passpoint

A young client has been arrested for assault and battery. The client has been admitted to the forensic psychiatric facility for a pretrial evaluation. Which client goal is most appropriate for the client? 1Accept responsibility for personal behavior. 2Participate in group therapy. 3Verbalize ways to express anger, such as playing age-appropriate video games. 4Avoid contact with others on the psychiatric forensic unit.

Accept responsibility for personal behavior.

A registered nurse is overseeing the care of clients in an acute mental health setting. Which task can the nurse delegate to an unlicensed assistive personnel? Sterile dressing changes to a client's lacerated wrists Initial assessment of a client admitted with bulimia Encouraging a client with depression to eat Teaching a client with schizophrenia about medications

Encouraging a client with depression to eat

The nurse, along with the treatment team for the client, uses critical pathways of care. Which statement regarding critical pathways is correct? 1. It is a care plan that provides outcome-based guidelines with a designated length of stay. 2. It is an outline of care designed for physicians to order medications, treatments, and activity levels. 3. It is a design of treatment that includes approved therapies and critical use of nontraditional therapies. 4. It is a holistic therapy technique that combines the use of meditation along with an emphasis on treatment team collaboration.

It is a care plan that provides outcome-based guidelines with a designated length of stay.

In group therapy, a client angrily speaks up and responds to a peer, "You're always whining, and I'm getting tired of listening to you! Here is the world's smallest violin playing for you." Which role is the client playing? blocker monopolizer recognition seeker aggressor

aggressor

An adolescent client is having difficulty coping following the drowning death of a close friend. The client reports recurring nightmares and intrusive thoughts about the friend's death. Which assessment is most important for the nurse to make? availability of social supports grades in school signs of isolation or withdrawal accessibility of drugs in school

availability of social supports

Which term refers to the primary unconscious defense mechanism that blocks intense, anxiety-producing situations from a person's conscious awareness? introjection regression repression denial

repression

A client lives in a group home and visits the community mental health center regularly. During one visit with the nurse, the client states, "The voices are telling me to hurt myself again." Which question by the nurse is most important to ask? "When do you hear the voices?" "Are you going to hurt yourself?" "How long have you heard the voices?" "Why are the voices starting again?"

"Are you going to hurt yourself?"

The nurse is teaching a group of unlicensed assistive personnel (UAP) new to psychiatry about balance in a therapeutic milieu. Which statement by a UAP indicates the need for further teaching? "Balance includes safe and effective treatment for all clients." "Controlling clients helps them feel more comfortable." "We don't fix clients, but we help them solve their problems." "We need to think of clients' rights as we provide care."

"Controlling clients helps them feel more comfortable."

During an insight group on a mental health unit, a client is demanding attention, interrupting others, and talking most of the time. What would be the best response by the nurse? "I'm going to ignore your behavior and allow others to speak." "I imagine I speak for the group when I say I am frustrated with your behavior." "I invite you to summarize your point briefly so that we can then hear from others." "I find your behavior drains the group."

"I invite you to summarize your point briefly so that we can then hear from others."

A client at a mental health clinic discusses having never been married, stating that there is no time to date and little time for a social life with family or friends. In assessing the client's social supports, which would be an appropriate question for the nurse to ask? "In what ways are you able to be a positive support system to others?" "With how many family members do you maintain close contact?" "What do you like to do for fun when you have some free time?" "What kind of emotional or material support do you receive from others?"

"What kind of emotional or material support do you receive from others?"

Which principle of the psychoanalytic model is particularly useful to psychiatric nurses? All behavior has meaning. Behavior that is reinforced will be perpetuated. The first 6 years of a person's life determine personality. Behavioral deviations result from an incongruence between verbal and nonverbal communication.

All behavior has meaning.

The nurse assists a client in responding to a loss. What is the best approach for the nurse to use with this client? Make sure the client progresses through all of the stages of the grief process. Encourage the client to work to resolve lingering family conflicts. Assist the client to engage in the work associated with the normal grieving process. Allow the client to express anger.

Assist the client to engage in the work associated with the normal grieving process.

A client with a personality disorder is upset and calls the nurse a "stupid cow." Which is the most effective initial response by the nurse to this client's behavior? 1. Demonstrate empathy by reaching out to touch the client. 2. Calmly discuss the inappropriateness of displacing anger to others. 3. Report the behavior to the physician so that consistency and consequences can be followed. 4. Walk away from the client.

Calmly discuss the inappropriateness of displacing anger to others.

During a mental health assessment interview, a client does not make eye contact with the nurse. The nurse suspects this behavior is culturally based. What should the nurse do first in relation to this assumption? Accept this behavior because it is culturally based Observe how the client and the client's family interact with each other and with other staff members Read several articles about this cultural group and their behaviors Ask staff members of a similar cultural group about their habits and behaviors

Observe how the client and the client's family interact with each other and with other staff members

The nurses assesses a client for physiologic responses to stress. Which finding would suggest to the nurse that the client is not experiencing anger? 1.increased respiratory rate 2decreased blood pressure 3increased muscle tension 4decreased peristalsis

decreased blood pressure

What does the nurse recognize as the primary goal of milieu management? facilitation of a client's growth, rehabilitation, and health restoration successful achievement of the needs of staff members provision of a sanctuary for helpless clients implementation of health care providers' prescriptions

facilitation of a client's growth, rehabilitation, and health restoration

A nurse may use self-disclosure with a client if: the nurse has experienced the same situation as the client. the client asks directly about the nurse's experience. it helps the client to talk more easily. it achieves a specific therapeutic goal.

it achieves a specific therapeutic goal.

The nurse assesses an aggressive client. Which behavior warrants the nurse's prompt reporting and use of safety precautions? crying when talking about their recent divorce starting a petition to delay bedtime declining attendance at a daily group therapy session naming another client as their adversary

naming another client as their adversary

A client in group therapy is restless. The client's face is flushed and the client makes sarcastic remarks to group members. The nurse responds by saying, "You look angry." The nurse is using which technique? a broad, opening statement reassurance clarification observation

observation

A nurse is caring for a newly admitted client on the psychiatric unit. The nurse would most hinder therapeutic communication by performing what action? offering advice and opinions using open-ended questions avoiding judgment, false reassurance, and approval providing factual information

offering advice and opinions

Which action demonstrates the role of the psychiatric nurse in primary prevention? handling crisis intervention in an outpatient setting visiting a client's home to discuss medication management conducting a postdischarge support group providing sexual education classes for adolescents

providing sexual education classes for adolescents

In closed or locked units, the nurse judges the milieu as therapeutic when priorities are given to which factors? socialization and self-understanding recreation and vocation counseling safety, structure, and support communication, social, and leisure skills

safety, structure, and support

The nurse should integrate which principle when a client's mental status interferes with the ability to participate in milieu activities? norms structure balance schedule modification

schedule modifcation

The nurse teaches unlicensed assistive personnel (UAP) about caring for a client who is withdrawing from alcohol and street drugs. Which communication technique when observed by the nurse indicates the UAP has understood the instructions? using matter-of-fact manner and short sentences conveying a cheerful tone, using humor when appropriate speaking with a loud voice and giving general comments providing detailed explanations in a quiet voice

using matter-of-fact manner and short sentences

A nurse is leading group therapy with psychiatric clients. During the working phase of the group, what should the nurse do? Explain the purposes and goals of the group. Offer advice to help resolve conflicts. Encourage group cohesiveness. Encourage a discussion of feelings of loss regarding the group's termination.

Encourage group cohesiveness.

A nurse is instructing a group of clients on the difference between mental health and mental illness. Which statement by a client displays an accurate understanding of mental health? Select all that apply. "I am healthy if I can change other people." "I am healthy if I accept my positives and negatives." "I am healthy if I am unable to fulfill work responsibilities." "I am healthy if I can cope with stressors." "I am healthy if I need to love others and feel loved."

"I am healthy if I accept my positives and negatives." "I am healthy if I can cope with stressors." "I am healthy if I need to love others and feel loved."

A teenage client and their family is referred to family therapy after the client was suspended due to behavioral problems. Which statement by the parent of the client indicates an understanding of the purpose of family therapy? 1"My child will just have to realize that there are consequences for their behaviors and they must try harder to behave at school." 2"I suspect the therapist will notice how my spouse babies our child. My spouse has to make some changes, or our child will never become an adult." 3"I hope we can all learn some new skills and begin to problem solve better with the help of the therapist." 4"The therapist will tell us how to make our child behave better so they can go back to school."

"I hope we can all learn some new skills and begin to problem solve better with the help of the therapist."

The nurse assesses the progress of a client who has behavioral manifestations of stress. Which client statement indicates that the client has gained insight into the use of the defense mechanism of displacement? "I can't think about the weekend right now. I've got to study for the exam." "I know I'm not good at sports, but I feel good about my grades." "Now when I am mad at my spouse, I talk to them instead of taking it out on the kids." "For years I couldn't remember being molested; now I know I have to face it."

"Now when I am mad at my spouse, I talk to them instead of taking it out on the kids."

A client presents to the emergency department confused and disoriented after being pulled out of a house fire. The client is mumbling incoherently. Which statement by the nurse exemplifies therapeutic communication? 1"You are at the hospital now, and you are safe." 2"You must talk so I can figure out what is going on with you." 3"I understand how you feel. I lost my parents in a fire." 4"Has anything like this happened to you before?"

"You are at the hospital now, and you are safe."

Two nurses disagree on what is the most important information for a client with a stress-related illness to have during a discharge teaching session. How should the nurse who is assigned to provide the discharge teaching proceed? 1 Share all the information that both nurses thought was important. 2 Review the policies related to required discharge teaching. 3 Be aware of different interpretations and personal biases held by nurses. 4 Ask the client what is most important for them as they prepare for discharge.

Ask the client what is most important for them as they prepare for discharge.

During a unit meeting attended by clients and staff, several clients are criticizing their primary nurses. These clients have also been intimidating two other clients who have recently been admitted to the unit, and now the new clients have stopped sharing their opinions during the meeting. What is the first action for the nurse to take? 1. Help the new clients express the reasons they have stopped sharing their ideas. 2. Ask the clients criticizing their nurses to suggest some possible solutions for the practices they are criticizing. 3. Give the clients who are publicly criticizing the nurses a verbal warning that this behavior is not acceptable. 4. Use the next unit meeting to discuss respect and the importance of collaboration with the treatment team.

Ask the clients criticizing their nurses to suggest some possible solutions for the practices they are criticizing.

During a meeting with nurse managers from the crisis intake unit, acute mental health unit, and mental health long-term care unit, the hospital risk manager says, "Approximately 57% of our client safety problems can be directly attributed to poor handoffs." What solution might the nurse managers implement to improve these statistics? All shift handoff reports should be face-to-face instead of being tape-recorded. Nursing staff should complete a checklist to take more care in interpreting primary health care provider prescriptions. Nursing staff should complete and document admission history and physicals within 1 hour of arrival on a unit. Initiate a template of transfer information to be communicated when a client is transferred from one care setting to another.

Initiate a template of transfer information to be communicated when a client is transferred from one care setting to another.

On the second day of hospitalization, the nurse and the client are discussing concerns about unhealthy family relationships. During a nurse-client interaction, the client changes the subject to a job situation. The nurse responds, "Let's go back to what we were just talking about." What therapeutic communication technique did the nurse use? reflecting restating focusing summarizing

focusing

A client is admitted to the inpatient psychiatric unit. The client is unshaven, has body odor, and has spots on their shirt and pants. The client moves slowly, gazes at the floor, and has a flat affect. What should the nurse ask the client about first when completing the admission assessment? how they sleep at night if they are thinking about hurting themself about recent stresses how they feel about themself

if they are thinking about hurting themself

In an ongoing assessment, the nurse should identify the client's thoughts and feelings about a situation in addition to what other factors? 1whether the client's behavior is appropriate in the context of the current situation 2whether the client is motivated to decrease dysfunctional behaviors 3which of the client's problems have the highest priority 4which of the client's behaviors should be addressed through group therapy

whether the client's behavior is appropriate in the context of the current situation

A nurse is conducting a psychoeducational group for family members of clients hospitalized with depression. Which family member's statement indicates a need for additional teaching? "My spouse will slowly feel better as his medicine takes effect over the next 2 to 4 weeks." "My spouse will need to take her antidepressant medicine and go to group to stay well." "My child will only need to attend outpatient appointments when they starts to feel depressed again." "My parent might need help with grocery shopping, cooking, and cleaning for a while."

"My child will only need to attend outpatient appointments when they starts to feel depressed again."

The nurse is admitting a client diagnosed with depression. Which statements by the nurse should be made in the orientation phase of the nurse-client relationship? Select all that apply. 1"Walk me through your emotions and feelings on a normal day." 2"I won't share any information with your family without your permission." 3"We'll be meeting every day at 10:00 a.m. for 15 minutes." 4"Tell me what brought you here today." 5"Let's talk about what you can do to help reduce your stress."

"I won't share any information with your family without your permission." "We'll be meeting every day at 10:00 a.m. for 15 minutes." "Tell me what brought you here today."

A family member accompanies a client to the clinic. The client's speech is disorganized but reports abdominal pain for several days. When the nurse attempts to assess the abdomen, the client pulls away and states "Do not touch me. I am sick from the poison the government puts in our water." The family member states the client has schizoaffective disorder. Which statement by the nurse shows effective communication with this client? "The government does not have time to poison our water, they are busy taking care of our country." "Let me see if I understand, you have had pain in your stomach for a while now. Can you tell me more?" "Your illness causes you to be rude and will not let you see the truth. You are not accountable." "I completely understand where you are coming from. You are sick and it is the government's fault."

"Let me see if I understand, you have had pain in your stomach for a while now. Can you tell me more?"

A client is admitted to the psychiatric hospital for evaluation after numerous incidents of threatening, angry outbursts, and two episodes of hitting a coworker at the grocery store where they work. The client is very anxious and tells the nurse who admits them, "I didn't mean to hit them. They made me so mad that I just couldn't help it. I hope I don't hit anyone here." How should the nurse respond? 1. "When you start to feel angry here, talk to the staff about your feelings." 2"You'd better not hit anyone here, even if you do get mad." 3"Tell me more about what happened." 4"I'm sure you didn't mean to hit them and that it won't happen here."

"When you start to feel angry here, talk to the staff about your feelings."

A client in a group therapy setting is very demanding. The client repeatedly interrupts others and monopolizes most of the group time. The nurse's best response would be: "Will you briefly summarize your point? Others also need time." "Your behavior is obnoxious and drains the group." "I'm so frustrated by your behavior." to ignore the behavior and allow the client to vent.

"Will you briefly summarize your point? Others also need time."

A client is admitted to the psychiatric unit and appears agitated. While putting personal items away, the client talks rapidly and folds and unfolds garments several times. The client cannot seem to relax. What statement by the nurse is best? "You have been folding the same clothing several times. How do you feel right now?" "Please come with me to the common room; it's time for group therapy." "Let's see if the healthcare provider ordered any medications to help you relax." "You need to calm down. Take some deep breaths into this paper bag."

"You have been folding the same clothing several times. How do you feel right now?"

A hospital nurse is conducting a psychiatric assessment for a client being discharged the next day. Which nursing intervention(s) is appropriate when conducting this assessment? SELECT ALL Allow the client to direct the conversation and provide redirection as necessary. Choose a public location in the hospital that is well-populated. Sit at an angle toward the client and provide undivided attention. Ask the client to clarify any unclear or ambiguous statement. Stop the assessment if the client reports feeling uneasy.

Allow the client to direct the conversation and provide redirection as necessary. Sit at an angle toward the client and provide undivided attention. Ask the client to clarify any unclear or ambiguous statement. Stop the assessment if the client reports feeling uneasy.

The nurse in a mental health clinic is conducting group therapy. The nurse leads the clients into the working phase of the group therapy. During this phase, which is the most important strategy for the nurse to use to facilitate progress with the clients? Encourage group cohesiveness. Explain the purpose and goals of the group. Offer advice to help resolve conflicts. Discuss feelings of loss regarding termination.

Encourage group cohesiveness.

A nurse is working with a group on an inpatient psychiatric unit. While planning strategies and approaches for group therapy, what intervention will best promote group cohesiveness? 1Make decisions in advance of the group meeting so that they can be announced and the group can move forward quickly. 2Seat the most talkative members closest to the facilitators so they can be seen and heard more and take over as co-facilitators. 3Help the group establish shared goals that are consistent with the individual goals of members. 4Have the group members challenge each other for truthfulness and meeting group expectations.

Help the group establish shared goals that are consistent with the individual goals of members.

When the nurse is providing a therapeutic milieu for clients, which intervention is most appropriate? Use psychotropic drugs primarily. Foster dependent client behavior. Promote optimal functioning of an individual or group. Meet one's own needs while helping clients meet their needs.

Promote optimal functioning of an individual or group.

A nurse learns that another staff nurse in an outpatient mental health clinic has recently sought money from a group of mental health center clients to invest in a new business. How should the nurse respond to learning this information? Take over the care of the nurse's clients. Report concerns to the nursing supervisor. Call the board of nursing to report the coercion of vulnerable clients into business deals. Contact the media to file a "consumer report" on the multilevel marketing scam.

Report concerns to the nursing supervisor.

A nurse in a psychiatric care unit finds that a client with psychosis has become violent and has struck another client in the unit. What action should the nurse take in this case? 1. Do not restrain the client, as it is equivalent to false imprisonment. 2. Restrain the client, as they are harmful to the other clients. 3. Do not restrain the client, as it is equivalent to battery. 4. Inform the physician and complete a comprehensive assessment.

Restrain the client, as they are harmful to the other clients.

A client asks the nurse for medication because they feel nervous. Within a therapeutic milieu, what action should the nurse take initially? 1. Talk with the client about her feelings. 2. Suggest that the client play a game with another client. 3. Advise the client to lie down in her room until she feels better. 4. Administer lorazepam 1 mg orally as needed, as prescribed.

Talk with the client about her feelings.

A nurse hears a client state, "I've had it with this marriage. It would be so much easier to just hire someone to kill my husband!" What action should the nurse take? Since the client is still admitted to the hospital, the nurse must hold the statement in confidence. The nurse must start the process to warn the client's husband. An assessment of the client's response to treatment must be performed. The comment must be held in confidence because the client did not report the statement directly to the nurse.

The nurse must start the process to warn the client's husband.

A client is admitted to an inpatient psychiatric unit. After the assessment and admission procedures have been completed, the nurse states, "I'll try to be available to talk with you when needed and will spend time with you each morning from 10:00 until 10:30 in the corner of the dayroom." What is the rationale for communicating these planned nursing interventions? To attempt to establish a trusting relationship To provide a structured environment for the client To instill hope in the client To provide time for completing nursing responsibilities

To attempt to establish a trusting relationship

The nurse in an inpatient psychiatric adult unit is assigned care for a group of clients. Which client would the nurse see first during morning rounds? 1 client admitted to the hospital for agitation and paranoia 2 client with schizophrenia scheduled to be discharged today 3 client with depression who refused medications last evening and will not get out of bed 4 client with advanced dementia who has not communicated in the 2 days since arriving on the unit

client admitted to the hospital for agitation and paranoia

The nurse is helping a client deal with personal issues and painful feelings. What does the nurse identify as a crucial goal of therapeutic communication? communicating empathy through gentle touch 1conveying client respect and acceptance even if not all of the client's 2behaviors are tolerated 3mutual sharing of information, spontaneity, emotions, and intimacy 4guaranteeing total confidentiality and anonymity for the clie

conveying client respect and acceptance even if not all of the client's behaviors are tolerated

A client who is suspicious of others, including staff, is brought to the hospital wearing a wrinkled dress with stains on the front. The assessment also reveals a flat affect, confusion, and slow movements. Which goal should the nurse identify as the initial priority when planning this client's care? helping the client feel safe and accepted introducing the client to other clients giving the client information about the program providing the client with clean, comfortable clothes

helping the client feel safe and accepted

A client exhibits psychomotor deficits, withdrawal, minimal eye contact, and unresponsiveness to the nurse's questions. Which outcome should the nurse include in the initial plan of care? The client will: initiate interactions with peers. participate in milieu activities. discuss adaptive coping techniques. interact with the nurse.

interact with the nurse.

When asked about their stresses before admission, an anxious client stares blankly at the nurse and mutters unintelligibly. Which description of the client's behaviors should the nurse document in the client's medical record? "The client: cannot answer any questions asked at this time." is uncooperative during admission procedure, refusing to answer any questions." responded to questions with a blank look and incomprehensible mumble." stared at the wall when asked questions and was disoriented and incoherent."

responded to questions with a blank look and incomprehensible mumble."

A client with depression has been admitted to the mental health unit and is attending group therapy sessions as part of treatment. The client asks the nurse leading the group if he is married or has a girlfriend. The nurse responds, "I am curious what made you ask this question; however, what is important is how you are feeling today." The nurse's response is which of the following? Inappropriate, because the client was just making small talk about the nurse's personal situation to get to know the nurse better. Inappropriate, because the nurse should have answered to establish a therapeutic relationship. Appropriate, because the nurse is neither married nor has a girlfriend. Appropriate, because the focus of the therapeutic relationship is the client, not the nurse.

Appropriate, because the focus of the therapeutic relationship is the client, not the nurse.

The nurse is performing a psychological assessment on a client with history of alcohol abuse. Which findings should the nurse anticipate? Select all that apply. 1low self-esteem and depression 2family history of alcoholism 3dependent personality disorder 4avoidant personality disorder 5desire to inflict pain upon one's self

low self-esteem and depression family history of alcoholism

During therapy, a client on the mental health unit is restless and is starting to make sarcastic remarks to others in the therapy session. The nurse responds by saying, "you look angry." Which communication techniques is the nurse using? 1reaffirming 2clarification 3mirroring 4making observations

making observations

A client is admitted to a mental health unit with a diagnosis of depression and is participating in group sessions. The client asks a nurse if they are married or in a romantic relationship. What is the best response by the nurse to maintain a therapeutic relationship? "Group therapy is not the appropriate time to discuss my relationships." "It sounds as though you are interested in developing a relationship with me." "Tell me how you knew that I was not married or in a romantic relationship." "I'm curious about your question but I want to know how you are

"I'm curious about your question but I want to know how you are feeling today."

The nurse is admitting a client who is anxious, fearful, and pleads not to be left alone. The client states, "I'm worthless!" Which statement(s) by the nurse will help build a strong, therapeutic nurse-client relationship? Select all that apply. "I know how you feel. I get very anxious at times, too." "I'm here if you would like to talk about anything." "You're not worthless. Don't think that way." "Just take one day at a time, and everything will be okay." "I'll stay with you until you feel less anxious."

"I'm here if you would like to talk about anything." "I'll stay with you until you feel less anxious."