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The feeling experienced by a patient that should be assessed by the nurse as most predictive of elevated suicide risk is: a. hopelessness. b. sadness. c. elation. d. anger.
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A 26-month-old child displays negative behaviors. The parent says, "My child refuses toilet training and shouts, 'No!' when given direction. What do you think is wrong?" Select the nurse's best reply. a. "This is normal for your child's age. The child is striving for independence." b. "The child needs firmer control. Punish the child for disobedience and say, 'No.'" c. "There may be developmental problems. Most children are toilet trained by age 2 years." d. "Some undesirable attitudes are developing. A child psychologist can help you develop a remedial plan."
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A 4-year-old child grabs toys from siblings, saying, "I want that toy now!" The siblings cry, and the child's parent becomes upset with the behavior. Using the Freudian theory, a nurse can interpret the child's behavior as a product of impulses originating in the: a. id. b. ego. c. superego. d. preconscious.
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A 40-year-old adult living with parents states, "I'm happy but I don't socialize much. My work is routine. When new things come up, my boss explains them a few times to make sure I understand. At home, my parents make decisions for me, and I go along with them." A nurse should identify interventions to improve this patient's: a. self-concept. b. overall happiness. c. appraisal of reality. d. control over behavior.
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A Mexican-American patient puts a picture of the Virgin Mary on the bedside table. Under which section of the assessment should the nurse document this behavior? a. Culture b. Ethnicity c. Verbal communication d. Nonverbal communication
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A bill introduced in Congress would reduce funding for the care of people with mental illnesses. A group of nurses write letters to their elected representatives in opposition to the legislation. Which role have the nurses fulfilled? a. Advocacy b. Attending c. Recovery d. Evidence-based practice
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A child was abducted and raped. In the emergency department, this victim is confused and crying. Which personal reaction by the nurse could interfere with this victim's care? a. Anger b. Concern c. Empathy d. Compassion
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A college student who attempted suicide by overdose is hospitalized. When the parents are contacted, they respond, "There must be a mistake. This could not have happened. We've given our child everything." The parents' reaction reflects: a. denial. b. anger. c. anxiety. d. rescue feelings.
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A community mental health nurse has worked with a patient for 3 years but is moving out of the city and terminates the relationship. A new nurse who begins work with this patient will: a. begin at the orientation phase. b. resume the working relationship. c. enter into a social relationship. d. return to the emotional catharsis phase.
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A community mental health nurse wants to establish a relationship with a very withdrawn patient diagnosed with schizophrenia. The patient lives at home with a supportive family. Select the nurse's best plan: a. Visit daily for 4 days, then visit every other day for 1 week; stay with the patient for 20 minutes; accept silence; state when the nurse will return b. Arrange to spend 1 hour each day with the patient; focus on asking questions about what the patient is thinking or experiencing; avoid silences c. Visit twice daily; sit beside the patient with a hand on the patients arm; leave if the patient does not respond within 10 minutes d. Visit every other day; reminded patient of the nurse's identity; encouraged patient to talk while the nurse works on reports
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A depressed patient says, "Nothing matters anymore." What is the most appropriate response by the nurse? a. "Are you having thoughts of suicide?" b. "I am not sure I understand what you are trying to say." c. "Try to stay hopeful. Things have a way of working out." d. "Tell me more about what interested you before you began feeling depressed."
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A drug causes muscarinic-receptor blockade. A nurse will assess the patient for: a. dry mouth b. gynecomastia c. pseudoparkinsonism d. orthostatic hypotension
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A health teaching plan for a patient taking lithium should include instructions to: a. Maintain normal salt and fluids in the diet. b. Drink twice the usual daily amount of fluids. c. Double the lithium dose if diarrhea or vomiting occurs. d. Avoid eating aged cheese, processed meats, and red wine.
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A hospitalized patient diagnosed with delirium misinterprets reality, while a patient diagnosed with dementia wanders about the home. Which outcome is the priority in both scenarios? The patients will: a. remain safe in the environment. b. participate actively in self-care. c. communicate verbally. d. acknowledge reality.
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A mentally ill person's current global assessment of functioning (GAF) score is 10. Select the nurse's highest priority related to this patient's care. a. Safety b. Hygiene c. Nutrition d. Socialization
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A multidisciplinary health care team meets 12 hours after an adolescent is hospitalized after a suicide attempt. Members of the team report their assessments. What outcome can be expected from this meeting? a. A treatment plan will be determined. b. The health care provider will order neuroimaging studies. c. The team will request a court-appointed advocate for the patient. d. Assessment of the patient's need for placement outside the home will be undertaken.
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A new nurse says to a peer, "My newest patient is diagnosed with schizophrenia. At least I won't have to worry about suicide risk." Which response by the peer would be most helpful? a. "Let's reconsider your plan. Suicide risk is high in patients diagnosed with schizophrenia." b. "Suicide is a risk for any patient diagnosed with schizophrenia who uses alcohol or drugs." c. "Patients diagnosed with schizophrenia are usually too disorganized to attempt suicide." d. "Visual hallucinations often prompt suicide among patients diagnosed with schizophrenia."
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A nurse administers a medication that potentiates the action of gamma-aminobutyric acid (GABA). Which finding would be expected? a. Reduced anxiety b. Improved memory c. More organized thinking d. Fewer sensory perceptual alterations
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A nurse assesses a patient diagnosed with functional neurological (conversion) disorder. Which comment is most likely from this patient? a. "Since my father died, I've been short of breath and had sharp pains that go down my left arm, but I think it's just indigestion." b. "I have daily problems with nausea, vomiting, and diarrhea. My skin is very dry and I think I'm getting seriously dehydrated." c. "Sexual intercourse is painful. I pretend as if I'm asleep so I can avoid it. I think it's starting to cause problems with my marriage." d. "I get choked very easily and have trouble swallowing when I eat. I think I might have cancer of the esophagus."
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A nurse assesses an inpatient psychiatric unit, noting that exits are free from obstruction, no one is smoking, the janitor's closet is locked, and all sharp objects are being used under staff supervision. These observations relate to: a. management of milieu safety b. coordinating care of patients c. management of the interpersonal climate d. use of therapeutic intervention strategies
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A nurse assesses an older adult patient brought to the emergency department by a family member. The patient was wandering outside, saying, "I can't find my way home." The patient is confused and unable to answer questions. Select the nurse's best action. a. Document the patient's mental status. Obtain other assessment data from the family member. b. Record the patient's answers to questions on the nursing assessment form. c. Ask an advanced practice nurse to perform the assessment interview. d. Call for a mental health advocate to maintain the patient's rights.
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A nurse assesses soldiers in a combat zone in Afghanistan. When is it most important for the nurse to screen for signs and symptoms of traumatic brain injury (TBI)? a. After a fall, vehicle crash, or exposure to a blast b. Before departing Afghanistan to return to the United States c. One year after returning to the United States from Afghanistan d. Immediately upon return to the United States from Afghanistan
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A nurse assesses that a patient is suspicious and frequently manipulates others. Using the Freudian theory, these traits are related to which psychosexual stage? a. Oral b. Anal c. Phallic d. Genital
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A nurse at a behavioral health clinic sees an unfamiliar psychiatric diagnosis on a patient's insurance form. Which resource should the nurse consult to discern the criteria used to establish this diagnosis? a. DSM-IV-TR b. Nursing Diagnosis Manual c. A psychiatric nursing textbook d. A behavioral health reference manual
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A nurse at the mental health center prepares to administer a scheduled injection of haloperidol decanoate (Haldol depot injection) to a patient with schizophrenia. As the nurse swabs the site, the patient shouts, "Stop, stop! I don't want to take that medicine anymore. I hate the side effects." Select the nurse's best initial action. a. Stop the medication administration procedure and say to the patient, "Tell me more about the side effects you've been having." b. Say to the patient, "Since I've already drawn the medication in the syringe, I'm required to give it, but let's talk to the doctor about skipping next month's dose." c. Proceed with the injection but explain to the patient that other medications are available that may help reduce the unpleasant side effects. d. Notify other staff members to report to the room for a show of force and proceed with the injection, using restraint if necessary.
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A nurse caring for a patient taking a serotonin reuptake inhibitor (SSRI) will develop outcome criteria related to: a. mood improvement b. logical thought processes c. reduced levels of motor activity d. decreased extrapyramidal symptoms
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A nurse counseling a patient with a dissociative identity disorder should understand that the assessment of highest priority is: a. Risk for self-harm b. Cognitive functioning c. Identification of drug abuse d. Readiness to reestablish identity or memory
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A nurse explains to the family of a patient who is mentally ill how the nurse-patient relationship differs from social relationships. Which is the best explanation? a. "The focus is on the patient. Problems are discussed by the nurse and patient, but solutions are implemented by the patient." b. "The focus shifts from nurse to patient as the relationship develops. Advice is given by both, and solutions are implemented." c. "The focus of the relationship is socialization. Mutual needs are met, and feelings are openly shared." d. "The focus is the creation of a partnership in which each member is concerned with the growth and satisfaction of the other."
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A nurse receives this laboratory result: lithium level 1 mEq/L. This result is: a. within therapeutic limits b. below therapeutic limits c. above therapeutic limits d. incorrect because of inaccurate testing
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A nurse says, "I'm the only one who truly understands this patient. Other staff members are too critical." The nurse's statement indicates: a. boundary blurring. b. sexual harassment. c. positive regard. d. advocacy.
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A nurse says, "When I was in school I learned to call upset patients by name to get their attention, but I read a descriptive research study that says that this approach doesn't work. I'm going stop calling patients by name." Which statement is the best appraisal of this nurse's comment? a. One descriptive research study rarely provides enough evidence to change practice. b. Staff nurses apply new research findings only with the help from clinical nurse specialists. c. New research findings should be incorporated into clinical algorithms before using them in practice. d. The nurse misinterpreted the results of the study. Classic tenets of practice do not change.
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A nurse should assess a patient taking a medication with anticholinergic properties for inhibited function of the: a. parasympathetic nervous system b. sympathetic nervous system c. reticular activating system d. medulla oblongata
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A nurse surveys the medical records for violations of patients' rights. Which finding signals a violation? a. No treatment plan is present in record. b. Patient belongings are searched at admission. c. Physical restraint is used to prevent harm to self. d. Patient is placed on one-to-one continuous observation.
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A nurse talks with the caregiver of a combat veteran with severe traumatic brain injuries. The caregiver says, "I don't know how much longer I can do it. My whole life is consumed with taking care of my partner." Select the nurse's best response. a. "How are you taking care of yourself?" b. "Let's review your partner's diagnostic results." c. "I have some web-based programs for you to visit." d. "Your partner is lucky to have someone so devoted."
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A nurse teaching a patient about a tyramine-restricted diet would approve which meal? a. Mashed potatoes, ground beef patty, corn, green beans, apple pie b. Avocado salad, ham, creamed potatoes, asparagus, chocolate cake c. Macaroni and cheese, hot dogs, banana bread, caffeinated coffee d. Noodles with cheddar cheese sauce, smoked sausage, lettuce salad, yeast rolls
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A nurse uses Maslow's hierarchy of needs to plan care for a psychotic patient. Which problem will receive priority? The patient: a. refuses to eat or bathe. b. reports feelings of alienation from family. c. is reluctant to participate in unit social activities. d. needs to be taught about medication action and side effects.
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A nurse wishes to teach alternative coping strategies to a patient who is experiencing severe anxiety. The nurse will first need to: a. Lower the patient's current anxiety level. b. Verify the patient's learning style. c. Create outcomes and a teaching plan. d. Assess how the patient uses defense mechanisms.
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A nurse with a history of narcotic abuse is found unconscious in the hospital locker room after overdosing. The nurse is transferred to an inpatient substance abuse unit for care. Which attitudes or behaviors by nursing staff may be enabling? a. Conveying understanding that pressures associated with nursing practice underlie substance abuse. b. Pointing out that work problems are the result, but not the cause, of substance abuse. c. Conveying empathy when the nurse discusses fears of disciplinary action by the state board of nursing. d. Providing health teaching about stress management.
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A nurse works with a patient with paranoid schizophrenia regarding the importance of medication management. The patient repeatedly says, "I don't like taking pills." Family members say they feel helpless to foster compliance. Which treatment strategy should the nurse discuss with the healthcare provider? a. Use of a long acting antipsychotic preparation b. Addiction of a benzodiazepine, such as lorazepam (Ativan) c. Adjunctive use of an antidepressant, such as amitriptyline (Elavil) d. Prolong hospitalization; this patient is not ready for discharge
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A patient asks for information about Alcoholics Anonymous (AA). Which is the nurse's best response? a. "It is a self-help group with the goal of sobriety." b. "It is a form of group therapy led by a psychiatrist." c. "It is a group that learns about drinking from a group leader." d. "It is a network that advocates strong punishment for drunk drivers."
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A patient became depressed after the last of six children moved out of the home 4 months ago. The patient has been self-neglectful, slept poorly, lost weight, and repeatedly says, "No one cares about me anymore. I'm not worth anything." Select an appropriate initial outcome for the nursing diagnosis Situational low self-esteem, related to feelings of abandonment. The patient will: a. verbalize realistic positive characteristics about self by (date) . b. consent to take antidepressant medication regularly by (date) . c. initiate social interaction with another person daily by (date) . d. identify two personal behaviors that alienate others by (date) .
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A patient being treated in an alcohol rehabilitation unit reveals to the nurse, "I feel terrible guilt for sexually abusing my 6-year-old child before I was admitted." Based on state and federal law, the best action for the nurse to take is to: a. anonymously report the abuse by telephone to the local child abuse hotline. b. reply, "I'm glad you feel comfortable talking to me about it." c. respect nurse-patient relationship of confidentiality. d. file a written report on the agency letterhead.
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A patient diagnosed with borderline personality disorder has a history of self-mutilation and suicide attempts. The patient reveals feelings of depression and anger with life. The psychiatrist suggests the use of a medication. Which type of medication should the nurse expect? a. Selective serotonin reuptake inhibitor (SSRI) b. Monoamine oxidase inhibitor (MAOI) c. Benzodiazepine d. Antipsychotic
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A patient diagnosed with borderline personality disorder is hospitalized several times after self-inflicted lacerations. The patient remains impulsive. Dialectical behavior therapy starts on an outpatient basis. Which nursing diagnosis is the focus of this therapy? a. Risk for self-mutilation b. Impaired skin integrity c. Risk for injury d. Powerlessness
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A patient was admitted last night with a hip fracture sustained in a fall while intoxicated. The patient points to the Buck's traction and screams, "Somebody tied me up with ropes." The patient is experiencing: a. an illusion. b. a delusion. c. hallucinations. d. hypnagogic phenomenon.
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A patient diagnosed with delirium is experiencing perceptual alterations. Which environmental adjustment should the nurse make for this patient? a. Provide a well-lit room without glare or shadows. Limit noise and stimulation. b. Maintain soft lighting day and night. Keep a radio on low volume continuously. c. Light the room brightly day and night. Awaken the patient hourly to assess mental status. d. Keep the patient by the nurse's desk while awake. Provide rest periods in a room with a television on.
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A patient has a fear of public speaking. The nurse should be aware that social phobias are often treated with which type of medication? a. (beta)-blockers. b. Antipsychotic medications. c. Tricyclic antidepressant agents. d. Monoamine oxidase inhibitors.
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A patient has a history of physical violence against family members when frustrated and then experiences periods of remorse after each outburst. Which finding indicates success in the plan of care? The patient: a. expresses frustration verbally instead of physically. b. explains the rationale for behaviors to the victim. c. identifies three personal strengths. d. agrees to seek counseling.
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A patient has dementia. The health care provider wants to make a differential diagnosis between Alzheimer disease and multiple infarctions. Which diagnostic procedure should a nurse expect to prepare the patient for first? a. Computed tomography (CT) scan b. Positron emission tomography (PET) scan c. Functional magnetic resonance imaging (fMRI) d. Single-photon-emission computed tomography (SPECT) scan
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A patient has progressive memory deficits associated with dementia. Which nursing intervention would best help the individual function in the environment? a. Assist the patient to perform simple tasks by giving step-by-step directions. b. Reduce frustration by performing activities of daily living for the patient. c. Stimulate intellectual function by discussing new topics with the patient. d. Read one story from the newspaper to the patient every day.
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A patient in an alcohol treatment program says, "I have been a loser all my life. I'm so ashamed of what I have put my family through. Now, I'm not even sure I can succeed at staying sober." Which nursing diagnosis applies? a. Chronic low self-esteem b. Situational low self-esteem c. Disturbed personal identity d. Ineffective health maintenance
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A patient in the emergency department exhibits disorganized behavior and incoherence after a friend suggested a homosexual encounter. In which room should the nurse place the patient? a. Interview room furnished with a desk and two chairs b. Small, empty storage room with no windows or furniture c. Room with an examining table, instrument cabinets, desk, and chair d. Nurse's office, furnished with chairs, files, magazines, and bookcases
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A patient is having difficulty making a decision. The nurse has mixed feelings about whether to provide advice. Which principle usually applies? Giving advice: a. Is rarely helpful. b. Fosters independence. c. Lifts the burden of personal decision making. d. Helps the patient develop feelings of personal adequacy.
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A patient is hospitalized for depression and suicidal ideation after their spouse asks for a divorce. Select the nurse's most caring comment. a. "Let's discuss some means of coping other than suicide when you have these feelings." b. "I understand why you're so depressed. When I got divorced, I was devastated too." c. "You should forget about your marriage and move on with your life." d. "How did you get so depressed that hospitalization was necessary?"
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A patient says, "I feel detached and weird all the time, like I'm looking at life through a cloudy window. Everything seems unreal. These feelings really interfere with my work and study." Which term should the nurse use to document this complaint? a. Depersonalization b. Hypochondriasis c. Dissociation d. Malingering
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A patient says, "I've done a lot of cheating and manipulating in my relationships." Select a nonjudgmental response by the nurse. a. "How do you feel about that?" b. "It's good that you realize this." c. "That's not a good way to behave." d. "Have you outgrown that type of behavior?"
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A patient says, "Please don't share information about me with the other people." How should the nurse respond? a. "I won't share information with your family or friends without your permission, but I will share information about you with other staff members." b. "A therapeutic relationship is just between the nurse and the patient. It's up to you to tell others what you want them to know." c. "It really depends on what you choose to tell me. I will be glad to disclose at the end of each session what I will report to others." d. "I cannot tell anyone about you. It will be as though I am talking about my own problems, and we can help each other by keeping it between us."
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A patient tells a nurse, "I sometimes get into trouble because I make quick decisions and act on them." A therapeutic response would be: a. "Let's consider the advantages of being able to stop and think before acting." b. "It sounds as though you've developed some insight into your situation." c. "I'll bet you have some interesting stories to share about overreacting." d. "It's good that you're showing readiness for behavioral change."
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A patient tells the nurse at the clinic, "I haven't been taking my antidepressant medication as directed. I leave out the midday dose. I have lunch with friends and don't want them to ask me about the pills." Select the nurse's most appropriate intervention. a. Investigate the possibility of once-daily dosing of the antidepressant. b. Suggest to the patient to take the medication when no one is watching. c. Explain how taking each dose of medication on time relates to health maintenance. d. Add the nursing diagnosis—Ineffective therapeutic regimen management, related to lack of knowledge—to the plan of care.
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A patient tells the nurse, "My husband is abusive most often when he drinks too much. His family was like that when he was growing up. He always apologizes and regrets hurting me." What risk factor was most predictive for the husband to become abusive? a. History of family violence b. Loss of employment c. Abuse of alcohol d. Poverty
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A patient was abducted and raped at gunpoint by an unknown assailant. Which assessment finding best indicates the patient is in the acute phase of rape trauma syndrome? a. Confusion and disbelief b. Decreased motor activity c. Flashbacks and dreams d. Fears and phobias
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A patient was responding to auditory hallucinations earlier in the morning. The patient approaches the nurse, shaking a fist and shouting, "Back off!" and then goes into the day room. As the nurse follows the patient into the day room, the nurse should: a. make sure adequate physical space exists between the nurse and the patient. b. move into a position that allows the patient to be close to the door. c. maintain one arm's length distance from the patient. d. sit down in a chair near the patient.
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A patient who immigrated to the United States from Honduras was diagnosed with schizophrenia. The patient took an antipsychotic medication for 3 weeks but showed no improvement. Which resource should the treatment team consult for information on more effective medications for this patient? a. Clinical algorithm b. Clinical pathway c. Clinical practice guideline d. International Statistical Classification of Diseases and Related Health Problems (ICD)
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A patient with a high level of motor activity runs from chair to chair and cries, "They're coming! They're coming!" The patient does not follow the staff's directions or respond to verbal interventions. The initial nursing intervention of highest priority is to: a. provide for patient safety. b. increase environmental stimuli. c. respect the patient's personal space. d. encourage the clarification of feelings.
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A patient with a high level of motor activity runs from chair to chair and cries, "They're coming! They're coming!" The patient is unable to follow staff direction or respond to verbal interventions. Which nursing diagnosis has the highest priority? a. Risk for injury b. Self-care deficit c. Disturbed energy field d. Disturbed thought processes
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A patient with anorexia nervosa virtually stopped eating 5 months ago and has lost 25% of body weight. A nurse asks, "Describe what you think about your present weight and how you look." Which response by the patient is most consistent with the diagnosis? a. "I'm fat and ugly." b. "What I think about myself is my business." c. "I'm grossly underweight, but that's what I want." d. "I'm a few pounds overweight, but I can live with it."
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A patient with bipolar disorder commands other patients, "Get me a book. Take this stuff out of here," and other similar demands. The nurse wants to interrupt this behavior without entering into a power struggle. Select the best initial approach by the nurse. a. Distraction: "Let's go to the dining room for a snack." b. Humor: "How much are you paying servants these days?" c. Limit setting: "You must stop ordering other patients around." d. Honest feedback: "Your controlling behavior is annoying others."
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A patient with bipolar disorder is dressed in a red leotard and brightly colored scarves. The patient says, "I'll punch you, munch you, crunch you," while twirling and shadowboxing. Then the patient says gaily, "Do you like my scarves? Here...they are my gift to you." How should the nurse document the patient's mood? a. Labile and euphoric b. Irritable and belligerent c. Highly suspicious and arrogant d. Excessively happy and confident
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A patient with bipolar disorder, who is being treated on an outpatient basis, takes lithium carbonate 300 mg three times daily. The patient complains of nausea. To reduce the nausea, the nurse can suggest that the lithium be taken with: a. meals b. an antacid c. an antiemetic medication d. a large glass of juice
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A patient with delusions of persecution about being poisoned has refused all hostile meals for 3 days. Which intervention is most likely to be acceptable to the patient? a. Allowing the patient to have supervised access to food vending machines b. Allowing the patient to telephone a local restaurant to deliver meals c. Offering to taste each portion on the tray for the patient d. Providing two feedings are total parenteral nutrition
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A patient with depression does not interact with others except when addressed and then only in monosyllables. The nurse wants to show nonjudgmental acceptance and support for the patient. Select the nurse's most effective action. a. Make observations. b. Ask the patient direct questions. c. Phrase questions to require "yes" or "no" answers. d. Frequently reassure the patient to reduce guilt feelings.
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A patient with depression is taking a tricyclic antidepressant. The patient says, "I don't think I can keep taking these pills. They make me so dizzy, especially when I stand up." The nurse should: a. explain how to manage hypotension, and educate the patient that side effects go away after several weeks. b. tell the patient that the side effects are a minor inconvenience compared with the feelings of depression. c. withhold the drug, force oral fluids, and notify the health care provider to examine the patient. d. update the patient's mental status examination.
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A patient with major depression has lost 20 pounds in one month has chronic low self-esteem and a plan for suicide. The patient has taken an antidepressant medication for 1 week. Which nursing intervention is most directly related to this outcome: "Patient will refrain from gestures and attempts to harm self"? a. Implement suicide precautions. b. Frequently offer high-calorie snacks and fluids. c. Assist the patient to identify three personal strengths. d. Observe patient for therapeutic effects of antidepressant medication.
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A patient with major depression was hospitalized for 8 days. Treatment included six electroconvulsive therapy sessions and aggressive dose adjustments of antidepressant medications. The patient owns a small business and was counseled not to make major decisions for a month. Select the correct rationale for this counseling. a. Temporary memory impairments and confusion are associated with electroconvulsive therapy. b. Antidepressant medications alter catecholamine levels, which impair decision-making abilities. c. Antidepressant medications may cause confusion related to a limitation of tyramine in the diet. d. The patient needs time to reorient him- or herself to a pressured work schedule.
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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. Impaired social interaction d. Ineffective therapeutic regimen management
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A patient with mental illness asks a psychiatric technician, "What's the matter with me?" The technician replies, "Your wing nuts need tightening." The patient looks bewildered and wanders off. The nurse who overheard the exchange should take action based on: a. violation of the patient's right to be treated with dignity and respect. b. the nurse's obligation to report caregiver negligence. c. preventing defamation of the patient's character. d. supervisory liability.
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A patient with schizophrenia begins to talks about "volmers" hiding in the warehouse at work. The term "volmers" should be documented as: a. neologism b. concrete thinking c. thought insertion d. idea of reference
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A patient with schizophrenia is acutely disturbed and violent. After several doses of haloperidol (Haldol), the patient is calm. Two hours later the nurse sees the patients head rotated to one side in a stiff position; the lower jaw is thrust forward, and the patient is drooling. Which problem is most likely? a. Acute dystonic reaction b. Tardive dyskinesia c. Waxy flexibility d. Akathisia
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A patient's spouse, who is a chemist, asks a nurse how serotonin reuptake inhibitors (SSRIs) lift depression. The nurse should explain that SSRIs: a. destroy increased amounts of neurotransmitters. b. make more serotonin available at the synaptic gap. c. increase production of acetylcholine and dopamine. d. block muscarinic and alpha1-norepinephrine receptors.
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A person who has been unable to leave home for more than a week because of severe anxiety says, "I know it does not make sense, but I just can't bring myself to leave my apartment alone." Which nursing intervention is appropriate? a. Teach the person to use positive self-talk. b. Assist the person to apply for disability benefits. c. Ask the person to explain why the fear is so disabling. d. Advise the person to accept the situation and use a companion.
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A person who is speaking about a rival for a significant other's affection says in a gushy, syrupy voice, "What a lovely person. That's someone I simply adore." The individual is demonstrating: a. Reaction formation b. Repression c. Projection d. Denial
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A professor's 4-year-old child has a body temperature of 101.6° F, diarrhea, and complains of stomach pain. The professor is scheduled to teach three classes today. Which nursing diagnosis best applies to this scenario? a. Decisional conflict b. Unilateral neglect c. Disabled family coping d. Ineffective management of the therapeutic regimen
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A psychiatric nurse addresses Axis I of the DSM-IV-TR as the focus of care but also considers the presence of other long-term, nonmedical disorders that may affect treatment. To which axis should the nurse refer for this information? a. II b. III c. IV d. V
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A psychiatric technician says, "Little of what takes place on the behavioral health unit seems to be theory based." A nurse educates the technician by identifying which common use of Sullivan's theory? a. Structure of the therapeutic milieu of most behavioral health units b. Frequent use of restraint and seclusion as behavior management tools c. Assessment tools based on age-appropriate versus arrested behaviors d. Method nurses use to determine the best sequence for nursing actions
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A soldier in a combat zone tells the nurse, "I saw a child get blown up over a year ago, but I keep seeing bits of flesh everywhere. I see something red and the visions race back to my mind." Which phenomenon associated with post-traumatic stress disorder (PTSD) is this soldier describing? a. Reexperiencing b. Hyperarousal c. Avoidance d. Psychosis
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A soldier returns to the United States from active duty in a combat zone in Afghanistan. The soldier is diagnosed with posttraumatic stress disorder (PTSD). The nurse's highest priority is to screen this soldier for which problem? a. Major depression b. Bipolar disorder c. Schizophrenia d. Dementia
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A student nurse tells the instructor, "I don't need to interact with my patients. I learn what I need to know by observation." The instructor can best interpret the nursing implications of Sullivan's theory to the student by responding: a. "nurses cannot be isolated. We must interact to provide patients with opportunities to practice interpersonal skills." b. "observing patient interactions can help you formulate priority nursing diagnoses and appropriate interventions." c. "I wonder how accurate your assessment of the patient's needs can be if you do not interact with the patient." d. "noting patient behavioral changes is important because these signify changes in personality."
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A student says, "Before taking a test, I feel a heightened sense of awareness and restlessness." The nursing intervention most suitable for assisting the student is to: a. Explain that the symptoms are the result of mild anxiety, and discuss the helpful aspects. b. Advise the student to discuss this experience with a health care provider. c. Encourage the student to begin antioxidant vitamin supplements. d. Listen without comment.
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A victim of a sexual assault that occurred approximately 1 hour earlier sits in the emergency department rocking back and forth and repeatedly saying, "I can't believe I've been raped." This behavior is characteristic of which phase of the rape trauma syndrome? a. Acute phase b. Outward adjustment phase c. Long-term reorganization phase d. Anger phase
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A victim of a violent rape has been in the emergency department for 3 hours. Evidence collection is complete. As discharge counseling begins, the patient says softly, "I will never be the same again. I can't face my friends. There is no sense of trying to go on." Select the nurse's most important response. a. "Are you thinking of suicide?" b. "It will take time, but you will feel the same as before." c. "Your friends will understand when you tell them." d. "You will be able to find meaning in this experience as time goes on."
A
A victim of physical abuse by a domestic partner is treated for a broken wrist. The patient has considered leaving but says, "You stay together, no matter what happens." Which outcome should be met before the patient leaves the emergency department? The patient will: a. name two community resources that can be contacted. b. limit contact with the abuser by obtaining a restraining order. c. demonstrate insight into the abusive relationship. d. facilitate counseling for the abuser.
A
A woman was grabbed by an attacker as she walked home from work. The attacker put a gun to her head, taped her mouth, tied her hands, took her to a remote location, and raped her. Which aspect of this crisis produced the greatest amount of psychologic trauma? a. Threat to her life b. Memory of the event c. Being in a remote location d. Physical pain experienced
A
At what point in the nurse-patient relationship should a nurse plan to first address termination? a. In the orientation phase b. In the working phase c. In the termination phase d. When the patient initially brings up the topic
A
An 11-year-old child says, "My parents don't like me. They call me stupid and say I never do anything right, but it doesn't matter. I'm too dumb to learn." Which nursing diagnosis applies to this child? a. Chronic low self-esteem, related to negative feedback from parents b. Deficient knowledge, related to interpersonal skills with parents c. Disturbed personal identity, related to negative self-evaluation d. Complicated grieving, related to poor academic performance
A
An adult attempts suicide after declaring bankruptcy. The patient is hospitalized and takes an antidepressant medication for five days. The patient is now more talkative and shows increased energy. Select the highest priority nursing intervention. a. Supervise the patient 24 hours a day. b. Begin discharge planning for the patient. c. Refer the patient to art and music therapists. d. Consider the discontinuation of suicide precautions.
A
An adult with depression was treated with medication and cognitive behavioral therapy. The patient now recognizes how passivity contributed to the depression. Which intervention should the nurse suggest? a. Social skills training b. Relaxation training classes c. Use of complementary therapy d. Learning desensitization techniques
A
An advanced practice nurse determines a group of patients would benefit from therapy in which peers and interdisciplinary staff all have a voice in determining the level of the patients' privileges. The nurse would arrange for: a. milieu therapy b. cognitive therapy c. short-term dynamic therapy d. systematic desensitization
A
An elderly person presents with symptoms of delirium. The family reports, "Everything was fine until yesterday." What is the most important assessment information for the nurse to gather? a. A list of all medications the person currently takes b. Whether the person has experienced any recent losses c. Whether the person has ingested aged or fermented foods d. The person's recent personality characteristics and changes
A
An individual experiences sexual dysfunction and blames it on a partner by calling the person unattractive and unromantic. Which defense mechanism is evident? a. Rationalization b. Compensation c. Introjection d. Regression
A
An older adult is prescribed digoxin (Lanoxin) and hydrochlorothiazide daily as well as lorazepam (Ativan) as needed for anxiety. Over 2 days, the patient developed confusion, slurred speech, an unsteady gait, and fluctuating levels of orientation. What is the most likely reason for the patient's change in mental status? a. Drug actions and interactions b. Benzodiazepine withdrawal c. Hypotensive episodes d. Renal failure
A
An older adult patient in the intensive care unit has visual and auditory illusions. Which intervention will be most helpful? a. Using the patient's glasses and hearing aids b. Placing personally meaningful objects in view c. Placing large clocks and calendars on the wall d. Assuring that the room is brightly lit but very quiet at all times
A
An older adult patient takes multiple medications daily. Over 2 days, the patient developed confusion, slurred speech, an unsteady gait, and fluctuating levels of orientation. These findings are most characteristic of: a. delirium. b. dementia c. amnestic syndrome. d. Alzheimer's disease
A
An older adult with Alzheimer disease lives with family. After observing multiple bruises, the home health nurse talks with the older adult's daughter, who becomes defensive and says, "My mother often wanders at night. Last night she fell down the stairs." Which nursing diagnosis has priority? a. Risk for injury, related to poor judgment, cognitive impairment, and lack of caregiver supervision b. Noncompliance, related to confusion and disorientation as evidenced by lack of cooperation c. Impaired verbal communication, related to brain impairment as evidenced by the confusion d. Insomnia, related to cognitive impairment as evidenced by wandering at night
A
An older adult with Alzheimer's disease lives with family. During the week, the person attends a day care center while the family is at work. In the evenings, members of the family provide care. Which factor makes this patient most vulnerable to abuse? a. Dementia b. Living in a rural area c. Being part of a busy family d. Being home only in the evening
A
An older adult with moderately severe dementia forgets where the bathroom is and has episodes of incontinence. Which intervention should the nurse suggest to the patient's family? a. Label the bathroom door. b. Take the older adult to the bathroom hourly. c. Place the older adult in disposable adult briefs. d. Limit the intake of oral fluids to 1000 ml per day.
A
An outpatient diagnosed with anorexia nervosa has begun refeeding. Between the first and second appointments, the patient gained 8 pounds. The nurse should: a. assess lung sounds and extremities. b. suggest the use of an aerobic exercise program. c. positively reinforce the patient for the weight gain. d. establish a higher goal for weight gain the next week.
A
An unconscious person is brought to the emergency department by a friend. The friend found the person in a bedroom at a college fraternity party. Semen is observed on the person's underclothes. The priority actions of staff members should focus on: a. maintaining the airway. b. preserving rape evidence. c. obtaining a description of the rape. d. determining what drug was ingested.
A
And acutely violent patient with schizophrenia receive several doses of haloperidol (Haldol). Two hours later the nurse notices the patients head rotated to one side any stiffly fixed position; the lower jaw is thrust forward, and the patient is drooling. Which intervention by the nurse's indicated? a. Administer diphenhydramine (Benadryl) 50mg IM from the PRN medication administration record b. Reassure the patient that the symptoms will subside. Practice relaxation exercises with the patient c. Give trihexyphenidyl (Artane) 5mg orly at the next regularly scheduled medication administration time d. Administer atropine sulfate 2mg subcut from the PRN medication administration record
A
As a nurse discharges a patient, the patient gives the nurse a card of appreciation made in an arts and crafts group. What is the nurse's best action? a. Recognize the effectiveness of the relationship and patient's thoughtfulness. Accept the card. b. Inform the patient that accepting gifts violates the policies of the facility. Decline the card. c. Acknowledge the patient's transition through the termination phase but decline the card. d. Accept the card and invite the patient to return to participate in other arts and crafts groups.
A
Four individuals have given information about their suicide plans. Which plan evidences the highest suicide risk? a. Jumping from a 100-foot-high railroad bridge located in a deserted area late at night b. Turning on the oven and letting gas escape into the apartment during the night c. Cutting the wrists in the bathroom while the spouse reads in the next room d. Overdosing on aspirin with codeine while the spouse is out with friends
A
Goals of care for an older adult patient diagnosed with delirium caused by fever and dehydration will focus on: a. returning to premorbid levels of function. b. identifying stressors negatively affecting self. c. demonstrating motor responses to noxious stimuli. d. exerting control over responses to perceptual distortions
A
In the emergency department, a patient's vital signs are: blood pressure (BP), 66/40 mm Hg; pulse (P), 140 beats per minute (bpm); and respirations (R), 8 breaths per minute and shallow. The patient overdosed on illegally obtained hydromorphone (Dilaudid). Select the priority outcome. a. Within 8 hours, vital signs will stabilize as evidenced by BP greater than 90/60 mm Hg, P less than 100 bpm, and respirations at or above 12 breaths per minute. b. The patient will be able to describe a plan for home care and achieve a drug-free state before being released from the emergency department. c. The patient will attend daily meetings of Narcotics Anonymous within 1 week of beginning treatment. d. The patient will identify two community resources for the treatment of substance abuse by discharge.
A
In what significant ways is the therapeutic environment different for a patient who has ingested D-lysergic acid diethylamide (LSD) than for a patient who has ingested phencyclidine (PCP)? a. For LSD ingestion, one person stays with the patient and provides verbal support. For PCP ingestion, a regimen of limited contact with staff members is maintained, and continual visual monitoring is provided. b. For PCP ingestion, the patient is placed on one-on-one intensive supervision. For LSD ingestion, a regimen of limited interaction and minimal verbal stimulation is maintained. c. For LSD ingestion, continual moderate sensory stimulation is provided. For PCP ingestion, continual high-level stimulation is provided. d. For LSD ingestion, the patient is placed in restraints. For PCP ingestion, seizure precautions are implemented.
A
One bed is available on the inpatient eating disorders unit. Which patient should be admitted? The patient whose weight dropped from: a. 150 to 100 pounds over a 4-month period. Vital signs: temperature, 35.9° C; pulse, 38 beats/min; blood pressure, 60/40 mm Hg b. 120 to 90 pounds over a 3-month period. Vital signs: temperature, 36° C; pulse, 50 beats/min; blood pressure, 70/50 mm Hg c. 110 to 70 pounds over a 4-month period. Vital signs: temperature 36.5° C; pulse, 60 beats/min; blood pressure, 80/66 mm Hg d. 90 to 78 pounds over a 5-month period. Vital signs: temperature, 36.7° C; pulse, 62 beats/min; blood pressure, 74/48 mm Hg
A
Others describe a worker as very shy and lacking in self-confidence. This worker stays in an office cubicle all day and never comes out for breaks or lunch. Which term best describes this behavior? a. Avoidant b. Dependent c. Histrionic d. Paranoid
A
Physical assessment of a patient with bulimia often reveals: a. prominent parotid glands. b. peripheral edema. c. thin, brittle hair. d. amenorrhea.
A
Planning for patients with mental illness is facilitated by understanding that inpatient hospitalization is generally reserved for patients who: a. present a clear danger to self or others. b. are noncompliant with medications at home. c. have no support systems in the community. d. develop new symptoms during the course of an illness.
A
Priority teaching for a patient taking clozapine (Clozaril) should include which instruction? a. Report sore throat and fever immediately. b. Avoid foods high in polyunsaturated fat. c. Use water-based lotions for rashes. d. Avoid unprotected sex.
A
Select the nursing intervention necessary after administering naloxone (Narcan) to a patient experiencing an opiate overdose. a. Monitor the airway and vital signs every 15 minutes. b. Insert a nasogastric tube and test gastric pH. c. Treat hyperpyrexia with cooling measures. d. Insert an indwelling urinary catheter.
A
Several nurses are concerned that agency policies related to restraint and seclusion practices are inadequate. Which statement about the relationship of substandard institutional policies and individual nursing practice should guide nursing practice? a. The policies do not absolve an individual nurse of the responsibility to practice according to the professional standards of nursing care. b. Agency policies are the legal standard by which a professional nurse must act and therefore override other standards of care. c. In an institution with substandard policies, the nurse has a responsibility to inform the supervisor and leave the premises. d. Interpretation of policies by the judicial system is rendered on an individual basis and therefore cannot be predicted.
A
The cause of bipolar disorder has not been determined, but: a. several factors, including genetics, are implicated. b. brain structures were altered by stresses early in life. c. excess norepinephrine is probably a major factor. d. excess sensitivity in dopamine receptors may exist.
A
The causes of somatic system disorders may be related to: a. faulty perceptions of body sensations. b. traumatic childhood events. c. culture-bound phenomena. d. depressive equivalents.
A
The family of a patient whose insurance will not pay for continuing hospitalization considers transferring the patient to a public psychiatric hospital. The family expresses concern that the patient will "never get any treatment." Which reply by the nurse would be most helpful? a. "Under the law, treatment must be provided. Hospitalization without treatment violates patients' rights." b. "That's a justifiable concern because the right to treatment extends only to the provision of food, shelter, and safety." c. "Much will depend on other patients because the right to treatment for a psychotic patient takes precedence over the right to treatment of a patient who is stable." d. "All patients in public hospitals have the right to choose both a primary therapist and a primary nurse."
A
The family of a patient with undifferentiated schizophrenia is unfamiliar with the illness and the family's role in recovery. Which type of therapy should the nurse recommend? a. Psychoeducational b. Psychoanalytic c. Transactional d. Family
A
The laboratory report for a patient taking clozapine (Clozaril) shows a white blood cell count of 3000 mm3 and a granulocyte count of 1500 mm3. The nurse should: a. report the laboratory results to the health care provider. b. give the next dose as prescribed. c. administer aspirin and force fluids. d. repeat the laboratory tests.
A
The nurse cares for a victim of a violent sexual assault. What is the most therapeutic intervention? a. Use accepting, nurturing, and empathetic communication techniques. b. Educate the victim about strategies to avoid attacks in the future. c. Discourage the expression of feelings until the victim stabilizes. d. Maintain a matter-of-fact manner and objectivity.
A
The parents of identical twins ask a nurse for advice. One twin committed suicide a month ago. Now the parents are concerned that the other twin may also have suicidal tendencies. Which comment by the nurse is accurate? a. "Genetics are associated with suicide risk. Monitoring and support are important." b. "Apathy underlies suicide. Instilling motivation is the key to health maintenance." c. "Your child is unlikely to act out suicide when identifying with a suicide victim." d. "Fraternal twins are at higher risk for suicide than identical twins."
A
The staff development coordinator plans to teach the use of physical management techniques when patients become assaultive. Which topic should be emphasized? a. Practice and teamwork b. Spontaneity and surprise c. Caution and superior size d. Diversion and physical outlets
A
The therapeutic action of monoamine oxidase inhibitors (MAOIs) blocks neurotransmitter reuptake, causing: a. increased concentration of neurotransmitters in the synaptic gap b. decreased concentration of neurotransmitters in serum c. destruction of receptor sites d. limbic system stimulation
A
The treatment team plans care for a person diagnosed with schizophrenia and cannabis abuse. The person has recently used cannabis daily and is experiencing increased hallucinations and delusions. Which principle applies to care planning? a. Consider each disorder primary and provide simultaneous treatment. b. The person will benefit from treatment in a residential treatment facility. c. Withdraw the person from cannabis, and then treat the schizophrenia. d. Treat the schizophrenia first, and then establish the goals for the treatment of substance abuse.
A
Two staff nurses applied for promotion to nurse manager. The nurse not promoted initially had feelings of loss but then became supportive of the new manager by helping make the transition smooth and encouraging others. Which term best describes the nurse's response? a. Altruism b. Sublimation c. Suppression d. Passive aggression
A
What assessment findings mark the prodromal stage of schizophrenia? a. Withdrawal, misinterpreting, poor concentration, and preoccupation with religion b. Auditory hallucinations, ideas of reference, thought insertion, and broadcasting c. Stereotyped behavior,echopraxia, echolalia, and waxy flexibility d. Lease associations, concrete thinking, and echolalia neologisms
A
What is the focus of priority nursing interventions for the period immediately after electroconvulsive therapy treatment? a. Supporting physiologic stability b. Reducing disorientation and confusion c. Establishing random eye movement latency d. Assisting the patient to identify and test negative thoughts
A
What is the priority intervention for a nurse beginning a therapeutic relationship with a patient diagnosed with a schizotypal personality disorder? a. Respect the patient's need for periods of social isolation. b. Prevent the patient from violating the nurse's rights. c. Engage the patient in many community activities. d. Teach the patient how to match clothing.
A
What is the priority nursing diagnosis for a patient with fluctuating levels of consciousness, disturbed orientation, and visual and tactile hallucinations? a. Risk for injury related to altered cerebral function, fluctuating levels of consciousness, disturbed orientation, and misperception of the environment b. Bathing/hygiene self-care deficit related to cerebral dysfunction, as evidenced by confusion and inability to perform personal hygiene tasks c. Disturbed thought processes related to medication intoxication, as evidenced by confusion, disorientation, and hallucinations d. Fear related to sensory perceptual alterations as evidenced by visual and tactile hallucinations
A
When a female Mexican-American patient and a female nurse sit together, the patient often holds the nurse's hand. The patient also links arm and arm with the nurse when they walk. The nurse is uncomfortable with this behavior and thinks the patient is homosexual. Which alternative is a more accurate assessment? a. The patient is accustomed to touch during conversations, as are members of many Hispanic subcultures. b. The patient understands that touch makes the nurse uncomfortable and controls the relationship based on that factor. c. The patient is afraid of being alone. When touching the nurse, the patient is reassured and comforted. d. The nurse is homophobic.
A
When a nurse assesses an older adult 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. "How can I make this assessment interview easier for you?" c. "I notice you are frowning. Are you feeling annoyed with me?" d. "You're having trouble focusing on what I'm saying. What is distracting you?"
A
When a patient with paranoid schizophrenia was discharged six months ago, haloperidol (Haldol) Was prescribed. The patient now says, "I stop taking those pills. They made me feel like a robot." What common satisfaction of the nurse validate the patient? a. Sedation and muscle stiffness b. Sweating, nausea, and diarrhea c. Mile fever, sore throat, and skin rash d. Headache, watery eyes, and runny nose
A
When a person first begins drinking alcohol, two drinks produce relaxation and drowsiness. After one year of drinking, four drinks are needed to achieve the same relaxed, drowsy state. Why does this change occur? a. Tolerance develops. b. The alcohol is less potent. c. Antagonistic effects occur. d. Hypomagnesemia develops.
A
When working with a patient beginning treatment for alcohol abuse, what is the nurse's most therapeutic approach? a. Empathetic, supportive b. Strong, confrontational c. Skeptical, guarded d. Cool, distant
A
Which action by a psychiatric nurse best supports patients' rights to be treated with dignity and respect? a. Consistently addressing each patient by title and surname. b. Strongly encouraging a patient to participate in the unit milieu. c. Discussing a patient's condition with another health care provider in the elevator. d. Informing a treatment team that a patient is too drowsy to participate in care planning.
A
Which assessment finding best supports dissociative fugue? The patient states: a. "I cannot recall why I'm living in this town." b. "I feel as if I'm living in a fuzzy dream state." c. "I feel like different parts of my body are at war." d. "I feel very anxious and worried about my problems."
A
Which assessment has priority when a nurse interviews a rape victim in the emergency department? a. Coping mechanisms the patient is using b. Patient's previous sexual experience c. Adequacy of interpersonal relationships d. Patient's history of sexually transmitted diseases
A
Which behavior best demonstrates aggression? a. Stomping away from the nurses' station, going to the day room, and grabbing a pool cue from a patient standing by the pool table. b. Bursting into tears, leaving the community meeting, and sitting on a bed hugging a pillow and sobbing. c. Telling the primary nurse, "I felt angry when you said I could not have a second helping at lunch." d. Telling the medication nurse, "I am not going to take that or any other medication you try to give me."
A
Which comment by a person who is experiencing severe anxiety indicates the possibility of obsessive-compulsive disorder? a. "I check where my car keys are eight times." b. "My legs often feel weak and spastic." c. "I'm embarrassed to go out in public." d. "I keep reliving the car accident."
A
Which documentation indicates that the treatment plan for a patient in an alcohol treatment program was effective? a. Is abstinent for 10 days and states, "I can maintain sobriety one day at a time." Spoke with employer, who is willing to allow the patient to return to work in three weeks. b. Is abstinent for 15 days and states, "My problems are under control." Plans to seek a new job where co-workers will not know history. c. Attends AA daily; states many of the members are "real" alcoholics and says, "I may be able to help some of them find jobs at my company." d. Is abstinent for 21 days and says, "I know I can't handle more than one or two drinks in a social setting."
A
Which documentation indicates that the treatment plan for a patient with acute mania has been effective? a. "Converses without interrupting, clothing matches, participates in activities." b. "Irritable, suggestible, distractible, napped for 10 minutes in afternoon." c. "Attention span short, writing copious notes, intrudes in conversations." d. "Heavy makeup, seductive toward staff, pressured speech."
A
Which documentation indicates the treatment plan of a patient with major depression was effective? a. Slept 6 hours uninterrupted. Sang with activity group. Anticipates seeing grandchild. b. Slept 10 hours uninterrupted. Attended craft group; stated "project was a failure, just like me." c. Slept 5 hours with brief interruptions. Personal hygiene adequate with assistance. Weight loss of 1 pound. d. Slept 7 hours uninterrupted. Preoccupied with perceived inadequacies. States, "I feel tired all the time."
A
Which employer's health plan is required to include parity provisions related to mental illnesses? a. Employer with more than 50 employees b. Cancer thrift shop staffed by volunteers c. Daycare center that employs 7 teachers d. Church that employs 15 people
A
Which family scenario presents the greatest risk for family violence? a. An unemployed husband with low self-esteem, a wife who loses her job, and a developmentally delayed 3-year-old child b. A husband who finds employment 2 weeks after losing his previous job, a wife with stable employment, and a child doing well in school c. A single mother with an executive position, a talented child, and a widowed grandmother living in the home to provide child care d. A single homosexual male parent, an adolescent son who has just begun dating girls, and the father's unmarried sister who has come to visit for 2 weeks
A
Which intervention is appropriate for a patient diagnosed with an antisocial personality disorder who frequently manipulates others? a. Refer the patient's requests and questions to the case manager. b. Explore the patient's feelings of fear and inferiority. c. Provide negative reinforcement for acting-out behavior. d. Ignore, rather than confront, inappropriate behavior.
A
Which is an effective nursing intervention to assist an angry patient to learn to manage anger without violence? a. Help the patient identify a thought that increases anger, find proof for or against the belief, and substitute reality-based thinking. b. Provide negative reinforcement such as restraint or seclusion in response to angry outbursts, whether or not violence is present. c. Use aversive conditioning, such as popping a rubber band on the wrist, to help extinguish angry feelings. d. Administer an antipsychotic or antianxiety medication.
A
Which nursing intervention has the highest priority for a patient with bulimia nervosa? a. Assist the patient to identify triggers to binge eating. b. Provide corrective consequences for weight loss. c. Assess for signs of impulsive eating. d. Explore patient needs for health teaching.
A
Which principle takes priority for the psychiatric inpatient staff when addressing behavioral crises? a. Resolve behavioral crises with the least restrictive intervention possible. b. Rights of the majority of patients supersede the rights of individual patients. c. Swift intervention is justified to maintain the integrity of the therapeutic milieu. d. Allow patients the opportunities to regain control without intervention if the safety of other patients is not compromised.
A
Which statement is a nurse most likely to hear from a patient with anorexia nervosa? a. "I'm fat and ugly." b. "I have nice eyes." c. "I'm thin for my height." d. "My parents don't pay much attention to me."
A
Which statement is mostly likely to be made by a patient with agoraphobia? a. "Being afraid to go out seems ridiculous, but I can't go out the door." b. "I'm sure I'll get over not wanting to leave home soon. It takes time." c. "When I have a good incentive to go out, I can do it." d. "My family says they like it now that I stay home."
A
Which statement most accurately describes substance addiction? a. It is a lack of control over use. Tolerance, craving, and withdrawal symptoms occur when intake is reduced or stopped. b. It occurs when psychoactive drug use interferes with the action of competing neurotransmitters. c. Symptoms occur when two or more drugs that affect the central nervous system (CNS) have additive effects. d. It involves using a combination of substances to weaken or inhibit the effect of another drug.
A
Which statement provides the best rationale for why a nurse should closely monitor a severely depressed patient during antidepressant medication therapy? a. As depression lifts, physical energy becomes available to carry out suicide. b. Suicide may be precipitated by a variety of internal and external events. c. Suicidal patients have difficulty using social supports. d. Suicide is an impulsive act.
A
Which statement shows a nurse has empathy for a patient who made a suicide attempt? a. "You must have been very upset when you tried to hurt yourself." b. "It makes me sad to see you going through such a difficult experience." c. "If you tell me what is troubling you, I can help you solve your problems." d. "Suicide is a drastic solution to a problem that may not be such a serious matter."
A
Which technique will best communicate to a patient that the nurse is interested in listening? a. Restate a feeling or thought the patient has expressed. b. Ask a direct question, such as "Did you feel angry?" c. Make a judgment about the patient's problem. d. Say, "I understand what you're saying."
A
While talking with a patient with severe depression, a nurse notices the patient is unable to maintain eye contact. The patient's chin lowers to the chest while the patient looks at the floor. Which aspect of communication has the nurse assessed? a. Nonverbal communication b. A message filter c. A cultural barrier d. Social skills
A
A nurse ends a relationship with a patient. Which actions by the nurse should be included in the termination phase? Select all that apply. a. Focus dialogs with the patient on problems that may occur in the future. b. Help the patient express feelings about the relationship with the nurse. c. Help the patient prioritize and modify socially unacceptable behaviors. d. Reinforce expectations regarding the parameters of the relationship. e. Help the patient identify strengths, limitations, and problems.
A B
A professor's 4-year-old child has a temperature of 101.6° F, diarrhea, and complains of stomach pain. The professor is scheduled to teach three classes today. Which actions by the professor demonstrate effective parenting? Select all that apply. a. Telephoning a grandparent to stay with the child at home for the day. b. Telephoning a colleague to teach his classes and stays home with the sick child. c. Taking the child to the university and keeps the child in a private office for the day. d. Taking the child to a daycare center and hopes daycare workers will not notice the child is sick. e. Giving the child one dose of ibuprofen (Motrin) and takes the child to the daycare center.
A B
An experienced nurse says to a new graduate, "When you've practiced as long as I have, you'll instantly know how to take care of psychotic patients." What is the new graduate's best analysis of this comment? Select all that apply. a. The experienced nurse may have lost sight of patients' individuality, which may compromise the integrity of practice. b. New research findings must be continually integrated into a nurse's practice to provide the most effective care. c. Experience provides mental health nurses with the tools and skills needed for effective professional practice. d. Experienced psychiatric nurses have learned the best ways to care for psychotic patients through trial and error. e. Effective psychiatric nurses should be continually guided by an intuitive sense of patients' needs.
A B
Which situations qualify as abandonment on the part of a nurse? (Select all that apply.) The nurse: a. allows a patient with acute mania to refuse hospitalization without taking further action. b. terminates employment without referring a seriously mentally ill for aftercare. c. calls police to bring a suicidal patient to the hospital after a suicide attempt. d. refers a patient with persistent paranoid schizophrenia to community treatment. e. asks another nurse to provide a patient's care because of concerns about countertransference.
A B
A patient with major depression shows vegetative signs of depression. Which nursing actions should be implemented? Select all that apply. a. Offer laxatives, if needed. b. Monitor food and fluid intake. c. Provide a quiet sleep environment. d. Eliminate all daily caffeine intake. e. Restrict the intake of processed foods.
A B C
A patient with major depression will begin electroconvulsive therapy tomorrow. Which interventions are routinely implemented before the treatment? Select all that apply. a. Administer pretreatment medication 30 to 45 minutes before treatment. b. Withhold food and fluids for a minimum of 6 hours before treatment. c. Remove dentures, glasses, contact lenses, and hearing aids. d. Restrain the patient in bed with padded limb restraints. e. Assist the patient to prepare an advance directive.
A B C
Which benefits are most associated with the use of telehealth? Select all that apply. a. Cost savings for patients b. Maximization of care management c. Access to services for patients in rural areas d. Prompt reimbursement by third-party payers e. Rapid development of trusting relationships with patients
A B C
An individual says to the nurse, "I feel so stressed out lately. I think the stress is affecting my body also." Which somatic complaints are most likely to accompany this feeling? Select all that apply. a. Headache b. Neck pain c. Insomnia d. Anorexia e. Myopia
A B C D
A nurse assesses a patient suspected to have complex somatic system disorder. Which findings support the diagnosis? Select all that apply. a. Patient is a woman. b. Patient reports frequent syncope. c. Patient complains of heavy menstrual bleeding. d. Patient was first diagnosed with psoriasis at 12 years of age. e. Patient reports back pain, painful urination, frequent diarrhea, and hemorrhoids.
A B C E
A nurse can best address factors of critical importance to successful community treatment for persons with mental illness by including assessments related to which of the following? Select all that apply. a. housing adequacy and stability b. income adequacy and stability c. family and other support systems d. early psychosocial development e. substance abuse history and current use
A B C E
A patient states, "I'm starting cognitive behavioral therapy. What can I expect from the sessions?" Which responses by the nurse are appropriate? Select all that apply. a. "The therapist will be active and questioning." b. "You may be given homework assignments." c. "The therapist will ask you to describe your dreams." d. "The therapist will help you look at ideas and beliefs you have about yourself." e. "The goal is to increase your subjectivity about thoughts that govern your behavior."
A B D
A patient asks a nurse, "The pamphlet I read about depression says psychosocial factors influence depression. What does that mean?" Which examples could the nurse cite to support the information? Select all that apply. a. Having a hostile family b. Having an over- or underinvolved family c. Having two first-degree relatives with bipolar disorder d. Experiencing the sudden death of a parent or loved one e. Feeling strong guilt over having an abortion when one's religion forbids it f. Experiencing symptom remission when treated with an antidepressant medication
A B D E
A basic level registered nurse works with patients in a community setting. Which groups should this nurse expect to lead? Select all that apply. a. Symptom management b. Medication education c. Family therapy d. Psychotherapy e. Self-care
A B E
A child is placed in a foster home after being removed from parental contact because of abuse. The child is apprehensive and overreacts to environmental stimuli. The foster parents ask the nurse how to help the child. What should the nurse recommend? Select all that apply. a. Use a calm manner and low voice. b. Maintain simplicity in the environment. c. Avoid repetition in what is said to the child. d. Minimize opportunities for exercise and play. e. Explain and reinforce reality to avoid distortions.
A B E
A community member asks a nurse, "People with mental illnesses used to go to a state hospital. Why has that changed?" Select the nurse's accurate responses. Select all that apply. a. "Science has made significant improvements in drugs for mental illness, so now many people may live in their communities." b. "A better selection of less restrictive settings is now available in communities to care for individuals with mental illness." c. "National rates of mental illness have declined significantly. The need for state institutions is actually no longer present." d. "Most psychiatric institutions were closed because of serious violations of patients' rights and unsafe conditions." e. "Federal legislation and payment for treatment of mental illness have shifted the focus to community rather than institutional settings."
A B E
A nurse performing an assessment interview for a patient with a substance use disorder decides to use a standardized rating scale. Which scales are appropriate? Select all that apply. a. Addiction Severity Index (ASI) b. Brief Drug Abuse Screen Test (B-DAST) c. Abnormal Involuntary Movement Scale (AIMS) d. Cognitive Capacity Screening Examination (CCSE) e. Recovery Attitude and Treatment Evaluator (RAATE)
A B E
Which patient statements identify qualities of nursing practice with high therapeutic value? (Select all that apply.) "The nurse: a. talks in language I can understand." b. helps me keep track of my medications." c. is willing to go to social activities with me." d. lets me do whatever I choose without interfering." e. looks at me as a whole person with different needs."
A B E
Which suggestions are appropriate for the family of a patient with bipolar disorder who is being treated as an outpatient during a hypomanic episode? Select all that apply. a. Provide structure. b. Limit credit card access. c. Encourage group-social interaction. d. Suggest limiting work to half days. e. Monitor the patient's sleep patterns.
A B E
A patient tells the nurse, "I am so ashamed of being bipolar. When I'm manic, my behavior embarrasses my family. Even if I take my medication, there's no guarantee I won't have a relapse. I am such a burden to my family." These statements support which nursing diagnoses? Select all that apply. a. Powerlessness b. Defensive coping c. Chronic low self-esteem d. Impaired social interaction e. Risk-prone health behavior
A C
A nurse plans health teaching for a patient with generalized anxiety disorder who takes lorazepam (Ativan). What information should be included? Select all that apply. a. Use caution when operating machinery. b. Allowed tyramine-free foods in diet. c. Understand the importance of caffeine restriction. d. Avoid alcohol and other sedatives. e. Take the medication on an empty stomach.
A C D
An individual is experiencing problems associated with memory. Which cerebral structures are most likely to be involved in this deficit? Select all that apply. a. Prefrontal cortex b. Occipital lobe c. Temporal lobe d. Parietal lobe e. Basal ganglia
A C D
Which descriptors exemplify consistency regarding nurse-patient relationships? Select all that apply. a. Having the same nurse care for a patient on a daily basis b. Encouraging a patient to share initial impressions of staff c. Providing a schedule of daily activities to a patient d. Setting a time for regular sessions with a patient e. Offering solutions to a patient's problems
A C D
A student nurse caring for a patient with depression reads in the patient's medical record, "This patient shows vegetative signs of depression." Which nursing diagnoses most clearly relate to the vegetative signs? Select all that apply. a. Imbalanced nutrition: less than body requirements b. Chronic low self-esteem c. Sexual dysfunction d. Self-care deficit e. Powerlessness f. Insomnia
A C D F
A nurse prepares to administer an antipsychotic medication to a patient with schizophrenia. Additional monitoring of the medication's effects and side effects will be most important if the patient is also diagnosed with which health problem? Select all that apply. a. Parkinson disease b. Graves disease c. Osteoarthritis d. Epilepsy e. Diabetes
A D E
A patient being treated with paroxetine (Paxil) 50 mg/day orally for depression reports to the clinic nurse, "I took a few extra tablets earlier in the day and now I feel bad." Which assessments are most critical? Select all that apply. a. Vital signs b. Urinary frequency c. Increased suicidal ideation d. Presence of abdominal pain and diarrhea e. Hyperactivity or feelings of restlessness
A D E
A patient referred to the eating disorders clinic has lost 35 pounds in 3 months and has developed amenorrhea. For which physical manifestations of anorexia nervosa should a nurse assess? Select all that apply. a. Peripheral edema b. Parotid swelling c. Constipation d. Hypotension e. Dental caries f. Lanugo
ACDF
A new psychiatric nurse has a parent with bipolar disorder. This nurse angrily recalls embarrassing events concerning the parent's behavior in the community. Select the best ways for this nurse to cope with these feelings. Select all that apply. a. Seek ways to use the understanding gained from childhood to help patients cope with their own illnesses. b. Recognize that these feelings are unhealthy, and try to suppress them when working with patients. c. Recognize that psychiatric nursing is not an appropriate career choice, and explore other nursing specialties. d. Begin new patient relationships by saying, "My own parent had mental illness, so I accept it without stigma." e. Recognize that the feelings may add sensitivity to the nurse's practice, but supervision is important.
A E
A patient with predominant pain disorder says, "Why has God chosen me to be sick all the time and unable to provide for my family? The burden on my family is worse than the pain I bear." Which nursing diagnoses apply to this patient? Select all that apply. a. Spiritual distress b. Decisional conflict c. Adult failure to thrive d. Impaired social interaction e. Ineffective role performance
A E
A patient with paranoid schizophrenia is hospitalized after arguing with coworkers and is threatening to harm them. The patient is aloof and suspicious and says, "Two staff members I saw talking we're plotting To kill me." Based on data gathered at this point which nursing diagnoses relate? (Select all that apply) a. Risk for other-directed violence b. Disturbed thought processes c. Risk for loneliness d. Spiritual distress e. Social isolation
AB
A 10-year-old child cares for siblings while the parents work because the family cannot afford a babysitter. This child says, "My father doesn't like me. He calls me stupid all the time." The mother says the father is easily frustrated and has trouble disciplining the children. The community health nurse should consider which resources to stabilize the home situation? Select all that apply. a. Parental sessions to teach childrearing practices b. Anger management counseling for the father c. Continuing home visits to provide support d. Safety plan for the wife and children e. Placement of the children in foster care
ABC
A community health nurse visits a family with four children. The father behaves angrily, finds fault with a child, and asks twice, "Why are you such a stupid kid?" The wife says, "I have difficulty disciplining the children. It's so frustrating." Which comments by the nurse will facilitate the interview with these parents? Select all that apply. a. "Tell me how you punish your children." b. "How do you stop your baby from crying?" c. "Caring for four small children must be difficult." d. "Do you or your husband ever beat the children?" e. "Calling children 'stupid' injures their self-esteem."
ABC
A patient with suicidal impulses is on the highest level of suicide precautions. Which measures should the nurse incorporate into the patient's plan of care? Select all that apply. a. Allow no glass or metal on meal trays. b. Remove all potentially harmful objects from the patient's possession. c. Maintain arm's length, one-on-one nursing observation around the clock. d. Check the patient's whereabouts every hour. Make verbal contact at least three times each shift. e. Check the patient's whereabouts every 15 minutes, and make frequent verbal contacts. f. Keep the patient within visual range while he or she is awake. Check every 15 to 30 minutes while the patient is sleeping.
ABC
A person was abducted and raped at gunpoint by an unknown assailant. Which interventions should the nurse use while caring for this person in the emergency department? Select all that apply. a. Allow the patient to talk at a comfortable pace. b. Pose questions in nonjudgmental, empathic ways. c. Place the patient in a private room with a caregiver. d. Reassure the patient that a family member will arrive as soon as possible. e. Invite family members to the examination room and involve them in taking the history. f. Put an arm around the patient to offer reassurance that the nurse is caring and compassionate.
ABC
Which assessment findings would the nurse expect in a patient experiencing delirium? Select all that apply. a. Impaired level of consciousness b. Disorientation to place, time c. Wandering attention d. Apathy e. Agnosia
ABC
A nurse directs the intervention team who must take an aggressive patient to seclusion. Other patients were removed from the area. Before approaching the patient, the nurse should ensure that the staff takes which of the following actions? Select all that apply. a. Remove jewelry, glasses, and harmful items from the patient and staff members. b. Appoint a person to clear a path and open, close, or lock doors. c. Quickly approach the patient, and grab the closest extremity. d. Select the person who will communicate with the patient. e. Move behind the patient to use the element of surprise.
ABD
For which patients diagnosed with personality disorders would a family history of similar problems be most likely? Select all that apply. a. Obsessive-compulsive b. Antisocial c. Dependent d. Schizotypal e. Narcissistic
ABD
A nurse assesses five newly hospitalized patients. Which patients have the highest suicide risk? Select all that apply. a. 82-year-old white man b. 17-year-old white female adolescent c. 39-year-old African-American man d. 29-year-old African-American woman e. 22-year-old man with traumatic brain injury
ABE
A patient diagnosed with moderately severe Alzheimer's disease has a self-care deficit of dressing and grooming. Designate appropriate interventions to include in the patient's plan of care. Select all that apply. a. Provide clothing with elastic and hook-and-loop closures. b. Label clothing with the patient's name and name of the item. c. Administer anti-anxiety medication before bathing and dressing. d. Provide necessary items and direct the patient to proceed independently. e. If the patient resists dressing, use distraction and try again after a short interval.
ABE
Because an intervention is required to control a patient's aggressive behavior, a critical incident debriefing takes place. Which topics are the primary focuses of the discussion? Select all that apply a. Patient behavior associated with the incident b. Genetic factors associated with aggression c. Intervention techniques used by staff d. Effect of environmental factors e. Review of theories of aggression
ACD
When an emergency department nurse teaches a victim of the rape trauma syndrome about reactions that may occur during the long-term reorganization phase, which symptoms should be included? Select all that apply. a. Development of fears and phobias b. Decreased motor activity c. Feelings of numbness d. Flashbacks, dreams e. Syncopal episodes
ACD
A nurse can assist a patient diagnosed with addiction and the patient's family in which aspects of RELAPSE PREVENTION? Select all that apply. (3) a. Rehearsing techniques to handle anticipated stressful situations b. Advising the patient to accept residential treatment if relapse occurs c. Assisting the patient to identify life skills needed for effective coping d. Isolating self from significant others and social situations until sobriety is established e. Teaching the patient about the physical changes to expect as the body adapts to functioning without substances
ACE
A nurse assists a victim of spousal abuse to create a plan for escape if it becomes necessary. The plan should include which components? Select all that apply. a. Keep a cell phone fully charged. b. Hide money with which to buy new clothes. c. Have the telephone number for the nearest shelter. d. Take enough toys to amuse the children for 2 days. e. Secure a supply of current medications for self and children. f. Determine a code word to signal children that it is time to leave. g. Assemble birth certificates, Social Security cards, and licenses.
ACEFG
The family members of a patient Diagnosed with paranoid schizophrenia state that they do not understand what has caused the illness. Nurse's response should be based on which models? (Select all that apply) a. Neurobiological b. Developmental c. Family theory d. Genetic e. Stress
AD
Which central nervous system structures are most associated with anger and aggression? Select all that apply. a. Amygdala b. Cerebellum c. Basal ganglia d. Temporal lobe e. Parietal lobe
AD
A patient with a history of command hallucinations approaches the nurse, yelling obscenities. The patient mumbles and then walks away. The nurse follows. Which nursing actions are most likely to be effective in de-escalating this scenario? Select all that apply. a. State the expectation that the patient will stay in control. b. State that the patient cannot be understood when mumbling. c. Tell the patient, "You are behaving inappropriately." d. Offer to provide the patient with medication to help. e. Speak in a firm but calm voice.
ADE
Which behaviors are most consistent with the clinical picture of a patient who is becoming increasingly aggressive? Select all that apply. a. Pacing b. Crying c. Withdrawn affect d. Rigid posture with clenched jaw e. Staring with narrowed eyes into the eyes of another
ADE
A nurse wants to demonstrate genuineness with a patient diagnosed with schizophrenia. The nurse should: a. restate what the patient says. b. use congruent communication strategies. c. use self-revelation in patient interactions. d. consistently interpret the patient's behaviors.
B
A nurse wants to enhance the growth of a patient by showing positive regard. The action consistent with this wish is: a. making rounds daily. b. staying with a tearful patient. c. administering daily medication as prescribed. d. examining personal feelings about a patient.
B
Cortisol is released in response to a patient's prolonged stress. Which initial effect would the nurse expect to result from the increased cortisol level? a. Diuresis and electrolyte imbalance b. Focused and alert mental status c. Drowsiness and lethargy d. Restlessness and anxiety
B
What is a nurse's legal responsibility if child abuse or neglect is suspected? a. Discuss the findings with the child's teacher, principal, and school psychologist. b. Report the suspected abuse or neglect according to state regulations. c. Document the observations and speculations in the medical record. d. Continue the assessment.
B
What is the desirable outcome for the orientation stage of a nurse-patient relationship? The patient will demonstrate behaviors that indicate: a. great sense of independence. b. rapport and trust with the nurse. c. self-responsibility and autonomy. d. resolved transference.
B
A patient in the long-term reorganization phase of the rape trauma syndrome has experienced intrusive thoughts of the rape and developed a fear of being alone. Which finding demonstrates the patient has made improvement? The patient: a. temporarily withdraws from social situations. b. plans coping strategies for fearful situations. c. uses increased activity to reduce fear. d. expresses a desire to be with others.
B
What is the priority intervention for a patient diagnosed with delirium who has fluctuating levels of consciousness, disturbed orientation, and perceptual alterations? a. Distraction using sensory stimulation b. Careful observation and supervision c. Avoidance of physical contact d. Activation of the bed alarm
B
A patient is admitted to the psychiatric hospital for assessment and evaluation. Which assessment finding best indicates that the patient has a mental illness? The patient: a. describes coping and relaxation strategies used when feeling anxious. b. describes mood as consistently sad, discouraged, and hopeless. c. can perform tasks attempted within the limits of own abilities. d. reports occasional problems with insomnia.
B
A patient is hospitalized for major depression. Of the medications listed, a nurse can expect to provide the patient with teaching about: a. chlordiazepoxide (Librium) b. fluoxetine (Prozac) c. clozapine (Clozaril) d. tacrine (Cognex)
B
What is the priority nursing diagnosis for a patient diagnosed with antisocial personality disorder who has made threats against staff, ripped art off the walls, and thrown objects? a. Disturbed sensory perception-auditory b. Risk for other-directed violence c. Ineffective denial d. Ineffective coping
B
A patient performs ritualistic hand washing. What should the nurse do to help the patient develop more effective coping strategies? a. Allow the patient to set a hand-washing schedule. b. Encourage the patient to participate in social activities. c. Encourage the patient to discuss hand-washing routines. d. Focus on the patient's symptoms rather than on the patient.
B
Information from a patient's record that indicates marginal coping skills and the need for careful assessment of the risk for violence is a history of: a. childhood trauma. b. family involvement. c. academic problems. d. chemical dependence.
D
When a hyperactive patient with acute mania is hospitalized, what initial nursing intervention is a priority? a. Allow the patient to act out his or her feelings. b. Set limits on patient behavior as necessary. c. Provide verbal instructions to the patient to remain calm. d. Restrain the patient to reduce hyperactivity and aggression.
B
A nurse uses the SAD PERSONS scale to interview a patient. This tool provides data relevant to: a. current stress level. b. mood disturbance. c. suicide potential. d. level of anxiety.
C
A patient with paranoid schizophrenia believes evil spirits are being summoned by a local minister and verbally threatens to bomb a local church. The psychiatrist notifies the minister. The psychiatrist has: a. released information without proper authorization. b. demonstrated the duty to warn and protect. c. violated the patient's confidentiality. d. avoided charges of malpractice.
B
A nurse finds a new patient uncommunicative about recent life events. The nurse suspects marital and economic problems. The social worker's assessment is not available. The most effective action the nurse can take is to: a. ask the patient who shares a room with him or her. b. consult Axis IV of the DSM-IV-TR in the medical record. c. focus questions on the topics of marital and economic issues. d. delay discussion of these topics until the social worker's assessment is available.
B
A nurse in the emergency department tells an adult, "Your mother had a severe stroke." The adult tearfully says, "Who will take care of me now? My mother always told me what to do, what to wear, and what to eat. I need someone to reassure me when I get anxious." Which term best describes this behavior? a. Histrionic b. Dependent c. Narcissistic d. Borderline
B
A nurse instructs a patient taking a drug that inhibits the action of a monoamine oxidase (MAO) to avoid certain foods and drugs because of the risk of: a. hypotensive shock. b. hypertensive crisis. c. cardiac dysrhythmia. d. cardiogenic shock.
B
What is the primary motivator for most rapists? a. Anxiety b. Need for humiliation c. Overwhelming sexual desires d. Desire to humiliate or control others
D
A nurse observes a patient who is in a catatonic state and standing immobile, facing the wall with one arm extended in a salute. The patient remains immobile in this position for 15 minutes, moving only when the nurse gently lowers the arm. What is the name of this phenomenon? a. Echolalia b. Waxy flexibility c. Depersonalization d. Fault withdrawal
B
A nurse set limits for a patient diagnosed with a borderline personality disorder. The patient tells the nurse, "You used to care about me. I thought you were wonderful. Now I can see I was mistaken. You're terrible." This outburst can be assessed as: a. denial. b. splitting. c. reaction formation. d. separation-individuation strategies.
B
After formulating the nursing diagnoses for a new patient, what is the next action a nurse should take? a. Design interventions to include in the plan of care. b. Determine the goals and outcome criteria. c. Implement the nursing plan of care. d. Complete the spiritual assessment.
B
A nurse should introduce the matter of a contract during the first session with a new patient because contracts: a. specify what the nurse will do for the patient. b. spell out the participation and responsibilities of each party. c. indicate the feeling tone established between the participants. d. are binding and prevent either party from prematurely ending the relationship.
B
A nurse uses Peplau's interpersonal therapy while working with an anxious, withdrawn patient. Interventions should focus on: a. changing the patient's perceptions about self b. improving the patient's interactional skills c. using medications to relieve anxiety d. reinforcing specific behaviors
B
What is the priority need for a patient with late-stage dementia? a. Promotion of self-care activities b. Meaningful verbal communication c. Preventing the patient from wandering d. Maintenance of nutrition and hydration
D
A nurse visits the home of an 11-year-old child and finds the child caring for three younger siblings. Both parents are at work. The child says, "I want to go to school but we can't afford a babysitter. It doesn't matter though; I'm too dumb to learn." What preliminary assessment is evident? a. Insufficient data are present to make an assessment. b. Child and siblings are experiencing neglect. c. Children are at high risk for sexual abuse. d. Children are experiencing physical abuse.
B
A patient should be considered for involuntary commitment for psychiatric care when he or she: a. is noncompliant with the treatment regimen. b. sold sells and distributes illegal drugs. c. threatens to harm self and others. d. fraudulently files for bankruptcy.
C
A 26-month-old child displays negative behavior, refuses toilet training, and often shouts, "No!" when given directions. Using Freud's stages of psychosexual development, a nurse would assess the child's behavior is based on which stage? a. Oral b. Anal c. Phallic d. Genital
B
A clinic nurse interviews a patient who reports fatigue, back pain, headaches, and sleep disturbances. The patient seems tense, then becomes reluctant to provide more information, and is in a hurry to leave. How can the nurse best serve the patient? a. Explore the possibility of patient social isolation. b. Have the patient fill out an abuse assessment screen. c. Ask whether the patient has ever had psychiatric counseling. d. Ask the patient to disrobe; then assess for signs of physical abuse.
B
A college student observes a roommate going out wearing uncharacteristically seductive clothing, returning 12 to 24 hours later and sleeping for 8 to 12 hours. At other times, the roommate sits on the floor speaking like a young child. Which health problem should be considered? a. Functional neurological (conversion) disorder b. Dissociative identity disorder c. Depersonalization disorder d. Body dysmorphic disorder
B
A community mental health nurse has worked for 6 months to establish a relationship with a delusional, suspicious patient. The patient recently lost employment and stopped taking medications because of inadequate money. The patient says, "Only a traitor would make me go to the hospital." Which solution is best? a. Arrange a bed in a local homeless shelter with nightly onsite supervision. b. Negotiate a way to provide medication so the patient can remain at home. c. Hospitalize the patient until the symptoms have stabilized. d. Seek inpatient hospitalization for up to 1 week.
B
A community psychiatric nurse assesses that a patient with a mood disorder is more depressed than on the previous visit a month ago; however, the patient says, "I feel the same." Which intervention supports the nurse's assessment while preserving the patient's autonomy? a. Arrange for a short hospitalization. b. Schedule weekly clinic appointments. c. Refer the patient to the crisis intervention clinic. d. Call the family and ask them to observe the patient closely.
B
A medical-surgical nurse works with a patient diagnosed with a somatic system disorder. Care planning is facilitated by understanding that the patient will probably: a. Readily seek psychiatric counseling. b. Be resistant to accepting psychiatric help. c. Attend psychotherapy sessions without encouragement. d. Be eager to discover the true reasons for physical symptoms.
B
A new patient immediately requires seclusion on admission. The assessment is incomplete, and no prescriptions have been written. Immediately after safely secluding the patient, which action has priority? a. Provide an opportunity for the patient to go to the bathroom. b. Notify the health care provider and obtain a seclusion order. c. Notify the hospital risk manager. d. Debrief the staff.
B
A newly admitted patient diagnosed with paranoid schizophrenia is hypervigilant and constantly scans the environment. The patient states,"I saw two doctors talking in the hall. They were plotting to kill me." The nurse may correctly assessed this behavior as: a. echolalia b. Idea of reference c. Delusions of infidelity d. Auditory hallucinations
B
A nurse asks a patient, "If you had fever and vomiting for 3 days, what would you do?" Which aspect of the mental status examination is the nurse assessing? a. Behavior b. Cognition c. Affect and mood d. Perceptual disturbances
B
A nurse assesses a confused older adult. The nurse experiences sadness and reflects, "The patient is like one of my grandparents...so helpless." What feelings does the nurse describe? a. Transference b. Countertransference c. Catastrophic reaction d. Defensive coping reaction
B
A nurse consistently strives to demonstrate caring behaviors during interactions with patients. Which reaction by a patient indicates this nurse is effective? A patient reports feeling: a. distrustful l of others. b. connected with others. c. uneasy about the future. d. discouraged with efforts to improve.
B
A nurse counsels a patient diagnosed with body dysmorphic disorder. Which nursing diagnosis would be a priority for the plan of care? a. Anxiety b. Risk for suicide c. Disturbed body image d. Ineffective role performance
B
A nurse counsels the family of a patient diagnosed with Alzheimer's disease who lives at home and wanders at night. Which action is most important for the nurse to recommend to enhance safety? a. Apply a medical alert bracelet to the patient. b. Place locks at the tops of doors. c. Discourage daytime napping. d. Obtain a bed with side rails.
B
A nurse encourages an anxious patient to talk about feelings and concerns. What is the rationale for this intervention? a. Offering hope allays and defuses the patient's anxiety. b. Concerns stated aloud become less overwhelming and help problem solving to begin. c. Anxiety is reduced by focusing on and validating what is occurring in the environment. d. Encouraging patients to explore alternatives increases the sense of control and lessens anxiety.
B
A nurse worked at a hospital for several months, resigned, and then took a position at another hospital. In the new position, the nurse often volunteers to be the medication nurse. After several serious medication errors, an investigation reveals that the nurse was diverting patient narcotics for self-use. What early indicator of the nurse's drug use was evident? a. Accepting responsibility for medication errors. b. Seeking to be assigned as a medication nurse. c. Frequent complaints of physical pain. d. High sociability with peers.
B
A nurse's neighbor asks, "Why aren't people with mental illness kept in state institutions anymore?" What is the nurse's best response? a. "Many people are still in psychiatric institutions. Inpatient care is needed because many people who are mentally ill are violent." b. "Less restrictive settings are now available to care for individuals with mental illness." c. "Our nation has fewer persons with mental illness; therefore fewer hospital beds are needed." d. "Psychiatric institutions are no longer popular as a consequence of negative stories in the press."
B
A patient approaches the nurse and impatiently blurts out, "You've got to help me! Something terrible is happening. My heart is pounding." The nurse responds, "It's almost time for visiting hours. Let's get your hair combed." Which approach has the nurse used? a. Distracting technique to lower anxiety b. Bringing up an irrelevant topic c. Responding to physical needs d. Addressing false cognitions
B
A patient asks a nurse, "What are neurotransmitters? My doctor says mine are out of balance." The best reply would be: a. "You must feel relieved to know that your problem has a physical basis." b. "Neurotransmitters are chemicals that pass messages between brain cells." c. "It is a high-level concept to explain. You should ask the doctor to tell you more." d. "Neurotransmitters are substances we eat daily that influence memory and mood."
B
A patient being admitted suddenly pulls a knife from a coat pocket and threatens, "I will kill anyone who tries to get near me." An emergency code is called. The patient is safely disarmed and placed in seclusion. Justification for the use of seclusion is that the patient: a. evidences a thought disorder, rendering rational discussion ineffective. b. presents a clear and present danger to others. c. presents a clear escape risk. d. is psychotic.
B
A patient comes to the hospital for treatment of injuries sustained during a rape. The patient abruptly decides to decline treatment and return home. Before the patient leaves, the nurse should: a. tell the patient, "You may not leave until you receive prophylactic treatment for sexually transmitted diseases." b. provide written information concerning the physical and emotional reactions that may be experienced. c. explain the need and importance of human immunodeficiency virus (HIV) testing. d. offer verbal information about legal resources.
B
A patient diagnosed with borderline personality disorder has self-inflicted wrist lacerations. The health care provider prescribes daily dressing changes. The nurse performing this care should: a. encourage the patient to express anger. b. provide care in a matter-of-fact manner. c. be very kind, sympathetic, and concerned. d. offer to listen to the patient's feelings about cutting.
B
A patient diagnosed with paranoid schizophrenia says, "my coworkers are out to get me. I also saw two doctors plotting to kill me." How did this patient perceives the environment? a. Disorganized b. Dangerous c. Supportive d. Bizarre
B
A patient experiences an episode of severe anxiety. Of these medications in the patient's medical record, which is most appropriate to administer as an as-needed (prn) anxiolytic medication? a. buspirone (BuSpar) b. lorazepam (Ativan) c. amitriptyline (Elavil) d. desipramine (Norpramin)
B
A patient has a history of impulsively acting out anger by striking others. Which would be an appropriate plan for avoiding such incidents? a. Explain that restraint and seclusion will be used if violence occurs. b. Help the patient identify incidents that trigger impulsive acting out. c. Offer one-on-one supervision to help the patient maintain control. d. Give the patient lorazepam (Ativan) every 4 hours to reduce anxiety.
B
A patient has blindness related to a functional neurological (conversion) disorder but is unconcerned about this problem. Which understanding should guide the nurse's planning for this patient? The patient is: a. suppressing accurate feelings regarding the problem. b. relieving anxiety through the physical symptom. c. meeting needs through hospitalization. d. refusing to disclose genuine fears.
B
A patient has blindness related to a functional neurological (conversion) disorder. To help the patient eat, the nurse should: a. establish a "buddy" system with other patients who can feed the patient at each meal. b. expect the patient to feed him- or herself after explaining the arrangement of the food on the tray. c. direct the patient to locate items on the tray independently and feed self unassisted. d. address the needs of other patients in the dining room, and then feed this patient.
B
A patient has delusions and hallucinations. Before beginning treatment with a psychotropic medication, the health care provider wants to rule out the presence of a brain tumor. For which test will a nurse need to prepare the patient? a. Cerebral arteriogram b. Computed tomography (CT) scan or magnetic resonance imaging (MRI) c. Positron emission tomography (PET) or single photon emission computed tomography (SPECT) d. Functional magnetic resonance imaging (fMRI)
B
A patient has smoked two packs of cigarettes daily for many years. When the patient does not smoke or tries to cut back, anxiety, craving, poor concentration, and headache result. What does this scenario describe? a. Substance abuse b. Substance addiction c. Substance intoxication d. Recreational use of a social drug
B
A patient has taken trifluoperazine (Stelazine) 30mg/day oraly for 3 years. The clinic nurse notes that the patient grimaces and constantly smacked both lips. The patients neck and shoulders twist in a slow, snakelike motion. Which problem within our suspect? a. Agranulocytosis b. Tardive dyskinesia c. Tourette syndrome d. Anticholinergic effects
B
A patient hospitalized with a mood disorder has aggression, agitation, talkativeness, and irritability. A nurse begins the care plan based on the expectation that the health care provider is most likely to prescribe a medication classified as a(n): a. anticholinergic b. mood stabilizer c. psychostimulant d. antidepressant
B
A patient recently hospitalized for two weeks committed suicide during the night. Which initial measure will be most helpful for staff members and other patients regarding this event? a. Request the public information officer to make an announcement to the local media. b. Hold a staff meeting to express feelings and plan the care for other patients. c. Ask the patient's roommate not to discuss the event with other patients. d. Quickly discharge as many patients as possible to prevent panic.
B
A patient reports fears of having cervical cancer and says to the nurse, "I've had Pap smears by six different doctors. The results are normal, but I'm sure that's because of errors in the laboratory." Which disorder would the nurse suspect? a. Functional neurologic (conversion) disorder b. Prominent health anxiety (hypochondriasis) c. Predominant (pain) disorder d. Dissociative fugue
B
A patient says to the nurse, "My life doesn't have any happiness in it anymore. I once enjoyed holidays, but now they're just another day." How would the nurse document the complaint? a. Dysthymia b. Anhedonia c. Euphoria d. Anergia
B
A patient says, "I know I have a brain tumor despite the results of the magnetic resonance image (MRI). The radiologist is wrong. People who have brain tumors vomit, and yesterday I vomited all day." Which response by the nurse fosters cognitive restructuring? a. "You do not have a brain tumor. The more you talk about it, the more it reinforces your illogical thinking." b. "Let's see whether any other explanations for your vomiting are possible." c. "You seem so worried. Let's talk about how you're feeling." d. "We'll talk about something else."
B
A patient shows the nurse an article from the Internet about a health problem. Which characteristic of the web site's address most alerts the nurse that the site may have biased and prejudiced information? a. Address ends in ".org." b. Address ends in ".com." c. Address ends in ".gov." d. Address ends in ".net."
B
A patient taking medication for mental illness develops restlessness and an uncontrollable need to be in motion. A nurse can correctly analyze that these symptoms are related to which drug action? a. Anticholinergic effects b. Dopamine-blocking effects c. Endocrine-stimulating effects d. Ability to stimulate spinal nerves
B
A patient tells the nurse, "I wanted my health care provider to prescribe diazepam (Valium) for my anxiety disorder, but buspirone (BuSpar) was prescribed instead. Why?" The nurse's reply should be based on the knowledge that buspirone: a. Does not produce blood dyscrasias. b. Does not cause dependence. c. Can be administered as needed. d. Is faster acting than diazepam.
B
A patient who is preparing for surgery has moderate anxiety and is unable to understand preoperative information. Which nursing intervention is appropriate? a. Reassure the patient that all nurses are skilled in providing postoperative care. b. Describe the procedure again in a calm manner using simple language. c. Tell the patient that the staff is prepared to promote recovery. d. Encourage the patient to express feelings to his or her family.
B
A patient with a history of anger and impulsivity is hospitalized after an accident resulting in injuries. When in pain, the patient loudly scolds the nursing staff for "not knowing enough to give me pain medicine when I need it." Which nursing intervention would best address this problem? a. Tell the patient to notify nursing staff 30 minutes before the pain returns so the medication can be prepared. b. Urge the health care provider to change the prescription for pain medication from as needed to a regular schedule. c. Tell the patient that verbal assaults on nurses will not shorten the wait for pain medication. d. Have the clinical nurse leader request a psychiatric consultation.
B
A patient with a history of daily alcohol abuse was hospitalized at 0200 today. When would the nurse expect withdrawal symptoms to peak? a. Between 0800 and 1000 today (6 to 8 hours after drinking stopped) b. Between 0200 tomorrow and hospital day 2 (24 to 48 hours after drinking stopped) c. About 0200 on hospital day 3 (72 hours after drinking stopped) d. About 0200 on hospital day 4 (96 hours after drinking stopped)
B
A patient with a mass in the left upper lobe of the lung is scheduled for a biopsy. The patient has difficulty understanding the nurse's comments and asks, "What do you mean? What are they going to do?" Assessment findings include a tremulous voice, respirations at 28 breaths per minute, and a pulse rate at 110 beats per minute. What is the patient's level of anxiety? a. Mild b. Moderate c. Severe d. Panic
B
A patient with a somatic symptom disorder has the nursing diagnosis: Interrupted family processes, related to patient's disabling symptoms as evidenced by spouse and children assuming roles and tasks that previously belonged to patient. An appropriate outcome is that the patient will: a. Assume roles and functions of the other family members. b. Demonstrate a resumption of former roles and tasks. c. Focus energy on problems occurring in the family. d. Rely on family members to meet his or her personal needs.
B
A patient with acute depression states, "God is punishing me for my past sins." What is the nurse's best response? a. "Why do you think that?" b. "You sound very upset about this." c. "You believe God is punishing you for your sins?" d. "If you feel this way, you should talk to a member of your clergy."
B
A patient with acute mania has exhausted the staff members by noon. The patient has joked, manipulated, insulted, and fought all morning. Staff members are feeling defensive and fatigued. Which is the best action? a. Confer with the health care provider to consider the use of seclusion for this patient. b. Hold a staff meeting to discuss consistency and limit-setting approaches. c. Conduct a meeting with all patients to discuss the behavior. d. Explain to the patient that the behavior is unacceptable.
B
A patient with acute mania is dancing atop the pool table in the recreation room. The patient waves a cue in one hand and says, "I'll throw the pool balls if anyone comes near me." The nurse's first intervention is to: a. tell the patient, "You need to be secluded." b. clear the room of all other patients. c. help the patient down from the table. d. assemble a show of force.
B
Consider these diagnostic findings: apolipoprotein E (apoE) malfunction, neurofibrillary tangles, neuronal degeneration in the hippocampus, and brain atrophy. Which health problem corresponds to these diagnostic findings? a. Huntington's disease b. Alzheimer's Disease c. Parkinson's disease d. Vascular dementia
B
A patient with acute mania waves a newspaper and says, "I must have my credit card and use the computer right now. A store is having a big sale and I need to order 10 dresses and four pairs of shoes." Select the nurse's most appropriate intervention. a. Suggest to the patient to have a friend do the shopping and bring purchases to the unit. b. Invite the patient to sit with the nurse and look at new fashion magazines. c. Tell the patient that computer use is not allowed until self-control improves. d. Ask whether the patient has enough money to pay for the purchases.
B
A patient with anorexia nervosa is resistant to weight gain. What is the rationale for establishing a contract with the patient to participate in measures designed to produce a specified weekly weight gain? a. Because severe anxiety concerning eating is expected, objective and subjective data must be routinely collected. b. Patient involvement in decision-making increases a sense of control and promotes compliance with the treatment. c. A team approach to planning the diet ensures that physical and emotional needs are met. d. Because of increased risk of physical problems with refeeding, obtaining patient permission is essential.
B
A patient with bipolar disorder and who takes lithium telephones the nurse at the clinic to say, "I've had severe diarrhea for 4 days. I feel very weak and unsteady when I walk. My usual hand tremor has gotten worse. What should I do?" The nurse should advise the patient: a. "Restrict food and fluids for 24 hours, and stay in bed." b. "Have someone bring you to the clinic immediately." c. "Drink a large glass of water with 1 teaspoon of salt added." d. "Take an over-the-counter antidiarrheal medication hourly until the diarrhea subsides."
B
A patient with bipolar disorder is in the maintenance phase of treatment. The patient asks, "Do I have to keep taking this lithium even though my mood is stable now?" Select the nurse's most appropriate response. a. "You will be able to stop the medication in approximately 1 month." b. "Taking the medication every day helps prevent relapses and recurrences." c. "Usually patients take this medication for approximately 6 months after discharge." d. "It's unusual that the health care provider hasn't already stopped your medication."
B
A patient with blindness related to a functional neurological (conversion) disorder says, "All the doctors and nurses in this hospital stop by often to check on me. Too bad people outside the hospital don't find me interesting." Which nursing diagnosis is most relevant? a. Social isolation b. Chronic low self-esteem c. Interrupted family processes d. Ineffective health maintenance
B
A patient with burn injuries has had good coping skills for several weeks. Today, a newly assigned nurse is poorly organized. The patient's usual schedule was not followed. By mid-afternoon, the patient is angry and loudly complains to the nurse manager. Which is the nurse manager's best response? a. Explain the reasons for the disorganization, and take over the patient's care for the rest of the shift. b. Acknowledge and validate the patient's distress and ask, "What would you like to have happen?" c. Apologize and explain that the patient will have to accept the situation for the rest of the shift. d. Ask the patient to control the anger and explain that allowances must be made for new staff members.
B
A patient with catatonic schizophrenia exhibits little spontaneous movement and demonstrate waxy flexibility. Which patient needs are a priority importance? a. Psychosocial b. Psychologic c. Self-actualization d. Safety and security
B
A patient with catatonic schizophrenia is semistuporous, demonstrates little spontaneous movement, and has waxy flexibility. The patient's activities of daily living are severely compromised. An appropriate outcome isn't the patient will: a. Demonstrated increased interest in the environment by the end of week 1. b. Perform self-care activities with coaching by the end of day 3 c. Gradually take the initiative for self-care by the end of week 2 d. Except tube feeding without objection by day 2
B
A patient with depression begins selective serotonin reuptake inhibitor (SSRI) antidepressant therapy, and priority information is given to the patient and family. This information should include a directive to: a. avoid exposure to bright sunlight. b. report increased suicidal thoughts. c. restrict sodium intake to 1 g daily. d. maintain a tyramine-free diet.
B
A patient with depression repeatedly tells staff members, "I have cancer. It's my punishment for being a bad person." Diagnostic tests reveal no cancer. Select the priority nursing diagnosis. a. Powerlessness b. Risk for suicide c. Stress overload d. Spiritual distress
B
A patient with depression tells the nurse, "Bad things that happen are always my fault." To assist the patient in reframing this overgeneralization, the nurse should respond: a. "I really doubt that one person can be blamed for all the bad things that happen." b. "Let's look at one bad thing that happened to see if another explanation exists." c. "You are being exceptionally hard on yourself when you imply you are a jinx." d. "What about the good things that happen; are any of them ever your fault?"
B
A patient with liver failure has been on the transplant waiting list for 8 months. The patient says to the nurse, "Why is it taking so long to have the surgery? Maybe I'm meant to die for all the bad things I've done." The nurse should document the patient's comment in which section of the assessment? a. Physical b. Spiritual c. Financial d. Psychological
B
A patient with major depression says, "No one cares about me anymore. I'm not worth anything." The nurse wants to reinforce positive self-esteem. Today, the patient is wearing a new shirt and has neat, clean hair. Which remark is most appropriate? a. "You look nice this morning." b. "You're wearing a new shirt." c. "I like the shirt you're wearing." d. "You must be feeling better today."
B
A patient with mania dances around the unit, seldom sits, monopolizes conversations, interrupts, and intrudes. Which nursing intervention will best assist the patient with energy conservation? a. Monitor physiologic functioning. b. Provide a subdued environment. c. Supervise personal hygiene. d. Observe for mood changes.
B
A patient with mania relapsed after discontinuing lithium. New orders are written to resume lithium twice daily and begin olanzapine (Zyprexa). The addition of olanzapine to the medication regimen will: a. minimize the side effects of lithium. b. bring hyperactivity under rapid control. c. enhance the antimanic actions of lithium. d. be used for long-term control of hyperactivity.
B
A patient with paranoid schizophrenia tells the nurse, "The CIA is monitoring us through the fluorescent lights in this room. Be careful what you say." Which response by the nurse would be most therapeutic? a. "Let's talk about something other than the CIA." b. "It sounds like you're concerned about your privacy." c. "The CIA is prohibited from operating in health care facilities." d. "You have lost touch with reality, which is a symptom of your illness."
B
A patient with schizophrenia begins a new prescription for lurasidone HCl (Latuda). The patient is 5'6" tall and currently weighs 204 pounds. Which topic is most important for the nurse to include in the teaching plan related to this medication? a. How to recognize tardive dyskinesia b. Weigh management strategies c. Ways to manage constipation d. Sleep hygiene measures
B
A patient with schizophrenia has been stable in the community. Today, the spouse reports the patient is delusional and explosive. The patient says, "I'm willing to take my medicine, but I forgot to get my prescription refilled." Which outcome should the nurse add to the plan of care? a. Nurse will obtain prescription refills every 90 days and deliver them to the patient. b. Patient's spouse will mark dates for prescription refills on the family calendar. c. Patient will report to the hospital for medication follow-up every week. d. Patient will call the nurse weekly to discuss medication-related issues.
B
A patient with schizophrenia has taken a conventional antipsychotic medication for a year. Hallucinations are less intrusive, but the patient continues to have apathy, poverty of thought, and social isolation. The nurse expect a change to which medication? a. haloperidol (Haldol) b. olanzapine (Zyprexa) c. cholorpromazine (Thorazine) d. diphenhydramine (Benadryl)
B
A patient with severe dementia no longer recognizes family members and becomes anxious and agitated when they attempt reorientation. Which alternative could the nurse suggest to the family members? a. Wear large name tags. b. Focus interaction on familiar topics. c. Frequently repeat the reorientation strategies. d. Place large clocks and calendars strategically
B
A patient with stage 3 Alzheimer's disease tires easily and prefers to stay home rather than attend social activities. The spouse does the grocery shopping because the patient cannot remember what to buy. Which nursing diagnosis applies at this time? a. Self-care deficit b. Impaired memory c. Caregiver role strain d. Adult failure to thrive
B
A patient's care plan includes monitoring for auditory hallucinations. Which assessment findings suggested patient maybe hallucinating? a. Aloofness, haughtiness, suspicion b. Darting eyes, tilted head, mumbling to yourself c. Elevated mood, hyperactivity, distractibility d. Performing rituals, avoiding open places
B
A person at the emergency department is diagnosed with a concussion. The individual is accompanied by a spouse who insists on staying in the room and answering all questions. The patient avoids eye contact and has a sad affect and slumped shoulders. Assessment of which additional problem has priority? a. Phobia of crowded places b. Risk of domestic abuse c. Migraine headaches d. Major depression
B
A person comes to the clinic reporting, "I wear a scarf across my lower face when I go out but because of my ugly appearance." Assessment reveals an average appearance with no actual disfigurement. Which problem is most likely? a. Dissociative identity disorder b. Body dysmorphic disorder c. Pseudocyesis d. Malingering
B
A person has had difficulty keeping a job because of arguing with coworkers and accusing them of conspiracy. Today the person shouts, "They're all plotting to destroy me. Isn't that true?" Select the nurse's most therapeutic response. a. "Everyone here is trying to help you. No one wants to harm you." b. "Feeling that people want to destroy you must be very frightening." c. "No, that is not true. People here are trying to help you if you will let them." d. "Staff members are healthcare professionals who are qualified to help you."
B
A priority intervention for a patient with major depression is: a. distracting the patient from self-absorption. b. carefully and unobtrusively observing the patient around the clock. c. allowing the patient to spend long periods alone in meditation. d. offering opportunities for the patient to assume a leadership role in the therapeutic milieu.
B
A rape victim tells the emergency department nurse, "I feel so dirty. Please let me take a shower before the doctor examines me." The nurse should: a. arrange for the patient to shower. b. explain that washing would destroy evidence. c. give the patient a basin of hot water and towels. d. instruct the victim to wash above the waist only.
B
A soldier returned home from active duty in a combat zone in Afghanistan and was diagnosed with post-traumatic stress disorder (PTSD). The soldier says, "If there's a loud noise at night, I get under my bed because I think we're getting bombed." What type of experience has the soldier described? a. Illusion b. Flashback c. Nightmare d. Auditory hallucination
B
A soldier returns to the United States from active duty in a combat zone in Afghanistan. The soldier is diagnosed with post-traumatic stress disorder (PTSD). Which comment by the soldier requires the nurse's immediate attention? a. "It's good to be home. I missed my family and friends." b. "I saw my best friend get killed by a roadside bomb. It should have been me instead." c. "Sometimes I think I hear bombs exploding, but it's just the noise of traffic in my hometown." d. "I want to continue my education but I'm not sure how I will fit in with other college students."
B
A staff nurse tells another nurse, "I evaluated a new patient using the SAD PERSONS scale and got a score of 10. I'm wondering if I should send the patient home." Select the best reply by the second nurse. a. "That action would seem appropriate." b. "A score over 8 requires immediate hospitalization." c. "I think you should strongly consider hospitalization for this patient." d. "Give the patient a follow-up appointment. Hospitalization may be needed soon."
B
A voluntarily hospitalized patient tells the nurse, "Get me the forms for discharge against medical advice so I can leave now." What is the nurse's best initial response? a. "I can't give you those forms without your health care provider's knowledge." b. "I will get them for you, but let's talk about your decision to leave treatment." c. "Since you signed your consent for treatment, you may leave if you desire." d. "I'll get the forms for you right now and bring them to your room."
B
After leaving work, a staff nurse realizes that documentation of the administration of a medication to a patient was omitted. This off-duty nurse telephones the unit and tells the nurse, "Please document the administration of the medication I forgot to do. My password is alpha1." The nurse should: a. fulfill the request. b. refer the matter to the charge nurse to resolve. c. access the record and document the information. d. report the request to the patient's health care provider.
B
After treatment for a detached retina, a victim of domestic violence says, "My partner only abuses me when intoxicated. I've considered leaving, but I was brought up to believe you stay together, no matter what happens. I always get an apology, and I can tell my partner feels bad after hitting me." Which nursing diagnosis applies? a. Social isolation, related to lack of community support system b. Risk for injury, related to partner's physical abuse when intoxicated c. Deficient knowledge, related to resources for escape from the abusive relationship d. Disabled family coping, related to uneven distribution of power within a relationship
B
An African-American patient says to a Caucasian nurse, "There's no sense talking. You wouldn't understand because you live in a white world." The nurse's best action would be to: a. explain, "Yes, I do understand. Everyone goes through the same experiences." b. say, "Please give an example of something you think I wouldn't understand." c. reassure the patient that nurses are in contact with people from all cultures. d. change the subject to one that is less emotionally disturbing.
B
An adolescent tells the school nurse, "My friend threatened to take an overdose of pills." The nurse talks to the friend who verbalized the suicide threat. The most critical question for the nurse to ask would be: a. "Why do you want to kill yourself?" b. "Do you have access to medications?" c. "Have you been taking drugs and alcohol?" d. "Did something happen with your parents?"
B
An adult patient assaults another patient and is restrained. One hour later, which statement by this restrained patient necessitates the nurse's immediate attention? a. "I hate all of you!" b. "My fingers are tingly." c. "You wait until I tell my lawyer." d. "It was not my fault. The other patient started it."
B
An appropriate intervention for a patient with bulimia nervosa who binges and purges is to teach the patient to: a. eat a small meal after purging. b. avoid skipping meals or restricting food. c. concentrate intake after 4 PM daily. d. understand the value of reading journal entries aloud to others.
B
An elderly patient is admitted with delirium secondary to a urinary tract infection. The family asks whether the patient will ever recover. Select the nurse's best response. a. "The health care provider is the best person to answer your question." b. "The confusion will probably get better as we treat the infection." c. "Unfortunately, delirium is a progressively disabling disorder." d. "I will be glad to contact the chaplain to talk with you."
B
An emergency department nurse realizes that the spouse of a patient is becoming increasingly irritable while waiting. Which intervention should the nurse use to prevent escalation of anger? a. Explain that the patient's condition is not life threatening. b. Periodically provide an update and progress report on the patient. c. Explain that all patients are treated in order, based on their medical needs. d. Suggest that the spouse return home until the patient's treatment is completed.
B
An intramuscular dose of antipsychotic medication needs to be given to a patient who is becoming increasingly more aggressive. The patient is in the day room. The nurse should enter the day room: a. and say, "Would you like to come to your room and take some medication your doctor prescribed for you?" b. accompanied by three staff members and say, "Please come to your room so I can give you some medication that will help you feel more comfortable." c. and place the patient in a basket-hold and then say, "I am going to take you to your room to give you an injection of medication to calm you." d. accompanied by a male nursing assistant and tell the patient, "You can come to your room willingly so I can give you this medication, or the aide and I will take you there."
B
An older adult with dementia lives with family and attends day care. After observing poor hygiene, the nurse at the center talks with the patient's adult child. This caregiver becomes defensive and says, "It takes all my time and energy to care for my mother. She's awake all night. I never get any sleep." Which nursing intervention has priority? a. Teach the caregiver more about the effects of dementia. b. Secure additional resources for the mother's evening and night care. c. Support the caregiver to grieve the loss of the mother's ability to function. d. Teach the family how to give physical care more effectively and efficiently.
B
As a patient with mental illness is being discharged from a facility, a nurse invites the patient to the annual staff picnic. What is the best analysis of this scenario? a. The invitation facilitates dependency on the nurse. b. The nurse's action blurs the boundaries of the therapeutic relationship. c. The invitation is therapeutic for the patient's diversional activity deficit. d. The nurse's action assists the patient's integration into community living.
B
As part of the stress response, the HPA axis is stimulated. Which structures make up this system? a. Hippocampus, parietal lobe, and amygdala b. Hypothalamus, pituitary gland, and adrenal glands c. Hind brain, pyramidal nervous system, and anterior cerebrum d. Hepatic artery, parasympathetic nervous system, and acoustic nerve
B
At a unit meeting, staff members discuss the decor for a special room for patients with mania. Select the best option. a. Extra-large window with a view of the street b. Neutral walls with pale, simple accessories c. Brightly colored walls and print drapes d. Deep colors for walls and upholstery
B
Before assessing a new patient, a nurse is told by another health care worker, "I know that patient. No matter how hard we work, there isn't much improvement by the time of discharge." The nurse's responsibility is to: a. document the other worker's assessment of the patient. b. assess the patient based on data collected from all sources. c. validate the worker's impression by contacting the patient's significant other. d. discuss the worker's impression with the patient during the assessment interview.
B
Consider these health problems: Lewy body disease, frontal-temporal lobar degeneration, and Huntington's disease. Which term unifies these problems? a. Cyclothymia b. Dementia c. Delirium d. Amnesia
B
During a psychiatric assessment, the nurse observes a patient's facial expressions that are without emotion. The patient says, "Life feels so hopeless to me. I've been feeling sad for several months." How should the nurse document the patient's affect and mood? a. Affect depressed; mood flat b. Affect flat; mood depressed c. Affect labile; mood euphoric d. Affect and mood are incongruent
B
During morning care, a nurse asks a patient diagnosed with dementia, "How was your night?" The patient replies, "It was lovely. I went out to dinner and a movie with my friend." Which term applies to the patient's response? a. Sundown syndrome b. Confabulation c. Perseveration d. Delirium
B
During the first interview with a parent whose child died in a car accident, the nurse feels empathic and reaches out to take the patient's hand. Select the correct analysis of the nurse's behavior. a. It shows empathy and compassion. It will encourage the patient to continue to express feelings. b. The gesture is premature. The patient's cultural and individual interpretation of touch is unknown. c. The patient will perceive the gesture as intrusive and overstepping boundaries. d. The action is inappropriate. Patients in a psychiatric setting should not be touched.
B
During the third week of treatment, the spouse of a patient in an alcoholism rehabilitation program says, "After discharge, I'm sure everything will be just fine." Which remark by the nurse will be most helpful to the spouse? a. "It is good that you're supportive of your spouse's sobriety and want to help maintain it." b. "Although sobriety solves some problems, new ones may emerge as one adjusts to living without alcohol." c. "It will be important for you to structure life to avoid as much stress as possible. You will need to provide social protection." d. "Remember that alcoholism is a disorder of self-destruction. You will need to observe your spouse's behavior carefully."
B
Outcome identification for the treatment plan of a patient with grandiose thinking associated with acute mania focuses on: a. developing an optimistic outlook b. self-control of distorted thinking c. maintaining an interest in the environment d. stabilizing the sleep pattern
B
Police bring a patient to the emergency department after an automobile accident. The patient is ataxic with slurred speech and mild confusion. The blood alcohol level is 400 mg/dl (0.40 mg %). Considering the relationship between behavior and blood alcohol level, which conclusion can the nurse draw? The patient: a. rarely drinks alcohol. b. has a high tolerance to alcohol. c. has been treated with disulfiram (Antabuse). d. has recently ingested both alcohol and sedative drugs.
B
Select the most appropriate outcome for a patient completing the fourth alcohol detoxification program in one year. Before discharge, the patient will a. use rationalization in healthy ways. b. state, "I see the need for ongoing treatment." c. identify constructive outlets for expression of anger. d. develop a trusting relationship with one staff member.
B
The acronym QSEN refers to: a. Qualitative Standardized Excellence in Nursing. b. Quality and Safety Education for Nurses. c. Quantitative Effectiveness in Nursing. d. Quick Standards Essential for Nurses.
B
The patient says, "My marriage is just great. My spouse and I usually agree on everything." The nurse observes the patient's foot moving continuously as the patient twirls a shirt button. What conclusion can the nurse draw? The patient's communication is: a. clear. b. mixed. c. precise. d. inadequate.
B
The relationship between a nurse and patient as it relates to status and power is best described by which term? a. Symmetric b. Complementary c. Incongruent d. Paralinguistic
B
The spouse of a patient with bipolar disorder asks what evidence supports the possibility of genetic transmission of bipolar disorders. Select the nurse's best response. a. "A high proportion of patients with bipolar disorders are found among creative writers." b. "A higher rate of relatives with bipolar disorder is found among patients with bipolar disorder." c. "Patients with bipolar disorder have higher rates of relatives who respond in an exaggerated way to daily stresses." d. "More individuals with bipolar disorder come from high socioeconomic and educational backgrounds."
B
This nursing diagnosis applies to a patient with mania: Imbalanced nutrition: less than body requirements related to insufficient caloric intake and hyperactivity as evidenced by 5-pound weight loss in 4 days. Select the most appropriate outcome. The patient will: a. ask staff for assistance with feeding within 4 days. b. drink six servings of a high-calorie, high-protein drink each day. c. consistently sit with others for at least 30 minutes at mealtime within 1 week. d. consistently wear appropriate attire for age and sex within 1 week while in the psychiatric unit.
B
Two nursing students discuss career plans after graduation. One student wants to enter psychiatric nursing. The other student asks, "Why would you want to be a psychiatric nurse? All they do is talk. You'll lose your skills." Select the best response by the student interested in psychiatric nursing. a. "Psychiatric nurses practice in safer environments than other specialties. Nurse-to-patient ratios must be better because of the nature of patients' problems." b. "Psychiatric nurses use complex communication skills, as well as critical thinking, to solve multidimensional problems. I'm challenged by those situations." c. "I think I'll be good in the mental health field. I do not like clinical rotations in school, so I don't want to continue them after I graduate." d. "Psychiatric nurses don't have to deal with as much pain and suffering as medical surgical nurses. That appeals to me."
B
What behavior by a nurse caring for a patient with an eating disorder indicates the nurse needs supervision? a. The nurse's comments are nonjudgmental. b. The nurse uses an authoritarian manner when interacting with the patient. c. The nurse teaches the patient to recognize signs of increasing anxiety and ways to intervene. d. The nurse refers the patient to a self-help group for individuals with eating disorders.
B
What feelings are most commonly experienced by nurses working with abusive families? a. Outrage toward the victim and sympathy for the abuser b. Sympathy for the victim and anger toward the abuser c. Unconcern for the victim and dislike for the abuser d. Vulnerability for self and empathy with the abuser
B
A patient tells a nurse, "My new friend is the most perfect person one could imagine—kind, considerate, and good looking. I can't find a single flaw." This patient is demonstrating: a. denial. b. projection. c. idealization. d. compensation.
C
When a victim of sexual assault is discharged from the emergency department, the nurse should: a. arrange support from the victim's family. b. provide referral information verbally and in writing. c. advise the victim to try not to think about the assault. d. offer to stay with the victim until stability is regained.
B
Which assessment finding presents the greatest risk for violent behavior? A patient who: a. is severely agoraphobic. b. has a history of spousal abuse. c. demonstrates bizarre somatic delusions. d. verbalizes hopelessness and powerlessness.
B
Which assessment finding would be likely for a patient experiencing a hallucination? The patient: a. looks at shadows on a wall and says, "I see scary faces." b. states, "I feel bugs crawling on my legs and biting me." c. reports telepathic messages from the television. d. speaks in rhymes.
B
Which changes in brain biochemical function is most associated with suicidal behavior? a. Dopamine excess b. Serotonin deficiency c. Acetylcholine excess d. Gamma-aminobutyric acid deficiency
B
Which common assessment finding would be most applicable to a patient diagnosed with any personality disorder? The patient: a. demonstrates behaviors that cause distress to self rather than to others. b. has self-esteem issues, despite his or her outward presentation. c. usually becomes psychotic when exposed to stress. d. does not experience real distress from symptoms.
B
Which entry in the medical record best meets the requirement for problem-oriented charting? a. "A: Pacing and muttering to self. P: Sensory perceptual alteration, related to internal auditory stimulation. I: Given fluphenazine (Prolixin) 2.5 mg at 0900, and went to room to lie down. E: Calmer by 0930. Returned to lounge to watch TV." b. "S: States, 'I feel like I'm ready to blow up.' O: Pacing hall, mumbling to self. A: Auditory hallucinations. P: Offer haloperidol (Haldol) 2 mg . I: (Haldol) 2 mg at 0900. E: Returned to lounge at 0930 and quietly watched TV." c. "Agitated behavior. D: Patient muttering to self as though answering an unseen person. A: Given haloperidol (Haldol) 2 mg and went to room to lie down. E: Patient calmer. Returned to lounge to watch TV." d. "Pacing hall and muttering to self as though answering an unseen person. haloperidol (Haldol) 2 mg administered at 0900 with calming effect in 30 minutes. Stated, 'I'm no longer bothered by the voices.'"
B
Which historical nursing leader helped focus practice to recognize the importance of science in psychiatric nursing? a. Abraham Maslow b. Hildegard Peplau c. Kris Martinsen d. Harriet Bailey
B
Which intervention should a nurse recommend for the distressed family and friends of someone who has committed suicide? a. Participating in reminiscence therapy b. Attending a self-help group for survivors c. Contracting for two sessions of group therapy d. Completing a psychological postmortem assessment
B
Which nursing diagnosis would likely apply both to a patient diagnosed with schizophrenia as well as a patient diagnosed with amphetamine-induced psychosis? a. Powerlessness b. Disturbed thought processes c. Ineffective thermoregulation d. Impaired oral mucous membrane
B
Which nursing diagnosis would most likely apply to 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
Which nursing intervention demonstrates false imprisonment? a. A confused and combative patient says, "I'm getting out of here and no one can stop me." The nurse restrains this patient without a health care provider's order and then promptly obtains an order. b. A patient has been irritating, seeking the attention of nurses most of the day. Now a nurse escorts the patient down the hall saying, "Stay in your room or you'll be put in seclusion." c. An involuntarily hospitalized patient with suicidal ideation runs out of the psychiatric unit. A nurse rushes after the patient and convinces the patient to return to the unit. d. An involuntarily hospitalized patient with suicidal ideation attempts to leave the unit. A nurse calls the security team and uses established protocols to prevent the patient from leaving.
B
Which nursing intervention has priority as a patient with anorexia nervosa begins to gain weight? a. Assess for depression and anxiety. b. Observe for adverse effects of refeeding. c. Communicate empathy for the patient's feelings. d. Help the patient balance energy expenditure and caloric intake.
B
Which outcome, focused on recovery, would be expected in the plan of care for a patient living in the community with serious and persistent mental illness? Within 3 months, the patient will: a. deny suicidal ideation. b. report a sense of well-being. c. take medications as prescribed. d. attend clinic appointments on time.
B
Which patient statement would lead a nurse to suspect that the developmental task of infancy was not successfully completed? a. "I have very warm and close friendships." b. "I'm afraid to let anyone really get to know me." c. "I am always right, so don't bother saying more." d. "I'm ashamed that I didn't do it correctly in the first place."
B
Which personality characteristic is a nurse most likely to assess in a patient with anorexia nervosa? a. Carefree flexibility b. Rigidity, perfectionism c. Open displays of emotion d. High spirits and optimism
B
Which question has the highest priority when assessing a newly admitted patient with a history of alcohol abuse? a. "Have you ever had blackouts?" b. "When did you have your last drink?" c. "Has drinking caused you any problems?" d. "When did you decide to seek treatment?"
B
Which rationale best explains why a nurse should be aware of personal feelings while working with a family experiencing family violence? a. Self-awareness protects one's own mental health. b. Strong negative feelings interfere with assessment and judgment. c. Strong positive feelings lead to underinvolvement with the victim. d. Positive feelings promote the development of sympathy for patients.
B
Which research evidence would most influence a group of nurses to change their practice? a. Expert committee report of recommendations for practice b. Systematic review of randomized controlled trials c. Nonexperimental descriptive study d. Critical pathway
B
Which scenario best demonstrates an example of eustress? An individual: a. loses a beloved family pet. b. prepares to take a 1 week vacation to a tropical island with a group of close friends. c. receives a bank notice there were insufficient funds in their account for a recent rent payment. d. receives notification that their current employer is experiencing financial problems and some workers will be terminated.
B
Which situation constitutes consensual sex rather than rape? a. After coming home intoxicated from a party, a person forces the spouse to have sex. The spouse objects. b. A person's lover pleads to have oral sex. The person gives in but then regrets the decision. c. A person is beaten, robbed, and forcibly subjected to anal penetration by an assailant. d. A physician gives anesthesia for a procedure and has intercourse with an unconscious patient.
B
Which statement by a patient during an assessment interview should alert the nurse to the patient's need for immediate, active intervention? a. "I am mixed up, but I know I need help." b. "I have no one for help or support." c. "It is worse when you are a person of color." d. "I tried to get attention before I shot myself."
B
Which symptoms are expected for a patient with disorganized schizophrenia? a. Extremes of motor activity, from excitement to stupor b. Social withdrawal and ineffective communication c. Severe anxiety with ritualistic behavior d. Highly suspicious, delusional behavior
B
Which treatment modality should a nurse recommend to help a patient with pain disorder cope more effectively? a. Flooding b. Relaxation c. Response prevention d. Systematic desensitization
B
A nurse prepares the plan of care for a patient having a manic episode. Which nursing diagnoses are most likely? Select all that apply. a. Imbalanced nutrition: more than body requirements b. Disturbed thought processes c. Sleep deprivation d. Chronic confusion e. Social isolation
B C
A new nurse tells a mentor, "I want to convey to my patients that I am interested in them and that I want to listen to what they have to say." Which behaviors are helpful in meeting the nurse's goal? Select all that apply. a. Sitting behind a desk, facing the patient. b. Introducing self to a patient and identifying own role. c. Using facial expressions that convey interest and encouragement. d. Assuming an open body posture and sometimes mirror imaging. e. Maintaining control of the topic under discussion by asking direct questions.
B C D
A patient cries as the nurse explores the patient's relationship with a deceased parent. The patient says, "I shouldn't be crying like this. It happened a long time ago." Which responses by the nurse will facilitate communication? Select all that apply. a. "Why do you think you are so upset?" b. "I can see that you feel sad about this situation." c. "The loss of your parent is very painful for you." d. "Crying is a way of expressing the hurt you're experiencing." e. "Let's talk about something else because this subject is upsetting you.
B C D
A patient in the emergency department reports, "I hear voices saying someone is stalking me. They want to kill me because I found the cure for cancer. I will stab anyone that threatens me." Which aspects of mental health have the greatest immediate concern to a nurse? Select all that apply. a. Happiness b. Appraisal of reality c. Control over behavior d. Effectiveness in work e. Healthy self-concept
B C E
A patient is very suspicious and states, "The FBI has me under surveillance." Which strategies should a nurse use when gathering initial assessment data about this patient? Select all that apply. a. Tell the patient that medication will help this type of thinking. b. Ask the patient, "Tell me about the problem as you see it." c. Seek information about when the problem began. d. Tell the patient, "Your ideas are not realistic." e. Reassure the patient, "You are safe here."
B C E
A nurse assesses a patient who reluctantly participates in activities, answers questions with minimal responses, and rarely makes eye contact. What information should be included when documenting the assessment? Select all that apply. a. Uncooperative patient b. Patient's subjective responses c. Only data obtained from the patient's verbal responses d. Description of the patient's behavior during the interview e. Analysis of why the patient is unresponsive during the interview
B D
After assessing a victim of sexual assault, which terms could the nurse use in the documentation? Select all that apply. a. Alleged b. Reported c. Penetration d. Intercourse e. Refused f. Declined
BCF
A nurse plans the care for an individual diagnosed with antisocial personality disorder. Which characteristic behaviors will the nurse expect? Select all that apply. a. Reclusive behavior b. Callous attitude c. Perfectionism d. Aggression e. Clinginess f. Anxiety
BD
Which activities are in the scope of practice of a sexual assault nurse examiner? Select all that apply. a. Requiring HIV testing of a victim b. Collecting and preserving evidence c. Providing long-term counseling for rape victims d. Obtaining signed consents for photographs and examinations e. Providing pregnancy and sexually transmitted disease prophylaxis
BDE
A nurse at the mental health clinic plans a series of psychoeducational groups for persons with schizophrenia. Which two topics would take priority? a. How to complete an application for employment b. The importance of correctly taken your medication c. How to dress when attending community events d. How to give and receive compliments e. Ways to quit smoking
BE
A patient undergoing alcohol rehabilitation decides to accept disulfiram (Antabuse) therapy to avoid impulsively responding to drinking cues. Which information should be included in the discharge teaching for this patient? Select all that apply. (2) a. Avoid aged cheeses. b. Read labels of all liquid medications. c. Wear sunscreen and avoid bright sunlight. d. Maintain an adequate dietary intake of sodium. e. Avoid breathing fumes of paints, stains, and stripping compounds.
BE
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 independent. d. role model ways to ask for help from others.
C
A patient tells the nurse, "I don't go to restaurants because people might laugh at the way I eat or I could spill food and be laughed at." The nurse assesses this behavior as consistent with: a. Acrophobia b. Agoraphobia c. Social phobia d. Posttraumatic stress disorder
C
A cognitively impaired patient has been a widow for 30 years. This patient is frantically trying to leave the unit, saying, "I have to go home to cook dinner before my husband arrives from work." To intervene with validation therapy, the nurse should say: a. "You must come away from the door." b. "You have been a widow for many years." c. "You want to go home to prepare your husband's dinner?" d. "Was your husband angry if you did not have dinner ready on time?"
C
A college student failed two tests. Afterward, the student cried for hours and then tried to telephone a parent but got no answer. The student then gave several expensive sweaters to a roommate. Which behavior provides the strongest clue of an impending suicide attempt? a. Calling parents b. Excessive crying c. Giving away sweaters d. Staying alone in a dorm room
C
A confused older adult patient in a skilled care facility is in bed sleeping. The nurse enters the room quietly and touches the bed to see if it is wet. The patient awakens and hits the nurse in the face. Which statement best explains the patient's action? a. Older adult patients often demonstrate exaggerations of behaviors used earlier in life. b. Crowding in skilled care facilities increases individual tendencies toward violence. c. The patient interpreted the health care worker's behavior as potentially harmful. d. This patient learned violent behavior by watching other patients act out.
C
A hospitalized patient, injured in a fall while intoxicated, believes spiders are spinning entrapping webs in the room. The patient is anxious, agitated, and diaphoretic. Which nursing intervention has priority? a. Check the patient every 15 minutes. b. Rigorously encourage fluid intake. c. Provide one-on-one supervision. d. Keep the room dimly lit.
C
A married individual has recently been absent from work for 3-day periods on several occasions. Each time, the individual returns to work wearing dark glasses. Facial and body bruises are apparent. What is the occupational health nurse's priority question? a. "Do you drink excessively?" b. "Did your partner beat you?" c. "How did this happen to you?" d. "What did you do to deserve this?"
C
A new staff nurse completes orientation to the psychiatric unit. This nurse will expect to ask an advanced practice nurse to perform which action for patients? a. Perform mental health assessment interviews. b. Establish therapeutic relationships. c. Prescribe psychotropic medications. d. Individualize nursing care plans.
C
A newly admitted patient with major depression has lost 20 pounds over the past month and has suicidal ideation. The patient has taken an antidepressant medication for 1 week without remission of symptoms. Select the priority nursing diagnosis. a. Imbalanced nutrition: Less than body requirements b. Chronic low self-esteem c. Risk for suicide d. Hopelessness
C
A newly admitted patient with schizophrenia says, "the voices are bothering me. They yell and tell me I'm bad. I have got to get away from them." Select the nurse's most helpful reply a. "Do you hear the voices often?" b. "Do you have a plan for getting away from the voices?" c. "I'll stay with you focus on what we are talking about, not the voices." d. "Forget the voices, and asked some other patients to play cards with you."
C
A newly hospitalized patient has needle tracks on both arms. A friend states that the patient uses heroin daily but has not used in the past 24 hours. The nurse should assess the patient for: a. slurred speech, excessive drowsiness, and bradycardia. b. paranoid delusions, tactile hallucinations, and panic. c. runny nose, yawning, insomnia, and chills. d. anxiety, agitation, and aggression.
C
A nurse administering psychotropic medications should be prepared to intervene when giving a drug that blocks the attachment of norepinephrine to alpha1 receptors because the patient may experience: a. increased psychotic symptoms b. severe appetite disturbance c. orthostatic hypotension d. hypertensive crisis
C
A nurse and patient construct a no-suicide contract. Select the preferable wording for the contract. a. "I will not try to harm myself during the next 24 hours." b. "I will not make a suicide attempt while I am hospitalized." c. "For the next 24 hours, I will not kill or harm myself in any way." d. "I will not kill myself until I call my primary nurse or a member of the staff."
C
A nurse assesses a patient who reports a 3-week history of depression and crying spells. The patient says, "My business is bankrupt, and I was served with divorce papers." Which subsequent statement by the patient alerts the nurse to a concealed suicidal message? a. "I wish I were dead." b. "Life is not worth living." c. "I have a plan that will fix everything." d. "My family will be better off without me."
C
A nurse explains multiaxial diagnoses to a psychiatric technician. Which information is accurate? a. It is a template for treatment planning. b. Nursing and medical diagnoses are included. c. Assessments of several aspects of functioning are included. d. It incorporates the framework of a specific biopsychosocial theory.
C
A nurse gives anticipatory guidance to the family of a patient diagnosed with stage 3, mild cognitive decline Alzheimer's disease. Which problem common to that stage should the nurse address? a. Violent outbursts b. Emotional disinhibition c. Communication deficits d. Inability to feed or bathe self
C
A nurse must assess several new patients at a community mental health center. Conclusions concerning current functioning should be made on the basis of: a. the degree of conformity of the individual to society's norms. b. the degree to which an individual is logical and rational. c. a continuum from mentally healthy to unhealthy. d. the rate of intellectual and emotional growth.
C
A nurse provided medication education for a patient who takes phenelzine (Nardil) for depression. Which behavior indicates effective learning? The patient: a. Monitors sodium intake and weight daily. b. Wears support stockings and elevates the legs when sitting. c. Consults the pharmacist when selecting over-the-counter medications. d. Can identify foods with high selenium content, which should be avoided.
C
A nurse reports to the interdisciplinary team that a patient diagnosed with an antisocial personality disorder lies to other patients, verbally abuses a patient diagnosed with dementia, and flatters the primary nurse. This patient is detached and superficial during counseling sessions. Which behavior most clearly warrants limit setting? a. Flattering the nurse b. Lying to other patients c. Verbal abuse of another patient d. Detached superficiality during counseling
C
A nurse working a rape telephone hotline should focus communication to: a. arrange long-term patient counseling. b. provide callers with a sympathetic listener. c. explain immediate steps that a victim of rape should take. d. obtain information to relay to the local police.
C
A nurse works with a patient to establish outcomes. The nurse believes that one outcome suggested by the patient is not in the patient's best interest. What is the nurse's best action? a. Remain silent. b. Educate the patient that the outcome is not realistic. c. Explore with the patient possible consequences of the outcome. d. Formulate an appropriate outcome without the patient's input.
C
A patient admitted yesterday for injuries sustained while intoxicated believes the window blinds are snakes trying to get into the room. The patient is anxious, agitated, and diaphoretic. Which medication can the nurse anticipate the health care provider will prescribe? a. Monoamine oxidase inhibitor, such as phenelzine (Nardil) b. Phenothiazine, such as thioridazine (Mellaril) c. Benzodiazepine, such as lorazepam (Ativan) d. Narcotic analgesic, such as morphine
C
A patient being treated for depression has taken 300 mg amitriptyline (Elavil) daily for a year. The patient calls the case manager at the clinic and says, "I stopped taking my antidepressant 2 days ago. Now I am having cold sweats, nausea, a rapid heartbeat, and nightmares." The nurse should advise the patient: a. "Go to the nearest emergency department immediately." b. "Do not to be alarmed. Take two aspirin and drink plenty of fluids." c. "Take one dose of the antidepressant. Come to the clinic to see the health care provider." d. "Resume taking the antidepressant for 2 more weeks, and then discontinue them again."
C
A patient comments, "I never know the right answer" and "My opinion is not important." Using Erikson's theory, which psychosocial crisis did the patient have difficulty resolving? a. Initiative versus Guilt b. Trust versus Mistrust c. Autonomy versus Shame and Doubt d. Generativity versus Self-Absorption
C
A patient diagnosed with a personality disorder has used manipulation to get his or her needs met. The staff decides to apply limit-setting interventions. What is the correct rationale for this action? a. It provides an outlet for feelings of anger and frustration. b. It respects the patient's wishes so assertiveness will develop. c. External controls are necessary while internal controls are developed. d. Anxiety is reduced when staff members assume responsibility for the patient's behavior.
C
A patient diagnosed with borderline personality disorder and a history of self-mutilation has now begun dialectical behavior therapy (DBT) on an outpatient basis. Counseling focuses on self-harm behavior management. Today the patient telephones to say, "I'm feeling empty and want to cut myself." The nurse should: a. arrange for emergency inpatient hospitalization. b. send the patient to the crisis intervention unit for 8 to 12 hours. c. assist the patient to identify the trigger situation and choose a coping strategy. d. advise the patient to take an antianxiety medication to decrease the anxiety level.
C
A patient discloses several concerns and associated feelings. If the nurse wants to seek clarification, which comment would be appropriate? a. "What are the common elements here?" b. "Tell me again about your experiences." c. "Am I correct in understanding that...?" d. "Tell me everything from the beginning."
C
A patient has the nursing diagnosis: Anxiety, related to __________, as evidenced by an inability to control compulsive cleaning. Which phrase correctly completes the etiologic portion of the diagnosis? a. Ensuring the health of household members b. Attempting to avoid interactions with others c. Having persistent thoughts about bacteria, germs, and dirt d. Needing approval for cleanliness from friends and family
C
A patient hurriedly tells the community mental health nurse, "Everything's a disaster! I can't concentrate. My disability check didn't come. My roommate moved out, and I can't afford the rent. My therapist is moving away. I feel like I'm coming apart." Which nursing diagnosis applies? a. Decisional conflict, related to challenges to personal values b. Spiritual distress, related to ethical implications of treatment regimen c. Anxiety, related to changes perceived as threatening to psychological equilibrium d. Impaired environmental interpretation syndrome, related to solving multiple problems affecting security needs
C
A patient is admitted in a comatose state after ingesting 30 capsules of pentobarbital sodium. A friend of the patient says, "Often my friend drinks, along with taking more of the drug than is prescribed." What is the effect of the use of alcohol with this drug? a. The drug's metabolism is stimulated. b. The drug's effect is diminished. c. A synergistic effect occurs. d. There is no effect.
C
A patient is hospitalized for a reaction to a psychotropic medication and then is closely monitored for 24 hours. During a predischarge visit, the case manager learns the patient received a notice of eviction on the day of admission. The most appropriate intervention for the case manager is to: a. cancel the patient's discharge from the hospital. b. contact the landlord who evicted the patient to further discuss the situation. c. arrange a temporary place for the patient to stay until new housing can be arranged. d. document that the adverse medication reaction was feigned because the patient had nowhere to live.
C
A patient is pacing the hall near the nurses' station, swearing loudly. An appropriate initial intervention for the nurse would be to address the patient by name and say: a. "Hey, what's going on?" b. "Please quiet down immediately." c. "I'd like to talk with you about how you're feeling right now." d. "You must go to your room and try to get control of yourself."
C
A patient receiving lithium should be assessed for which evidence of complications? a. Pharyngitis, mydriasis, and dystonia b. Alopecia, purpura, and drowsiness c. Diaphoresis, weakness, and nausea d. Ascites, dyspnea, and edema
C
A patient says, "I'm still on restriction, but I want to attend some off-unit activities. Would you ask the doctor to change my privileges?" What is the nurse's best response? a. "Why are you asking me when you're able to speak for yourself?" b. "I will be glad to address it when I see your doctor later today." c. "That's a good topic for you to take up with your doctor." d. "Do you think you can't speak to a doctor?"
C
A patient tells the nurse, "I don't think I'll ever get out of here." Select the nurse's most therapeutic response. a. "Don't talk that way. Of course you will leave here!" b. "Keep up the good work and you certainly will." c. "You don't think you're making progress?" d. "Everyone feels that way sometimes."
C
A patient was admitted 48 hours ago for injuries sustained while intoxicated. The patient is shaky, irritable, anxious, and diaphoretic. The pulse rate is 130 beats per minute. The patient shouts, "Snakes are crawling on my bed. I've got to get out of here." What is the most accurate assessment of the situation? The patient: a. is attempting to obtain attention by manipulating staff. b. may have sustained a head injury before admission. c. has symptoms of alcohol withdrawal delirium. d. is having a recurrence of an acute psychosis.
C
A patient was started on escitalopram (Lexapro) 5 days ago and now says, "This medicine isn't working." The nurse's best intervention would be to: a. discuss with the health care provider the need to change medications. b. reassure the patient that the medication will be effective soon. c. explain the time lag before antidepressants relieve symptoms. d. critically assess the patient for symptom relief.
C
A patient who is experiencing moderate anxiety says, "I feel undone." An appropriate response for the nurse would be: a. "Why do you suppose you are feeling anxious?" b. "What would you like me to do to help you?" c. "I'm not sure I understand. Give me an example." d. "You must get your feelings under control before we can continue."
C
A patient who is referred to the eating disorders clinic has lost 35 pounds during 3 months. To assess eating patterns, the nurse should ask the patient: a. "Do you often feel fat?" b. "Who plans the family meals?" c. "What do you eat in a typical day?" d. "What do you think about your present weight?"
C
A patient who was admitted for a heroin overdose received naloxone (Narcan), which improved the breathing pattern. Two hours later, the patient reports muscle aches, abdominal cramps, gooseflesh and says, "I feel terrible." Which analysis is correct? a. The patient is exhibiting a prodromal symptom of seizures. b. An idiosyncratic reaction to naloxone is occurring. c. Symptoms of opiate withdrawal are present. d. The patient is experiencing a relapse.
C
A patient with acute mania undresses in the group room and dances. The nurse's first intervention would be to: a. quietly ask the patient, "Why don't you put on your clothes?" b. firmly tell the patient, "Stop dancing, and put on your clothing." c. put a blanket around the patient, and walk with the patient to a quiet room. d. allow the patient stay in the group room. Move the other patients to a different area.
C
A patient with bipolar disorder has rapid cycles. The health care provider prescribes an anticonvulsant medication. To prepare teaching materials, which drug should the nurse anticipate will be prescribed? a. phenytoin (Dilantin) b. clonidine (Catapres) c. carbamazepine (Tegretol) d. chlorpromazine (Thorazine)
C
A patient with bipolar disorder is hyperactive after discontinuing lithium and has not slept for 3 days. The patient threatens to hit another patient. Which comment by the nurse is appropriate? a. "Stop that! No one did anything to provoke an attack by you." b. "If you do that one more time, you will be secluded immediately." c. "Do not hit anyone. If you are unable to control yourself, we will help you." d. "You know we will not let you hit anyone. Why do you continue this behavior?"
C
A patient with fluctuating levels of awareness, confusion, and disturbed orientation shouts, "Bugs are crawling on my legs. Get them off!" Which problem is the patient experiencing? a. Aphasia b. dystonia c. Tactile hallucinations d. Mnemonic disturbance
C
A patient with pneumonia has been hospitalized for 4 days. Family members describe the patient as "a difficult person who finds fault with others." The patient verbally abuses nurses for their poor care. The most likely explanation lies in: a. poor childrearing that did not teach respect for others. b. automatic thinking, leading to cognitive distortion. c. personality style that externalizes problems. d. delusions that others wish to deliver harm
C
A patient with predominant pain disorder has been in treatment for 4 weeks. The patient says, "Although I'm still having pain, I notice it less and am able to perform more activities." The nurse should evaluate the treatment plan as: a. unsuccessful. b. minimally successful. c. partially successful. d. totally achieved.
C
A patient with predominant pain disorder says, "My pain is from an undiagnosed injury. I can't take care of myself. I need pain medicine six or seven times a day. I feel like a baby because my family has to help me so much." It is important for the nurse to assess: a. Mood b. Cognitive style c. Secondary gains d. Identity and memory
C
A patient with schizophrenia has auditory hallucinations, delusions of grandeur, Poor personal hygiene, and motor agitation. Which assessment finding with the nurse regarding negative symptoms of schizophrenia? a. Auditory hallucinations b. Delusions of grandeur c. Poor personal hygiene d. Motor agitation
C
A patient with schizophrenia has taken fluphenazine (Prolixin) 5mg orally twice daily for 3 weeks. The nurse now assesses a shuffling propulsinve gait, a masklike face, and drooling. Which term applies to these symptoms? a. Neuroleptic malignant syndrome b. Hepatocellular effects c. Pseudoparkinsonism d. Akathisia
C
A patient with severe injuries is irritable, angry, and belittles the nurses. As a nurse changes a dressing, the patient screams, "Don't touch me! You are so stupid. You will make it worse!" Which intervention uses a cognitive technique to help the patient? a. Wordlessly discontinue the dressing change, and then leave the room. b. Stop the dressing change, saying, "Perhaps you would like to change your own dressing." c. Continue the dressing change, saying, "Do you know this dressing change is needed so your wound will not get infected?" d. Continue the dressing change, saying, "Unfortunately, you have no choice in this because your doctor ordered this dressing change."
C
A patient's employment is terminated and major depression results. The patient says to the nurse, "I'm not worth the time you spend with me. I'm the most useless person in the world." Which nursing diagnosis applies? a. Powerlessness b. Defensive coping c. Situational low self-esteem d. Disturbed personal identity
C
A person has minor physical injuries after an automobile accident. The person is unable to focus and says, "I feel like something awful is going to happen." This person has nausea, dizziness, tachycardia, and hyperventilation. What is this person's level of anxiety? a. Mild b. Moderate c. Severe d. Panic
C
A person intentionally overdoses on antidepressant drugs. Which nursing diagnosis has the highest priority? a. Powerlessness b. Social isolation c. Risk for suicide d. Ineffective management of the therapeutic regimen
C
A person is directing traffic on a busy street and rapidly shouting, "To work, you jerk, for perks," and making obscene gestures at cars. The person has not slept or eaten for 3 days. Which assessment findings will have priority concern for this patient's plan of care? a. Insulting, provocative behavior b. Pressured speech and grandiosity c. Hyperactivity; not eating and sleeping d. Poor concentration and decision making
C
A person is directing traffic on a busy street and shouting, "To work, you jerk, for perks," and making obscene gestures at cars. The person has not slept or eaten for 3 days. What features of mania are evident? a. Increased muscle tension and anxiety b. Vegetative signs and poor grooming c. Poor judgment and hyperactivity d. Cognitive deficit and sad mood
C
A person received an invitation to be in the wedding of a friend who lives across the country. The individual is afraid of flying. What type of therapy should the nurse recommend? a. Psychoanalysis b. Milieu therapy c. Systematic desensitization d. Short-term dynamic therapy
C
A person with a fear of heights drives across a high bridge. Which division of the autonomic nervous system is stimulated in response to this experience? a. Limbic system b. Peripheral nervous system c. Sympathetic nervous system d. Parasympathetic nervous system
C
A person with a fear of heights drives across a high bridge. Which structure will stimulate a response from the autonomic nervous system? a. Thalamus b. Parietal lobe c. Hypothalamus d. Pituitary gland
C
A rape victim tells the nurse, "I should not have been out on the street alone." Which is the nurse's most therapeutic response? a. "Rape can happen anywhere." b. "Blaming yourself only increases your anxiety and discomfort." c. "You believe this would not have happened if you had not been alone?" d. "You are right. You should not have been alone on the street at night."
C
A soldier who served in a combat zone returned to the United States. The soldier's spouse complains to the nurse, "We had planned to start a family, but now he won't talk about it. He won't even look at children." The spouse is describing which symptom associated with post-traumatic stress disorder (PTSD)? a. Reexperiencing b. Hyperarousal c. Avoidance d. Psychosis
C
A student nurse prepares to administer oral medications to a patient with major depression, but the patient refuses the medication. The student nurse should: a. tell the patient, "I'll get an unsatisfactory grade if I don't give you the medication." b. tell the patient, "Refusing your medication is not permitted. You are required to take it." c. explore the patient's concerns about the medication, and report to the staff nurse. d. document the patient's refusal of the medication without further comment.
C
A suspicious and socially isolated patient lives alone, eats one meal a day at a nearby shelter, and spends the remaining daily food allowance on cigarettes. Select the community psychiatric nurse's best initial action. a. Report the situation to the manager of the shelter. b. Tell the patient, "You must stop smoking to save money." c. Assess the patient's weight; determine the foods and amounts eaten. d. Seek hospitalization for the patient while a new plan is being formulated.
C
A tearful, anxious patient at the outpatient clinic reports, "I should be dead." The initial task of the nurse conducting the assessment interview is to: a. assess the lethality of a suicide plan. b. encourage expression of anger. c. establish a rapport with the patient. d. determine risk factors for suicide.
C
A woman is 5'7" tall, weighs 160 pounds, and wears a size 8 shoe. She says, "My feet are huge. I've asked three orthopedists to surgically reduce my feet." The patient tries to buy shoes to make her feet look smaller, and in social settings conceals both feet under a table or chair. Which health problem is likely? a. Dissociative fugue b. Prominent pain disorder c. Body dysmorphic disorder d. Depersonalization disorder
C
After an assault by a patient, a nurse has difficulty sleeping, startles easily, and is preoccupied with the incident. The nurse says, "I dread facing potentially violent patients." Which response would be the most urgent reason for this nurse to seek supervision? a. Startle reactions b. Difficulty sleeping c. Wish for revenge d. Preoccupation with the incident
C
After several therapeutic encounters with a patient who recently attempted suicide, which occurrence should cause the nurse to consider the possibility of countertransference? a. The patient's reactions toward the nurse seem realistic and appropriate. b. The patient states, "Talking to you feels like talking to my parents." c. The nurse feels oddly happy when the patient's mood begins to lift. d. The nurse develops a trusting relationship with the patient.
C
An 11-year-old child is absent from school to care for siblings while the parents work. The family cannot afford a babysitter. When asked about the parents, the child reluctantly says, "My parents don't like me. They call me stupid and say I never do anything right." Which type of abuse is likely? a. Sexual b. Physical c. Emotional d. Economic
C
An adolescent asks a nurse conducting an assessment interview, "Why should I tell you anything? You'll just tell my parents whatever you find out." Select the nurse's best reply. a. "That isn't true. What you tell us is private and held in strict confidence. Your parents have no right to know." b. "Yes, your parents may find out what you say, but it is important that they know about your problems." c. "What you say about feelings is private, but some things, like suicidal thinking, must be reported to the treatment team." d. "It sounds as though you are not really ready to work on your problems and make changes."
C
The most challenging nursing intervention for patients diagnosed with personality disorders who use manipulation to get their needs met is: a. supporting behavioral change. b. monitoring suicide attempts. c. maintaining consistent limits. d. using aversive therapy.
C
An adult tells the nurse, "My partner abuses me most often when drinking. The drinking has increased lately, but I always get an apology afterward and a box of candy. I've considered leaving but haven't been able to bring myself to actually do it." Which phase in the cycle of violence prevents the patient from leaving? a. Tension building b. Acute battering c. Honeymoon d. Recovery
C
An older adult drove to a nearby store but was unable to remember how to get home or state an address. When police intervened, they found that this adult was wearing a heavy coat and hat, even though it was July. Which stage of Alzheimer's disease is evident? a. Preclinical Alzheimer's disease b. Mild cognitive decline c. Moderately severe cognitive decline d. Severe cognitive decline
C
An older adult was stopped by police for driving through a red light. When asked for a driver's license, the adult hands the police officer a pair of sunglasses. What sign of dementia is evident? a. Aphasia b. Apraxia c. Agnosia d. Anhedonia
C
An older adult with dementia lives with family and attends a day care center. A nurse at the day care center notices the adult has a disheveled appearance, a strong odor of urine, and bruises on the limbs and back. What type of abuse might be occurring? a. Psychological b. Financial c. Physical d. Sexual
C
As a nurse escorts a patient being discharged after treatment for major depression, the patient gives the nurse a necklace with a heart pendant and says, "Thank you for helping mend my broken heart." Which is the nurse's best response? a. "Accepting gifts violates the policies and procedures of the facility." b. "I'm glad you feel so much better now. Thank you for the beautiful necklace." c. "I'm glad I could help you, but I can't accept the gift. My reward is seeing you with a renewed sense of hope." d. "Helping people is what nursing is all about. It's rewarding to me when patients recognize how hard we work."
C
As a nurse prepares to administer a medication to a patient diagnosed with a borderline personality disorder, the patient says, "Just leave it on the table. I'll take it when I finish combing my hair." What is the nurse's best response? a. Reinforce this assertive action by the patient. Leave the medication on the table as requested. b. Respond to the patient, "I'm worried that you might not take it. I will come back later." c. Say to the patient, "I must watch you take the medication. Please take it now." d. Ask the patient, "Why don't you want to take your medication now?"
C
As a patient admitted to the eating disorders unit undresses, a nurse observes that the patient's body is covered by fine, downy hair. The patient weighs 70 pounds and is 5 feet, 4 inches tall. Which term should be documented? a. Amenorrhea b. Alopecia c. Lanugo d. Stupor
C
Consider these comments made to three different nurses by a patient diagnosed with an antisocial personality disorder: "You're a better nurse than the day shift nurse said you were"; "Another nurse said you don't do your job right"; "You think you're perfect, but I've seen you make three mistakes." Collectively, these interactions can be assessed as: a. seductive. b. detached. c. manipulative. d. guilt producing.
C
Consider these three drugs: divalproex (Depakote), carbamazepine (Tegretol), and gabapentin (Neurontin). Which drug also belongs to this group? a. clonazepam (Klonopin) b. risperidone (Risperdal) c. lamotrigine (Lamictal) d. aripiprazole (Abilify)
C
Documentation in a patient's chart shows, "Throughout a 5-minute interaction, patient fidgeted and tapped left foot, periodically covered face with hands, and looked under chair while stating, 'I enjoy spending time with you.'" Which analysis is most accurate? a. Patient is giving positive feedback about the nurse's communication techniques. b. Nurse is viewing the patient's behavior through a cultural filter. c. Patient's verbal and nonverbal messages are incongruent. d. Patient is demonstrating psychotic behaviors.
C
During which phase of the nurse-patient relationship can the nurse anticipate that identified patient issues will be explored and resolved? a. Preorientation b. Orientation c. Working d. Termination
C
For a patient experiencing panic, which nursing intervention should be first? a. Teach relaxation techniques. b. Administer an anxiolytic medication. c. Provide calm, brief, directive communication. d. Gather a show of force in preparation for gaining physical control.
C
If a cruel and abusive person rationalizes this behavior, which comment is most characteristic of this person? a. "I don't know why it happens." b. "I have poor impulse control." c. "That person shouldn't have provoked me." d. "I'm really a coward who is afraid of being hurt."
C
Operant conditioning will be used to encourage speech in a child who is nearly mute. Which technique would a nurse include in the treatment plan? a. Ignore the child for using silence. b. Have the child observe others talking. c. Give the child a small treat for speaking. d. Teach the child relaxation techniques, then coax speech.
C
Over the past year, a woman has cooked gourmet meals for her family but eats only tiny servings. This person wears layered loose clothing and now has amenorrhea. Her current weight is 95 pounds, a loss of 35 pounds. Which medical diagnosis is most likely? a. Binge eating b. Bulimia nervosa c. Anorexia nervosa d. Eating disorder not otherwise specified
C
Several children are seen in the emergency department for treatment of illnesses and injuries. Which finding would create a high index of suspicion for child abuse? The child who has: a. repeated middle ear infections b. severe colic c. bite marks d. croup
C
Termination of a therapeutic nurse-patient relationship with a patient has been successful when the nurse: a. avoids upsetting the patient by shifting focus to other patients before the discharge. b. gives the patient a personal telephone number and permission to call after discharge. c. discusses with the patient changes that have happened during the relationship and evaluates the outcomes. d. offers to meet the patient for coffee and conversation three times a week after discharge.
C
The goal for a patient is to increase resiliency. Which outcome should a nurse add to the plan of care? Within 3 days, the patient will: a. describe feelings associated with loss and stress. b. meet own needs without considering the rights of others. c. identify healthy coping behaviors in response to stressful events. d. allow others to assume responsibility for major areas of own life.
C
The nurse wants to assess for disturbances in circadian rhythms in a patient admitted for depression. Which question best implements this assessment? a. "Do you ever see or hear things that others do not?" b. "Do you have problems with short-term memory?" c. "What are your worst and best times of day?" d. "How would you describe your thinking?"
C
The parent of a 4-year-old rewards and praises the child for helping a younger sibling, being polite, and using good manners. A nurse supports the use of praise because according to the Freudian theory, these qualities will likely be internalized and become part of the child's: a. id. b. ego. c. superego. d. preconscious.
C
The parent of a child who has schizophrenia tearfully asks a nurse, "What could I have done differently to prevent this illness?" Select the nurse's most caring response. a. "Although schizophrenia is caused by impaired family relationships, try not to feel guilty. No one can predict how a child will respond to parental guidance." b. "Most of the damage is done, but there is still hope. Changing your parenting style can help your child learn to cope more effectively with the environment." c. "Schizophrenia is a biological illness with similarities to diabetes and heart disease. You are not to blame for your child's illness." d. "Most mental illnesses result from genetic inheritance. Your genes are more at fault than your parenting."
C
To assist a patient with a somatic system disorder, a nursing intervention of high priority is to: a. imply that somatic symptoms are not real. b. help the patient suppress feelings of anger. c. shift the focus from somatic symptoms to feelings. d. investigate each physical symptom as it is offered.
C
To provide comprehensive care to patients, which competency is more important for a nurse who works in a community mental health center than a psychiatric nurse who works in an inpatient unit? a. Problem-solving skills b. Calm external manner c. Ability to cross service systems d. Knowledge of psychopharmacology
C
Two hospitalized patients fight when they are in the same room. During a team meeting, a nurse asserts that safety is of paramount importance and therefore the treatment plans should call for both patients to be secluded to prevent them from injuring each other. This assertion: a. reveals that the nurse values the principle of justice. b. reinforces the autonomy of the two patients. c. violates the civil rights of the two patients. d. represents the intentional tort of battery.
C
Two patients in a residential care facility have dementia. One shouts to the other, "Move along, you're blocking the road." The other patient turns, shakes a fist, and shouts, "You're trying to steal my car." What is the nurse's best action? a. Administer one dose of an antipsychotic medication to both patients. b. Reinforce reality. Say to the patients, "Walk along in the hall. This is not a traffic intersection." c. Separate and distract the patients. Take one to the day room and the other to an activities area. d. Step between the two patients and say, "Please quiet down. We do not allow violence here."
C
Two staff nurses applied for a charge nurse position. After the promotion was announced, the nurse who was not promoted said, "The nurse manager had a headache the day I was interviewed." Which defense mechanism is evident? a. Introjection b. Conversion c. Projection d. Splitting
C
What is an appropriate initial outcome for a patient diagnosed with a personality disorder who frequently manipulates others? The patient will: a. identify when feeling angry. b. use manipulation only to get legitimate needs met. c. acknowledge manipulative behavior when it is called to his or her attention. d. accept fulfillment of his or her requests within an hour rather than immediately.
C
When a new patient is hospitalized, a nurse takes the patient on a tour, explains the rules of the unit, and discusses the daily schedule. The nurse is engaged in: a. counseling. b. health teaching. c. milieu management. d. psychobiologic intervention.
C
When alprazolam (Xanax) is prescribed for acute anxiety, health teaching should include instructions to: a. Report drowsiness. b. Eat a tyramine-free diet. c. Avoid alcoholic beverages. d. Adjust dose and frequency based on anxiety level.
C
When assessing a patient's plan for suicide, what aspect has priority? a. Patient's financial and educational status b. Patient's insight into suicidal motivation c. Availability of means and lethality of method d. Quality and availability of patient's social support
C
When counseling patients with major depression, an advanced practice nurse will address the negative thought patterns by using: a. psychoanalytic therapy. b. desensitization therapy. c. cognitive behavioral therapy. d. alternative and complementary therapies.
C
When working with rape victims, immediate care focuses first on: a. collecting evidence. b. notifying law enforcement. c. helping the victim feel safe. d. documenting the victim's comments.
C
Which assessment findings best correlate to the withdrawal from CNS DEPRESSEANTS? a. Dilated pupils, tachycardia, elevated blood pressure, elation b. Labile mood, lack of coordination, fever, drowsiness c. Nausea, vomiting, diaphoresis, anxiety, tremors d. Excessive eating, constipation, headache
C
Which characteristic of individuals diagnosed with personality disorders makes it most necessary for staff to schedule frequent meetings? a. Ability to achieve true intimacy b. Flexibility and adaptability to stress c. Ability to evoke interpersonal conflict d. Inability to develop trusting relationships
C
Which dinner menu is best suited for the patient with bipolar disorder experiencing acute mania? a. Spaghetti and meatballs, salad, and a banana b. Beef and vegetable stew, a roll, and chocolate pudding c. Broiled chicken breast on a roll, an ear of corn, and an apple d. Chicken casserole, green beans, and flavored gelatin with whipped cream
C
Which finding indicates that a patient with moderate-to-severe anxiety has successfully lowered the anxiety level to mild? The patient: a. Asks, "What's the matter with me?" b. Stays in a room alone and paces rapidly. c. Can concentrate on what the nurse is saying. d. States, "I don't want anything to eat. My stomach is upset."
C
A nurse assessing a new patient asks, "What is meant by the saying, 'You can't judge a book by its cover'?" Which aspect of cognition is the nurse assessing? a. Mood b. Attention c. Orientation d. Abstraction
D
Which individual with a mental illness may need emergency or involuntary hospitalization for mental illness? The individual who: a. resumes using heroin while still taking methadone. b. reports hearing angels playing harps during thunderstorms. c. throws a heavy plate at a waiter at the direction of command hallucinations. d. does not show up for an outpatient appointment with the mental health nurse.
C
Which issues should a nurse address during the first interview with a patient with a psychiatric disorder? a. Trust, congruence, attitudes, and boundaries b. Goals, resistance, unconscious motivations, and diversion c. Relationship parameters, the contract, confidentiality, and termination d. Transference, countertransference, intimacy, and developing resources
C
Which medication prescribed to patients diagnosed with Alzheimer's disease antagonizes N-Methyl-D-Aspartate (NMDA) channels rather than cholinesterase? a. Donepezil (Aricept) b. Rivastigmine (Exelon) c. Memantine (Namenda) d. Galantamine (Razadyne)
C
Which medication should a nurse administer to provide immediate intervention for a psychotic patient whose aggressive behavior continues to escalate despite verbal intervention? a. lithium (Eskalith) b. trazodone (Desyrel) c. olanzapine (Zyprexa) d. valproic acid (Depakene)
C
Which principle should guide the nurse in determining the extent of silence to use during patient interview sessions? a. Nurses are responsible for breaking silences. b. Patients withdraw if silences are prolonged. c. Silence provides meaningful moments for reflection. d. Silence helps patients know that what they have said is understood.
C
Which referral is most appropriate for a woman who is severely beaten by her husband, has no relatives or friends in the community, is afraid to return home, and has limited financial resources? a. Support group b. Law enforcement c. Women's shelter d. Vocational counseling
C
Which scenario predicts the highest risk for directing violent behavior toward others? a. Major depression with delusions of worthlessness b. Obsessive-compulsive disorder; performing many rituals c. Paranoid delusions of being followed by alien monsters d. Completing alcohol withdrawal and beginning a rehabilitation program
C
While providing health teaching for a patient with binge-purge bulimia, a nurse should emphasize information about: a. self-monitoring of daily food and fluid intake. b. establishing the desired daily weight gain. c. recognizing the symptoms of hypokalemia. d. self-esteem maintenance.
C
In which situations does a nurse have a duty to intervene and report? Select all that apply. a. A peer is unable to write behavioral outcomes. b. A health care provider consults the Physicians' Desk Reference. c. A peer tries to provide patient care in an alcohol-impaired state. d. A team member has violated the boundaries of a vulnerable patient. e. A patient refuses a medication prescribed by a licensed health care provider.
C D
A patient's roommate has observed the patient behaving in uncharacteristic ways, but the patient cannot remember the episodes. A dissociative identity disorder is suspected. Which questions are most relevant to the assessment of this patient? Select all that apply. a. "Are you sexually promiscuous?" b. "Do you think you need an antidepressant medication?" c. "Have you ever found yourself someplace and did not know how you got there?" d. "Are your memories of childhood clear and complete, or do you have blank spots?" e. "Have you ever found new things in your belongings that you can't remember buying?"
C D E
The admission note indicates a patient with depression has anergia and anhedonia. For which measures should the nurse plan? Select all that apply. a. Channeling excessive energy b. Reducing guilty ruminations c. Instilling a sense of hopefulness d. Assisting with self-care activities e. Accommodating psychomotor retardation
C D E
What information is conveyed by nursing diagnoses? Select all that apply. a. Medical judgments about the disorder b. Goals and outcomes for the plan of care c. Unmet patient needs currently present d. Supporting data that validate the diagnoses e. Probable causes that will be targets for nursing interventions
C D E
Which assessment questions are most appropriate to ask a patient with possible obsessive-compulsive disorder? Select all that apply. a. "Have you been a victim of a crime or seen someone badly injured or killed?" b. "Are there certain social situations that cause you to feel especially uncomfortable?" c. "Do you have to do things in a certain way to feel comfortable?" d. "Is it difficult to keep certain thoughts out of awareness?" e. "Do you do certain things over and over again?"
C D E
Which experiences are most likely to precipitate post-traumatic stress disorder (PTSD)? Select all that apply. a. A young adult jumps from a bridge with a bungee cord with a best friend. b. An 8-year-old child watches an R-rated movie with both parents. c. An adolescent is kidnapped and held for 2 years in the home of a sexual predator. d. A passenger is in a bus that overturns on a sharp curve in the road, tumbling down an embankment. e. An adult is trapped for 3 hours at an angle in an elevator after a portion of the supporting cable breaks.
C D E
Which statements most clearly reflect the stigma of mental illness? Select all that apply. a. "Many mental illnesses are hereditary." b. "Mental illness can be evidence of a brain disorder." c. "People claim mental illness so they can get disability checks." d. "If people with mental illness went to church, they would be fine." e. "Mental illness is a result of the breakdown of the American family."
C D E
A nurse assesses the health status of soldiers returning from Afghanistan. Screening will be a priority for signs and symptoms of which health problems? Select all that apply. a. Schizophrenia b. Eating disorder c. Traumatic brain injury d. Seasonal affective disorder e. Posttraumatic stress disorder
C E
A nurse volunteers for a committee that must revise the hospital policies and procedures for suicide precautions. Which resources would provide the best guidance? Select all that apply. a. Diagnostic and Statistical Manual of Mental Disorders (fourth edition, text revision) (DSM-IV-TR) b. State's nurse practice act c. State and federal regulations that govern hospitals d. Summary of common practices of several local hospitals e. American Nurses Association Scope and Standards of Practice for Psychiatric-Mental Health Nursing Practice
C E
A college student failed two examinations. The student cried for hours and then tried to call a parent but got no answer. The student then suspended access to his social networking web site. Which suicide risk factors are present? Select all that apply. a. History of earlier suicide attempt b. Co-occurring medical illness c. Recent stressful life event d. Self-imposed isolation e. Shame or humiliation
CDE
A patient diagnosed with anorexia nervosa is hospitalized for treatment. What features should the milieu provide? Select all that apply. a. Flexible mealtimes b. Unscheduled weight checks c. Adherence to a selected menu d. Observation during and after meals e. Monitoring during bathroom trips f. Privileges correlated with emotional expression
CDE
Which nursing diagnoses are most applicable for a patient diagnosed with severe Alzheimer's disease? Select all that apply. a. Acute confusion b. Anticipatory grieving c. Urinary incontinence d. Disturbed sleep pattern e. Risk for caregiver role strain
CDE
A nurse assesses the health status of soldiers returning from Afghanistan. Screening for which health problems will be a priority? Select all that apply. a. Schizophrenia b. Eating disorder c. Traumatic brain injury d. Oppositional defiant disorder e. Post-traumatic stress disorder
CE
A 26-month-old child displays negative behavior, refuses toilet training, and often shouts, "No!" when given direction. The nurse's counseling with the parent should be based on the premise that the child is engaged in which of Erikson's psychosocial crises? a. Trust versus Mistrust b. Initiative versus Guilt c. Industry versus Inferiority d. Autonomy versus Shame and Doubt
D
A Filipino-American patient had this nursing diagnosis: Situational low self-esteem, related to poor social skills as evidenced by lack of eye contact. Interventions were used to raise the patient's self-esteem; however, after 3 weeks, the patient's eye contact did not improve. What is the most accurate analysis of this scenario? a. The patient's eye contact should have been directly addressed by role-playing to increase comfort with eye contact. b. The nurse should not have independently embarked on assessment, diagnosis, and planning for this patient. c. The patient's poor eye contact is indicative of anger and hostility that remain unaddressed. d. The nurse should have assessed the patient's culture before making this diagnosis and plan.
D
A Puerto Rican-American patient uses dramatic body language when describing emotional discomfort. Which analysis most likely explains the patient's behavior? The patient: a. Has a histrionic personality disorder. b. Believes dramatic body language is sexually appealing. c. Wishes to impress staff with the degree of emotional pain. d. Belongs to a culture in which dramatic body language is the norm.
D
A community psychiatric nurse facilitates medication compliance for a patient by having the health care provider prescribe depot medications by injection every 3 weeks at the clinic. For this plan to be successful, which factor will be of critical importance? a. Attitude of significant others toward the patient b. Nutritional services in the patient's neighborhood c. Level of trust between the patient and the nurse d. Availability of transportation to the clinic
D
A critical care nurse asks a psychiatric nurse about the difference between a DSM-IV-TR diagnosis and a nursing diagnosis. Select the psychiatric nurse's best response. a. "No functional difference exists between the two diagnoses. Both serve to identify a human deviance." b. "The DSM-IV-TR diagnosis disregards culture, whereas the nursing diagnosis includes cultural variables." c. "The DSM-IV-TR diagnosis profiles present distress or disability, whereas a nursing diagnosis considers past and present responses to actual mental health problems." d. "The DSM-IV-TR diagnosis influences the medical treatment; the nursing diagnosis offers a framework to identify interventions for problems a patient has or may experience."
D
A disheveled patient with severe depression and psychomotor retardation has not showered for several days. The nurse should: a. avoid forcing the issue. b. bring up the issue at the community meeting. c. calmly tell the patient, "You must bathe daily." d. firmly and neutrally assist the patient with showering.
D
A healthcare provider considers which antipsychotic medications prescribed for a patient with schizophrenia who has auditory hallucinations and poor social functioning. The patient is also overweight and has hypertension. Which drugs should the nurse advocate? a. clozapine (Clozaril) b. ziprasidone (Geodon) c. olanzapine (Zyprexa) d. aripiprazole (Abilify)
D
A new patient in an alcoholism rehabilitation program says, "I'm just a social drinker. I usually have a drink or two at brunch, a few cocktails in the afternoon, wine at dinner, and a few drinks in the evening." Which response by the nurse will help the patient view the drinking more honestly? a. "I see," and use interested silence. b. "I think you may be drinking more than you report." c. "Being a social drinker involves having a drink or two once or twice a week." d. "You describe drinking steadily throughout the day and evening. Am I correct?"
D
A newly admitted patient is profoundly depressed, mute, and motionless. The patient has refused to bathe and eat for a week. Which score would be expected on the patient's global assessment of functioning? a. 100 b. 80 c. 50 d. 10
D
A newly admitted patient who is acutely psychotic is a private patient of the senior psychiatrist. To whom does the psychiatric nurse who is assigned to this patient owe the duty of care? a. Health care provider b. Profession c. Hospital d. Patient
D
A nurse answers a suicide crisis line. A caller says, "I live alone in a home several miles from my nearest neighbors. I have been considering suicide for 2 months. I have had several drinks and now my gun is loaded. I'm going to shoot myself in the heart." How would the nurse assess the lethality of this plan? a. No risk b. Low level c. Moderate level d. High level
D
A nurse assesses a newly admitted patient with depression. Which statement is an example of "attending"? a. "We all have stress in life. Being in a psychiatric hospital isn't the end of the world." b. "Tell me why you felt you had to be hospitalized to receive treatment for your depression." c. "You will feel better after we get some antidepressant medication started for you." d. "I'd like to sit with you a while so you may feel more comfortable talking with me."
D
A nurse assessing a patient with a somatic system disorder is most likely to note that the patient: a. Readily sees a relationship between symptoms and interpersonal conflicts. b. Rarely derives personal benefit from the symptoms. c. Has little difficulty communicating emotional needs. d. Has altered comfort and activity needs.
D
A nurse can anticipate anticholinergic side effects will be likely when a patient is taking: a. lithium (Lithobid) b. buspirone (BuSpar) c. risperidone (Risperdal) d. fluphenazine (Prolixin)
D
A nurse cares for a rape victim who received flunitrazepam (Rohypnol) from the assailant. Which intervention has priority? Monitoring for: a. coma. b. seizures. c. hypotonia. d. respiratory depression.
D
A nurse cares for an older adult patient admitted for the treatment of depression. The health care provider prescribes an antidepressant medication, but the dose is more than the usual adult dose. The nurse should: a. implement the order. b. consult a drug reference. c. give the usual geriatric dosage. d. hold the medication and consult the health care provider.
D
A nurse cares for patients taking various medications, including buspirone (BuSpar), haloperidol (Haldol), trazodone (Desyrel), and phenelzine (Nardil). The nurse will order a special diet for the patient taking: a. buspirone b. haloperidol c. trazodone d. phenelzine
D
A nurse caring for a withdrawn, suspicious patient recognizes the development of feelings of anger toward the patient. The nurse should: a. suppress the angry feelings. b. express the anger openly and directly with the patient. c. tell the nurse manager to assign the patient to another nurse. d. discuss the anger with a clinician during a supervisory session.
D
A nurse conducting group therapy on the eating disorders unit schedules the sessions immediately after meals for the primary purpose of: a. Maintaining patients' concentration and attention. b. Shifting the patients' focus from food to psychotherapy. c. Focusing on weight control mechanisms and food preparation. d. Processing the heightened anxiety levels associated with eating.
D
A nurse counsels a patient with recent suicidal ideation. Which is the nurse's most therapeutic comment? a. "Let's make a list of all your problems and think of solutions for each one." b. "I'm happy you're taking control of your problems and trying to find solutions." c. "When you have bad feelings, try to focus on positive experiences from your life." d. "Let's consider which problems are most important and which are less important."
D
A nurse documents: "Patient is mute, despite repeated efforts to elicit speech. Makes no eye contact. Is inattentive to staff. Gazes off to the side or looks upward rather than at the speaker." Which nursing diagnosis should be considered? a. Defensive coping b. Decisional conflict c. Risk for other-directed violence d. Impaired verbal communication
D
A nurse interacts with a newly hospitalized patient. Select the nurse's comment that applies the communication technique of "offering self." a. "I've also had traumatic life experiences. Maybe it would help if I told you about them." b. "Why do you think you had so much difficulty adjusting to this change in your life?" c. "I hope you will feel better after getting accustomed to how this unit operates." d. "I'd like to sit with you for a while to help you get comfortable talking to me."
D
A nurse interviews a person abducted and raped at gunpoint by an unknown assailant. The person says, "I can't talk about it. Nothing happened. I have to forget!" What is the person's present coping strategy? a. Somatic reaction b. Repression c. Projection d. Denial
D
A nurse is called to the home of a neighbor and finds an unconscious person still holding a medication bottle labeled "pentobarbital sodium." What is the nurse's first action? a. Test reflexes b. Check pupils c. Initiate vomiting d. Establish a patent airway
D
A nurse is caring for a patient with low self-esteem. Which nonverbal communication should the nurse anticipate? a. Arms crossed b. Staring at the nurse c. Smiling inappropriately d. Eyes pointed downward
D
A nurse is talking with a patient, and 5 minutes remain in the session. The patient has been silent for most of the session. Another patient comes to the door of the room, interrupts, and says to the nurse, "I really need to talk to you." The nurse should: a. say to the interrupting patient, "I am not available to talk with you at the present time." b. end the unproductive session with the current patient and spend time with the patient who has just interrupted. c. invite the interrupting patient to join in the session with the current patient. d. tell the patient who has interrupted, "This session is 5 more minutes; then I will talk with you."
D
A nurse listens to a group of recent retirees. One says, "I volunteer with Meals on Wheels, coach teen sports, and do church visitation." Another laughs and says, "I'm too busy taking care of myself to volunteer. I don't have time to help others." These comments contrast which developmental tasks? a. Trust versus Mistrust b. Industry versus Inferiority c. Intimacy versus Isolation d. Generativity versus Self-Absorption
D
A nurse psychotherapist works with an anxious, dependent patient. The therapeutic strategy most consistent with the framework of psychoanalytic psychotherapy is: a. emphasizing medication compliance b. identifying the patient's strengths and assets c. offering psychoeducational materials and groups d. focusing on feelings developed by the patient toward the nurse
D
A nurse sits with a patient diagnosed with disorganized schizophrenia. The patient starts to laugh uncontrollably, although the nurse has not said anything funny. Select a nurse's best response a. "Why are you laughing?" b. "Please share the joke with me." c. "I don't think I said anything funny." d. "You're laughing. Tell me what's happening."
D
A nurse supports parental praise of a child who is behaving in a helpful way. When the individual behaves with politeness and helpfulness in adulthood, which feeling will most likely result? a. Guilt b. Anxiety c. Loneliness d. Self-esteem
D
A nurse wants to find a description of diagnostic criteria for a person with schizophrenia. Which resource should the nurse consult? a. U.S. Department of Health and Human Services b. Journal of the American Psychiatric Association c. North American Nursing Diagnosis Association (NANDA) International d. DSM-IV-TR
D
A nurse worked with a patient with major depression who displayed severely withdrawn behavior and psychomotor retardation. After 3 weeks, the patient did not improve. The nurse is at risk for feelings of: a. overinvolvement. b. guilt and despair. c. interest and pleasure. d. ineffectiveness and frustration.
D
A nursing care plan for a patient with anorexia nervosa includes the intervention "monitor for complications of refeeding." Which system should a nurse closely monitor for dysfunction? a. Renal b. Endocrine c. Central nervous d. Cardiovascular
D
A nursing diagnosis for a patient with bulimia nervosa is: Ineffective coping, related to feelings of loneliness as evidenced by overeating to comfort self, followed by self-induced vomiting. The best outcome related to this diagnosis is that within 2 weeks the patient will: a. appropriately express angry feelings. b. verbalize two positive things about self. c. verbalize the importance of eating a balanced diet. d. identify two alternative methods of coping with loneliness.
D
A older patient diagnosed with severe, late-stage dementia no longer recognizes family members. The family asks how long it will be before this patient recognizes them when they visit. What is the nurse's best reply? a. "Your family member will never again be able to identify you." b. "I think that is a question the health care provider should answer." c. "One never knows. Consciousness fluctuates in persons with dementia." d. "It is disappointing when someone you love no longer recognizes you."
D
A participant at a community education conference asks, "What is the most prevalent mental disorder in the United States?" Select the nurse's best response. a. "Why do you ask?" b. "Schizophrenia" c. "Affective disorders" d. "Anxiety disorders"
D
A patient admitted to an alcoholism rehabilitation program says, "I'm just a social drinker. I usually have a drink or two at brunch, a few cocktails in the afternoon, wine at dinner, and several drinks during the evening." The patient is using which defense mechanism? a. Rationalization b. Introjection c. Projection d. Denial
D
A patient admitted yesterday for injuries sustained in a fall while intoxicated believes snakes are crawling on the bed. The patient is anxious, agitated, and diaphoretic. What is the priority nursing diagnosis? a. Disturbed sensory perception b. Ineffective coping c. Ineffective denial d. Risk for injury
D
A patient became severely depressed when the last of six children moved out of the home 4 months ago. The patient repeatedly says, "No one cares about me. I'm not worth anything." Which response by the nurse would be the most helpful? a. "Things will look brighter soon. Everyone feels down once in a while." b. "The staff here cares about you and wants to try to help you get better." c. "It is difficult for others to care about you when you repeatedly say the same negative things." d. "I'll sit with you for 10 minutes now and return for 10 minutes at lunchtime and again at 2:30 this afternoon."
D
A patient begins a new program to assist with building social skills. In which part of the plan of care should a nurse record the item "Encourage patient to attend one psychoeducational group daily"? a. Assessment b. Analysis c. Planning d. Implementation e. Evaluation
D
A patient begins therapy with a phenothiazine medication. What teaching should a nurse provide related to the drug's strong dopaminergic effect? a. Chew sugarless gum. b. Increase dietary fiber. c. Arise slowly from bed. d. Report muscle stiffness.
D
A patient being admitted to the eating disorders unit has a yellow cast to the skin and fine, downy hair covering the body. The patient weighs 70 pounds; height is 5 feet, 4 inches. The patient is quiet and says only, "I won't eat until I look thin." What is the priority initial nursing diagnosis? a. Anxiety, related to fear of weight gain b. Disturbed body image, related to weight loss c. Ineffective coping, related to lack of conflict resolution skills d. Imbalanced nutrition: less than body requirements, related to self-starvation
D
A patient checks and rechecks electrical cords related to an obsessive thought that the house may burn down. The nurse and patient explore the likelihood of an actual fire. The patient states that a house fire is not likely. This counseling demonstrates the principles of: a. Flooding b. Desensitization c. Relaxation technique d. Cognitive restructuring
D
A patient comes to an outpatient appointment obviously intoxicated. The nurse should: a. explore the patient's reasons for drinking today. b. arrange admission to an inpatient psychiatric unit. c. coordinate emergency admission to a detoxification unit. d. tell the patient, "We cannot see you today because you've been drinking."
D
A patient diagnosed with Alzheimer's disease calls the fire department saying, "My smoke detectors are going off." Firefighters investigate and discover that the patient misinterpreted the telephone ringing. Which problem is this patient experiencing? a. Hyperorality b. Aphasia c. Apraxia d. Agnosia
D
A patient diagnosed with borderline personality disorder self-inflicted wrist lacerations after gaining new privileges on the unit. The cause of the self-mutilation is probably related to: a. inherited disorder that manifests itself as an incapacity to tolerate stress. b. use of projective identification and splitting to bring anxiety to manageable levels. c. constitutional inability to regulate affect, predisposing to psychic disorganization. d. fear of abandonment associated with progress toward autonomy and independence.
D
A patient diagnosed with disorganized schizophrenia says, "It's beat. Time to eat. No room for the cat." What type of verbalization is evident? a. Neologism b. Idea of reference c. Thought broadcasting d. Associative looseness
D
A patient diagnosed with paranoid schizophrenia angrily tells a nurse, "You act like a homosexual. No one trust you or wants to be around you." Select the most likely analysis. The patient: a. Issuing reaction formation in response to feelings of abandonment b. Is unleashing unconscious, hostile feelings toward the nurse c. Is dwelling on others' shortcomings, thus placing them on the defensive d. Maybe projecting homosexual urges
D
A person was abducted and raped at gunpoint. The nurse observes this victim is confused, talks rapidly in disconnected phrases, and is unable to concentrate or make simple decisions. What is the patient's level of anxiety? a. Weak b. Mild c. Moderate d. Severe
D
A patient has anorexia nervosa. The history shows the patient virtually stopped eating 5 months ago and has lost 25% of body weight. The serum potassium is 2.7 mg/dl. Which nursing diagnosis applies? a. Adult failure to thrive, related to abuse of laxatives as evidenced by electrolyte imbalances and weight loss b. Disturbed energy field, related to physical exertion in excess of energy produced through caloric intake as evidenced by weight loss and hyperkalemia c. Ineffective health maintenance, related to self-induced vomiting as evidenced by swollen parotid glands and hyperkalemia d. Imbalanced nutrition: less than body requirements, related to reduced oral intake as evidenced by loss of 25% of body weight and hypokalemia
D
A patient has anxiety, increased heart rate, and fear. The nurse would suspect the presence of a high concentration of which neurotransmitter? a. GABA b. Histamine c. Acetylcholine d. Norepinephrine
D
A patient has disorganized thinking associated with schizophrenia. Neuroimaging would most likely show dysfunction in which part of the brain? a. Brainstem b. Cerebellum c. Temporal lobe d. Prefrontal cortex
D
A patient has symptoms of acute anxiety related to the death of a parent in an automobile accident 2 hours earlier. The nurse should prepare to teach the patient about a medication from which group? a. Tricyclic antidepressants b. Atypical antipsychotics c. Anticonvulsants d. Benzodiazepines
D
A patient has taken many conventional antipsychotic drugs over years. The health care provider, who is concerned about early signs of tardive dyskinesia, prescribes risperidone (Risperdal). A nurse planning care for this patient understands that atypical antipsychotics: a. are less costly. b. have higher potency. c. are more readily available. d. produce fewer motor side effects.
D
A patient is brought to the emergency department after a motorcycle accident. The patient is alert, responsive, and diagnosed with a broken leg. The patient's vital signs are temperature (T), 98.6° F; pulse (P), 72 beats per minute (bpm); and respirations (R), 16 breaths per minute. After being informed that surgery is required for the broken leg, which vital sign readings would be expected? a. T, 98.6°; P, 64; R, 14 b. T, 98.6°; P, 68; R, 12 c. T, 98.6°; P, 62; R, 16 d. T, 98.6°; P, 84; R, 22
D
A patient is hospitalized after an arrest for breaking windows in the home of a former domestic partner. The history reveals childhood abuse by a punitive parent, torturing family pets, and an arrest for disorderly conduct. Which nursing diagnosis has priority? a. Risk for injury b. Posttrauma response c. Disturbed thought processes d. Risk for other-directed violence
D
A patient is undergoing diagnostic tests. The patient says, "Nothing is wrong with me except a stubborn chest cold." The spouse reports that the patient smokes, coughs daily, has lost 15 pounds, and is easily fatigued. Which defense mechanism is the patient using? a. Displacement b. Regression c. Projection d. Denial
D
A patient receiving risperidone (Risperdal) reports severe muscle stiffness at 10:30 AM. By noon, the patient had difficulty swallowing and is strolling. By 4:00 PM, vital signs are body temperature, 102.8°F; polls, 110 bpm; respiration, 26 breaths per minute; and blood pressure, 150/90 mm Hg. The patient is diaphoretic. Select the nurse's best analysis and action a. Agranulocytosis. Institute reverse isolation b. Tardive dyskinesia. Withhold the next is the medication c. Cholestatic jaundice. Begin a high-protein, high cholesterol diet d. Neuroleptic malignant syndrome. Immediately notify the healthcare provider
D
A patient says to the nurse, "I dreamed I was stoned. When I woke up, I felt emotionally drained, as though I hadn't rested well." Which comment would be appropriate if the nurse seeks clarification? a. "It sounds as though you were uncomfortable with the content of your dream." b. "I understand what you're saying. Bad dreams leave me feeling tired, too." c. "So, all in all, you feel as though you had a rather poor night's sleep?" d. "Can you give me an example of what you mean by 'stoned'?"
D
A patient says, "People should be allowed to commit suicide without interference from others." A nurse replies, "You're wrong. Nothing is bad enough to justify death." What is the best analysis of this interchange? a. The patient is correct. b. The nurse is correct. c. Neither person is totally correct. d. Differing values are reflected in the two statements.
D
A patient sits in silence for 20 minutes after a therapy appointment, appearing tense and vigilant. The patient abruptly stands and paces back and forth, clenching and unclenching fists, and then stops and stares in the face of a staff member. The patient is: a. demonstrating withdrawal. b. working through angry feelings. c. attempting to use relaxation strategies. d. exhibiting clues to potential aggression.
D
A patient states, "I'm not worth anything. I have negative thoughts about myself. I feel anxious and shaky all the time. Sometimes I feel so sad that I want to go to sleep and never wake up." Which nursing intervention should have the highest priority? a. Self-esteem-building activities b. Anxiety self-control measures c. Sleep enhancement activities d. Suicide precautions
D
A patient tells a nurse, "I have psychiatric problems and am in and out of hospitals all the time. Not one of my friends or relatives has these problems." Select the nurse's best response. a. "Comparing yourself with others has no real advantages." b. "Why do you blame yourself for having a psychiatric illness?" c. "Mental illness affects 50% of the adult population in any given year." d. "It sounds like you are concerned that others don't experience the same challenges as you."
D
A patient underwent psychotherapy weekly for 3 years. The therapist used free association, dream analysis, and facilitated transference to help the patient understand unconscious processes and foster personality changes. Which type of therapy was used? a. Short-term dynamic psychotherapy b. Transactional analysis c. Cognitive therapy d. Psychoanalysis
D
A patient who fears serious heart disease was referred to the mental health center by a cardiologist after extensive diagnostic evaluation showed no physical illness. The patient says, "I have tightness in my chest and my heart misses beats. I'm frequently absent from work. I don't go out much because I need to rest." Which health problem is most likely? a. Dysthymic disorder b. Antisocial personality disorder c. Simple somatic symptom disorder d. Prominent health anxiety (hypochondriasis)
D
A patient with a history of daily alcohol abuse says, "Drinking helps me cope with being a single parent." Which response by the nurse would help the individual conceptualize the drinking more objectively? a. "Sooner or later, alcohol will kill you. Then what will happen to your children?" b. "I hear a lot of defensiveness in your voice. Do you really believe this?" c. "If you were coping so well, why were you hospitalized again?" d. "Tell me what happened the last time you drank."
D
A patient with acute mania has disrobed in the hall three times in 2 hours. The nurse should: a. direct the patient to wear clothes at all times. b. ask if the patient finds clothes bothersome. c. tell the patient that others feel embarrassed. d. arrange for one-on-one supervision.
D
A patient with bipolar disorder was hospitalized 7 days earlier and has been taking lithium 600 mg three times daily. Staff members observe increased agitation, pressured speech, poor personal hygiene, hyperactivity, and bizarre clothing. What is the nurse's best intervention? a. Educate the patient about the proper ways to perform personal hygiene and coordinate clothing. b. Continue to monitor and document the patient's speech patterns and motor activity. c. Ask the health care provider to prescribe an increased dose and frequency of lithium. d. Consider the need to check the lithium level. The patient may not be swallowing medications.
D
A patient with depersonalization disorder tells the nurse, "It's starting again. I feel as though I'm going to float away." The nurse should help the patient by: a. encouraging meditation. b. administering an anxiolytic medication. c. helping the patient visualize a pleasant scene. d. helping the patient focus on the here and now.
D
A patient with depression is receiving imipramine (Tofranil) 200 mg every night at bedtime. Which assessment finding would prompt the nurse to collaborate with the health care provider regarding potentially hazardous side effects of this drug? a. Dry mouth b. Blurred vision c. Nasal congestion d. Urinary retention
D
A patient with fluctuating levels of consciousness, disturbed orientation, and perceptual alteration begs, "Someone get these bugs off me." What is the nurse's best response? a. "No bugs are on your legs. You are having hallucinations." b. "I will have someone stay here and brush off the bugs for you." c. "Try to relax. The crawling sensation will go away sooner if you can relax." d. "I don't see any bugs, but I can tell you are frightened. I will stay with you."
D
A patient with schizophrenia anxiously says, "I can see the left side of my body merging with the wall, then my face appears and disappears in the mirror." While listening, the nurse should: a. sit close to the patient b. place an arm protectively around the patient's shoulders c. place a hand on the patient's arm and exert light pressure d. maintain a normal social interaction distance form the patient
D
A patient with schizophrenia has been stable for a year; however, the family now reports the patient is tense, sleeps 3 to 4 hours per night, and has difficulty concentrating. The patient says, "Volmers are hiding in the house." The nurse can correctly assess this information as an indication of: a. need for psychoeducation b. medication noncompliance c. chronic deterioration d. relapse
D
A patient with schizophrenia says, "Contagious bacteria are everywhere. When they get in your body, you will be locked up with other infected people." Which problem is evident? a. Poverty of content b. Concrete thinking c. Neologisms d. Paranoia
D
A patient with schizophrenia tells the nurse, "I eat skiller. Tend to end. Easter. It blows away. Get it?" Select the nurse's best response: a. "Nothing you are saying is clear." b. "Your thoughts are very disconnected." c. "Try to organize your thoughts, and then tell me again." d. "I'm having difficulty understanding what you are saying."
D
A patient with severe anxiety suddenly begins running and shouting, "I'm going to explode!" The nurse should: a. Ask, "I'm not sure what you mean. Give me an example." b. Chase after the patient, and give instructions to stop running. c. Capture the patient in a basket-hold to increase feelings of control. d. Assemble several staff members and state, "We will help you regain control."
D
A patient's history shows intense and unstable relationships with others. The patient initially idealizes an individual and then devalues the person when the patient's needs are not met. Which aspect of mental health is a problem? a. Effectiveness in work b. Communication skills c. Productive activities d. Fulfilling relationships
D
A patient's nursing diagnosis is Insomnia. The desired outcome is: "Patient will sleep for a minimum of 5 hours nightly by October 31." On November 1, a review of the sleep data shows the patient sleeps an average of 4 hours nightly and takes a 2-hour afternoon nap. What is the nurse's next action? a. Continue the current plan without changes. b. Remove this nursing diagnosis from the plan of care. c. Write a new nursing diagnosis that better reflects the problem. d. Revise the target date for outcome attainment and examine interventions.
D
A patient's nursing diagnosis is Insomnia. The desired outcome is: "Patient will sleep for a minimum of 5 hours nightly by October 31." On November 1, a review of the sleep data shows the patient sleeps an average of 4 hours nightly and takes a 2-hour afternoon nap. Which evaluation should be documented? a. Consistently demonstrated b. Often demonstrated c. Sometimes demonstrated d. Never demonstrated
D
A person attempts suicide by overdose, is treated in the emergency department, and then hospitalized. What is the best initial outcome? The patient will: a. verbalize a will to live by the end of the second hospital day. b. describe two new coping mechanisms by the end of the third hospital day. c. accurately delineate personal strengths by the end of first week of hospitalization. d. exercise suicide self-restraint by refraining from gestures or attempts to kill self for 24 hours.
D
A person tells a nurse, "I was the only survivor in a small plane crash, but three business associates died. I got anxious and depressed and saw a counselor three times a week for a month. We talked about my feelings related to being a survivor, and now I'm fine, back to my old self." Which type of therapy was used? a. Milieu therapy b. Psychoanalysis c. Behavior modification d. Interpersonal therapy
D
A person who feels unattractive repeatedly says, "Although I'm not beautiful, I am smart." This is an example of: a. Repression b. Devaluation c. Identification d. Compensation
D
A person's spouse filed charges of battery. The person has a long history of acting-out behaviors and several arrests. Which statement by the person suggests an antisocial personality disorder? a. "I have a quick temper, but I can usually keep it under control." b. "I've done some stupid things in my life, but I've learned a lesson." c. "I'm feeling terrible about the way my behavior has hurt my family." d. "I hit because I'm tired of being nagged. My spouse deserved the beating."
D
A psychiatric clinical nurse specialist uses cognitive therapy techniques with a patient diagnosed with anorexia nervosa. Which statement by the staff nurse supports this type of therapy? a. "What are your feelings about not eating the food that you prepare?" b. "You seem to feel much better about yourself when you eat something." c. "It must be difficult to talk about private matters to someone you just met." d. "Being thin doesn't seem to solve your problems. You're thin now but still unhappy."
D
A psychiatric nurse best implements the ethical principle of autonomy when he or she: a. intervenes when a self-mutilating patient attempts to harm self. b. stays with a patient who is demonstrating a high level of anxiety. c. suggests that two patients who are fighting be restricted to the unit. d. explores alternative solutions with a patient, who then makes a choice.
D
A rape victim asks an emergency department nurse, "Maybe I did something to cause this attack. Was it my fault?" Which response by the nurse is the most therapeutic? a. Pose questions about the rape, helping the patient explore why it happened. b. Reassure the victim that the outcome of the situation will be positive. c. Make decisions for the victim because of the temporary confusion. d. Support the victim to separate issues of vulnerability from blame.
D
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." Which is the nurse's best response? a. "I wonder what this sudden change is all about. Please tell me more." b. "I am glad you are feeling better. The team will consider your request." c. "You should not try to direct your care. Leave that to the treatment team." d. "Because we are concerned about your safety, we will continue with our plan."
D
A single parent is experiencing feelings of inadequacy related to work and family since one teenaged child ran away several weeks ago. The parent seeks the help of a therapist specializing in cognitive therapy. The psychotherapist who uses cognitive therapy will treat the patient by: a. discussing ego states b. focusing on unconscious mental processes c. negatively reinforcing an undesirable behavior d. helping the patient identify and change faulty thinking
D
A soldier returned 3 months ago from Afghanistan and was diagnosed with post-traumatic stress disorder (PTSD). Which social event would most likely be disturbing for this soldier? a. Halloween festival with neighborhood children b. Singing carols around a Christmas tree c. Family outing to the seashore d. Fireworks display on July 4th
D
A soldier returned home last year after deployment to a war zone. The soldier's spouse complains, "We were going to start a family but now he won't talk about it. He will not look at children. I wonder if we're going to make it as a couple." Select the nurse's best response. a. "Posttraumatic stress disorder often changes a person's sexual functioning." b. "I encourage you to continue to participate in social activities where children are present." c. "Have you talked with your spouse about these reactions? Sometimes we just need to confront behavior." d. "Posttraumatic stress disorder often strains relationships. Here are some community resources for help and support."
D
A soldier served in combat zones in Iraq in 2010 and was deployed to Afghanistan in 2011. When is it most important for the nurse to screen for signs and symptoms of post-traumatic stress disorder (PTSD)? a. Immediately upon return to the United States from Afghanistan b. Before departing Afghanistan to return to the United States c. One year after returning from Afghanistan d. Screening should be ongoing
D
A student says, "Before taking a test, I feel a heightened sense of awareness and restlessness." The nurse can correctly assess the student's experience as: a. Culturally influenced b. Displacement c. Trait anxiety d. Mild anxiety
D
A supervisor assigns a worker a new project. The worker initially agrees but feels resentful. The next day when asked about the project, the worker says, "I've been working on other things." When asked 4 hours later, the worker says, "Someone else was using the copier, so I couldn't finish it." The worker's behavior demonstrates: a. acting out. b. projection. c. rationalization. d. passive aggression.
D
A therapist recently convicted of multiple counts of Medicare fraud says, "Sure I overbilled. Why not? Everyone takes advantage of the government, so I did too." These statements show: a. shame. b. suspiciousness. c. superficial remorse. d. lack of guilt feelings.
D
A woman gave birth to a healthy newborn 1 month ago. The patient now reports she cannot cope and is unable to sleep or eat. She says, "I feel like a failure. I can't take care of my baby. This baby is the root of my problems." The priority nursing diagnosis is: a. Insomnia b. Ineffective coping c. Situational low self-esteem d. Risk for other-directed violence
D
A woman in the last trimester of pregnancy drinks 8 to 12 ounces of alcohol daily. The nurse plans for the delivery of an infant who is: a. jaundiced. b. dependent on alcohol. c. healthy but underweight. d. microcephalic and cognitively impaired.
D
After hospital discharge, what is the priority intervention for a patient with bipolar disorder, who is taking antimanic medication, and for the patient's family? a. Decreasing physical activity b. Increasing food and fluids c. Meeting self-care needs d. Psychoeducation
D
An adolescent hospitalized after a violent physical outburst tells the nurse, "I'm going to kill my father, but you can't tell anyone." Select the nurse's best response. a. "You're right. Federal law requires me to keep that information private." b. "Those kinds of thoughts will make your hospitalization longer." c. "You really should share this thought with your psychiatrist." d. "I am obligated to share information with the treatment team."
D
An adult expresses the wish to be taken care of and often behaves in a helpless fashion. This adult has needs related to which of Freud's stages of psychosexual development? a. Latency b. Phallic c. Anal d. Oral
D
An adult has recently been absent from work for 3-day periods on several occasions. Each time, the individual returns wearing dark glasses. Facial and body bruises are apparent. What is the occupational health nurse's priority assessment? a. Interpersonal relationships b. Work responsibilities c. Socialization skills d. Physical injuries
D
An adult has recently been absent from work on several occasions. Each time, the adult returns wearing dark glasses. Facial and body bruises are apparent. During the occupational health nurse's interview, the adult says, "My partner beat me, but it was because there are problems at work." What should the nurse's next action be? a. Call the police. b. Arrange for hospitalization. c. Call the adult protective agency. d. Document injuries with a body map.
D
An adult in the emergency department states, "I feel restless. Everything I look at wavers. Sometimes I'm outside my body looking at myself. I hear colors. I think I'm losing my mind." Vital signs are slightly elevated. The nurse should suspect a: a. cocaine overdose. b. schizophrenic episode. c. phencyclidine (PCP) intoxication. d. D-lysergic acid diethylamide (LSD) ingestion.
D
An essential difference between somatic system disorders and dissociative disorders is: a. Somatic system disorders are under voluntary control, whereas dissociative disorders are unconscious and automatic. b. Dissociative disorders are precipitated by psychologic factors, whereas somatic system disorders are related to stress. c. Dissociative disorders are individually determined and related to childhood sexual abuse, whereas somatic system disorders are culture bound. d. Dissociative disorders entail stress-related disruptions of memory, consciousness, or identity, whereas somatic system disorders involve the expression of psychologic stress through somatic symptoms.
D
An example of a breach of a patient's right to privacy occurs when a nurse: a. asks a family to share information about a patient's prehospitalization behavior. b. discusses the patient's history with other staff members during care planning. c. documents the patient's daily behaviors during hospitalization. d. releases information to the patient's employer without consent.
D
An informal group of patients discuss their perceptions of nursing care. Which comment best indicates a patient's perception that his or her nurse is caring? a. "My nurse always asks me which type of juice I want to help me swallow my medication." b. "My nurse explained my treatment plan to me and asked for my ideas about how to make it better." c. "My nurse told me that if I take all the medicines the doctor prescribes I will get discharged soon." d. "My nurse spends time listening to me talk about my problems. That helps me feel like I'm not alone."
D
And auditory hallucinations anxiously tells the nurse, "The voices telling me to do things." Select the nurse's priority assessment question a. "How long has the voice been directing your behavior?" b. "Does what the voice tells you to do frighten you?" c. "Do you recognize the voice speaking to you?" d. "What is the voice telling you to do?"
D
At what point in an assessment interview would a nurse 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
Cognitive therapy was provided for a patient who frequently said, "I'm stupid." Which statement by the patient indicates the therapy was effective? a. "I'm disappointed in my lack of ability." b. "I always fail when I try new things." c. "Things always go wrong for me." d. "Sometimes I do stupid things."
D
Disturbed body image is the nursing diagnosis for a patient with an eating disorder. Which outcome indicator is most appropriate to monitor? a. Weight, muscle, and fat are congruent with height, frame, age, and sex. b. Calorie intake is within the required parameters of the treatment plan. c. Weight reaches the established normal range for the patient. d. Patient expresses satisfaction with body appearance.
D
During an interview, a patient attempts to shift the focus from self to the nurse by asking personal questions. The nurse should respond by saying: a. "You've turned the tables on me." b. "Nurses direct the interviews with patients." c. "Do not ask questions about my personal life." d. "The time we spend together is to discuss your concerns."
D
During the first interview, a nurse notices that the patient does not make eye contact. The nurse can correctly analyze that: a. the patient is not truthful. b. the patient is feeling sad. c. the patient has a poor self-concept. d. more information is needed to draw a conclusion.
D
For a patient with dissociative amnesia, complete this outcome: Within 4 weeks, the patient will demonstrate an ability to execute complex mental processes by: a. functioning independently." b. verbalizing feelings of safety." c. regularly attending diversional activities." d. describing previously forgotten experiences."
D
For which behavior would limit setting be most essential? The patient: a. clings to the nurse and asks for advice about inconsequential matters. b. is flirtatious and provocative with staff members of the opposite sex. c. is hypervigilant and refuses to attend unit activities. d. urges a suspicious patient to hit anyone who stares.
D
In a team meeting a nurse says, "I'm concerned whether we are behaving ethically by using restraint to prevent one patient from self-mutilation while the care plan for another patient who has also self-mutilated calls for one-on-one supervision." Which ethical principle most clearly applies to this situation? a. Beneficence b. Autonomy c. Fidelity d. Justice
D
In the majority culture of the United States, which individual is at greatest risk to be incorrectly labeled mentally ill? a. Person who is usually pessimistic but strives to meet personal goals b. Wealthy person who gives $20 bills to needy individuals in the community c. Person with an optimistic viewpoint about life and getting his or her own needs met d. Person who attends a charismatic church and describes hearing God's voice
D
In the shift-change report, an off-going nurse criticizes a patient who wears heavy makeup. Which comment by the nurse who receives the report best demonstrates advocacy? a. "This is a psychiatric hospital. Craziness is what we are all about." b. "Let's all show acceptance of this patient by wearing lots of makeup too." c. "Your comments are inconsiderate and inappropriate. Keep the report objective." d. "Our patients need our help to learn behaviors that will help them get along in society."
D
Lithium is prescribed for a new patient. Which information from the patient's history indicates that monitoring serum concentrations of the drug will be challenging and critical? a. Arthritis b. Epilepsy c. Psoriasis d. Congestive heart failure
D
Nursing behaviors associated with the implementation phase of the nursing process are concerned with: a. participating in the mutual identification of patient outcomes. b. gathering accurate and sufficient patient-centered data. c. comparing patient responses and expected outcomes. d. carrying out interventions and coordinating care.
D
On the basis of current knowledge of neurotransmitter effects, a nurse anticipates that the treatment plan for a patient with memory difficulties may include medications designed to: a. inhibit GABA production. b. increase dopamine sensitivity. c. decrease dopamine at receptor sites. d. prevent destruction of acetylcholine.
D
Outpatient treatment is planned for a patient diagnosed with anorexia nervosa. Select the most important desired outcome related to the nursing diagnosis: Imbalanced nutrition: less than body requirements. Within 1 week, the patient will: a. Weigh self accurately using balanced scales. b. Limit exercise to less than 2 hours daily. c. Select clothing that fits properly. d. Gain 1 to 2 pounds.
D
Select the best outcome for a patient with the nursing diagnosis: Impaired social interaction, related to sociocultural dissonance as evidenced by stating, "Although I'd like to, I don't join in because I don't speak the language very well." The patient will: a. demonstrate improved social skills. b. express a desire to interact with others. c. become more independent in decision making. d. select and participate in one group activity per day.
D
Select the correct etiology to complete this nursing diagnosis for a patient with dissociative identity disorder. Disturbed personal identity, related to: a. obsessive fears of harming self or others. b. poor impulse control and lack of self-confidence. c. depressed mood secondary to nightmares and intrusive thoughts. d. cognitive distortions associated with unresolved childhood abuse issues.
D
Select the most appropriate label to complete this nursing diagnosis: ___________, related to feelings of shyness and poorly developed social skills as evidenced by watching television alone at home every evening. a. Deficient knowledge b. Ineffective coping c. Powerlessness d. Social isolation
D
Select the most helpful response for a nurse to make when a patient being treated as an outpatient states, "I am considering suicide." a. "I'm glad you shared this. Please do not worry. We will handle it together." b. "I think you should admit yourself to the hospital to get help." c. "We need to talk about the good things you have to live for." d. "Bringing this up is a very positive action on your part."
D
The following patients are seen in the emergency department. The psychiatric unit has one bed available. Which patient should the admitting officer recommend for admission to the hospital? The patient who: a. experiencing dry mouth and tremor related to side effects of haloperidol (Haldol). b. experiencing anxiety and a sad mood after a separation from a spouse of 10 years. c. who self-inflicted a superficial cut on the forearm after a family argument. d. who is a single parent and hears voices saying, "Smother your infant."
D
The history shows that a newly admitted patient has impulsivity. The nurse would expect behavior characterized by: a. adherence to a strict moral code. b. manipulative, controlling strategies. c. postponing gratification to an appropriate time. d. little time elapsed between thought and action.
D
The nursing diagnosis rape trauma syndrome applies to a rape victim in the emergency department. Which outcome should occur before the patient's discharge? a. Patient states, "I feel safe and entirely relaxed." b. Memory of the rape is less vivid and frightening. c. Physical symptoms of pain and discomfort are no longer present. d. Patient agrees to keep a follow-up appointment with the rape victim advocate.
D
The parent of an adolescent with schizophrenia asks a nurse, "My child's doctor ordered a positron-emission tomography (PET) scan. What is that?" Select the nurse's best reply. a. "PET uses a magnetic field and gamma waves to identify problems areas in the brain. Does your teenager have any metal implants?" b. "It's a special type of x-ray image that shows structures of the brain and whether a brain injury has ever occurred." c. "PET is a scan that passes an electrical current through the brain and shows brain wave activity. PET can help diagnose seizures." d. "PET is a special scan that shows blood flow and activity in the brain."
D
The relapse of a patient with schizophrenia is related to medication noncompliance. The patient is hospitalized for 5 days, medication is restarted, and the patient's thoughts are now more organized. The patient's family members are upset and say, "It's too soon about the patient being scheduled for discharge. Hospitalization is needed for at least a month." The nurse should: a. call the psychiatrist to come explain the discharge rationale. b. explain that health insurance will not pay for a longer stay for the patient. c. call security to handle the disturbance and escort the family off the unit. d. explain that the patient will continue to improve if medication is taken regularly.
D
The spouse of a patient who has delusions asks the nurse, "Are there any circumstances under which the treatment team is justified in violating the patient's right to confidentiality?" The nurse must reply that confidentiality may be breached: a. under no circumstances. b. at the discretion of the psychiatrist. c. when questions are asked by law enforcement. d. if the patient threatens the life of another person.
D
The spouse of a patient with schizophrenia says, "I don't understand why childhood experiences have anything to do with this disabling illness." Select the nurse's response that will best help the spouse understand this condition. a. "Psychological stress is actually at the root of most mental disorders." b. "We now know that all mental illnesses are the result of genetic factors." c. "It must be frustrating for you that your spouse is sick so much of the time." d. "Although this disorder more likely has a biological rather than psychological origin, the support and involvement of caregivers is very important."
D
To plan effective care for patients with somatic system disorders, the nurse should understand that patients have difficulty giving up the symptoms because the symptoms: a. Are generally chronic. b. Have a physiological basis. c. Can be voluntarily controlled. d. Provide relief from health anxiety.
D
When a nurse finds a patient with anorexia nervosa vigorously exercising before gaining the agreed-upon weekly weight, the nurse should state: a. "You and I will have to sit down and discuss this problem." b. "It bothers me to see you exercising. You'll lose more weight." c. "Let's discuss the relationship between exercise and weight loss and how that affects your body." d. "According to our agreement, no exercising is permitted until you have gained a specific amount of weight."
D
When a patient's aggression quickly escalates, which principle applies to the selection of nursing interventions? a. Staff members should match the patient's affective level and tone of voice. b. Ask the patient what intervention would be most helpful. c. Immediately use physical containment measures. d. Begin with the least restrictive measure possible.
D
When assessing a patient who has ingested flunitrazepam (Rohypnol), the nurse would expect: a. acrophobia. b. hypothermia. c. hallucinations. d. anterograde amnesia.
D
When preparing to interview a patient diagnosed with narcissistic personality disorder, a nurse can anticipate the assessment findings will include: a. preoccupation with minute details; perfectionism. b. charm, drama, seductiveness; seeking admiration. c. difficulty being alone; indecisiveness, submissiveness. d. grandiosity, attention seeking, and arrogance.
D
Which assessment finding for a patient in the community requires priority intervention by the nurse? The patient: a. receives Social Security disability income plus a small check from a trust fund. b. lives in an apartment with two patients who attend day hospital programs. c. has a sibling who is interested and active in care planning. d. purchases and uses marijuana on a frequent basis.
D
Which assessment finding for a patient with an eating disorder meets a criterion for hospitalization? a. Urine output: 40 ml/hr b. Pulse rate: 58 beats/min c. Serum potassium: 3.4 mEq/L d. Systolic blood pressure: 62 mm Hg
D
Which assessment findings support a nurse's suspicion that a patient has been using inhalants? a. Pinpoint pupils and respiratory rate of 12 breaths per minute b. Perforated nasal septum and hypertension c. Drowsiness, euphoria, and constipation d. Confusion, mouth ulcers, and ataxia
D
Which assessment findings will the nurse expect in an individual who has just injected HEROIN? a. Anxiety, restlessness, paranoid delusions b. Heightened sexuality, insomnia, euphoria c. Muscle aching, dilated pupils, tachycardia d. Drowsiness, constricted pupils, slurred speech
D
Which assessment question would be most appropriate to ask a patient who has possible generalized anxiety disorder? a. "Have you been a victim of a crime or seen someone badly injured or killed?" b. "Do you feel especially uncomfortable in social situations involving people?" c. "Do you repeatedly do certain things over and over again?" d. "Do you find it difficult to control your worrying?"
D
Which behavior shows that a nurse values autonomy? The nurse: a. sets limits on a patient's romantic overtures toward the nurse. b. suggests one-on-one supervision for a patient who is suicidal. c. informs a patient that the spouse will not be in during visiting hours. d. discusses available alternatives and helps the patient weigh the consequences.
D
Which belief by a nurse supports the highest degree of patient advocacy during a multidisciplinary patient care planning session? a. All mental illnesses are culturally determined. b. Schizophrenia and bipolar disorder are cross-cultural disorders. c. Symptoms of mental disorders are constant from culture to culture. d. Some symptoms of mental disorders reflect a person's cultural patterns.
D
Which beverage should the nurse offer to a patient with depression who refuses solid food? a. Tomato juice b. Orange juice c. Hot tea d. Milk
D
Which documentation of a patient's behavior best demonstrates a nurse's observations? a. Isolates self from others. Frequently fell asleep during group. Vital signs stable. b. Calmer and more cooperative. Participated actively in group. No evidence of psychotic thinking. c. Appeared to hallucinate. Patient frequently increased volume on television, causing conflict with others d. Wears four layers of clothing. States, "I need protection from dangerous bacteria trying to penetrate my skin."
D
Which documentation of diagnosis would a nurse expect for a person with mental illness? a. I Rheumatoid arthritis II 100 III Posttraumatic stress disorder IV Arrested for shoplifting 2 months earlier V None b. I Mental retardation II Histrionic personality disorder III 75 IV Hypertension V Home destroyed by tornado last year c. I Schizophrenia, paranoid II Death of spouse last year III 40 IV None V Alcohol abuse d. I Generalized anxiety disorder II Avoidant personality disorder III Fibromyalgia IV Declared bankruptcy 6 months ago V 60
D
Which individual in the emergency department should be considered at the highest risk for completing suicide? a. An adolescent Asian-American girl with superior athletic and academic skills who has asthma b. A 38-year-old single African-American female church member with fibrocystic breast disease c. A 60-year-old married Hispanic man with 12 grandchildren who has type 2 diabetes d. A 79-year-old single white man with cancer of the prostate gland
D
Which is an important nursing intervention when giving care to a patient withdrawing from a central nervous system (CNS) stimulant? a. Make physical contact by frequently touching the patient. b. Offer intellectual activities requiring concentration. c. Avoid manipulation by denying the patient's requests. d. Observe for depression and suicidal ideation.
D
Which medication is the nurse most likely to see prescribed as part of the treatment plan for both a patient in an alcoholism treatment program and a patient in a program for the treatment of opioid addiction? a. methadone (Dolophine) b. bromocriptine (Parlodel) c. disulfiram (Antabuse) d. naltrexone (Revia)
D
Which nursing diagnosis is more applicable to a patient with anorexia nervosa who restricts intake and is 20% below normal weight than for a 130-pound patient with bulimia nervosa who purges? a. Powerlessness b. Ineffective coping c. Disturbed body image d. Imbalanced nutrition: less than body requirements
D
Which patient with schizophrenia would be expected to have the lowest score and global assessment of functioning? a. 39 years old; paranoid ideation since age 35 years b. 32 years old; diagnosed as catatonic at age 24 years; stable for 3 years c. 19 years old; diagnosed with undifferentiated schizophrenia at age 17 d. 40 years old; diagnose schizophrenia since age 18; frequent relapses
D
Which patient would a nurse refer to partial hospitalization? An individual who: a. spent yesterday in the 24-hour supervised crisis care center and continues to be actively suicidal. b. because of agoraphobia and panic episodes needs psychoeducation for relaxation therapy c. has a therapeutic lithium level and reports regularly for blood tests and clinic follow-up. d. states, "I'm not sure I can avoid using alcohol when my spouse goes to work every morning."
D
Which remark by a patient indicates passage from the orientation phase 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 my problems." c. "I don't know how talking about things twice a week can help." d. "I want to find a way to deal with my anger without becoming violent."
D
Which scenario is an example of a tort? a. The primary nurse does not complete the plan of care for a patient within 24 hours of the patient's admission. b. An advanced practice nurse recommends that a patient who is dangerous to self and others be voluntarily hospitalized. c. A patient's admission status is changed from involuntary to voluntary after the patient's hallucinations subside. d. A nurse gives an as-needed dose of an antipsychotic drug to a patient to prevent violent acting-out because a unit is short staffed.
D
Which statement made by a patient diagnosed with borderline personality disorder indicates the treatment plan is effective? a. "I think you are the best nurse on the unit." b. "I'm never going to get high on drugs again." c. "I hate my doctor for not giving me what I ask for." d. "I felt empty and wanted to cut myself, so I called you."
D
Which statement made by a patient during an initial assessment interview should serve as the priority focus for the plan of care? a. "I can always trust my family." b. "It seems like I always have bad luck." c. "You never know who will turn against you." d. "I hear evil voices that tell me to do bad things."
D
Which treatment approach is most appropriate for a patient with antisocial tendencies who has been treated several times for substance addiction but has relapsed? a. One-week detoxification program b. Long-term outpatient therapy c. Twelve-step self-help program d. Residential program
D
Which understanding about individuals who attempt suicide will help a nurse plan the care for a suicidal patient? Every suicidal person should be considered: a. mentally ill. b. intent on dying. c. cognitively impaired. d. experiencing hopelessness.
D
Withdrawn patients with schizophrenia: a. Universally fear sexual involvement with therapist b. Are socially disabled by the positive symptoms of schizophrenia c. Exhibit a high degree of hostility as evidenced by rejecting behavior d. Avoid relationships because they become anxious with emotional closeness
D
The spouse of a patient with schizophrenia asks, "Which neurotransmitters are more active when a person has schizophrenia?" The nurse should state, "The current thinking is that the thought disturbances are related to increased activity of: (Select all that apply.) a. GABA." b. substance P." c. histamine." d. dopamine." e. norepinephrine."
D E
While caring for a patient with a methamphetamine overdose, which tasks are the priorities of care? Select all that apply. (2) a. Administration of naloxone (Narcan) b. Vitamin B12 and folate supplements c. Restoring nutritional integrity d. Prevention of seizures e. Reduction of fever
DE