MH Exam 2 Questions
A nurse is providing teaching for a pt who is to start taking valproic acid. Which of the following instructions should the nurse include? A. "You should expect the provider to gradually decrease your dosage of valproic acid." B. "You should take aspirin for pain you have while taking valproic acid." C. "You should undergo thyroid function tests every 6 months while taking valproic acid." D. "You should have your liver function levels monitored regularly while taking valproic acid"
(ANTICONVULSANT) ANSWER: D - The nurse should inform the pt of the need to regularly monitor liver function levels due to the risk for hepatotoxicity while taking valproic acid. It is recommended to obtain baseline levels and then repeat every 2 months during the first 6 months of therapy. A: The nurse should inform the pt that the provider will initially prescribe a small dose, and then gradually increase the dose until a maintenance dosage is achieved. B: The nurse should instruct the pt to avoid aspirin while taking valproic acid because of the increased risk of spontaneous bleeding. C: The nurse should identify that hypothyroidism is an adverse effect of lithium rather than valproic acid.
Which of the following is a covert statement of suicidal ideation? A. "I don't want to be alive any longer." B. "I think every day about killing myself.' C. "My parents will be happier when i'm dead." D. "I won't have to deal with things much longer."
ANSWER: D
A nurse is preparing to administer a benzodiazepine to a pt. The nurse should tell the pt to expect which of the following adverse effects? A. Tinnitus (ringing of the ears) B. Bradycardia C. Halitosis (bad breath) D. Sedation
ANSWER: D - The nurse should tell the pt to expect sedation as an adverse effect of benzodiazepines because of the CNS depression effects. A: Tinnitus is not an adverse effect of benzodiazepines. B: Tachycardia, rather than bradycardia, is a potential adverse effect of benzodiazepines. C: Halitosis is not an adverse effect of benzodiazepines.
A nurse is assessing a pt prior to admin lithium. The pt has been taking lithium for a week for treatment of mania. Which findings should the nurse hold the dose for? A. Report of nausea with frequent episodes of vomiting B. Weight gain of 1.8 kg (4lb) since the start of treatment C. Fine hand tremors in both hands D. Serum lithium lvl of 1.1 mEq/L
ANSWER: A
A nurse is assessing a pt w/ bipolar disorder. Which action indicates the client is experiencing a manic stage? A. The pt speaks rapidly w/ a sense of urgency B. The pt touches everything within her reach C. The pt states she is unable to enjoy her favorite activities D. The pt moves slowly & maintains a fixed gaze
ANSWER: A
A nurse is caring for a pt w/ anorexia nervosa who has light skin. Which of the following findings should the nurse expect? A. Presence of lanugo B. Flushed skin tone C. Hyperactive bowel syndrome D. Clubbing of the fingers and toes
ANSWER: A
A nurse is caring for a pt who has borderline personality disorder. Which of the following should the nurse expect? A. Self- mutilation B. Submission C. Exploitation of others D. Reclusive behavior
ANSWER: A
A nurse is teaching a parent who has admitted to verbally abusing his children about stress management techniques/ Which of the following strategies is the nurse providing? A. Tertiary prevention B. Secondary prevention C. Family psychotherapy D. Primary prevention
ANSWER: A
Which action should the nurse take for the treatment of a pt who was just admitted with anorexia nervosa? A. Discuss the nutritional value of foods during meal times B. Weigh the pt 3 mornings per wk C. Allow the pt to exercise for up to 1 hr/ day D. Monitor pt for 1 hr following meals & snacks
ANSWER: D
A nurse is providing teaching to gaurdians of an adolescent who has bipolar disorder. Which of the following manifestations should the nurse identify as acute mania? (Select all that apply) A. Completes school projects B. Naps during the day C. Eats large amounts D. Spends excessive amounts of money E. Speaks crassly using a loud voice
ANSWER: D&E
Lanugo on skis is consistent with which ED? A. Anorexia nervosa B. Bulimia nervosa C. Binge eating disorder D. Pica
ANSWER: A
A nurse is planning care for a pt who has a physical dependence to alprazolam & must discontinue the medication. Which of the following actions does the nurse include in this plan? A. Taper the medication gradually over several weeks. B. Encourage participation in stimulating physical activity. C. Monitor the client for a return of anxiety for up to 72 hr following discontinuation of the medication. D. Implement restraints and seclusion as needed.
(BENZO) ANSWER: A - The nurse should plan to taper the dosage of alprazolam gradually over several weeks, possibly months. This gradual reduction in dosage reduces the manifestations of withdrawal B: The nurse should provide the pt with a calm, low-stimulation environment to decrease the anxiety and physical manifestations that can result from alprazolam withdrawal. C: The nurse should plan to monitor the pt for at least 3 weeks following discontinuation of the medication for a return of anxiety manifestations. D: It is not necessary to restrain or seclude the pt during withdrawal from alprazolam. Restraints are considered restrictive, and the nurse should work to promote the least restrictive environment.
A nurse is reviewing the med record of a pt who has a new prescription for tranylcypromine. The pt still has a current prescription for sertraline. The nurse should notify the provider because taking these medications concurrently increases the risk of which of the following adverse effects? A. Increased intracranial pressure B. Serotonin syndrome C. Acute kidney injury D. Hypertensive crisis
(MAOIs), (SSRIs) ANSWER: B
A nurse is caring for a pt who has depression & started taking paroxetine one week ago. The pt states to the nurse, "My family would be better off without me." Which of the following responses should the nurse make? A. "Why do you feel your family would be better off without you?" B. "Many people feel this way when they are depressed." C. "You sound upset. Are you thinking of hurting yourself?" D. "Your medication hasn't started working yet. Then you'll be feeling differently."
(SSRIs) ANSWER: C - This response exemplifies the therapeutic communication technique of showing empathy. Telling the pt, "You sound upset," focuses on the pts feelings, which is a demonstration of therapeutic communication. In addition, the nurse addresses the possibility of suicidal ideation by asking the pt directly whether or not she has an intent to harm herself. A: The nurse should avoid asking a "why" question, which blocks communication by promoting a defensive pt reaction. B: This response exemplifies the nontherapeutic communication block of using a cliché. Telling the pt that "many people feel this way" minimizes and takes the focus off of the pts feelings. D: This response exemplifies the nontherapeutic communication block of giving false reassurance. While the nurse is correct that antidepressant medications often take up to 3 weeks to take effect, there is no guarantee that the pt will feel better at that time.
Which behavior would a pt with antisocial personality disorder exhibit? A. Lack of remorse B. Self mutilation C. Delusional behavior D. Splitting
ANSWER: A
A nurse is reviewing the lab report of a client who has been taking lithium carbonate for several months. Which of the following levels should the nurse recognize as a therapeutic lithium level? A. 1.2 mEq/L B. 1.6 mEq/L C. 2.0 mEq/L D. 2.5 mEq/L
ANSWER: A - Is within expected reference range. Pts taking lithium should drink 6-8 glasses of water/ day to maintain a normal state of hydration & should also consume adequate sodium to prevent lithium tox.
A nurse is caring for a pt who is taking a tricyclic antidepressant. Which of the following adverse effects should the nurse report to the clients provider immediately? A. Dry mouth B. Constipation C. Drowsiness D. Urinary retention
ANSWER: D - Urinary retention can lead to bladder infection & ultimately loss of bladder tone. (Safety & risk reduction priority setting framework.) A: Dry mouth = common adverse effect but does not require immediate provider notification. The nurse should advise the pt to alleviate dryness by increasing fluid or chewing sugar free gum. B: Constipation = common adverse effect but does not require immediate provider notification.The nurse should advise the pt to increase fluid intake & dietary fiber. C: Drowsiness = common, temporary adverse effect but does not require immediate provider notification. The pt should be advised to avoid any activities that require alertness, such as driving a car.
A nurse receives a call on a crisis intervention hotline from a pt. Which of the following statements should the nurse identify as an overt statement indicating the client's risk for suicide? A. "Everything will be better soon." B. "Soon no one will have to worry about me." C. "There is no point in living any longer." D. "I want to donate my organs to help others."
The term 'covert' means hidden or concealed. Overt behaviors can be observed. ANSWER: C - The nurse should identify this pt comment as an overt statement about the client's risk for suicide. The nurse should assess the pts suicidal ideation further and implement interventions to promote their safety. A,B & D: The nurse should identify this pt comment as a covert statement.
A nurse is providing teaching for a pt who has a new prescription for diazepam. Which of the following instructions should the nurse include in the teaching? A. "Expect this medication to make you feel anxious." B. "This medication can be habit-forming." C. "Take this medication on an empty stomach." D. " This medication takes 2 - 3 wks to reach full therapeutic effect."
(BENZO) ANSWER: B - Diazepam is a benzodiazepine agent. All drugs in this category can cause physical dependence & are considered controlled substances. A: The nurse should instruct the pt to notify the provider immediately if paradoxical excitement occurs. C: The nurse should instruct the pt to take this med w/ food to decrease GI adverse effects. D: Benzo's work immediately by exerting a depressant effect on the central nervous system. Antidepressants are associated with a 2 - 3 wk delay before the pt experiences full therapeutic effect.
A nurse is providing teaching to a pt who has a new prescription for phenelzine. The nurse should teach the ot which of the following OTC medications can cause a hypertensive crisis when taken concurrently with phenelzine? A. Acetaminophen B. Ranitidine C. Naproxen D. Pseudoephedrine
(MAOIs) ANSWER: D - Pseudoephedrine (NASAL DECONGESTANT) interacts with the MAOI medications & is therefore contraindicated. Ingesting products containing ephedrine along with phenelzine can precipitate a hypertensive crisis. A: Acetaminophen, a pain reliever, is not contraindicated for concurrent use with MAOI meds. B: Ranitidine is used for gastric ulceration & is not contraindicated for concurrent use with MAOI meds. C: Naproxen, an NSAID for mild to moderate pain, is not contraindicated for concurrent use with MAOI meds.
A nurse is providing discharge teaching for a pt who has a new prescription for doxepin. Which of the following adverse effects should the nurse inform the client is associated with this medication? A. Weight loss B. Diarrhea C. Drowsiness D. Bradycardia
(TCA) ANSWER: C - The nurse should inform the pt that drowsiness if one of the most common side effects of doxepin. A: Weight gain = an adverse side effect of doxepin B: Constipation = an adverse side effect of doxepin C. Tachycardia = an adverse side effect of doxepin
A nurse is counseling a pt who seems relaxed initially, but then becomes restless & begins wringing his hands. The nurse states that the pt seems tense, and the pt agrees. Which of the following statements should the nurse make? A. "Did I say something wrong that made you feel tense?" B. "Do you often feel tense when you are talking to a healthcare provider?" C. "What were we discussing when you began to feel uncomfortable?" D. "It is ok to feel nervous during our counseling sessions."
ANSWER: C - The nurse should use the therapeutic technique of focusing, which promotes discussion about a specific topic. This technique helps identify the cause of the pts feelings and promotes further communication. A & B: The nurse should avoid using closed-ended questions that block pt communication. D: The nurse should avoid providing approval for and assuming the cause of the pts feelings. These responses are nontherapeutic and block pt communication.
A nurse is admitting a pt following care in the emergency department for an intentional overdose of opioids. The pt states, "I feel so alone. No one can help me." Which of the following responses by the nurse is therapeutic? A. "Lets finish your admission and then talk about your feelings." B."How come you feel that no one can help you when you are receiving help now?" C. " Why do you feel that no one can help you?" D. "I would like to sit & talk wit you."
ANSWER: D - The nurse should use the therapeutic communication technique of offering oneself to demonstrate caring & interest in the pt & the pts feelings. A: The nurse should avoid using non therapeutic communication that changes the focus away for the pts feelings & blocks further communication. B: The nurse should avoid using non therapeutic communication that makes a value judgment on the pts feelings & blocks further communication. C: The nurse should avoid using non therapeutic communication that asks the pt a "why" question, which promotes a defensive pt response.
A nurse is caring for a pt w/ borderline personality disorder who has been engaging in self-mutilation. The nurse should encourage the pt to participate in which of the following groups? A. Co-dependents support group B. National alliance on Mental Illness C. Dialectical behavior treatment group D. Dual diagnosis treatment group
ANSWER: C
A nurse is teaching a pt who has seasonal affective disorder (SAD) about the use of light therapy. Which of the following statements should the nurse make? A. "Light therapy suppresses the natural night time release of melatonin." B. "You should plan your light therapy session before going to bed." C. "You should begin with 2- min light therapy session & gradually progress to 10 min sessions." D. Light therapy is less effective at treating SAD than antidepressant medications."
ANSWER: C
Following ECT, which action should the nurse take first? A. Admin oxygen B. Admin an anticonvulsant B. Admin an opioid antagonist D. Admin IV fluids
ANSWER: A
A nurse is establishing a therapeutic relationship with a pt who has hallucinations. Which of the following actions should the nurse take during the orientation phase? A. Identify the client's perception of the reason for therapy B. Ask the client to provide a detailed description of the hallucinations. C. Assist the client with the development of problem-solving skills. D. Explore the client's relationship with family members.
ANSWER: A - In the initial, orientation phase of the nurse-client relationship, the nurse should establish rapport and confidentiality with the pt. The nurse should assess the pts beliefs about the reason for therapy. B: The nurse should gather further data, including a detailed assessment of the pts hallucinations, during the working phase of the therapeutic nurse-client relationship. C: The nurse should assist the pt with the development of problem-solving skills during the working phase of the therapeutic nurse-client relationship. D: The nurse should gather further data, including an assessment of the pts family relationships, during the working phase of the therapeutic nurse-client relationship.
A nurse in the emergency department is caring for a toddler who has a fractured arm. Which of the following should the nurse identify as possible indication of physical abuse? A. The parent provides a history that is inconsistent with the child's injury. B. The child is brought to the emergency department immediately following the injury. C. The parent requests to remain present with the child throughout treatment of the injury. D. The child clings to the parent when the nurse begins to assess the injury.
ANSWER: A - The nurse should suspect possible abuse when the child's injury conflicts with the history of the injury that is reported by his parent. B: The nurse should suspect possible abuse when there is a delay in seeking medical care following an injury. C: The nurse should suspect possible abuse when the parent leaves the treatment area or facility after bringing the child in for treatment of an injury. D: The nurse should suspect possible abuse if the child displays fear of the parent.
Which approaches should a nurse use to manage the behavior of a pt w/ antisocial personality disorder who is becoming increasingly loud and belligerent? A. Confront the pt about breaking the rules B. Stand near the pt to offer comfort and support C. Speak to the pt with clear, calm, caring statements D. Escort the pt to the nurses station
ANSWER: C
A nurse at an acute MH facility is caring for a pt who has acute mania due to bipolar disorder. At 0300, the pt runs to the nurses station & demands to see the provider immediately. Which of the following responses should the nurse make? A. "Your request is unreasonable. We cannot call your provider at 3:00 in the morning." B. "If you can calm down for 5 minutes then I will call your provider for you." C. "Calm down, go back to your room, and come back in 15 minutes and we'll talk about how you're feeling." D. "You must be very upset about something to want to see your provider in the middle of the night."
ANSWER: D - The nurse should respond to the pts concern with empathy, which shows concern for the pts feelings and offers an opportunity for the pt to clarify the situation. A: The nurse should avoid using nontherapeutic communication that indicates disapproval and blocks further communication. Depending on the pts needs, it might be necessary for the nurse to contact the pts therapist regardless of the time. B: The nurse should clearly state expectations for the pts behavior and avoid bargaining with the pt, which can result in power struggles. C: The nurse should promptly address the pts concerns and should avoid giving several directions at once, which can be confusing and difficult to follow for a pt who is experiencing acute mania.
A nurse is planning to administer a dose of lithium carbonate to a pt who has bipolar disorder. The lab report indicates that the pts current lithium lvl is 1.0 mEq/L. Which of the following actions should the nurse take? A. Contact the provider for a dose increase. B. Request a repeat of the lithium lvl. C. Administer the medication. C. Prepare the pt for gastric lavage.
Maintenance lvl: 0.6-1.2 Initial lvl: 1 - 1.5 ANSWER: C - The nurse should administer the med bc the lvl is within the expected reference range. A: The lvl is within the expected reference range; therefore there is NO indication for the nurse to contact the provider & increase the dose. B: There is no indication for the nurse to request a repeat of the lvls. Requesting a repeat would be indicated if the lvl were between therapeutic & toxic bc there such a small increment exists btw the two. D. There is no indication for the nurse to prepare the pt for gastric lavage. Gastric lavage is an intervention that would be indicated if the pts lithium lvls were toxic.
A nurse is providing teaching for a patient who has a new prescription for alprazolam. Which of the following is the priority information the nurse should include in this teaching? A. This medication can affect your ability to drive or handle mechanical equipment. B. You should avoid drinking beverages that contain caffeine with this medication. C. You should avoid taking antacids within 2 hours of this medication. D. This medication should be taken shortly after meals.
(BENZO) ANSWER: A. - Safety & risk reduction is priority factor in this situation. B: consumption of caffeine can decrease desired action of this med but its is not priority. C: Antacids can delay absorption but is not the priority. D: While taking this med with or shortly after meals can reduce GI discomfort, not the priority.
A nurse is assessing a pt who takes phenelzine for the treatment of depression. Which of the following findings is the priority for the nurse to report to the provider? A. Elevated BP B. Weight gain C. Muscle twitching D. 2+ peripheral edema
(MAOIs) ANSWER: A - The nurse should identify that the greatest risk to the pt is an elevated blood pressure, which increases his risk for a hypertensive crisis that can result from taking an MAOI, such as phenelzine. The nurse should apply the safety and risk reduction priority-setting framework. B: Weight gain as a common adverse effect of an MAOI, such as phenelzine. The nurse should report the adverse effect to the provider; however, there is another finding that is a greater risk to the client than weight gain. C: Muscle twitching as a common adverse effect of an MAOI, such as phenelzine. The nurse should report the adverse effect to the provider; however, there is another finding that is a greater risk to the client than muscle twitching. D: Peripheral edema as a common adverse effect of an MAOI, such as phenelzine. The nurse should report the adverse effect to the provider; however, there is another finding that is a greater risk to the client than peripheral edema.
A nurse in a MH facility is meeting with a pt who has a diagnosis of major depression. During the conversation, the pt stops speaking and the nurse sits silently next to the pt for several minutes. The nurse should identify that the therapeutic communication technique of silence is used for which of the purposes? A. To show approval of the pts desire not to talk B. To give the pt time to evaluate the nurse C. To encourage the pt to express feelings or concerns D. To prevent the nurse from making a non therapeutic response
ANSWER: C
A nurse is caring for a pt who has depression. The pt states, "I am too tired and too depressed to attend group therapy today." Which of the following responses should the nurse make? A. "Attending group therapy, even if you're tired, is an important part of your treatment." B. "That's okay if you're too tired to attend group therapy today, but you will have to go tomorrow." C. "It is normal to feel tired when you're feeling depressed. The others in group therapy also feel this way." D. "I agree with your decision to wait for participation in group therapy until you begin to feel better."
ANSWER: A - The nurse provides a therapeutic response by giving the pt information to make an informed decision. Group therapy is beneficial to the pt who has depression by promoting peer support and reducing social isolation. B: The nurse should recognize that a lack of energy is expected for a pt who has depression. There is no indication that the pt will have more energy for group therapy in the future. The nurse should also respect the pts autonomy and avoid giving a directive about required participation. C: The nurse should avoid minimizing the pts feelings by making a generalization about her status in relation to others. D: The nurse should avoid giving approval to the pts decision, which promotes the need for her to please the nurse. The nurse should also encourage her to participate in group therapy to promote improvement of her depression.
A nurse is caring for a pt at a college MG counseling center. The pt received a failing grade in a course and spends the entire session blaming the teacher. The nurse should recognize this behavior as an example of which of the following defense mechanisms? A. Projection B. Dissociation C. Undoing D. Compensation
ANSWER: A - The nurse should identify that a pt is using projection when unconsciously transferring unacceptable feelings, thoughts, or traits in oneself onto another person. This response is maladaptive because it prevents the pt from accepting responsibility for personal performance in school. B: The nurse should recognize that the pt is not using the defense mechanism of dissociation, which results in the pts compartmentalization of undesirable personal attributes. C: The nurse should recognize that the pt is not using the defense mechanism of undoing, which results in the pts attempt to make up for an unacceptable action. D: The nurse should recognize that the pt is not using the defense mechanism of compensation, which results in the pts attempt to focus on a strength to compensate for a perceived weakness.
A nurse is caring for a school-age pt who begins wetting the bed after finding out that her parents are getting a divorce. The nurse should identify that the pt is exhibiting which of the following defense mechanisms? A. Regression B. Projection C. Repression D. Splitting
ANSWER: A - The nurse should identify that regression represents a dysfunctional attempt to reduce anxiety and conflict by returning to less mature behaviors that help the pt better tolerate the anxiety. B: Projection is the unconscious rejection of unacceptable features in oneself by attributing them to others. C: Repression is the unconscious removal of thoughts or memories from one's awareness. D: Splitting is the inability to integrate the positive and negative qualities of oneself or others into a combined idea.
A nurse is caring for a pt that has borderline personality disorder. The pt has previously identified another nurse as his favorite stating, "He is the best nurse ever." When that nurse calls in sick, which of the following statements indicated the pt is using slitting as a method of coping? A. "He's the worst nurse that's ever taken care of me." B. "You're just lying to me. He's not really sick." C. "He's my favorite nurse and I'm really worried about him." D. "If anyone else tries to take care of me, I'm going to get really upset."
ANSWER: A - The nurse should identify that the pt is using splitting when he relates to others as if they are all good or all bad, rather than as integrated individuals who have both positive and negative attributes. Pts who have borderline personality disorder might use this coping style as a defense mechanism B: The nurse should identify this pt statement as an expression of paranoia and denial. C: The nurse should identify this pt statement as an expression of concern. D: The nurse should identify this pt statement as an expression of anger, which is expected for a pt who has borderline personality disorder.
A nurse is planning a staff education session about the admin of antidepressant medications in older adults. Which of the following info should the nurse include in the teaching? A. Older adult pts require a lower initial dose of antidepressant medication than adult pts. B. Older adult pts should not receive antidepressant medication. C. Older adult pts achieve the therapeutic effects of antidepressant medications more quickly than adult pts. D. Older adult pts have a decreased risk for adverse effects from antidepressant medication.
ANSWER: A - The nurse should recognize that older adult pts are recommended to start at half the adult dose for antidepressant medications. This is due to altered rates of absorption and the increased risk for adverse effects. B: The nurse should identify that antidepressant medications are commonly prescribed for older adult pts; however, adjustments are needed due to the pts' altered rates of absorption. C: The nurse should identify that older adult pts have a decreased rate of absorption, distribution, and metabolism, resulting in a delay in achieving therapeutic effects. It can take about 1 month of treatment for the older adult pt to achieve therapeutic effects. D: The nurse should identify that older adult pts have an increased risk for adverse effects due to a decreased rate of excretion.
A nurse in a MH unit sis planning care for a pt who is receiving treatment for self-inflicted injuries. The nurse should identify which of the following interventions as the priority when planning care for this pt? A. Promoting and maintaining pt safety B. Discussing reasons for the pts behavior C. Assisting the pt to recognize feelings D. Teaching the pt alternative coping strategies
ANSWER: A - The nurse should recognize that the pt who has self-inflicted injuries is at risk for further self-harm or suicide; therefore, the pts safety is the priority. The nurse should apply the safety and risk reduction priority-setting framework when planning care for this pt. B: The nurse should communicate with the pt to discuss reasons for the pts behavior; however, there is another action that is the priority. C: The nurse should assist the pt to recognize feelings; however, there is another action that is the priority. D: The nurse should teach the pt alternative coping strategies; however, there is another action that is the priority.
A nurse is assessing a pt who has major depressive disorder. The pt states, "I might as well be dead. I have always been a failure." Which of the following responses should the nurse make? A. "Why do you think you feel this way." B. "You have a great deal to offer in life." C. "Let's discuss these feelings further." D. "Feeling like a failure is expected with depression."
ANSWER: C
A nurse is evaluating the plan of care for a pt who has antisocial personality disorder. Which of the following pt actions indicates that he is making progress with the treatment? (Select all that apply) A. Assisting another pt who has depression to fill out a menu. B. Nominating himself to chair the pt government meeting. C. Requesting a weekend pass to go home is correct D. Serving as the judge for a unit talent show. E. Informing the nurse that the staff provides excellent care to clients.
ANSWER: A & C - A: Pts who have antisocial personality disorder tend to lack empathy for others and often display an inability to connect with others. Assisting another pt indicates the pts willingness to help and connect with others and demonstrates to the nurse his progress with treatment. - C: Pts who have antisocial personality disorder tend to disregard rules and have a lack of respect for authority. Requesting a weekend pass indicates the pts willingness to follow unit rules and demonstrates to the nurse his progress with the treatment. B: Pts who have antisocial personality disorder tend to see themselves as superior to others. Providing a self-nomination for chairperson status places him in a position of power over others; therefore, this behavior does not indicate progress with the treatment. D: Pts who have antisocial personality disorder tend to see themselves as superior to others. Serving as a judge places the pt in a position of power over others; therefore, this behavior does not indicate progress with the treatment. E: Pts who have antisocial personality disorder often use flattery as a form of manipulation to promote personal gain; therefore, providing a compliment to the nursing staff does not indicate progress with the treatment.
A nurse in an outpatient facility is assessing a 3 month old infant who has weight loss and injuries that indicate physical abuse. While preparing to interview the parent, which of the following actions should the nurse take? A. Insist that the parent tell the nurse how the child was injured B. Tell the parent that protective services has been notified C. Show disapproval to the parent regarding the condition D. Call at least 2 other staff members to sit in the room during the interview
ANSWER: B
A nurse is caring for a pt who spent the past several minutes mumbling about being "doomed to die" and is now pacing in an increasingly agitated and angry manner. Which of the following actions should the nurse take first? A. Admin PRN med for agitation B. Attempt to reduce environmental stimuli C. Request a prescription for physical restraints D. Place the pt in seclusion
ANSWER: B
A nurse is caring for a pt whos has antisocial personality disorder. Which nursing action should the nurse take? A. Encouraging the client to attend assertive behavior session B. Ensure staff members set limits on the pts behavior C. Tell the pt to increase socialization on the unit D. Frequently implement measures to increase the pts self-esteem
ANSWER: B
A nurse overhears a pt say she has plans to harm her father in law when discharged. Which intervention should the nurse take? A. Ask the pt to sign a contract agreeing not to harm others B. Notify the provider of the pts threat C. Keep the pts discussion confidential D. Place the pt in individual observation
ANSWER: B
Which statement shows a guardian understands teaching for their adolescent daughter who has bulimia nervosa? A. "My daughter is at risk for dev high blood pressure." B. "It is important for my daughter to have regular dental check ups." C. "I should weigh my daughter daily for several weeks." D. "Bleeding during my daughters periods will increase."
ANSWER: B
A nurse is admitting a pt who has an antisocial personality disorder to an acute care unit. The client is admitted under court order following theft & destruction of a car. Which of the following behaviors should the nurse expect the pt to display? A. Relief about finally receiving care for a problem for which he was previously afraid to ask for help B. Anger with the nursing staff for hospitalizing him against his will C. Withdrawal from others due to shame over his recent actions D. Remorse for stealing and destroying the car
ANSWER: B - A pt who has antisocial personality disorder exhibits a low frustration level and can quickly become angry and aggressive when the situation goes against his will or desires. A: A pt who has antisocial personality disorder exhibits a pattern of irresponsible behavior that lacks morals and ethics and brings the pt into conflict with society. The pt views this behavior as justified and does not perceive the need for help. C: Pts with antisocial behavior do not view their own behavior objectively and rarely experience any anxiety or guilt over their actions. D: Pts who have antisocial behavior usually display a sense of entitlement and rarely express any remorse for their illegal or unethical actions.
A nurse is obtaining a pts medical history prior to scheduling the pt for electroconvulsive therapy (ECT). Which of the following finding should the nurse identify as a potential complication of the procedure? A. Severe depression B. Cardiac arrhythmia C. Bipolar disorder D. Parkinson's disease
ANSWER: B - A pt who has cardiac arrhythmias needs further evaluation. The nurse should identify that the greatest risk for death due to ECT is related to cardiac complications. A: A pt can receive ECT for treatment of severe depression. C: A pt can receive ECT for treatment of bipolar disorder. D: A pt can receive ECT for treatment of Parkinson's disease.
A school nurse is caring for an adolescent ot who has a history of a depressive episode a year ago. He appears withdrawn from social activities & his school performance is declining. Which of the following actions should the nurse take first? A. Initiate a structured daily schedule of activities. B. Conduct a suicide - risk assessment. C. Encourage the pt to express his feelings in a journal. D. Ask teachers to monitor for other sign of depression.
ANSWER: B - The nurse should apply the safety & risk reduction priority-setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the pt. A: The nurse should initiate a structured daily schedule, however, there is another action the nurse should take first. C: The nurse should encourage the pt to keep a journal to express his feelings, however, there is another action the nurse should take first. D: The nurse should ask teachers to monitor the pt for other signs of depression and changes in mood, however, there is another action the nurse should take first.
A nurse is assessing a pt who has anorexia nervosa. The nurse should expect the pt to display which of the following characteristics? A. Refuses to participate is phys. exercise activities. B. Possesses feelings of decreased self-worth. C. Preoccupied with concerns about personal health. D. Avoids discussion of food.
ANSWER: B - The nurse should expect the pt who has anorexia nervosa to have an altered sense of self-image and self-identity. The pt often bases feelings of self-worth on body weight; therefore, feelings of self-worth are often decreased because the pt views herself as overweight. A: The nurse should expect the pt who has anorexia nervosa to participate in a rigorous exercise routine to promote increased weight loss. C: The nurse should expect the pt who has anorexia nervosa to have medical complications due to decreased body weight and malnutrition. The pt who has anorexia nervosa is focused on weight without regard to personal health consequences. D: The nurse should expect the pt who has anorexia nervosa to be obsessed with thoughts of food despite the personal restrictions on intake.
A nurse is interviewing a pt who has anorexia nervosa. Which of the following findings should the nurse expect? A. Poor personal hygiene habits B. Strenuous exercise regimen C. Grandiose behaviors D. Intense fear of death
ANSWER: B - The nurse should expect the pt who has anorexia nervosa to report a strenuous exercise regimen. The pt might participate in excessive physical activity due to the perceived need to burn calories and lose weight. A: The nurse should not expect the pt who has anorexia nervosa to have poor personal hygiene habits. Pts who have anorexia nervosa often exhibit compulsive behaviors, such as frequent handwashing, and are preoccupied with their appearance. C: The nurse should expect pts who have anorexia nervosa to have poor self-esteem and negative feelings about themselves. D: The nurse should expect the pt who has anorexia nervosa to have an intense fear of gaining weight. Pts who have anorexia nervosa exhibit behaviors that have negative health consequences in order to prevent weight gain.
A nurse is assessing a pt who has binge- eating disorder. Which of the following findings should the nurse expect? A. Amenorrhea B. Abdominal pain C. Restricted caloric intake D. Frequent use of laxatives
ANSWER: B - The nurse should expect the pt who has binge-eating disorder to report problems with abdominal pain. This is due to the gastrointestinal dilation that occurs as a result of eating excessive volumes of food. A: Pts who have binge-eating disorder often have an increased BMI; therefore, amenorrhea resulting from a low body weight is not expected. C: Pts who have binge-eating disorder often have an increased BMI resulting from eating excessive volumes of food. D: Pts who have binge-eating disorder have repeated episodes of binging without the use of compensatory behaviors, such as the use of laxatives.
A nurse in a pediatric emergency department is caring for four pts. The nurse should suspect possible abuse with which of the following pts? A. A 14-month-old toddler who has recently learned to walk and has many bruises on bony prominences in various stages of healing. B. A 9-month-old infant who reportedly nearly drowned after climbing into the tub and turning on the water. C. A 6-year-old toddler who has a fracture of the tibia and fibula, which reportedly occurred while riding a bicycle. D. A 3-year-old toddler who has burns in a splash pattern over the face and chest, reportedly sustained when a tablecloth was pulled, spilling a teapot.
ANSWER: B - The nurse should identify that, while a 9-month-old might have the ability to climb into the tub, it is unlikely that he could turn the water on. The nurse should suspect possible abuse because the reported cause of the accident seems inconsistent with the developmental abilities of most 9-month-old infants. A: Toddlers have recently mastered walking and experience many falls and collisions. Because the bruises are in various stages of healing and are located over bony prominences, this likely indicates falling on several occasions. C: Fractures can be caused by physical abuse, but this 6-year-old child is learning to ride a bicycle. This injury is consistent with having a fallen off of a bicycle. D: The history is consistent with the injury. Toddlers frequently help pull themselves up by pulling on objects that might be unstable. The splash of burns would occur from the head downward.
A nurse is planning care for a pt who has thoughts of suicide. Which of the following goals should the nurse include in the pts plan of care? A. The pt will identify positive aspects of others. B. The pt agrees to notify a staff member of thoughts of self-harm. C. The pt will engage in an independent diversional activity. D. The pt will not verbalize thoughts or feelings related to suicide.
ANSWER: B - The nurse should instruct the pt to notify staff if he has suicidal thoughts so that the pts needs are immediately addressed and actions are taken to prevent self-injury or suicide. A: The nurse should assist the pt to identify positive aspects about himself to improve the pts sense of self-worth. C: The nurse should encourage the pt to participate in activities with others to decrease the pts sense of isolation. D: The nurse should encourage the pt to verbalize thoughts and feelings related to suicide rather than suppress them.
A nurse in an emergency department is caring for an 18 month old toddler who has a fractured left femur. Which of the following statements by the toddler's parent should cause the nurse to suspect child abuse? A. "My child fell down the stairs." B. "My child was riding a bicycle & fell off." C. "My child slipped out of the high chair." D. "My child climbed up on a chair & it tipped over."
ANSWER: B - The nurse should suspect possible child abuse in response to this statement because an 18-month-old toddler is not expected to have the developmental ability to ride a bicycle. A, C & D: The nurse should identify that 18-month-old toddlers are at a high risk for accidental injury due to falls because of increased mobility and curiosity; therefore, this report by the parent does not indicate child abuse.
A nurse is caring for a pt who has depression. The nurse observes that the pt has not come to breakfast and is still in bed. The client states, "I'm not worth your time. Leave me alone and go help someone else." Which of the following responses should the nurse make? A. "Many people feel this way when they first start treatment." B. "In other words, you seem to be saying that you feel unworthy of help." C. "You'll feel better once you get up and have some breakfast." D. "I disagree with your feeling that you are not worth my time."
ANSWER: B - The nurse should use the therapeutic technique of paraphrasing to clarify the pts statement and promote further communication. A: The nurse should avoid using nontherapeutic communication that minimizes the pts feelings. C: The nurse should avoid using nontherapeutic communication that provides false reassurance. D: The nurse should avoid using nontherapeutic communication that offers disapproval of the pts feelings.
A nurse is planning a menu for a client wo has bipolar disorder & is experiencing an acute manic episode. Which of the following meals should the nurse provide for this client? A. Spaghetti & meatballs, a salad, and apple pie. B. Beef & vegetable stew, rice & vanilla pudding. C. Chicken nuggets, crackers with cheese sticks, and a cookie. D. Broiled fish filets, stewed tomatoes, and ice cream.
ANSWER: C - A nurse who is caring for a pt who is in the manic phase of bipolar disorder should provide them with high- caloric finger foods that can be carried & are relatively easy to manipulate. This meal is a good choice for a pt who is hyperactive, has a short attention span, & might not sit down to eat. A: A pt who is in the manic phase of bipolar disorder has a short attention span & might not be able to manipulate this meal, therefore, the client might give up before finishing. B: A pt who is in the manic phase of bipolar disorder will not be able to sit & concentrate on this type of meal. A pt who has a short attention span & low frustration tolerance might not eat this meal. D: A pt who is in the manic phase of bipolar disorder is hyperactive & has a limited attention span. This pt will do better with foods that are easy to manipulate & require little concentration to eat.
A nurse is planning care for a pt with borderline personality disorder who self - mutilates. Which of the following treatment approaches should the nurse plan to take? A. Restrict participation in group therapy sessions. B. Establish consequences for self-mutilation. C. Maintain close observation of the client. D. Provide an unstructured environment.
ANSWER: C - Pts who have borderline personality disorder are at risk for self-harm during times of increased anxiety. Maintaining close observation reduces the pts risk of injury. A: The nurse should encourage the pt who has borderline personality disorder to participate in group therapy sessions to encourage appropriate interaction with other pts. B: The nurse should respond to self-mutilation with a neutral affect and encourage the pt to write down feelings that occurred leading up to the incident. D: Providing an unstructured environment for a pt who has borderline personality disorder is not an effective treatment approach because it does not provide a safe environment to protect the pt from impulsive and self-injurious behavior.
A nurse is caring for a pt who attempted suicide & refuses to sign a no-suicide contract. Which of the following actions should the nurse take when implementing suicide precautions? A. Assign the pt to a private room. B. Request the dietary department provide the pt with finger foods. C. Place the pt on one to one observation. D. Keep the door to the pts room closed.
ANSWER: C - The nurse has both a legal and professional responsibility to provide a safe environment for the pt who is at risk for suicide. The pt who is at high risk for suicidal behavior requires constant one-to-one observation to ensure safety. A: The nurse should avoid placing the pt in a private room, where there is an increased opportunity for the pt to harm himself. B: The nurse should provide the pt with plastic rather than metal utensils to decrease the risk for self-harm; however, it is not necessary to provide finger foods. D: The nurse should avoid closing the door to the pts room, which gives the pt an increased opportunity to harm himself.
A nurse is caring for a pt who has major depressive disorder & recently started taking an antidepressant. The nurse should identify which of the following pt statements as the priority? A. "I hate being so helpless. I can't even manage my own finances anymore." B. " At group therapy today I wanted to leave. I didn't like being with other people." C. " I have it all figured out. Everything is going to be okay now." D. " I don't feel like showering. I'd rather just stay in bed today."
ANSWER: C - The nurse should apply the safety risk reduction priority-setting framework. Therefore, the nurse should identify the pts statement as the priority because it indicates a possible plan for suicide. This reaction is possible after starting an antidepressant, when the client gains the energy to act upon suicidal thoughts. A: The nurse should identify inability to perform daily tasks & low self-esteem as an expected findings of depression. The nurse should explore this statement further & plan interventions to raise the pts self-esteem; however, there is another statement that should be addressed first. B: The nurse should identify social withdrawal as an expected finding of depression. The nurse should explore this statement further & encourage participation in group therapy; however, there is another statement that should be addressed first. D: The nurse should identify neglect of personal hygiene & withdrawal as an expected finding of depression. The nurse should explore this statement further & encourage personal hygiene; however, there is another statement that should be addressed first.
A nurse is developing a plan of care for a pt who has anorexia nervosa. The nurse should identify that which of the following actions is contraindicated for this pt? A. Explaining that tube feedings are necessary if the pt refuses oral intake. B. Weighing the pt each day prior to any oral intake. C. Permitting the pt to spend some quiet time alone after each meal. D. Refraining from commenting about the pts eating during meal times.
ANSWER: C - The nurse should directly observe the pt for a minimum of 1 hr following meals. This intervention prevents the pt from purging or discarding hidden food. Therefore, permitting the pt to have alone time following meals is contraindicated for his plan of care. A: The nurse should inform the pt that he might require tube feedings to provide adequate nutritional intake if oral intake is inadequate. This intervention is not intended to be punitive but to ensure the pts safety. B: The nurse should weigh the pt each day prior to any oral intake to obtain accurate data and to monitor his progress toward weight gain goals. D: The nurse should encourage conversation during meals to promote a pleasurable eating environment; however, the nurse should avoid the topics of eating and food, which can increase the pts level of anxiety.
A nurse is assessing a pt who experienced a sexual assault 6 months ago. Which of the following finding should the nurse report to the provider as an indication of rape- trauma syndrome? A. Flat affect B. Refusal to accept help from others C. Report of intense guilt D. Denial of the sexual assault
ANSWER: C - The nurse should expect the pt who has rape-trauma syndrome to experience guilt about the sexual assault. These feelings of guilt can delay the healing process and produce a sustained and maladaptive response. A: The nurse should expect the pt who has rape-trauma syndrome to experience mood swings and intense emotions. B: The nurse should expect the pt who has rape-trauma syndrome to exhibit dependence toward others. D: The nurse should expect a pt to have denial immediately following a sexual assault; however, this is not a characteristic of rape-trauma syndrome.
A nurse in an acute MH facility is caring for a pt who is experiencing an acute manic episode. Which of the following actions is the nurse's priority? A. Maintain the pts contact with her family. B. Discourage the pts use of vulgar language. C. Protect the pt from impulsive behavior. D. Redirect excessive energy to creative tasks.
ANSWER: C - The nurse should protect the pt who is manic from impulsive behavior that puts the pt at risk for self-harm. The nurse should apply the safety and risk reduction priority-setting framework. A: The nurse should assist all acute care pts in maintaining contact with family during treatment; however, there is another action that is the priority. B: The nurse should discourage behaviors that disrupt the therapeutic milieu; however, there is another action that is the priority. D: The nurse should redirect the pts energy into a calming and constructive activity; however, there is another action that is the priority.
A nurse is reviewing the med record of a pt who has a new prescription for a benzodiazepine. For which of the following findings should the nurse question the provider's prescription? A. A skeletal muscle injury B. History of status epilepticus C. Hypotension D. Insomnia
ANSWER: C - The nurse should question the provider's prescription for a benzodiazepine for a pt who has hypotension. Benzodiazepines can cause severe hypotension and increase the client's risk for cardiac arrest. A: Benzodiazepines have muscle relaxant properties and can relieve muscle spasms; therefore, a skeletal muscle injury is not a contraindication for receiving benzodiazepines. B: Benzodiazepines can raise the seizure threshold and prevent seizures; therefore, a history of status epilepticus is not a contraindication for receiving benzodiazepines. D: Benzodiazepines induce sleep for clients who have a sleep disorder; therefore, insomnia is not a contraindication for receiving benzodiazepines.
A nurse enters a pts room & observes that the pt is agitated & pacing rapidly. The pt looks at the nurse and says, "Back off, leave me alone." Which of the following statements should the nurse make? A. "I demand that you calm down now. Your behavior is unacceptable." B. "I will close the door to provide privacy, and you can tell me what is bothering you." C. "I will give you space if you calm down. Tell me what is causing you so much stress." D. "I will leave you alone for a few minutes while you try to control yourself."
ANSWER: C - The nurse should stay a safe distance & remain calm while stressing the importance of maintaining control. The nurse should use verbal de-escalation techniques while determining the pts needs & respecting the pts personal space. A: The nurse should avoid confrontational communication that will likely increase the pts lvl of agitation. B: The nurse should consider staff safety when attempting to calm the pt. By closing the door, the nurse does not have an escape route should the pt become violent. D: The nurse should avoid leaving the pt alone while they are in an agitated state & a potential danger to themselves. If oter de-escalation techniques are ineffective, then the nurse might implement seclusion in a safe & monitored environment.
A nurse is interviewing an older adult pt about possible abuse by her caregiver. Which of the following techniques should the nurse use? A. Avoid directly asking the client if she has been abused. B. Use a confrontational approach. C. Maintain a nonjudgmental tone. D. Avoid being in the room alone with the client.
ANSWER: C - The nurse should use a nonjudgmental tone to promote trust and communication. A: The nurse should ask the pt directly about possible abuse to identify the pts physical, emotional, and safety needs. B: The nurse should avoid a confrontational approach, which can raise the pts defensive barriers and potentially block further communication. D: The nurse should conduct the interview in private to provide a calm and safe environment.
A nurse in an emergency department is caring for a female pt who has ecchymosis (discoloration of the skin resulting from bleeding underneath, typically caused by bruising) of the trunk & face. The pt reports that her partner hit her, causing the injuries. When offered information about shelters for intimate partner violence, the client declines, stating, "I could never leave my husband because of my kids." Which of the following responses should the nurse make? A. "Aren't you worried about the safety of your children?" B. "Can you identify your behaviors that provoke your partner?" C. "The next time this occurs, what might you do to ensure your safety?" D. "You need to remove yourself and your children from the abusive situation."
ANSWER: C - The nurse should use the therapeutic communication technique of encouraging formulation of a plan of action. With this technique, the nurse encourages the pt to explore alternative actions to ensure her safety if abuse occurs in the future. The nurse should assist the pt to develop a safety plan, which includes information about shelters, so that she has the information if she chooses to leave in the future. A: The nurse should avoid making responses that are judgmental and might make the pt defensive about her abilities as a mother to protect her children. B: The nurse should avoid making responses that imply that the pt is somehow to blame for the abuse. D: The nurse should avoid offering an opinion or advice, which is a nontherapeutic communication technique that blocks further dialogue with the pt.
A nurse at a college campus health clinic is caring for a pt who reports manifestations of bulimia nervosa. The pt tells the nurse, "I know my eating binges and vomiting are not normal, but I cannot control it." Which of the following responses should the nurse make? A. "Why do you think you are experiencing these behaviors of binges and vomiting?" B. "Are other students in your dorm also experiencing this behavior?" C. "You are feeling helpless about changing this behavior?" D. "You know you must stop because you are endangering your health."
ANSWER: C - The nurse should use the therapeutic communication technique of restating when responding to the feelings the pt has expressed. Restating focuses on the main idea of the pts statement and helps the pt understand and explore personal behaviors. A: The nurse should avoid the nontherapeutic use of a "why" question, which can promote a defensive pt response and block further communication. B: The nurse should avoid the use of a closed-end question that takes the focus off of the pt. D: The nurse should avoid offering premature advice, which implies that the nurse knows what is best for the pt and blocks communication and the pts use of independent problem solving.
A nurse in a MH clinic is caring for a pt who has bipolar disorder & states, "I no longer take my medication because I like the feeling of being manic." Which of the following responses by the nurse is an example of therapeutic communication? A. "You might feel good now, but what about when you get depressed?" B. "Why do you think you like feeling manic?" C. "You feel better when you don't take your medication?" D. "What do you think your provider will say about you going off your medication?"
ANSWER: C - The nurse should use the therapeutic communication tool of validating or clarifying the pts feelings. The pt has stated a preference for not taking the medication. This open-ended paraphrasing acknowledges the pts statement and allows for further exploration of the subject. A: The nurse should avoid nontherapeutic communication that minimizes the pts current feelings. B: The nurse should avoid nontherapeutic communication that promotes a defensive pt response. D: The nurse should avoid nontherapeutic communication that takes the focus from the pt and puts it on the provider.
A nurse is reviewing the medications for a pt who has bipolar disorder and a new prescription of lithium. The nurse should identify that it is safe to admin which of the following medications while the pt is on lithium? A. Ibuprofen B. Haloperidol C. Valproic acid D. Hydrochlorothiazide
ANSWER: C - Valproic acid and lithium are both indicated for the treatment of bipolar disorder. It is safe for the nurse to administer both of these medications to the pt. A: Ibuprofen is not safe to administer to a pt who is taking lithium because it can cause increased kidney absorption of lithium, which can lead to lithium toxicity. B: Haloperidol is not safe to administer to a pt who is taking lithium because the combination of these medications increases the pts risk for extrapyramidal adverse effects and tardive dyskinesia. D: Hydrochlorothiazide is not safe to administer to a pt who is taking lithium because it promotes sodium loss, which can lead to lithium toxicity.
A nurse is assessing a pt who has a new diagnosis of major depressive disorder. Which of the following questions is the priority for the nurse to ask? A. "How would you describe your mood today?" B. "How are you sleeping?" C. "Do you drink alcohol or use any substances?" D. "Do you ever think about suicide?"
ANSWER: D
A nurse is caring for a pt who has anorexia nervosa. The pt states, "If i gain weight, I'll never get a boyfriend." Which of the following cognitive distortions is the pt displaying? A. Overgeneralization B. Personalization C. Emotional reasoning D. Catastrophizing
ANSWER: D
A nurse is planning care for a pt who is scheduled to undergo electroconvulsive treatment (ECT). Which of the following interventions should the nurse include? A. Maintain a clear liquid diet for 6 to 8 hours prior to ECT B. Allow the pt to sleep for 3 to 4 hrs following ECT C. Admin IM epinephrine to the pt prior to ECT D. Reorient the pt to the environment after ECT
ANSWER: D
A nurse is providing dietary teaching to a pt who is newly prescribed an MAOI. Which food selection indicated understanding. A. Cheddar cheese B. Avocados C. Pepperoni D. Yogurt
ANSWER: D
A nurse is providing teaching to the family of a pt who is scheduled for electroconvulsive therapy (ECT). Which statements made by the family indicated understanding of ECT? A. "We are so glad there are not physical side effects of shock treatment." B. "Thank goodness there is no permanent memory loss." C. "Cardiac dysrhythmias can persist for several weeks." D. "We won't be alarmed if there is some confusion after treatment."
ANSWER: D
A nurse is treating a child who has bruises. The nurse suspects child abuse, but the provider disagrees & discharges the pt. Which action should the nurse take? A. Request a social services consultation B. Contact the child's guardian to discuss the suspicion C. Report the providers actions to the state medical board D. Report the suspected abuse to law enforcement
ANSWER: D
A nurse on a MH unit is caring for a pt who has depression. Which of the following actions should the nurse take to foster a therapeutic environment for this pt? A. Tell the pt that the nurse will talk to him at his request. B. Allow the pt to skip group activities if he chooses. C. Leave the pt alone for frequent rest periods throughout the day. D. Build trust with the pt by quietly sitting with him.
ANSWER: D
A pt who is taking lithium to treat bipolar disorder and has a lithium lvl of 2.2 mEq/L. Which of the following finding should the nurse expect? A. Muscle weakness B. Oliguria C. Vomiting D. Blurry vision
ANSWER: D
A pt who was hospitalized several days ago following a suicide attempt states, "I do not want visitors today because I look and feel terrible." Which of the following responses should the nurse make? A. "That is silly, You look just fine to me." B. "Nobody expects you to look good in a hospital." C. "I understand. Would you like me to wash your hair?" D. "Would you like to talk about why you feel this way?"
ANSWER: D
Assessing the lethality of a pts suicide plan. Which is identified as a soft method of suicide? A. Jumping off a bridge B. Inhaling carbon monoxide C. Hanging with a rope. D. Swallowing antidepressant pills
ANSWER: D
Which of the following actions should a nurse take first for pt who was admitted following a suicide attempt? A. Assess the pts lvl of self- esteem B. Document the pts mood and affect C. Attend an interdisciplinary meeting D. Search the pts belongings
ANSWER: D
A nurse in an acute MH facility is leading a nursing staff discussion about the legal aspects of involuntary admission. Which of the following informations should the nurse include? A. A client who is involuntarily admitted must take prescribed medications. B. An involuntary admission of a client is limited to 2 weeks. C. A client who is involuntarily admitted can leave the facility against medical advice. D. An involuntary admission is justified if the client is a danger to others.
ANSWER: D - A pt who is a danger to others or to himself qualifies for an involuntary admission. The inability to meet basic needs due to the need for mental health treatment is also a justification for an involuntary admission. A: Pts who are involuntarily admitted retain the legal right to refuse medications. B: Pts who are involuntarily admitted might be required to remain in the facility for up to 60 days. After this time a legal review of the case is required to determine if continued involuntary treatment is required. C: Pts who are involuntarily admitted retain certain rights; however, they are unable to leave the health care facility against medical advice. If a client who is involuntarily admitted feels that the admission is unjustified, the pt can file a legal petition requesting a review of the admission.
A nurse in a MH clinic is assessing a pt who has a history of mania. Which of the following findings indicates that the pt is experiencing a relapse? A. Weight gain B. Ritualistic behavior C. Anhedonia D. Pressured speech
ANSWER: D - Pressured speech is an indication of a relapse in a pt who has mania. Pressured speech occurs when an individual speaks at a rapid and sometimes frantic speed. The pace makes it difficult for people listening to make sense of what is being said. Pressured speech can be jumbled and difficult to understand, as the person speaking may not stop at appropriate points. A: Weight loss rather than weight gain can indicate a relapse in a pt who has mania. B: Ritualistic behavior is an indication of obsessive-compulsive disorder rather than mania. C: Anhedonia is a lack of interest in daily activities & is not an expected finding for a pt who has mania.
A nurse is caring for a pt who has borderline personality disorder. The nurse enters the pts room & finds the pt cutting into his flesh with a paperclip. After providing first aid, which of the following actions should the nurse take first? A. Encourage the pt to discuss feelings about his self-injurious behavior during group therapy. B. Fill out an incident report for risk management about the client's self-injurious behavior. C. Document the pts self-injurious behavior in his medical record. D. Identify the pts feelings that led to the self-injurious behavior.
ANSWER: D - The nurse should apply the nursing process priority-setting framework. Each step of the nursing process builds on the previous step, beginning with assessment or data collection. Therefore, the first action the nurse should take is to assist the pt to identify events or feelings that led to his self-injurious behavior. A: The nurse should encourage the pt to participate in group therapy or a support group to discuss feelings about self-injurious behavior; however, there is another action that the nurse should take first. B: The nurse should complete an incident report about the self-injurious behavior; however, there is another action that the nurse should take first. C: The nurse should document the self-injurious behavior in the pts medical record; however, there is another action that the nurse should take first.
A nurse is completing an admission assessment for an adolescent pt who has depression. The nurse should identify which of the following findings as the priority? A. The client is confrontational with his parents. B. The client is getting Ds in his classes because he frequently skips school. C. The client states he smokes half a pack of cigarettes per day. D. The client gave his favorite possessions to friends.
ANSWER: D - The nurse should apply the safety and risk reduction priority-setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the pt. Therefore, the nurse should identify this finding as the priority. Giving away valued and prized possessions is an indication of suicidal ideation, which is the greatest risk for pts who have depression. A: The nurse should identify that a confrontational attitude and anger with parents is an expected finding for an adolescent, as well as an indication of depression. The nurse should promote positive interactions between the pt and his parents and assist the pt to address feelings of anger; however, there is another finding that is the priority. B: The nurse should identify that withdrawal from social activities, including school, is an expected finding for an adolescent who has depression. The nurse should promote social interaction and school attendance; however, there is another finding that is the priority. C: The nurse should identify that substance use is an expected finding for an adolescent who has depression. The nurse should plan interventions to assist the pt in smoking cessation; however, there is another finding that is the priority.
A nurse in a MH facility is reviewing confidentiality requirements with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicated an understanding of the information? A. "I am legally required to notify a client's employer about a substance use disorder." B. "If a client is involuntarily committed, I can discuss information with the client's next of kin." C. "I can discuss a client's treatment with others as long as they are employees of the facility." D. "I should keep information private even after a client dies."
ANSWER: D - The nurse should be aware that a pts right to privacy continues even after death. A: The nurse should be aware that it is a breach of the pts confidentiality to disclose information to an employer without their consent. B: The nurse should be aware that it is a breach of the pts confidentiality to disclose information to the next of kin without their consent. This protection of the client's privacy applies to clients who are receiving treatment voluntarily or involuntarily. C: The nurse should be aware that it is a breach of the pts confidentiality to disclose information to other employees unless they are directly involved in the pts care and the information is needed to carry out the pts treatment plan
A nurse is assessing a pt who has conduct disorder. Which of the following findings should the nurse expect? A. Fearfulness of authority figures B. Flat affect C. Preoccupation with enforcing rules D. Aggressive behavior toward others
ANSWER: D - The nurse should expect the pt who has conduct disorder to exhibit aggression toward others and impulsively violate others' rights. A: Pts who have conduct disorder exhibit a lack of respect for authority figures and might attempt to initiate a fight with or intimidate others. B: Pts who have conduct disorder are easily angered and do not have a flat affect. C: Pts who have conduct disorder exhibit a lack of respect for rules.
A nurse is performing an admission assessment for a pt who has restricting type of anorexia nervosa. The nurse should expect which of the following findings? A. Recurrent binging B. Compensatory vomiting C. Loss of appetite D. Decreased caloric intake
ANSWER: D - The nurse should expect the pt who has restricting type anorexia nervosa to have a restricted and decreased caloric intake due to the pts intense fear of weight gain. A: Recurrent binging is an expected finding of binge-eating/purging type anorexia nervosa. Pts who have restricting type anorexia nervosa are not expected to exhibit bulimic manifestations, such as binge eating. B: Compensatory vomiting is an expected finding of binge-eating/purging type anorexia nervosa. Pts who have restricting type anorexia nervosa are not expected to exhibit bulimic manifestations, such as compensatory vomiting. C: Loss of appetite is not an expected finding of a pt who has anorexia nervosa. Pts who have restrictive type anorexia nervosa maintain an appetite; however, they have inadequate intake due to fear of gaining weight.
A nurse is reviewing the health history of a young adult pt who has a depressive disorder. Which of the following factors should the nurse identify as increasing the pts risk for depression? A. The pt is an only child. B. The pt lives in an urban setting. C. The pt is married. D. The pt is female.
ANSWER: D - The nurse should identify female gender as a primary risk factor for depression. The incidence of depressive disorder is greater in women than men by almost 2 to 1. A: Pts status as an only child = not a risk factor for depression. B: Living in an urban setting does not increase the pts risk for depression. A low socioeconomic status = a risk factor for depression. C: Pts who are not married are at greater risk for depression than pts who are married.
A nurse is planning care for a newly admitted pt who has bipolar disorder and is experiencing acute mania. Which of the following client goals should the nurse identify as the priority? A. Practicing problem-solving skills B. Understanding of medication regimen C. Identifying indications of relapse D. Maintaining adequate hydration
ANSWER: D - The nurse should identify that the priority goal is to prevent physical exhaustion, maintain health, and meet nutritional and rest needs during the acute phase of the pts manic episode. The nurse should consider Maslow's hierarchy of needs. A: The nurse should encourage the pt to practice problem-solving skills during the continuation phase of treatment; however, there is another intervention that is the priority during the acute phase of bipolar disorder. B: The nurse should ensure that the pt understands the medication regimen during the continuation phase of treatment; however, there is another intervention that is the priority during the acute phase of bipolar disorder. C: The nurse should teach the pt to recognize indications of relapse during the continuation phase of treatment; however, there is another intervention that is the priority during the acute phase of bipolar disorder.
A nurse is preparing to apply wrist restraints on a pt who is threatening to harm others & has not responded to less invasive interventions. Which of the following actions should the nurse plan to take? A. Obtain a PRN prescription for restraints from the pts provider. B. Visually observe the pt every 10 min until restraints are removed. C. Ensure that three fingers can fit between the restraint and the pts wrist. D. Document the pts behavior every 15 min while restraints are in place.
ANSWER: D - The nurse should plan to document the pts behavior every 15 min while restraints are in place. This frequent documentation meets the legal requirement for use of restraints; helps provide for prompt identification of complications related to restraint use; and helps ensure that restraints are removed as soon as possible, depending on the pts behavior. A: The nurse should obtain a prescription for restraints from the provider; however, this prescription is legally required to be current and specific to the pts present needs rather than PRN. B:The nurse should plan to have constant one-to-one observation by staff while the pt is in restraints. C: The nurse should ensure that two fingers can fit between the restraints and the pts wrist. This safety check ensures adequate circulation while maintaining the effectiveness of the restraint.
A nurse is planning care for a pt who has bipolar disorder & is experiencing a manic episode. Which of the following interventions should the nurse the nurse include in the plan? A. Discourage the client from taking naps during the day. B. Allow the client to choose which clothing to wear each day. C. Encourage the client to participate in group therapy. D. Provide the client frequently with high-calorie finger-foods.
ANSWER: D - The nurse should provide the pt with frequent, high-calorie snacks and meals during a manic episode to provide the calorie replacement needed due to excessive physical energy and activity. Providing finger-foods increases the pts intake by making it easier to eat when mania makes it difficult for her to sit down and concentrate on a meal. A: The nurse should encourage the pt to take naps and frequent rest periods during the day to avoid physical exhaustion due to mania. B: The nurse should closely supervise the pts choice of clothing to maintain her dignity and promote positive self-esteem during a manic episode. C: The nurse should encourage one-on-one therapy during the manic phase. Group therapy can cause anxiety and agitation in the pt.
A nurse is administering an oral sedative to a pt who is receiving care following an involuntary admission. The pt states. "I am not taking any more medication." Which of the following actions should the nurse take? A. Administer the medication by another route. B. Refer the pts refusal to the facility's ethics committee. C. Inform the pt that, due to her involuntary admission, she cannot refuse a sedative. D. Document the pts refusal of the medication in the medical record.
ANSWER: D - The nurse should respect the pts right to refuse medication, even if the pt is receiving treatment due to an involuntary admission. The nurse should document this refusal in the med record & assess the reasons for the pts refusal. A: It is beyond the nurse's scope of practice to admin a medication by a route other than what was prescribed by the provider. B: The pts refusal of med is a legal issue rather than an ethical issue. The nurse should recognize the pts right to refuse medication & collaborate with the provider to meet the pts needs. C: The nurse should be aware of the clients rights regarding involuntary admission. This is incorrect info to provide the pt.
A nurse is caring for a pt who has major depressive disorder & is severely withdrawn. Which of the following techniques should the nurse use to facilitate communication with the pt? A. Continue to talk if the client does not provide an immediate verbal response. B. Use platitudes when talking with the client. C. Ask the client direct questions. D. Speak to the client using simple and concrete terminology.
ANSWER: D - The nurse should use simple and concrete terminology when communicating with this pt. The pt who is severely withdrawn has impaired comprehension and difficulty concentrating; therefore, this technique facilitates communication. A: The nurse should allow the pt additional time to respond. Pts who are severely withdrawn might take longer to comprehend what is being said and formulate a response. B: The nurse should avoid the use of platitudes because this technique minimizes the pts feelings and promotes feelings of worthlessness in pts who are severely withdrawn. C: The nurse should avoid asking direct questions to a pt who is severely withdrawn because this technique can raise his level of anxiety.
