Psych Nursing Exam 1

in the majority culture of the US, which individual has the greatest risk to be labeled mentally ill? one who a)describes hearing gods voice speaking b)is usually pessimistic but strives to meet personal goals c)is wealthy and gives away $20 bills to needy individuals d)always has an optimistic viewpoint about life and having own needs met

a)describes hearing gods voice speaking

which findings are signs of a person who is mentally healthy?(SATA) a)says "I have some weakness but I feel I'm important to my family and friends b)adheres to religious beliefs of parents and family of origin c)spends all holidays alone watching old movies on televison d)considers past experiences when deciding about the future e)experiences feelings of conflict related to changing jobs

a)says "I have some weakness but I feel I'm important to my family and friends d)considers past experiences when deciding about the future e)experiences feelings of conflict related to changing jobs

which finding best indicates that the goal "demonstrate mentally healthy behavior" was achieved for an adult patient? the patient a)sees self as capable of achieving ideals and meeting demands b)behaves without considering the consequences of personal actions c)aggressively meets own needs without considering the rights of others d)seeks help from others when assuming responsibility for major areas of own life

a)sees self as capable of achieving ideals and meeting demands

an experienced nurse says to a new graduate "when you've practice as long as I have you automatically know how to take care of patients experiencing psychosis" which factors should the new graduate consider when analyzing this comment (SATA) a)the experienced nurse may have lost sight of patients individually which may compromise the integrity of the practice b)new research findings should be integrated continuously into a nurses practice to provide the most effective care c)experience provides mental health nurses with the essential tools and skills needed for effective professional practice d)an intuitive sense of patients need guides effective psychiatric nurses

a)the experienced nurse may have lost sight of patients individually which may compromise the integrity of the practice b)new research findings should be integrated continuously into a nurses practice to provide the most effective care

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. "Are you having difficulty hearing when I speak?"

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 became depressed."

a. "Are you having thoughts of suicide?"

After one of their identical twin daughters commits suicide, the parents express concern that the other twin may also have suicidal tendencies. Which reply should the nurse provide? 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. "Genetics are associated with suicide risk. Monitoring and support are important."

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. "I am glad that you realize this." c. "That's not a good way to behave." d. "Have you outgrown that type of behavior?"

a. "How do you feel about that?"

During a one-on-one interaction with the nurse, a patient frequently looks nervously at the door. Select the best comment by the nurse regarding this nonverbal communication. a. "I notice you keep looking toward the door." b. "This is our time together. No one is going to interrupt us." c. "It looks as if you are eager to end our discussion for today." d. "If you are uncomfortable in this room, we can move someplace else."

a. "I notice you keep looking toward the door."

A patient says, "Please don't 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 will 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 will share information about you with other staff."

A Chinese American patient diagnosed with an anxiety disorder says, "My problems began when my energy became imbalanced." The nurse asks for the patient's ideas about how to treat the imbalance. Which comment would the nurse expect from this patient? a. "My family will bring special foods to help me get well." b. "I hope my health care provider will prescribe some medication to help me." c. "I think I would benefit from talking to other patients with a similar problem." d. "I would like to have a native healer perform a ceremony to balance my energy."

a. "My family will bring special foods to help me get well."

A nurse interacts with patients diagnosed with various mental illnesses. Which statements reflect use of therapeutic communication? (Select all that apply.) a. "Tell me more about that situation." b. "Let's talk about something else." c. "I notice you are pacing a lot." d. "I'll stay with you a while." e. "Why did you do that?"

a. "Tell me more about that situation." c. "I notice you are pacing a lot." d. "I'll stay with you a while."

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 patient with acute depression states, "God is punishing me for my past sins." What is the nurse's most therapeutic response? a. "You sound very upset about this." b. "God always forgives us for our sins." c. "Why do you think you are being punished?" d. "If you feel this way, you should talk to your minister."

a. "You sound very upset about this."

A nurse assesses five newly hospitalized patients. Which patients have the highest suicide risk? (Select all that apply.) a. 82-year-old white male b. 17-year-old white female c. 22-year-old Hispanic male d. 19-year-old Native American male e. 39-year-old African American male

a. 82-year-old white male b. 17-year-old white female d. 19-year-old Native American male

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. Addiction Severity Index (ASI) b. Brief Drug Abuse Screen Test (B-DAST) e. Recovery Attitude and Treatment Evaluator (RAATE)

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. Prefrontal cortex

a. Amygdala d. Temporal lobe e. Prefrontal cortex

A nurse directs the intervention team who places an aggressive patient in seclusion. Before approaching the patient, which actions will the nurse direct team members to take? (Select all that apply.) a. Appoint a person to clear a path and open, close, or lock doors. b. Quickly approach the patient and take the closest extremity. c. Select the person who will communicate with the patient. d. Move behind the patient when the patient is not looking. e. Remove jewelry, glasses, and harmful items.

a. Appoint a person to clear a path and open, close, or lock doors. c. Select the person who will communicate with the patient. e. Remove jewelry, glasses, and harmful items.

Which statement provides the best rationale for closely monitoring a severely depressed patient during antidepressant medication therapy? a. As depression lifts, physical energy becomes available to carry out suicide. b. Patients who previously had suicidal thoughts need to discuss their feelings. c. For most patients, antidepressant medication results in increased suicidal thinking. d. Suicide is an impulsive act. Antidepressant medication does not alter impulsivity.

a. As depression lifts, physical energy becomes available to carry out suicide.

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.

Which benefits are most associated with use of telehealth technologies? (Select all that apply.) a. Cost savings for patients b. Maximize 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. Cost savings for patients b. Maximize care management c. Access to services for patients in rural areas

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 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. 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.

Which is an effective nursing intervention to assist an angry patient learn to manage anger without violence? a. Help a patient identify a thought that produces anger, evaluate the validity of 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. Help a patient identify a thought that produces anger, evaluate the validity of the belief, and substitute reality-based thinking.

A nurse caring for a patient diagnosed with major depressive disorder reads in the patient's medical record, "This patient shows vegetative signs of depression." Which nursing diagnoses most clearly relate to this documentation? (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. Imbalanced nutrition: less than body requirements c. Sexual dysfunction d. Self-care deficit f. Insomnia

A patient diagnosed with major depressive disorder has lost 20 pounds in one month, has chronic low self-esteem, and a plan for suicide. The patient has taken 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.

An experienced psychiatric nurse plans to begin a new job in a community-based medication clinic. The clinic sees culturally diverse patients. Which action should the nurse take first to prepare for this position? a. Investigate cultural differences in patients' responses to psychotropic medications. b. Contact the clinical nurse specialist for guidelines regarding cultural competence. c. Examine the literature on various health beliefs of members of diverse cultures. d. Complete an online continuing education offering about psychopharmacology.

a. Investigate cultural differences in patients' responses to psychotropic medications.

A patient was diagnosed with seasonal affective disorder (SAD). During which month would this patient's symptoms be most acute? a. January b. April c. June d. September

a. January

Which nursing interventions will be implemented for a patient who is actively suicidal? (Select all that apply.) a. Maintain arm's length, one-on-one direct observation at all times. b. Check all items brought by visitors and remove risk items. c. Use plastic eating utensils; count utensils upon collection. d. Remove the patient's eyeglasses to prevent self-injury. e. Interact with the patient every 15 minutes.

a. Maintain arm's length, one-on-one direct observation at all times. b. Check all items brought by visitors and remove risk items. c. Use plastic eating utensils; count utensils upon collection.

A patient diagnosed with major depressive disorder 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. Which communication technique will be effective? 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.

a. Make observations.

While talking with a patient diagnosed with major depressive disorder, a nurse notices the patient is unable to maintain eye contact. The patient's chin lowers to the chest. 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. Nonverbal communication

A patient diagnosed with major depressive disorder 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 intake of processed foods.

a. Offer laxatives if needed. b. Monitor food and fluid intake. c. Provide a quiet sleep environment.

Because an intervention was required to control a patient's aggressive behavior, the nurse plans a critical incident debriefing with staff members. Which topics should be the primary focus of this discussion? (Select all that apply.) a. Patient behaviors associated with the incident b. Genetic factors associated with aggression c. Intervention techniques used by the staff d. Effects of environmental factors e. Theories of aggression

a. Patient behaviors associated with the incident c. Intervention techniques used by the staff d. Effects of environmental factors

The nurse administers medications to a culturally diverse group of patients on a psychiatric unit. What expectation should the nurse have about pharmacokinetics? a. Patients of different cultural groups may metabolize medications at different rates. b. Metabolism of psychotropic medication is consistent among various cultural groups. c. Differences in hepatic enzymes will influence the rate of elimination of psychotropic medications. d. It is important to provide patients with oral and written literature about their psychotropic medications.

a. Patients of different cultural groups may metabolize medications at different rates.

The staff development coordinator plans to teach use of physical management techniques for use when patients become assaultive. Which topic should the coordinator emphasize? a. Practice and teamwork b. Spontaneity and surprise c. Caution and superior size d. Diversion and physical outlets

a. Practice and teamwork

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 patient's problem. d. Saying, "I understand what you're saying."

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

A novice psychiatric nurse has a parent diagnosed with bipolar disorder. This nurse angrily recalls feelings of embarrassment about 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. 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 nurse's practice, but supervision is important.

a. Seek ways to use the understanding gained from childhood to help patients cope with their own illnesses. e. Recognize that the feelings may add sensitivity to the nurse's practice, but supervision is important.

A college student is extremely upset after failing two examinations. The student said, "No one understands how this will hurt my chances of getting into medical school." The student then suspends access to his social networking website and turns off his cell phone. Which suicide risk factors are evident? (Select all that apply.) a. Shame b. Panic attack c. Humiliation d. Self-imposed isolation e. Recent stressful life event

a. Shame c. Humiliation d. Self-imposed isolation e. Recent stressful life event

Which documentation for a patient diagnosed with major depressive disorder indicates the treatment plan 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. Slept 6 hours uninterrupted. Sang with activity group. Anticipates seeing grandchild.

An adult diagnosed with major depressive disorder 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. Desensitization techniques d. Use of complementary therapy

a. Social skills training

A nurse prepares to teach important medication information to a patient of Mexican heritage. How should the nurse manage the teaching environment? a. Stand very close to the patient while teaching. b. Maintain direct eye contact with the patient while teaching. c. Maintain a neutral emotional tone during the teaching session. d. Sit 4 feet or more from the patient during the teaching session.

a. Stand very close to the patient while teaching.

A patient with a history of command hallucinations approaches the nurse yelling obscenities. Which nursing actions are most likely to be effective in deescalation for this scenario? (Select all that apply.) a. Stating the expectation that the patient will stay in control. b. Asking the patient, "Do you want to go into seclusion?" c. Telling the patient, "You are behaving inappropriately." d. Offering to provide the patient with medication to help. e. Speaking in a firm but calm voice.

a. Stating the expectation that the patient will stay in control. d. Offering to provide the patient with medication to help. e. Speaking in a firm but calm voice.

Which behavior best demonstrates aggression? a. Stomping away from the nurses' station, going to the hallway, and grabbing a tray from the meal cart. 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. Stomping away from the nurses' station, going to the hallway, and grabbing a tray from the meal cart.

It has been 5 days since a suicidal patient was hospitalized and prescribed an antidepressant medication. 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 discontinuation of suicide precautions.

a. Supervise the patient 24 hours a day.

Which viewpoint of an Asian American family will most affect decision making about care? a. The father is the authority figure. b. The mother is head of the household. c. Women should make their own decisions. d. Emotional communication styles are desirable.

a. The father is the authority figure.

When a female Mexican American patient and a female nurse sit together, the patient often holds the nurse's hand. The patient also links arms with the nurse when they walk. The nurse is uncomfortable with this behavior. Which analysis is most accurate? a. The patient is accustomed to touch during conversation, 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 patient is trying to manipulate the nurse using nonverbal techniques.

a. The patient is accustomed to touch during conversation, as are members of many Hispanic subcultures.

A patient being treated with paroxetine 50 mg po daily reports to the clinic nurse, "I took a few extra tablets earlier today and now I feel bad." Which assessments are most critical? (Select all that apply.) a. Vital signs b. Urinary frequency c. Psychomotor retardation d. Presence of abdominal pain and diarrhea e. Hyperactivity or feelings of restlessness

a. Vital signs d. Presence of abdominal pain and diarrhea e. Hyperactivity or feelings of restlessness

Which questions should the nurse ask to determine an individual's worldview? (Select all that apply.) a. What is more important: the needs of an individual or the needs of a community? b. How would you describe an ideal relationship between individuals? c. How long have you lived at your present residence? d. Of what importance are possessions in your life? e. Do you speak any foreign languages?

a. What is more important: the needs of an individual or the needs of a community? b. How would you describe an ideal relationship between individuals? d. Of what importance are possessions in your life?

A nurse says, "I am 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.

a. boundary blurring.

A college student who attempted suicide by overdose was hospitalized. When the parents were contacted, they responded, "We should have seen this coming. We did not do enough." The parents' reaction reflects a. guilt. b. denial. c. shame. d. rescue feelings.

a. guilt.

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.

a. hopelessness.

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.

a. is rarely helpful.

A patient who was responding to auditory hallucinations earlier in the morning now approaches the nurse shaking a fist and shouts, "Back off!" and then goes to the dayroom. While following the patient into the dayroom, the nurse should a. make sure there is adequate physical space between the nurse and patient. b. move into a position that places the patient close to the door. c. maintain one arm's length distance from the patient. d. begin talking to the patient about appropriate behavior.

a. make sure there is adequate physical space between the nurse and patient.

A nurse in the clinic has a full appointment schedule. A Hispanic American patient arrives at 1230 for a 1000 appointment. A Native American patient does not keep an appointment at all. What understanding will improve the nurse's planning? These patients are a. members of cultural groups that have a different view of time. b. immature and irresponsible in health care matters. c. acting-out feelings of anger toward the system. d. displaying passive-aggressive tendencies.

a. members of cultural groups that have a different view of time.

The nurse should be particularly alert to expression of psychological distress through physical symptoms among patients whose cultural beliefs include (Select all that apply) a. mental illness reflects badly on the family. b. mental illness shows moral weakness. c. intergenerational conflict is common. d. the mind, body, and spirit are merged. e. food choices influence one's health.

a. mental illness reflects badly on the family. b. mental illness shows moral weakness. d. the mind, body, and spirit are merged.

The sibling of an Asian American patient tells the nurse, "My sister needs help for pain. She cries from the hurt." Which understanding by the nurse will contribute to culturally competent care for this patient? Persons of an Asian American heritage a. often express emotional distress with physical symptoms. b. will probably respond best to a therapist who is impersonal. c. will require prolonged treatment to stabilize these symptoms. d. should be given direct information about the diagnosis and prognosis.

a. often express emotional distress with physical symptoms.

A patient is experiencing psychomotor agitation associated with major depressive disorder. Which observation would the nurse associate with this symptom? The patient a. paces aimlessly around the room. b. asks the nurse to repeat instructions. c. complains of prickly skin sensations. d. demonstrates slowed verbal responses.

a. paces aimlessly around the room.

A nurse speaks with family members of a Chinese American parent recently diagnosed with major depressive disorder. Which comment by the nurse will the family find most comforting? "The nursing staff will a. take good care of your parent." b. pray with your parent several times a day." c. teach your parent important self-care strategies." d. educate your parent about safety information regarding medication."

a. take good care of your parent."

A patient became depressed after the last of the family's six children moved out of the home 4 months ago. Select the best 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. agree to take an 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).

a. verbalize realistic positive characteristics about self by (date).

A psychiatric nurse leads a medication education group for Hispanic patients. This nurse holds a Western worldview and uses pamphlets as teaching tools. Groups are short and concise. After the group, the patients are most likely to believe a. the nurse was uncaring. b. the session was effective. c. the teaching was efficient. d. they were treated respectfully.

a.the nurse was uncaring.

A nursing student expresses concerns that mental health nurses "lose all their clinical skills". Select the best response by the mental health nurse. a)"psychiatric nurses practice in safer environments than other specialities. nurse to patient ratios most be better because of the nature of the patients problems" b)"psychiatric nurses use complex communication as well as critical thinking to solve multidimensional problems. I am challenged by those situations" c)"thats a misconception. psychiatric nurses frequently use high technology monitoring equipment and manage complex intravenous therapies" d)psychiatric nurses do not have to deal with as much pain and suffering as medical surgical nurses do. that appeals to me"

b)"psychiatric nurses use complex communication as well as critical thinking to solve multidimensional problems. I am challenged by those situations"

a nurse wants to find a description of diagnostic criteria for anxiety disorders. which resource would have the most complete information? a)nursing outcomes classification(NOC) b)DSM-V c) the ANAs psychiatric mental health nursing scope and standards of practice d)ICD-10

b)DSM-V

a patient int the emergency department says "voices say someone is stalking me. they want to kill me because I developed a cure for cancer. I have a knife and will stab anyone who is a threat" which aspects of the patents mental health have the greatest and most immediate concern to the nurse?(SATA) a)happiness b)appraisal of reality c)control over behavior d)effectiveness in world e)healthy self concept

b)appraisal of reality c)contro lover behavior e)healthy self concept

which component of treatment of mental illness is specifically recognized by quality and safety education for nurses? a)all genomes are unique b)care is centered on the patient c)healthy development is vital to mental health d)recovery occurs on a continuum from illness to health

b)care is centered on the patient

complete this analogy. NANDA: clinical judgment: NIC a)patient outcomes b)nursing actions c)diagnosis d)symptoms

b)nursing actions

A staff nurse completes orientation to a psychiatric unit. This nurse may expect an advanced practice nurse to perform which additional intervention? a)conduct mental health assessment b)prescribe psychotropic medication c)establish therapeutic relationships d)individualize nursing care plans

b)prescribe psychotropic medication

Which assessment finding most clearly indicates that a patient may be experiencing a mental illness? the patient a)reports occasional sleeplessness and anxiety b)reports a consistently sad, discouraged and hopeless mood c)is able to describe the difference between "as if" and "for real" d)perceives difficulty making a decision about whether to change jobs

b)reports a consistently sad, discouraged and hopeless mood

Select the most critical question for the nurse to ask an adolescent who has threatened to take an overdose of pills. 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. "Do you have access to medications?"

A patient cries as the nurse explores the patient's feelings about the death of a close friend. The patient sobs, "I shouldn't be crying like this. It happened a long time ago." Which responses by the nurse 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 a close friend is very painful for you." d. "Crying is a way of expressing the hurt you are experiencing." e. "Let's talk about something else because this subject is upsetting you."

b. "I can see that you feel sad about this situation." c. "The loss of a close friend is very painful for you." d. "Crying is a way of expressing the hurt you are experiencing."

Which statement by a depressed patient will 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 to turn to for help or support." c. "It is worse when you are a person of color." d. "I tried to get attention before I cut myself last time."

b. "I have no one to turn to for help or support."

Transcranial Magnetic Stimulation (TCM) is scheduled for a patient diagnosed with major depressive disorder. Which comment by the patient indicates teaching about the procedure was effective? a. "They will put me to sleep during the procedure so I won't know what is happening." b. "I might be a little dizzy or have a mild headache after each procedure." c. "I will be unable to care for my children for about 2 months." d. "I will avoid eating foods that contain tyramine."

b. "I might be a little dizzy or have a mild headache after each procedure."

A patient diagnosed with schizophrenia tells the nurse, "The Central Intelligence Agency is monitoring us through the fluorescent lights in this room. The CIA is everywhere, so be careful what you say." Which response by the nurse is 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. "It sounds like you're concerned about your privacy."

A patient diagnosed with major depressive disorder tells the nurse, "Bad things that happen are always my fault." Which response by the nurse will best assist the patient to reframe this overgeneralization? 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 extremely hard on yourself. Try to have a positive focus." d. "Are you saying that you don't have any good things happen?"

b. "Let's look at one bad thing that happened to see if another explanation exists."

An adult patient assaulted another patient and was then restrained. One hour later, which statement by the restrained patient requires 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. "The other patient started the fight."

b. "My fingers are tingly."

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."

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 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 I'm ready to blow up.' O: Pacing hall, mumbling to self. A: Auditory hallucinations. P: Offer haloperidol 2 mg po. I: Haloperidol 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 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 2 mg po administered at 0900 with calming effect in 30 minutes. Stated, 'I'm no longer bothered by the voices.'"

b. "S: States, 'I feel like I'm ready to blow up.' O: Pacing hall, mumbling to self. A: Auditory hallucinations. P: Offer haloperidol 2 mg po. I: Haloperidol 2 mg po given at 0900. E: Returned to lounge at 0930 and quietly watched TV."

A nurse wants to assess an adult patient's 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 breakfast this morning?"

A patient diagnosed with major depressive disorder says, "No one cares about me anymore. I'm not worth anything." Today the patient is wearing a new shirt and has neat, clean hair. Which remark by the nurse supports building a positive self-esteem for this patient? a. "You look nice this morning." b. "You're wearing a new shirt." c. "I like the shirt you are wearing." d. "You must be feeling better today."

b. "You're wearing a new shirt."

A nurse wants to engage an interpreter for a severely anxious 21-year-old male who immigrated to the United States 2 years ago. Of the four interpreters below who are available and fluent in the patient's language, which one should the nurse call? a. 65-year-old female professional interpreter b. 24-year-old male professional interpreter c. A member of the patient's family d. The patient's best friend

b. 24-year-old male professional interpreter

During a psychiatric assessment, the nurse observes a patient's facial expression is without emotion. The patient says, "Life feels so hopeless to me. I've been feeling sad for several months." How will 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. Affect flat; mood depressed

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. Ask the patient, "Tell me about the problem as you see it." c. Seek information about when the problem began. e. Reassure the patient, "You are safe here."

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 nurse's 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 patient's family history for cardiac problems. d. Arrange for the patient's hospitalization on the psychiatric unit.

b. Assess the patient for a history of renal problems.

A Native American patient describes a difficult childhood and dropping out of high school. The patient abused alcohol as a teenager to escape feelings of isolation but stopped 10 years ago. The patient now says, "I feel stupid. I've never had a good job. I don't help my people." Which nursing diagnosis applies? a. Risk for other-directed violence b. Chronic low self-esteem c. Deficient knowledge d. Social isolation

b. Chronic low self-esteem

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, "This patient is like one of my grandparents ... so 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 nurse's 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

An adult outpatient diagnosed with major depressive disorder has a history of several suicide attempts by overdose. Given this patient's history and diagnosis, which antidepressant medication would the nurse expect to be prescribed? a. Amitriptyline b. Fluoxetine c. Desipramine d. Tranylcypromine sulfate

b. Fluoxetine

A patient has a history of impulsively acting-out anger by striking others. Select the most appropriate intervention for avoiding similar incidents. a. Teach the patient about herbal preparations that reduce anger. b. Help the patient identify incidents that trigger impulsive anger. c. Explain that restraint and seclusion will be used if violence occurs. d. Offer one-on-one supervision to help the patient maintain control.

b. Help the patient identify incidents that trigger impulsive anger.

Which assessment finding presents the greatest risk for violent behavior directed at others? a. Severe agoraphobia b. History of spousal abuse c. Bizarre somatic delusions d. Verbalized hopelessness and powerlessness

b. History of spousal abuse

A patient previously hospitalized for 2 weeks committed suicide the day after discharge. Which initial nursing measure will be most important regarding this event? a. Request the information technology manager to verify the patient's medical record is secure in the hospital information system. b. Hold a meeting for staff to provide support, express feelings, and identify overlooked clues or faulty judgments. c. Consult the hospital's legal department regarding potential consequences of the event. d. Document a report of a sentinel event in the patient's medical record.

b. Hold a meeting for staff to provide support, express feelings, and identify overlooked clues or faulty judgments.

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 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. 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. Introducing self to a patient and identifying own role d. Using facial expressions to convey interest and encouragement e. Assuming an open body posture and sometimes mirror imaging

Which intervention best demonstrates that a nurse correctly understands the cultural needs of a hospitalized Asian American patient diagnosed with a mental illness? a. Encouraging the family to attend community support groups b. Involving the patient's family to assist with activities of daily living c. Providing educational pamphlets to explain the patient's mental illness d. Restricting homemade herbal remedies the family brings to the hospital

b. Involving the patient's family to assist with activities of daily living

A nurse taught a patient about a tyramine-restricted diet. Which menu selection would the nurse approve? a. Macaroni and cheese, hot dogs, banana bread, caffeinated coffee b. Mashed potatoes, ground beef patty, corn, green beans, apple pie c. Avocado salad, ham, creamed potatoes, asparagus, chocolate cake d. Noodles with cheddar cheese sauce, smoked sausage, lettuce salad, yeast rolls

b. Mashed potatoes, ground beef patty, corn, green beans, apple pie

A new patient acts out so aggressively that seclusion is required before the admission assessment is completed or orders written. Immediately after safely secluding the patient, which action is the nurse's priority? a. Complete the physical assessment. b. Notify the health care provider to obtain a seclusion order. c. Document the incident objectively in the patient's medical record. d. Explain to the patient that seclusion will be discontinued when self-control is regained.

b. Notify the health care provider to obtain a seclusion order.

A psychoeducational session will discuss medication management for a culturally diverse group of patients. Group participants are predominantly members of minority cultures. Of the four staff nurses below, which nurse should lead this group? a. Very young registered nurse b. Older, mature registered nurse c. Newly licensed registered nurse d. A registered nurse who is very thin

b. Older, mature registered nurse

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 patient diagnosed with major depressive disorder repeatedly tells staff, "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. Risk for suicide

A nurse cares for a first-generation American whose family emigrated from Germany. Which worldview about the source of knowledge would this patient likely have? a. Knowledge is acquired through use of affective or feeling senses. b. Science is the foundation of knowledge and proves something exists. c. Knowledge develops by striving for transcendence of the mind and body. d. Knowledge evolves from an individual's relationship with a supreme being.

b. Science is the foundation of knowledge and proves something exists.

Which change in the brain's biochemical function is most associated with suicidal behavior? a. Dopamine excess b. Serotonin deficiency c. Acetylcholine excess d. γ-aminobutyric acid deficiency

b. Serotonin deficiency

What is the focus of priority nursing interventions for the period immediately after electroconvulsive therapy (ECT) treatment? a. Nutrition and hydration b. Supporting physiological stability c. Reducing disorientation and confusion d. Assisting the patient to identify and test negative thoughts

b. Supporting physiological stability

A patient with a history of anger and impulsivity was hospitalized after an accident resulting in multiple injuries. The patient loudly scolds nursing staff, "I'm in pain all the time but you don't give me medicine until YOU think it's time." Which nursing intervention would best address this problem? a. Teach the patient to use coping strategies such as deep breathing and progressive relaxation to reduce the pain. b. Talk with the health care provider about changing the pain medication from prn to patient-controlled analgesia. c. Tell the patient that verbal assaults on nurses will not shorten the wait for analgesic medication. d. Talk with the patient about the risks of dependency associated with overuse of analgesic medication.

b. Talk with the health care provider about changing the pain medication from prn to patient-controlled analgesia.

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. Psychiatric patients should not be touched.

b. The gesture is premature. The patient's cultural and individual interpretation of touch is unknown.

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 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. The nurse's action blurs the boundaries of the therapeutic relationship.

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 patient's subjective responses c. Only data obtained from the patient's verbal responses d. A description of the patient's behavior during the interview e. Analysis of why the patient was unresponsive during the interview

b. The patient's subjective responses d. A description of the patient's behavior during the interview

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. Unmet patient needs currently present d. Supporting data that validate the diagnoses e. Probable causes that will be targets for nursing interventions

An intramuscular dose of antipsychotic medication needs to be administered to a patient who is becoming increasingly more aggressive and refused to leave 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 health care provider 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 regain control." 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 security guard and tell the patient, "Come to your room willingly so I can give you this medication, or the guard and I will take you there."

b. accompanied by three staff members and say, "Please come to your room so I can give you some medication that will help you regain control."

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." The nurse documents this report as an example of a. dysthymia. b. anhedonia. c. euphoria. d. anergia.

b. anhedonia.

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. assess the patient based on data collected from all sources.

Priority interventions for a patient diagnosed with major depressive disorder and feelings of worthlessness should include a. distracting the patient from self-absorption. b. careful unobtrusive observation around the clock. c. allowing the patient to spend long periods alone in meditation. d. opportunities to assume a leadership role in the therapeutic milieu.

b. careful unobtrusive observation around the clock.

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

b. distorted.

A nurse instructs a patient taking a medication that inhibits the action of 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. hypertensive crisis.

A black patient says to a white nurse, "There's no sense talking about how I feel. 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 interact with people from all cultures. d. change the subject to one that is less emotionally disturbing.

b. say, "Please give an example of something you think I wouldn't understand."

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 nurse's 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 patient's behaviors.

b. use congruent communication strategies.

A family has a long history of conflicted relationships among the members. which family members comment best reflects a mentally healthy perspective? a)"I've made mistakes but everyone else in this family has also" b)"I remember joy and mutual respect from our early years together" c)"I will make some changes in my behavior for the good of the family" d)"its best for me to move away from my family. things will never change"

c)"I will make some changes in my behavior for the good of the family"

When a new bill introduced in congress reduces funding for care of persons diagnosed with mental illness, a group of nurses write letters to the elected representatives in opposition to the legislation. which role have the nurses fulfilled? a)recovery b)attending c)advocacy d)evidence based practice

c)advocacy

a nurse encounters an unfamiliar psychiatric disorder on a new patients admission form. which resource should the nurse consult to determine criteria used to establish this diagnosis? a)international statistical classification of diseases and related health problems(ICD-10) b)the ANAs psychiatric mental health nursing scope and standards of practice c)diagnostic and statistical manual of mental disorders(DMS-V) d)a behavioral health reference manual

c)diagnostic and statistical manual of mental disorders(DMS-V)

a category 5 tornado occurred in a community of 400 people. many homes and businesses were destroyed. in the two years following the disaster 140 individuals were diagnosed with PTSD. which term best applies to these newly diagnosed cases? a)prevalence b)comorbidity c)incidence d)parity

c)incidence

the spouse of a patient diagnosed with schizophrenia says "I don't understand how events from childhood have anything to do with this disabling illness" which response by the nurse will best help the spouse understand the cause of this disorder? a)psychological stress is the basis of most mental disorders b)this illness results from developmental factors rather than stressors c)research shows that this condition more likely has a biological basis d)it must be frustrating for you that your spouse is sick so much of the time

c)research shows that this condition more likely has a biological basis

which disorder is an example of a culture bound syndrome? a)epilepsy b)schizophrenia c)running amok d)major depressive disorder

c)running amok

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."

A nurse interacts with an outpatient who has a history of multiple suicide attempts. Select the most helpful response for a nurse to make when the patient states, "I am considering committing 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 keep you safe." c. "Bringing up these feelings is a very positive action on your part." d. "We need to talk about the good things you have to live for."

c. "Bringing up these feelings is a very positive action on your part."

A nurse and patient construct a no-suicide contract. Select the preferable wording. 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 in any way attempt to harm or kill myself." d. "I will not kill myself until I call my primary nurse or a member of the staff."

c. "For the next 24 hours, I will not in any way attempt to harm or kill myself."

A nurse assesses a patient who reports a 3-week history of depression and periods of uncontrolled crying. 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. "I have a plan that will fix everything."

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. "What is going on?" b. "Please be quiet and sit down in this chair 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. "I'd like to talk with you about how you're feeling right now."

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. "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."

Which comments by a nurse demonstrate use of therapeutic communication techniques? (Select all that apply.) a. "Why do you think these events have happened to you?" b. "There are people with problems much worse than yours." c. "I'm glad you were able to tell me how you felt about your loss." d. "I noticed your hands trembling when you told me about your accident." e. "You look very nice today. I'm proud you took more time with your appearance."

c. "I'm glad you were able to tell me how you felt about your loss." d. "I noticed your hands trembling when you told me about your accident."

A patient being treated for depression has taken sertraline daily for a year. The patient calls the clinic nurse and says, "I stopped taking my antidepressant 2 days ago. Now I am having nausea, nervous feelings, and I can't sleep." The nurse will advise the patient to: a. "Go to the nearest emergency department immediately." b. "Do not to be alarmed. Take two aspirin and drink plenty of fluids." c. "Take a dose of your antidepressant now and come to the clinic to see the health care provider." d. "Resume taking your antidepressants for 2 more weeks and then discontinue them again."

c. "Take a dose of your antidepressant now and come to the clinic to see the health care provider."

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 discuss with your doctor." d. "Do you think you can't speak to a doctor?"

c. "That's a good topic for you to discuss with your doctor."

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." Which response by the nurse is appropriate? 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. "What you say about feelings is private, but some things, like suicidal thinking, must be reported to the treatment team."

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. "You don't think you're making progress?"

A cognitively impaired patient has been a widow for 30 years. This patient frantically tries to leave the facility, saying, "I have to go home to cook dinner before my husband arrives from work." To intervene with validation therapy, the nurse will 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. "Your husband gets angry if you do not have dinner ready on time?"

c. "You want to go home to prepare your husband's dinner?"

After an assault by a patient, a nurse has difficulty sleeping, startles easily, and is preoccupied with the incident. The nurse said, "That patient should not be allowed to get away with that behavior." Which response poses the greatest barrier to the nurse's ability to provide therapeutic care? a. Startle reactions b. Difficulty sleeping c. A wish for revenge d. Preoccupation with the incident

c. A wish for revenge

Which intervention will the nurse recommend for the distressed family and friends of someone who has committed suicide? a. Participating in reminiscence therapy b. Psychological postmortem assessment c. Attending a self-help group for survivors d. Contracting for at least two sessions of group therapy

c. Attending a self-help group for survivors

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. Availability of means and lethality of method

Why is the study of culture so important for psychiatric nurses in the United States? (Select all that apply.) a. Psychiatric nurses often practice in other countries. b. Psychiatric nurses must advocate for the traditions of the Western culture. c. Cultural competence helps protect patients from prejudice and discrimination. d. Patients should receive information about their illness and treatment in terms they understand. e. Psychiatric nurses often interface with patients and their significant others over a long period of time.

c. Cultural competence helps protect patients from prejudice and discrimination. d. Patients should receive information about their illness and treatment in terms they understand. e. Psychiatric nurses often interface with patients and their significant others over a long period of time.

A college student who failed two tests cried for hours and then tried to telephone a parent but got no answer. The student then gave several expensive sweaters to a roommate and asked to be left alone for a few hours. 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 dorm room

c. Giving away sweaters

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

The admission note indicates a patient diagnosed with major depressive disorder 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. Instilling a sense of hopefulness d. Assisting with self-care activities e. Accommodating psychomotor retardation

A Mexican American patient puts a picture of the Virgin Mary on the bedside table. What is the nurse's best action? a. Move the picture so it is beside a window. b. Send the picture to the business office safe. c. Leave the picture where the patient placed it. d. Send the picture home with the patient's family.

c. Leave the picture where the patient placed it.

Which medication from the medication administration record should a nurse administer to provide immediate intervention for a psychotic patient whose aggressive behavior continues to escalate despite verbal intervention? a. Lithium b. Trazodone c. Olanzapine d. Valproic acid

c. Olanzapine

Which clinical scenario predicts the highest risk for directing violent behavior toward others? a. Major depressive disorder with delusions of worthlessness b. Obsessive-compulsive disorder; performs many rituals c. Paranoid delusions of being followed by alien monsters d. Completed alcohol withdrawal; beginning a rehabilitation program

c. Paranoid delusions of being followed by alien monsters

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 further escalation of the spouse's anger? a. Offer the waiting spouse a cup of coffee. b. Explain that the patient's condition is not life threatening. c. Periodically provide an update and progress report on the patient. d. Suggest that the spouse return home until the patient's treatment is complete.

c. Periodically provide an update and progress report on the patient.

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 newly admitted patient diagnosed with major depressive disorder has gained 20 pounds over a few months and has suicidal ideation. The patient has taken 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 person intentionally overdosed on antidepressants. Which nursing diagnosis has the highest priority? a. Powerlessness b. Social isolation c. Risk for suicide d. Compromised family coping

c. Risk for suicide

Which principle should guide the nurse in determining the extent of silence to use during patient interview sessions? a. A nurse is responsible for breaking silences. b. Patients withdraw if silences are prolonged. c. Silence can provide meaningful moments for reflection. d. Silence helps patients know that what they said was understood.

c. Silence can provide meaningful moments for reflection.

Major depressive disorder resulted after a patient's employment was terminated. The patient now says to the nurse, "I'm not worth the time you spend with me. I am 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. Situational low self-esteem

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

Which communication strategy would be most effective for a nurse to use during an assessment interview with an adult Native American patient? a. Open and friendly; ask direct questions; touch the patient's arm or hand occasionally for reassurance. b. Frequent nonverbal behaviors, such as gestures and smiles; make an unemotional face to express negatives. c. Soft voice; break eye contact occasionally; general leads and reflective techniques. d. Stern voice; unbroken eye contact; minimal gestures; direct questions.

c. Soft voice; break eye contact occasionally; general leads and reflective techniques.

A patient diagnosed with major depressive disorder received six ECT sessions and aggressive doses of antidepressant medication. 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. Antidepressant medications alter catecholamine levels, which impairs decision-making abilities. b. Antidepressant medications may cause confusion related to limitation of tyramine in the diet. c. Temporary memory impairments and confusion may occur with ECT. d. The patient needs time to readjust to a pressured work schedule.

c. Temporary memory impairments and confusion may occur with ECT.

A group activity on an inpatient psychiatric unit is scheduled to begin at 1000. A patient, who was recently discharged from U.S. Marine Corps, arrives at 0945. Which analysis best explains this behavior? a. The patient wants to lead the group and give directions to others. b. The patient wants to secure a chair that will be close to the group leader. c. The military culture values timeliness. The patient does not want to be late. d. The behavior indicates feelings of self-importance that the patient wants others to appreciate.

c. The military culture values timeliness. The patient does not want to be late.

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

c. The nurse feels unusually happy when the patient's mood begins to lift.

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. The patient is giving positive feedback about the nurse's communication techniques. b. The nurse is viewing the patient's behavior through a cultural filter. c. The patient's verbal and nonverbal messages are incongruent. d. The patient is demonstrating psychotic behaviors.

c. The patient's verbal and nonverbal messages are incongruent.

A Vietnamese patient's family reports that the patient has wind illness. Which menu selection will be most helpful for this patient? a. Iced tea b. Ice cream c. Warm broth d. Gelatin dessert

c. Warm broth

A patient who has been hospitalized for 3 days with a serious mental illness says, "I've got to get out of here and back to my job. I get 60 to 80 messages a day, and I'm getting behind on my email correspondence." What is this patient's perspective about health and illness? a. Fateful, magical b. Eastern, holistic c. Western, biomedical d. Harmonious, religious

c. Western, biomedical

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

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 distortions. c. a personality style that externalizes problems. d. delusions that others wish to deliver harm.

c. a personality style that externalizes problems.

When counseling patients diagnosed with major depressive disorder, 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. cognitive-behavioral therapy.

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 patient's 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.

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 lethality of suicide plan. b. encourage expression of anger. c. establish trust with the patient. d. determine risk factors for suicide.

c. establish trust with the patient.

A patient diagnosed with major depressive disorder began taking escitalopram 5 days ago. The patient 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 increase the dose. 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 symptoms of improvement.

c. explain the time lag before antidepressants relieve symptoms.

A nurse can anticipate anticholinergic side effects are likely when a patient takes a. lithium. b. buspirone. c. imipramine. d. risperidone.

c. imipramine.

A Haitian patient diagnosed with major depressive disorder tells the nurse, "There's nothing you can do. This is a punishment. The only thing I can do is see a healer." The culturally aware nurse assesses that the patient a. has delusions of persecution. b. has likely been misdiagnosed with depression. c. may believe the distress is the result of a curse or spell. d. feels hopeless and helpless related to an unidentified cause.

c. may believe the distress is the result of a curse or spell. \

. 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. milieu management.

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 patient diagnosed with depressive disorder begins selective serotonin reuptake inhibitor (SSRI) antidepressant therapy. The nurse should provide information to the patient and family about a. restricting sodium intake to 1 gram daily. b. minimizing exposure to bright sunlight. c. reporting increased suicidal thoughts. d. maintaining a tyramine-free diet.

c. reporting increased suicidal thoughts.

A patient with multi-infarct dementia lashes out and kicks at people who walk past in the hall of a skilled nursing facility. Intervention by the nurse should begin by a. gently touching the patient's arm. b. asking the patient, "What do you need?" c. saying to the patient, "This is a safe place." d. directing the patient to cease the behavior.

c. saying to the patient, "This is a safe place."

Which comment best indicates that a patient perceived the nurse was caring? "My nurse a. always asks me which type of juice I want to help me swallow my medication." b. explained my treatment plan to me and asked for my ideas about how to make it better." c. spends time listening to me talk about my problems. That helps me feel like I am not alone." d. told me that if I take all the medicines the doctor prescribes, then I will get discharged sooner."

c. spends time listening to me talk about my problems. That helps me feel like I am not alone."

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. suicide potential.

A patient diagnosed with major depressive disorder began taking a tricyclic antidepressant 1 week ago. Today 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 will a. limit the patient's activities to those that can be performed in a sitting position. b. withhold the drug, force oral fluids, and notify the health care provider. c. teach the patient strategies to manage postural hypotension. d. update the patient's mental status examination.

c. teach the patient strategies to manage postural hypotension.

a citizen at a community health fair asks the nurse "what is the most prevalent mental health disorder in the US? a)schizophrenia b)bipolar disorder c)dissociative fugue d)Alzheimer's disease

d)Alzheimer's disease

which belief will best support a nurses efforts to provide 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 unchanged from culture to culture d)assessment findings in mental illness reflect a persons cultural patterns

d)assessment findings in mental illness reflect a persons cultural patterns

a nurse is part of a multidisciplinary team working with groups of depressed patients. one group of patients receives supportive interventions and antidepressant medication. the other group receives only medication. the team measures outcomes for each group. which type of study is evident? a)incidence b)prevalence c)comorbidity d)clinical epidemiology

d)clinical epidemiology

a patients relationships are intense and unstable. the patient initially idealizes the significant other and then devalues him or her, resulting in frequent feelings of emptiness. this patient will benefit from interventions to develop which aspect of mental health? a)effectiveness in work b)communication skills c)productive activities d)fulfilling relationships

d)fulfilling relationships

the DSM-V classifies: a)deviant behaviors b)present disability or distress c)people with mental disorders d)mental disorders people have

d)mental disorders people have

which nursing intervention below is part of the scope of an advance practice mental health nurse rather than a basic level RN a)coordination of care b)health teaching c)milieu therapy d)psychotherapy

d)psychotherapy

which individual is demonstrating the highest level of resilience? one a)is able to repress stressors b)becomes depressed after the death of a spouse c)lives in a shelter for 2 years after the home is destroyed by fire d)takes a temporary job to maintain financial stability after loss of permanent job

d)takes a temporary job to maintain financial stability after loss of permanent job

select the best response for the nurse to a question from another health professional regarding the difference between a diagnosis in DSM-V and a nursing diagnosis. a)there is no functional difference between the two. both identify human disorders b)the DSM-V diagnosis disregards culture, whereas the nursing diagnosis takes culture into account c)the DSM-V diagnosis describes causes of disorders whereas a nursing diagnosis does not explore etiology d)the DSM-V diagnosis guides medical treamtn whereas the nursing diagnosis offers a framework for identifying interventions for issues a patient is experiencing

d)the DSM-V diagnosis guides medical treamtn whereas the nursing diagnosis offers a framework for identifying interventions for issues a patient is experiencing

A nurse prepares to assess a new patient who moved to the United States from Central America 3 years ago. After introductions, what is the nurse's 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?"

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 patient's 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'?"

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 hear evil voices that tell me to do bad things."

Which remark by a patient indicates passage from orientation to the working phase of a nurse-patient relationship? a. "I don't have any problems." b. "It is so difficult for me to talk about problems." c. "I don't know how 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 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. "I'd like to sit with you for a while to help you get comfortable talking to me."

A patient became severely depressed when the last of the family's 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. "Our staff members care about you and want 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 10 minutes after lunch to help you feel that I care about you."

d. "I'll sit with you for 10 minutes now and 10 minutes after lunch to help you feel that I care about you."

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 very important and which are less important."

d. "Let's consider which problems are very important and which are less important."

A school age child tells the school nurse, "Other kids call me mean names and will not sit with me at lunch. Nobody likes me." Select the nurse's most therapeutic response. a. "Just ignore them and they will leave you alone." b. "You should make friends with other children." c. "Call them names if they do that to you." d. "Tell me more about how you feel."

d. "Tell me more about how you feel."

A black patient, originally from Haiti, has a diagnosis of major depressive disorder. A colleague tells the nurse, "This patient often looks down and is reluctant to share feelings. However, I've observed the patient spontaneously interacting with other black patients." Select the nurse's best response. a. "Black patients depend on the church for support. Have you consulted the patient's pastor?" b. "Encourage the patient to talk in a group setting. It will be less intimidating than one-to-one interaction." c. "Don't take it personally. Black patients often have a resentful attitude that takes a long time to overcome." d. "The patient may have difficulty communicating in English. Have you considered using a cultural broker?"

d. "The patient may have difficulty communicating in English. Have you considered using a cultural broker?"

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. "Why do you keep asking about 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. "The time we spend together is to discuss your concerns."

Which individual in the emergency department should be considered at 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 male diagnosed recently with terminal cancer of the prostate

d. A 79-year-old single, white male diagnosed recently with terminal cancer of the prostate

A white patient of German descent rocks back and forth, grimaces, and rubs both temples. What is the nurse's best action? a. Assess the patient for extrapyramidal symptoms. b. Sit beside the patient and rock in sync. c. Offer to pray with the patient. d. Assess the patient for pain.

d. Assess the patient for pain.

A patient with severe burn 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 action by the nurse will best help to diffuse the patient's anger? a. Stop the dressing change and say, "I will leave the supplies so that you can change your own dressing." b. Continue the dressing change and say, "This dressing change is necessary because you were careless with fire." c. Discontinue the dressing change, tell the patient, "I will return when you gain control of yourself," and leave the room. d. Continue the dressing change and say, "Dressing changes are needed to prevent infection. What are your ideas about how to make it less painful?"

d. Continue the dressing change and say, "Dressing changes are needed to prevent infection. What are your ideas about how to make it less painful?"

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 correct. d. Differing values are reflected in the two statements.

d. Differing values are reflected in the two statements.

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 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. Examine interventions for possible revision of the target date.

d. Examine interventions for possible revision of the target date.

Which measure would be considered a form of primary prevention for suicide? a. Psychiatric hospitalization of a suicidal patient b. Referral of a formerly suicidal patient to a support group c. Suicide precautions for 24 hours for newly admitted patients d. Helping school children learn to manage stress and be resilient

d. Helping school children learn to manage stress and be resilient

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

A patient in the emergency department shows a variety of psychiatrical symptoms, including restlessness and anxiety. The patient says, "I feel sad because evil spirits have overtaken my mind." Which worldview is most applicable to this individual? a. Eastern/balance b. Southern/holistic c. Western/scientific d. Indigenous/harmony

d. Indigenous/harmony

Four individuals have given information about their suicide plans. Which plan evidences the highest suicide risk? a. Turning on the oven and letting gas escape into the apartment during the night b. Cutting the wrists in the bathroom while the spouse reads in the next room c. Overdosing on aspirin with codeine while the spouse is out with friends d. Jumping from a railroad bridge located in a deserted area late at night

d. Jumping from a railroad bridge located in a deserted area late at night

A patient diagnosed with major depressive disorder refuses solid foods. In order to meet nutritional needs, which beverage will the nurse offer to this patient? a. Tomato juice b. Orange juice c. Hot tea d. Milk

d. Milk

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. Record the patient's 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 patient's rights. d. Obtain important information from the family member.

d. Obtain important information from the family member.

A patient begins therapy with a phenothiazine medication. What teaching should the 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 changes in muscle movement.

d. Report changes in muscle movement.

A patient was arrested for breaking windows in the home of a former domestic partner. The patient's history also 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. Ineffective coping c. Impaired social interaction d. Risk for other-directed violence

d. Risk for other-directed violence

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. Suicide precautions

A Filipino American patient had a nursing diagnosis of situational low self-esteem related to poor social skills as evidenced by lack of eye contact. Interventions were applied to increase the patient's self-esteem but 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 were unaddressed. d. The nurse should have assessed the patient's culture before making this diagnosis and plan.

d. The nurse should have assessed the patient's culture before making this diagnosis and plan.

A confused older adult patient in a skilled nursing facility was asleep when unlicensed assistive personnel (UAP) entered the room quietly and touched the bed to see if it was wet. The patient awakened and hit the UAP 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 nursing facilities increases an individual's tendency toward violence. c. The patient learned violent behavior by watching other patients act out. d. The patient interpreted the UAP's behavior as potentially harmful.

d. The patient interpreted the UAP's behavior as potentially harmful.

A patient diagnosed with major depressive disorder is receiving imipramine 200 mg qhs. 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. Urinary retention

A Native American patient sadly describes a difficult childhood. The patient abused alcohol as a teenager but stopped 10 years ago. The patient now says, "I feel stupid and good for nothing. I don't help my people." How should the treatment team focus planning for this patient? a. Psychopharmacological and somatic therapies should be central techniques. b. Apply a psychoanalytical approach, focused on childhood trauma. c. Depression and alcohol abuse should be treated concurrently. d. Use a holistic approach, including mind, body, and spirit.

d. Use a holistic approach, including mind, body, and spirit.

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. belongs to a culture in which dramatic body language is the norm.

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.

A nurse provided medication education for a patient diagnosed with major depressive disorder who began a new prescription for phenelzine (Nardil). 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. can identify foods with high selenium content that should be avoided. d. confers with a pharmacist when selecting over-the-counter medications.

d. confers with a pharmacist when selecting over-the-counter medications.

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

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 person who attempted suicide by overdose was treated in the emergency department and then hospitalized. The initial outcome is that 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 attempts to harm self for 24 hours.

d. exercise suicide self-restraint by refraining from attempts to harm self for 24 hours.

A patient sat in silence for 20 minutes after a therapy appointment, appearing tense and vigilant. The patient abruptly stood, paced back and forth, clenched and unclenched fists, and then stopped and stared in the face of a staff member. The patient is a. demonstrating withdrawal. b. working though angry feelings. c. attempting to use relaxation strategies. d. exhibiting clues to potential aggression.

d. exhibiting clues to potential aggression.

A nurse begins work in an agency that provides care to members of a minority ethnic population. The nurse will be better able to demonstrate cultural competence after a. identifying culture-bound issues. b. implementing scientifically proven interventions. c. correcting inferior health practices of the population. d. exploring commonly held beliefs and values of the population.

d. exploring commonly held beliefs and values of the population.

A disheveled patient in the acute phase of major depressive disorder is withdrawn, has psychomotor retardation, and has not showered for several days. The nurse will a. bring up the issue at the community meeting. b. calmly tell the patient, "You must bathe daily." c. make observations about the patient's poor personal hygiene. d. firmly and neutrally assist the patient with showering.

d. firmly and neutrally assist the patient with showering.

To provide culturally competent care, the nurse should a. accurately interpret the thinking of individual patients. b. predict how a patient may perceive treatment interventions. c. formulate interventions to reduce the patient's ethnocentrism. d. identify strategies that fit within the cultural context of the patient.

d. identify strategies that fit within the cultural context of the patient.

A nurse worked with a patient diagnosed with major depressive disorder, severe withdrawal, and psychomotor retardation. After 3 weeks, the patient did not improve. The nurse is most at risk for feelings of a. guilt and despair. b. over-involvement. c. interest and pleasure. d. ineffectiveness and frustration.

d. ineffectiveness and frustration.

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.

An emergency code was called after a patient pulled a knife from a pocket and threatened, "I will kill anyone who tries to get near me." The patient was safely disarmed and placed in seclusion. Justification for use of seclusion was that the patient a. was threatening to others. b. was experiencing psychosis. c. presented an undeniable escape risk. d. presented a clear and present danger to others.

d. presented a clear and present danger to others.

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 participate because I don't 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.

Which information from a patient's record would indicate marginal coping skills and the need for careful assessment of the risk for violence? A history of a. academic problems. b. family involvement. c. childhood trauma. d. substance abuse.

d. substance abuse.

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."

A nurse prepares to assess a newly hospitalized patient who moved to the United States 6 months ago from Somalia. The nurse should first determine a. if the patient's immunizations are current. b. the patient's religious preferences. c. the patient's specific ethnic group. d. whether an interpreter is needed.

d. whether an interpreter is needed.

Which Western cultural feature may result in establishing unrealistic outcomes for patients of other cultural groups? a.Interdependence b.Present orientation c.Flexible perception of time d.Direct confrontation to solve problems

d.Direct confrontation to solve problems

an adult says "most of the time I'm happy and feel good about myself. I have learned that what I get out of something is proportional to the effort I put into it" which number on this mental health continuum should the nurse select? a)a b)2 c)3 d)4 e)5

e)5

The nurse records this entry in a patient's progress notes: Patient escorted to unit by ER nurse at 2130. Patient's 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