psych exam 2

what is the abbreviation for the nursing process

ADPIE

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 dialogues 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 to identify strengths, limitations, and problems.

a, b

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

A novice psychiatric nurse has a parent with bipolar disorder. This nurse angrily recalls feelings of embarrassment about the parents 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. The nurse should try to suppress them when working with patients. c. Recognize that psychiatric nursing is not an appropriate career choice. Explore other nursing specialties. d. The nurse should 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 nurses practice, but supervision is important.

a, e

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. Youre having trouble focusing on what Im saying. What is distracting you?

a- are you having difficulty hearing when i speak

A patient diagnosed 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 has the highest priority? a. Implement suicide precautions. b. Offer high-calorie snacks and fluids frequently. c. Assist the patient to identify three personal strengths. d. Observe patient for therapeutic effects of antidepressant medication.

a- implement suicide precautions

A community mental health nurse has worked with a patient for 3 years but is moving out of the city and terminates the relationship. When a novice nurse begins work with this patient, what is the starting point for the relationship? a. Begin at the orientation phase. b. Resume the working relationship. c. Initially establish a social relationship. d. Return to the emotional catharsis phase.

a. Begin at the orientation phase.

At what point in the nurse-patient relationship should a nurse plan to first address termination? a. During the orientation phase b. At the end of the working phase c. Near the beginning of the termination phase d. When the patient initially brings up the topic

a. During the orientation phase

A patient says, Ive 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. I am glad that you realize this. c. Thats not a good way to behave. d. Have you outgrown that type of behavior?

a. How do you feel about that?

A patient says, Please dont share information about me with the other people. How should the nurse respond? a. I will not share information with your family or friends without your permission, but I share information about you with other staff. b. A therapeutic relationship is just between the nurse and the patient. It is up to you to tell others what you want them to know. c. It 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.

a. I will not share information with your family or friends without your permission, but I share information about you with other staff.

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 nurses best action? a. Recognize the effectiveness of the relationship and patients thoughtfulness. Accept the card. b. Inform the patient that accepting gifts violates policies of the facility. Decline the card. c. Acknowledge the patients 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. Recognize the effectiveness of the relationship and patients thoughtfulness. Accept the card.

Which technique will best communicate to a patient that the nurse is interested in listening? a. Restating a feeling or thought the patient has expressed. b. Asking a direct question, such as Did you feel angry? c. Making a judgment about the patients problem. d. Saying, I understand what youre saying.

a. Restating a feeling or thought the patient has expressed.

A nurse explains to the family of a mentally ill patient how a 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 shared openly. d. The focus is creation of a partnership in which each member is concerned with growth and satisfaction of the other.

a. The focus is on the patient. Problems are discussed by the nurse and patient, but solutions are implemented by the patient.

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. You must have been very upset when you tried to hurt yourself.

A nurse says, I am the only one who truly understands this patient. Other staff members are too critical. The nurses statement indicates: a. boundary blurring. b. sexual harassment. c. positive regard. d. advocacy.

a. boundary blurring.

as a nurse assess a new client, the nurse makes sure the door remains open. which type of communication factor is in this action? a. environmental b. relationship c. personal

a. environmental

a client preparing for discharge presents the nurse with a handmade card of appreciation for the care this nurse provided. should the nurse accept this card? a. yes b. no c. not sure

a. yes

when the group is norming what will occur

agreement and consensus

what is the stress response according to GAS

alarm, resistance, exhaustion

which of the following does not enhance therapeutic communication

asking many questions

the mental status exam

assesses mental health strengths and coping skills

group members have worked very hard, and the nurse is giving group feedback. the working phase is considered successful if group members:

assume more responsibility

a nurse is teaching a stress-management program for a client. which of the following beliefs will the nurse advocate as a method of coping with stressful life events

avoidance of stress is an important goal for living

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 HCL (Prolixin) 2.5 mg po 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 Im ready to blow up. O: Pacing hall, mumbling to self. A: Auditory hallucinations. P: Offer haloperidol (Haldol) 2 mg po. I: Haloperidol (Haldol) 2 mg po given 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 po 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 po administered at 0900 with calming effect in 30 minutes. Stated, Im no longer bothered by the voices.

b

A nurse assessed a patient who reluctantly participated in activities, answered questions with minimal responses, and rarely made eye contact. What information should be included when documenting the assessment? Select all that apply. a. The patient was uncooperative b. The patients subjective responses c. Only data obtained from the patients verbal responses d. A description of the patients behavior during the interview e. Analysis of why the patient was unresponsive during the interview

b & d

Which descriptors exemplify consistency regarding nurse-patient relationships? Select all that apply. a. Encouraging a patient to share initial impressions of staff b. Having the same nurse care for a patient on a daily basis 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 patients problems

b, c, d

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 novice 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 will be helpful in meeting the nurses goal? Select all that apply. a. Sitting behind a desk, facing the patient b. Introducing self to a patient and identifying own role c. Maintaining control of discussions by asking direct questions d. Using facial expressions to convey interest and encouragement e. Assuming an open body posture and sometimes mirror imaging

b, d, e

What information is conveyed by nursing diagnoses? Select all that apply. a. Medical judgments about the disorder b. Unmet patient needs currently present c. Goals and outcomes for the plan of care d. Supporting data that validate the diagnoses e. Probable causes that will be targets for nursing interventions

b, d, e

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 isnt much improvement by the time of discharge. The nurses responsibility is to: a. document the other workers assessment of the patient. b. assess the patient based on data collected from all sources. c. validate the workers impression by contacting the patients significant other. d. discuss the workers impression with the patient during the assessment interview.

b- assess the patient based on data collected from all sources

A patient presents to the emergency department with mixed psychiatric symptoms. The admission nurse suspects the symptoms may be the result of a medical problem. Lab results show elevated BUN (blood urea nitrogen) and creatinine. What is the nurses next best action? a. Report the findings to the health care provider. b. Assess the patient for a history of renal problems. c. Assess the patients family history for cardiac problems. d. Arrange for the patients hospitalization on the psychiatric unit.

b- assess the patient for a history of renal problems

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- cognition

A nurse assesses a confused older adult. The nurse experiences sadness and reflects, The patient is like one of my grandparentsso helpless. Which response is the nurse demonstrating? a. Transference b. Countertransference c. Catastrophic reaction d. Defensive coping reaction

b- countertransference

After formulating the nursing diagnoses for a new patient, what is a nurses next action? a. Designing interventions to include in the plan of care b. Determining the goals and outcome criteria c. Implementing the nursing plan of care d. Completing the spiritual assessment

b- determining the goals and outcome criteria

A new staff nurse completes an 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. Prescribe psychotropic medication. c. Establish therapeutic relationships. d. Individualize nursing care plans.

b- prescribe psychotropic medication

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- quality and safety education for nurses

A nurse wants to assess an adult patients recent memory. Which question would best yield the desired information? a. Where did you go to elementary school? b. What did you have for breakfast this morning? c. Can you name the current president of the United States? d. A few minutes ago, I told you my name. Can you remember it?

b- what did you have for bfast this morning

a nurse seeks to establish a relationship with a patient readmitted to the hospital. the pt has bipolar disorder, depressed type, and was hospitalized the preceding month. which statement by the nurse would contribute to establishing trust? a. "weren't you compliant with your medication regimen?" b. "it must be discouraging to be readmitted to the hospital so soon" c. "everyone with bipolar disorder ends up in the hospital occassionally" d. "you must take your drugs as prescribed or you will be rehospitalized"

b. "it must be discouraging to be readmitted to the hospital so soon"

A patient diagnosed with 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. Lets 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. It sounds like you're concerned about your privacy.

An advanced practice nurse observes a novice nurse expressing irritability regarding a patient with a long history of alcoholism and suspects the new nurse is experiencing countertransference. Which comment by the new nurse confirms this suspicion? a. This patient continues to deny problems resulting from drinking. b. My parents were alcoholics and often neglected our family. c. The patient cannot identify any goals for improvement. d. The patient said I have many traits like her mother.

b. My parents were alcoholics and often neglected our family.

As a patient diagnosed with a 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 nurses action blurs the boundaries of the therapeutic relationship. c. The invitation is therapeutic for the patients diversional activity deficit. d. The nurses action assists the patients integration into community living.

b. The nurses action blurs the boundaries of the therapeutic relationship.

a client tells the nurse, "I have something secret to tell you, but you can't tell anyone else". the nurse agrees. what is the likely consequence of the nurse's action? a. healthy feelings of sympathy by the nurse toward the client b. blurred boundaries in the nurse-pt relationship c. improved rapport b/w the nurse and client d. enhanced trust b/w the nurse and client

b. blurred boundaries in the nurse-pt relationship

a nurse doing a quick assessment of a newly hospitalized client. which communication technique will the nurse use most? a. rapid, high-pitch voice tones b. closed-ended questions c. direct eye contact d. frequent touch

b. closed-ended questions

The patient says, My marriage is just great. My spouse and I always agree. The nurse observes the patients foot moving continuously as the patient twirls a shirt button. The conclusion the nurse can draw is that the patients communication is: a. clear. b. mixed. c. precise. d. inadequate.

b. mixed.

A nurse introduces 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. spell out the participation and responsibilities of each party.

A nurse wants to enhance growth of a patient by showing positive regard. The nurses action most likely to achieve this goal is: a. making rounds daily. b. staying with a tearful patient. c. administering medication as prescribed. d. examining personal feelings about a patient.

b. staying with a tearful patient.

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 patients behaviors.

b. use congruent communication strategies

An adolescent asks a nurse conducting an assessment interview, Why should I tell you anything? Youll just tell my parents whatever you find out. Which response by the nurse is appropriate? a. That isnt 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- What you say about feelings is private, but some things, like suicidal thinking, must be reported to the treatment team.

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. Implementation d. Evaluation

c- implementation

When a new patient is hospitalized, a nurse takes the patient on a tour, explains rules of the unit, and discusses the daily schedule. The nurse is engaged in: a. counseling. b. health teaching. c. milieu management. d. psychobiological intervention.

c- mileu management

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. Social isolation d. Powerlessness

c- social isolation

A newly admitted patient diagnosed with major depression has gained 20 pounds over a few months 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: more than body requirements b. Chronic low self-esteem c. Risk for suicide d. Hopelessness

c-risk for suicide

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. Am I correct in understanding that . . .

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 nurses best response? a. Accepting gifts violates the policies and procedures of the facility. b. Im glad you feel so much better now. Thank you for the beautiful necklace. c. Im glad I could help you, but I cant accept the gift. My reward is seeing you with a renewed sense of hope. d. Helping people is what nursing is all about. Its rewarding to me when patients recognize how hard we work.

c. Im glad I could help you, but I cant accept the gift. My reward is seeing you with a renewed sense of hope.

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. Relationship parameters, the contract, confidentiality, and termination

A patient says, Im still on restriction, but I want to attend some off-unit activities. Would you ask the doctor to change my privileges? What is the nurses best response? a. Why are you asking me when youre able to speak for yourself? b. I will be glad to address it when I see your doctor later today. c. Thats a good topic for you to discuss with your doctor. d. Do you think you cant speak to a doctor?

c. Thats a good topic for you to discuss with your doctor.

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 patients 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 unusually happy when the patients mood begins to lift. d. The nurse develops a trusting relationship with the patient.

c. The nurse feels unusually happy when the patients mood begins to lift.

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. Working

A patient tells the nurse, I dont think Ill ever get out of here. Select the nurses most therapeutic response. a. Dont talk that way. Of course you will leave here! b. Keep up the good work, and you certainly will. c. You dont think youre making progress? d. Everyone feels that way sometimes.

c. You dont think youre making progress?

Which behavior shows that a nurse values autonomy? The nurse: a. suggests one-on-one supervision for a patient who has suicidal thoughts. b. informs a patient that the spouse will not be in during visiting hours. c. discusses options and helps the patient weigh the consequences. d. sets limits on a patients romantic overtures toward the nurse.

c. discusses options and helps the patient weigh the consequences.

Termination of a therapeutic nurse-patient relationship 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 happened during the relationship and evaluates outcomes. d. offers to meet the patient for coffee and conversation three times a week after discharge.

c. discusses with the patient changes that happened during the relationship and evaluates outcomes.

What is the desirable outcome for the orientation stage of a nurse-patient relationship? The patient will demonstrate behaviors that indicate: a. self-responsibility and autonomy. b. a greater sense of independence. c. rapport and trust with the nurse. d. resolved transference.

c. rapport and trust with the nurse.

A nurse prepares to assess a new patient who moved to the United States from Central America three years ago. After introductions, what is the nurses next comment? a. How did you get to the United States? b. Would you like for a family member to help you talk with me? c. An interpreter is available. Would you like for me to make a request for these services? d. Are you comfortable conversing in English, or would you prefer to have a translator present?

d- Are you comfortable conversing in English, or would you prefer to have a translator present?

Nursing behaviors associated with the implementation phase of nursing process are concerned with: a. participating in 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- carrying out interventions and coordinating care

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- coping strategies

The desired outcome for a patient experiencing insomnia is, Patient will sleep for a minimum of 5 hours nightly within 7 days. At the end of 7 days, review of sleep data shows the patient sleeps an average of 4 hours nightly and takes a 2-hour afternoon nap. What is the nurses 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. Examine interventions for possible revision of the target date.

d- examine interventions for possible revision of the target date

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- i have evil voices that tell me to do bad things

A nurse documents: Patient is mute despite repeated efforts to elicit speech. Makes no eye contact. Inattentive to staff. Gazes off to the side or looks upward rather than at speaker. Which nursing diagnosis should be considered? a. Defensive coping b. Decisional conflict c. Risk for other-directed violence d. Impaired verbal communication

d- impaired verbal communication

The desired outcome for a patient experiencing insomnia is, Patient will sleep for a minimum of 5 hours nightly within 7 days. At the end of 7 days, review of sleep data shows the patient sleeps an average of 4 hours nightly and takes a 2-hour afternoon nap. The nurse will document the outcome as: a. consistently demonstrated. b. often demonstrated. c. sometimes demonstrated. d. never demonstrated.

d- never demonstrated

A nurse assesses an older adult patient brought to the emergency department by a family member. The patient was wandering outside saying, I cant find my way home. The patient is confused and unable to answer questions. Select the nurses best action. a. Record the patients answers to questions on the nursing assessment form. b. Ask an advanced practice nurse to perform the assessment interview. c. Call for a mental health advocate to maintain the patients rights. d. Obtain important information from the family member.

d- obtain important info from the family member

Select the best outcome for a patient with the nursing diagnosis: Impaired social interaction related to sociocultural dissonance as evidenced by stating, Although Id like to, I dont join in because I dont speak the language very well. Patient will: a. show improved use of language. b. demonstrate improved social skills. c. become more independent in decision making. d. select and participate in one group activity per day.

d- select and participate in one group activity per day

A patient states, Im 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- suicide precautions

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 response should the nurse use to clarify the patients comment? 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 you feel as though you did not get enough quality sleep last night? d. Can you give me an example of what you mean by stoned?

d. Can you give me an example of what you mean by stoned?

A patient says, People should be allowed to commit suicide without interference from others. A nurse replies, Youre 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 correct. d. Differing values are reflected in the two statements.

d. Differing values are reflected in the two statements.

Which remark by a patient indicates passage from orientation to the working phase of a nurse-patient relationship? a. I dont have any problems. b. It is so difficult for me to talk about problems. c. I dont know how it will help to talk to you about my problems. d. I want to find a way to deal with my anger without becoming violent.

d. I want to find a way to deal with my anger without becoming violent.

A nurse interacts with a newly hospitalized patient. Select the nurses comment that applies the communication technique of offering self. a. Ive 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. Id like to sit with you for a while to help you get comfortable talking to me.

d. Id like to sit with you for a while to help you get comfortable talking to me.

A nurse caring for a withdrawn, suspicious patient recognizes 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. discuss the anger with a clinician during a supervisory session.

A nurse is talking with a patient, and 5 minutes remain in the session. The patient has been silent 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. invite the interrupting patient to join in the session with the current patient. b. say to the interrupting patient, I am not available to talk with you at the present time. c. end the unproductive session with the current patient and spend time with the interrupting patient. d. tell the interrupting patient, This session is 5 more minutes; then I will talk with you.

d. tell the interrupting patient, This session is 5 more minutes; then I will talk with you.

26. The nurse records this entry in a patients progress notes: Patient escorted to unit by ER nurse at 2130. Patients clothing was dirty. In interview room, patient sat with hands over face, sobbing softly. Did not acknowledge nurse or reply to questions. After several minutes, abruptly arose, ran to window, and pounded. Shouted repeatedly, Let me out of here. Verbal intervention unsuccessful. Order for stat dose 2 mg haloperidol PO obtained; medication administered at 2150. By 2215, patient stopped shouting and returned to sit wordlessly in chair. Patient placed on one-to-one observation. How should this documentation be evaluated? a. Uses unapproved abbreviations b. Contains subjective material c. Too brief to be of value d. Excessively wordy e. Meets standards

e- meets standards

a nurse taught a client about important precautions associated with new prescription. afterward the client accurately summarized major self-management strategies associated with this drug. which step of the nursing process applies to this client's summarization?

evaluation

what is canon's response to stress

fight or flight

the nurse is aware that the purpose of therapeutic communication is to

focus on the pt and the pt needs to facilitate a therapeutic relationship

Mr. Marquez reports of losing his job, not being able to sleep at night, and feeling upset with his wife. The nurse responds to the client, "You may want to talk about your employment situation in group today". The nurse is using which therapeutic technique

focusing

the primary nursing diagnosis for a female client with a medical diagnosis of major depression would be

impaired verbal communication related to depression

what is a mediating factor in the ability to handle stress

individual temperament

2 nurses are co-leading group therapy for 7 clients in the psychiatric unit. the leaders observe that the group members are anxious and look to the leaders for answers. which phase of development is this group in

initiation phase

In which part of the nursing care plan would the nurse expect to find this statement? "Provides client snacks and finger food frequently"

intervention

how does talking about your feelings relieve stress

it can give you a diff perspective

mental status includes

judgement

what are possible symptoms for stress

low energy, high bp, upset stomach, headache

what are the characteristics of a group forming

members are polite, are unsure and need directive leadership

which one is not part of the nursing process

never changing once a problem is identified

after assertiveness training, a formerly passive client appropriately confronts a peer in group therapy. the group leader states, "I'm so proud of you for being assertive. You are so good!" which communication technique has the leader employed?

nontherapeutic technique of giving approval

what is a barrier to therapeutic communication

offering advice

the nurse should first discuss terminating the nurse-client relationship with a client during the

orientations phase when a contract is established

group therapy is effective because

patients realize that others have the same condition

the implementation step of the nursing process involves

putting the care plan into action

the nurse develops a countertransference reaction. this is evidenced by...

revealing personal info to the client

what initiates the stress response

sympathetic branch

which of these statements by the nurse reflects a broad therapeutic interaction techniques

"you look upset. would you like to talk about it?"