illnesses." b. "You might be paying more attention to your mother since your father died, and you are noticing more things such as minor illnesses." c. "So far, the research on emotions or stress and becoming ill more easily is unclear—we just do not know for sure if there is a link." d. "Emotions and stress are believed to interfere with white blood cell production and can increase the likelihood of infectious diseases."

d. "Emotions and stress are believed to interfere with white blood cell production and can increase the likelihood of infectious diseases." Option D best explains evidence-based thinking. Research does support a link between negative emotions and/or prolonged stress and impaired immune system functioning, such as reduced white blood cell production. Activation of the immune system sends proinflammatory cytokines to the brain, and the brain in turn releases it own cytokines that signal the central nervous system to initiate myriad responses to stress. Prolonged stress suppresses the immune system and lowers resistance to infections. Although the daughter may be more aware of issues involving her mother, the pattern of illnesses described may be an increase from the mother's baseline.

(34) Which remark by a patient indicates movement from orientation to the working phase of a nurse-patient relationship? a. "I don't have any problems." b. "It is so difficult for me to talk about problems." c. "I don't know how talking about things twice a week can help." d. "I want to find ways to deal with my anger without blowing up."

d. "I want to find ways to deal with my anger without blowing up." Thinking about a more constructive approach to dealing with anger indicates a readiness to make a behavioral change. Behavioral change is associated with the working phase of the relationship. Denial or avoidance are often seen in the orientation phase.

(111) Which comment by the patient indicates use of a maladaptive or ineffective coping strategy? a. "That heart attack was no fun, but at least it woke me up to my need for a better diet and more exercise." b. "My family and God will see me through this. It won't be easy, but I'll never be alone." c. "I definitely have cancer. Now I need to look at the effects of treatment and decide whether I will be able to work daily." d. "I wouldn't be in this position if the company had better health benefits. If they paid for health club memberships, maybe I wouldn't be here now."

d. "I wouldn't be in this position if the company had better health benefits. If they paid for health club memberships, maybe I wouldn't be here now. Blaming someone else and rationalizing one's failure to exercise are not usually considered to be adaptive coping strategies. Seeing the glass as half full, using social and religious supports, and confronting one's situation are seen as more effective strategies.

(94) A nurse assesses a 4-year-old with hyperactive, impulsive behavior. Which developmental task should the child have achieved? a. Separation from parents and ability to socialize outside the family b. Forming satisfactory relationships with peers c. Ability to generate abstract ideas d. A sense of autonomy

d. A sense of autonomy A 4-year-old should have attained the developmental tasks of children aged 1 1/2 to 3 years: autonomy. The distracters relate to older children.

(70) A highly suspicious patient who has delusions of persecution about being poisoned has refused all hospital meals for 3 days. Which of the following interventions would be most appropriate under these circumstances? a. Feed the patient via tube, involuntarily via court order if needed. b. Offer to taste each food item on the tray yourself while he watches. c. Allow the patient to contact a local restaurant to deliver his meals. d. Allow him supervised access to use food vending machines in the hospital lobby.

d. Allow him supervised access to use food vending The patient may perceive foods in sealed containers, packages, or natural shells that he has selected himself as being less likely to have been adulterated. Attempts to tube feed are seen as threatening and tend to increase mistrust and worsen paranoia. His mistrust would cause him to assume that any food "taster" was simply making it seem as if the food was safe (e.g., the patient could believe that the staff member tasting the food has taken an antidote to the poison before tasting.) The patient who is delusional about his food being poisoned is likely to believe restaurant food might also be poisoned during preparation or delivery

(12) A category 5 hurricane is approaching. Which change in an individual's vital signs is most likely? a. Pulse rate changes from 90 to 72 b. Pupil size changes from 6 mm to 4 mm c. Complaints of intestinal cramping begin d. Blood pressure changes from 114/62 to 136/78

d. Blood pressure changes from 114/62 to 136/78 This frightening experience would stimulate the sympathetic nervous system, causing a release of norepinephrine, an excitatory neurotransmitter. It prepares the body for fight or flight. Increased blood pressure, pupil size, and pulse rate signify release of norepinephrine. Intestinal cramping would be associated with stimulation of the parasympathetic nervous system.

(116) A young female member in a therapy group relates to an older female patient as one might to a mother, accusing her of trying to control her whenever the older member offers observations or suggestions to her. Which therapeutic factor of a group is represented by this behavior? a. Instillation of hope b. Existential resolution c. Development of socializing techniques d. Corrective recapitulation of the primary family

d. Corrective recapitulation of the primary family The younger patient is demonstrating an emotional attachment to the older patient that mirrors patterns within her own family of origin, a phenomenon called corrective recapitulation of the primary family group. Feedback from the group then helps the member gain insight about this behavior and leads to more effective ways of relating to her own family members. Instillation of hope involves conveying optimism and sharing progress. Existential resolution refers to the realization that certain existential experiences such as death are part of life, aiding the adjustment to such realities. Development of socializing techniques involves gaining social skills through the group's feedback and practice within the group.

(107) A middle-class family is talking with the nurse about the impact a seriously mental ill son has had on the family. Insurance has only partially covered treatment expenses, and the family has spent much of their savings to care for him. The patient's younger sister mentions she feels lost because her parents are so focused on her brother that it seems as though they have no time for her. The parents are concerned that when the siblings move out and they themselves become aged, there will be no one to care for the patient. Which response would be most helpful? a. Acknowledge their concerns, and indicate that you will consult with the treatment team about ways to bring the patient's symptoms under better control. b. Give them the names of financial advisors and banks that could help them save or borrow sufficient funds to leave a trust fund to care for their loved one. c. Refer them to crisis intervention services to learn ways to manage caregiver stress, and provide the titles of some helpful books for families of SMI persons. d. Discuss the benefits of participating in National Alliance on Mental Illness programs, and discuss ways to help the son become more independent.

d. Discuss the benefits of participating in National Alliance on Mental Illness programs, and discuss ways to help the son become more independent. The family has raised a number of concerns, but the major issues appear to be the effect caregiving has had on the family and their concerns about the patient's future. The National Alliance on Mental Illness (NAMI) offers support, education, resources, and access to other families who have experience with the issues now facing this family. In particular, NAMI can help address caregiver burden and planning for the future needs of SMI persons. Improving the patient's symptom control and general functioning can help reduce caregiver burden but would likely be a slow process, whereas NAMI involvement could benefit them on a number of fronts, possibly in a shorter time period. The family will need more than financial planning help as their issues go beyond the financial. The family is distressed but not in crisis, and crisis intervention is not really an appropriate resource for the longer-term issues and needs affecting this family.

(24) A patient with psychosis became aggressive, struck another patient, and required seclusion. Select the best documentation. a. Patient struck another patient who attempted to leave day room to go to bathroom. Seclusion necessary at 1415. Plan: Maintain seclusion for 8 hours and keep these two patients away from each other for 24 hours. b. Seclusion ordered by physician at 1415 after command hallucinations told the patient to hit another patient. Careful monitoring of patient maintained during period of seclusion. c. Seclusion ordered by MD for aggressive behavior. Begun at 1415. Maintained for 2 hours without incident. Outcome: Patient calmer and apologized for outburst. d. Patient pacing, shouting. Haloperidol 5 mg given PO at 1300. No effect by 1315. At 1415 patient yelled, "I'll punch anyone who gets near me," and struck another patient with fist. Physically placed in seclusion at 1420. Seclusion order obtained from MD at 1430.

d. Patient pacing, shouting. Haloperidol 5 mg given PO at 1300. No effect by 1315. At 1415 patient yelled, "I'll punch anyone who gets near me," and struck another patient with fist. Physically placed in seclusion at 1420. Seclusion order obtained from MD at 1430. Documentation must be specific and detail the key aspects of care. It should demonstrate implementation of the least restrictive alternative. Justification for why a patient was secluded for 8 hours should be recorded, along with interventions attempted in an effort to avoid seclusion. Documentation should include a description of behavior and verbalizations, interventions tried and their outcomes, and the name of the health care provider ordering the use of seclusion.

(100) An 11-year-old has Asperger's disorder. Which assessment finding supports this diagnosis? a. Mutism b. Tics and twitching c. Severe developmental delays d. Restricted and repetitive patterns of behavior

d. Restricted and repetitive patterns of behavior Most children with Asperger's syndrome manifest restricted and repetitive patterns of behavior as their major symptoms. Idiosyncratic interests may also occur. Verbal skills are rarely impaired. Tics and twitching are more often a part of the clinical picture of Tourette's syndrome. Severe developmental delays are part of the clinical picture of autism rather than Asperger's syndrome.

(92) A woman has been severely beaten by her husband, has no relatives or friends in the community, is afraid to return home, has no financial resources of her own, and has no job skills. Which would be the most important referral for the nurse to make? a. Community food cupboard b. Vocational counseling c. Law enforcement d. Safe house or shelter

d. Safe house or shelter Because the wife wishes to leave the home and has no safe place to go, referral to a battered person's shelter or safe house is necessary. The shelter will provide other referrals as necessary.

(58) A student nurse working with a depressed patient finds herself becoming angry with the patient when he responds slowly or not at all to her efforts to improve his mood. Which explanation most likely explains her emotional response? a. The majority of depressed persons respond only partially to treatment interventions. b. This depressed patient is responding more slowly than most, leading to frustration. c. Depressed patients are often resistant to treatment and a source of frustration to staff. d. Staff can have unrealistic expectations, believing depressed people should "cheer up."

d. Staff can have unrealistic expectations, believing depressed people should "cheer up." Although it is true that depressed patients sometimes seem to reject the overtures of staff and seem to resist change despite the nurse's best efforts, the usual cause of negative emotional responses in staff are the staff's own unrealistic expectations. Nursing staff may expect the patient to respond more readily than the patient's depression allows; or they may believe that because the patient is lucid and coherent, he should respond readily and well to verbal interventions. Nurses may also hold unrealistic expectations of themselves, believing that they understand depression because they have been sad themselves and believe their own experiences will be comparable to the patient's (and that what would have been helpful to them will be sufficient to benefit patients as well). However, nursing staff sometimes underestimate how much the depression is affecting the patient's cognition, reasoning, and other higher neurological functions, and when such factors limit the patient's responsiveness, the nurse may experience feelings of anxiety, frustration, incompetence, and even helplessness as a result. Supervision can help the nurse develop realistic expectations for both patient and self. The majority of persons with depression respond well to treatment, showing significant improvement in mood and functioning. It is unlikely that this particular patient is exceptional in failing to respond directly and rapidly to staff's interventions, as most patients improve rather slowly. Depressed patients may resist treatment efforts, but this is not typical of depressed persons.

(36) Which action by a nurse shows positive regard? a. Making rounds according to the daily assignment. b. Administering daily medication as prescribed. c. Examining own feelings about a patient. d. Staying with a patient who is crying.

d. Staying with a patient who is crying. Staying with a crying patient offers support and shows positive regard. The distracters describe tasks, not necessarily with positive regard, and the nurse's efforts to remain self-aware.

(113) A patient being treated for an MI has been transferred from the intensive care unit to a step-down unit. She is anxious and uses the call bell as often as every 15 minutes, complaining or making a seemingly small request each time the staff member enters the room. Which indicator should staff focus on to monitor for the outcome of "anxiety self-control"? a. Patient monitors duration of anxiety episodes b. Patient sleeps 7 or more hours each night c. Patient has stopped using the call button d. Uses call button not more than once per hour

d. Uses call button not more than once per hour Using the button less frequently suggests that the patient is less needy because she is more secure and less anxious. Not using the call button at all suggests that she is reluctant to bother staff, which is not desirable if she truly needs assistance. Monitoring her own anxiety does not necessarily indicate improvement, and sleep duration does not necessarily reflect one's level of anxiety.

(69) When a patient with paranoid schizophrenia has a recurrence of positive symptoms after stopping his antipsychotic medication because of its postural hypotension (orthostasis) side effect, he is readmitted to the mental health unit. What measure should the nurse suggest to help the patient address this side effect? a. Ask the doctor to prescribe an anticholinergic drug like trihexyphenidyl (Artane). b. Chew sugarless gum or use sugarless hard candy to moisten your mouth. c. Increase the amount of sleep you get, and try to take frequent rest breaks. d. Wear elastic support hose, drink adequate fluids, and change position slowly.

d. Wear elastic support hose, drink adequate fluids, and change position slowly. Orthostasis involves an impaired ability to adjust one's blood pressure momentarily upward to compensate for changes in position; it produces dizziness or fainting when moving from a lying or seated position to a standing position. Arising slowly reduces dizziness. Maintaining adequate hydration and preventing blood pooling in lower extremities can also reduce the degree of orthostasis experienced. The use of support hose may also be helpful to prevent pooling of blood in the lower extremities. Postural hypotension is not an extrapyramidal side effect and will not be helped by anticholinergic medication. Dry mouth would be helped by foods that stimulate salivation, but this would not help hypotension.

(25) 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; more cooperative. Participated actively in group. No evidence of psychotic thinking. c. Appeared to hallucinate. Frequently increased volume on television, causing conflict with others. d. Wore four layers of clothing. States, "I need protection from evil bacteria trying to pierce my skin."

d. Wore four layers of clothing. States, "I need protection from evil bacteria trying to pierce my skin." 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.

(35) A nurse wants to demonstrate genuineness with a patient diagnosed with schizophrenia. The nurse should: a. use extensive self-disclosure in patient interactions. b. encourage dependence on the nurse for support and reassurance. c. consistently make interpretive judgments about the patient's behavior. d. be aware of own feelings and use congruent communication strategies.

d. be aware of own feelings and use congruent communication strategies. Genuineness is a desirable characteristic involving awareness of one's own feelings as they arise and the ability to communicate them when appropriate. The other possible options are undesirable in a therapeutic relationship.

(22) What is the legal significance of a nurse's action when a patient verbally refuses medication and the nurse gives the medication over the patient's objection? The nurse: a. has been negligent. b. committed malpractice. c.fulfilled the standard of care. d.can be charged with battery.

d. can be charged with battery. Battery is an intentional tort in which one individual violates the rights of another through touching without consent. Forcing a patient to take medication after the medication has been refused constitutes battery. The charge of battery can be brought against the nurse.

(32) At what point in an assessment interview could a nurse logically ask, "How does your faith help you in stressful situations?" During the assessment of: a. childhood growth and development. b. substance use and abuse. c. educational background. d. coping strategies.

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

(79) A patient with paranoid personality disorder is noted to sit alone in a corner of the unit living room. When anyone approaches, the patient is haughty or simply ignores the other person. When staff invite her to join an activity, she tells them, "I do not care to be with people who do not like me." A nursing diagnosis that should be considered is: a. splitting. b. activity intolerance. c. powerlessness. d. impaired social interaction.

d. impaired social interaction. Impaired social interaction is a state in which an individual participates in an insufficient (or excessive) quantity or quality of social exchange. A defining characteristic is dysfunctional interaction with others. The patient's suspiciousness, rigidity, and distortions of reality related to projection are likely responsible in this case. Splitting, powerlessness, and activity intolerance are not evident in this scenario.

(76) A patient with antisocial personality disorder tells Nurse A, "You're a much better nurse than Nurse B said you were." The patient tells Nurse B, "Nurse A's upset with you for some reason." To Nurse C the patient states, "You'd like to think you're perfect, but I've seen three of your mistakes this morning." These comments can best be assessed as: a. seductive. b. detached. c. guilt producing. d. manipulative.

d. manipulative. Patients manipulate and control staff in various ways. By keeping staff off balance or fighting among themselves, the antisocial person is left to operate as he or she pleases. Seductive behavior uses sexuality to achieve one's aims and is not evident here. The patient is interacting actively rather than detaching from those around him. Guilt is not overtly evident, although Nurse C might experience guilt in response to his criticism.

(78) To plan effective interventions, the nurse should understand that the underlying reason a patient with paranoid personality disorder is so critical of others probably lies in the patient's: a. need to control all aspects of the world around him. b. use of intellectualization to protect against anxiety. c. inflexible view of the environment and the people in it. d. projection of blame for his own shortcomings onto others.

d. projection of blame for his own shortcomings onto others. Projection allows the patient to disown negative feelings about himself and see these feelings as being directed at him from an outside source (the nurse) instead. The patient then can justifiably retaliate by being hostile to the nurse. To realize that the patient is accusing the nurse of his or her own faults makes the criticism easier to manage without retaliation. The other options are not related to the dynamics of critical behaviors on the part of the patient.

(2) A patient's relationships are intense and unstable. The patient initially idealizes the significant other and then devalues them, resulting in frequent feelings of emptiness. This patient will benefit from interventions to develop which aspect of mental health? a. Effectiveness in work b. Communication skills c. Productive activities d.Fulfilling relationships

d.Fulfilling relationships The information given centers on relationships with others, which are described as intense and unstable. The relationships of mentally healthy individuals are stable, satisfying, and socially integrated. Data are not present to describe work effectiveness, communication skills, or activities. PTS: 1 DIF: Cognitive Level: Comprehension REF: Text Page: 3 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity