Psych Nursing Exam I
A nurse provides spiritual care for a patient awaiting a liver transplant. The nurse should anticipate that the patient's most likely response will be: a. consideration of issues related to own mortality. b. devaluation of prayer and organized religion. c. misinterpretation of medical information. d. clinical depression.
A Although each of the options is possible, the most likely response is thinking about what the illness means in terms of lifespan, quality of life, and other mortality issues. The other responses are pathologic and are not seen as frequently.
A depressed patient expresses feelings of hopelessness, helplessness, and powerlessness. The patient's spiritual distress is related to an inability to: a. find meaning and hope through choices. b. develop wisdom in the face of adversity. c. draw strength from a higher power. d. live by higher principles.
A Although individuals cannot always choose their circumstances, they always have a choice of attitudes toward their experiences. Without finding meaning, individuals develop hopelessness. None of the other options relates directly to hopelessness.
What is the predominant religious tradition in the United States? a. Christian b. Buddhist c. Muslim d. Jewish
A Christians compose 78% of Americans.
A clinic patient comes to an appointment carrying a baby. The nurse notes abrasions on the baby's thighs and determines that skin scraping has been used. In an effort to use cultural negotiation, the nurse should: a. encourage using less pressure during scraping to prevent abrasions and infections. b. show the parent how to use moxibustion rather than skin scraping. c. explain that skin scraping does not effectively treat illness. d. caution that the scraped skin can become infected.
A Cultural negotiation is the nurse's ability to work within a patient's cultural belief system to develop culturally appropriate interventions. Only by suggesting a modification of the technique of skin scraping so as to perform it in a manner that will not cause injury or the potential for infection can the nurse reflect cultural negotiation.
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 Cytochrome P-450 enzyme systems, which vary among different cultural groups, influence the rate of metabolism of psychoactive drugs. Renal function influences elimination of psychotropic medication; hepatic function influences metabolism rates. Information about medication is important but does not apply to pharmacokinetics.
A patient tells the nurse, "I make decisions each day that have a positive effect on my life." This statement is most closely related to the spiritual construct of: a. making meaning through choices. b. a presence that orders the world. c. higher purpose and principles. d. higher power and achievement.
A Frankl advocated that humans find meaning when they commit themselves to something beyond themselves. Making meaningful choices improves an individual's mental health. The constructs mentioned in the other options have less to do with the individual's decision making described in the scenario.
A psychiatric nurse leads a medication education group for Hispanic outpatients. This nurse holds an analytic worldview and uses pamphlets as teaching tools. Group sessions are short and concise. After the group session, the patients are most likely to believe that: a. the nurse was uncaring. b. the session was effective. c. the teaching was efficient. d. they were treated respectfully.
A Hispanic individuals usually have a relational worldview. Their needs are for learning through verbal communication rather than reading and for having time to chat before approaching the task. An individual with a relational worldview would be unlikely to hold any of the other views.
A Hispanic patient says, "I have no energy and cannot eat. I want to sleep but can't, because pain moves around different parts of my body." A physical examination reveals no pathology. The nurse should hypothesize that the patient may be experiencing: a. lost soul (susto). b. spiritual distress. c. a broken heart. d. amok.
A Loss of one's soul, a culture-bound illness occasionally seen among Hispanic individuals, produces vague symptoms such as those described. Western medicine regards these as depressive symptoms, but individuals with lost soul speak only of physical symptoms, rather than psychological or emotional disequilibrium. The other options are culture-bound disorders with symptoms different from what is described in this scenario.
A nurse cares for a Chinese-American patient diagnosed with major depression. After the nurse reviews the therapeutic regimen with the patient, which action should occur next? a. Verify understanding by asking the patient to restate the information. b. Ask if the patient is willing to follow directions for medications. c. Reinforce cultural norms about eating hot and cold foods. d. Provide the information in written form to the patient.
A Many Asians and Asian-Americans believe that questioning an authority figure (nurse) would be disrespectful, so they do not ask for clarification when they do not understand directions for their treatment. Individuals of this culture are usually willing to comply once they understand. Written information may be provided later. Although hot and cold foods might be used by Asian-Americans, there is no evidence that this patient is interested in this therapy.
A Chinese-American infant is seen in a well-baby clinic. The parent reports that the baby is irritable and not eating well. The nurse notices several skin abrasions on the thighs and upper arms. What is the nurse's most appropriate initial intervention? a. Ask if the parent has used coining. b. Report the parent for suspected child abuse. c. Assess whether or not the parent desires to harm the child. d. Ask if the parent has taken the child to an acupuncturist.
A Recognition of the characteristic marks of coining or skin scraping can keep the nurse from making a culturally insensitive judgment that child abuse is occurring. Coining is used by Asian families to restore equilibrium for babies and small children. The other options would be inappropriate or ineffective.
Which statement by a mentally ill patient best exemplifies sick religiosity? a. "Suicide will result in eternal damnation for your soul." b. "Your illness has nothing to do with insufficient faith." c. "Questioning God is a common reaction to illness." d. "Your illness is not related to sin."
A Sick religiosity is marked by a lack of openness to other possibilities, a sense of exclusiveness, and absolutism. The correct option best exemplifies this thinking. The other options are supportive of the patient's spirituality.
A Hispanic patient reports symptoms consistent with the cultural phenomena of susto. A physical examination reveals no pathology, and depression is diagnosed. The effectiveness of selective serotonin reuptake inhibitors (SSRIs) may be increased if combined with: a. care from a traditional healer. b. acupuncture. c. skin scraping. d. moxibustion.
A The patient is probably experiencing lost soul, a culture-bound illness. Its symptoms are depressive in nature and might well respond to treatment with an antidepressant. However, because the individual sees the cause as loss of the soul, she will not have faith in medication as a cure. Using a traditional healer to return the lost soul will set the stage for medication to relieve symptoms. The other options are not culturally appropriate.
The patient says, "I know I'm very sick right now, but I trust that God will make me better." Based on this statement, the nurse can assess the patient's spirituality as being based in: a. theism. b. humanism. c. behaviorism. d. existentialism.
A Theism is the only model that suggests that people are inextricably tied to a transcendent being. This view provides hope for a better future. None of the other views have this basis.
A new nurse asks the mentor, "How can I help meet patients' spiritual needs?" Select the mentor's best responses. "Patients have reported that what they want most is for a spiritual care provider to (select all that apply): a. be authentic." b. be respectful." c. demonstrate caring." d. speak slowly and concretely." e. provide answers to theological questions."
A, B, C, D The needs elicited from patients (authenticity, caring, respect) can be seen as caregiver behaviors that enhance trust formation. The need to speak slowly and in concrete terms is important for patients with thought disorders who have cognitive problems that make comprehension slower and abstraction difficult to understand.
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, B, D The answers provide information about cultural values related to the importance of individuality, material possessions, relational connectedness, community needs versus individual needs, and interconnectedness between humans and nature. These will assist the nurse to determine whether the worldview of the individual is analytic, relational, community, or ecologic. Other follow-up questions would be needed to validate findings.
2. An outpatient diagnosed with schizophrenia has been omitting doses of medication. Which questions should the clinic nurse ask to determine the reasons for the problem? Select all that apply. a. "Are you experiencing any troublesome side effects?" b. "Is the medicine affecting your sexual performance?" c. "Does the medicine make you think slower?" d. "Do you believe your dose is too high?" e. "Do you believe you have an illness?"
ANS: A, B, C, D, E Each question listed refers to a common reason for patients not taking medication as prescribed.
3. A nurse plans to teach a group of patients the basics of the change process. How should the elements be sequenced for the presentation? a. Assess the success of new behaviors. b. Observe to gain awareness. c. Draw conclusions about the problem. d. Test new behaviors. e. Determine that change is necessary.
ANS: A, B, C, D, E This sequence proceeds logically from assessment of the problem to analysis of the problem to determining that change is necessary to testing new behaviors and evaluating their efficacy.
2. Which situations are most likely to place severe, disabling stress on a family? Select all that apply. a. A parent needs long-term care after sustaining a severe brain injury. b. The youngest child in a family leaves for college in another state. c. A spouse is diagnosed with liver failure and needs a transplant. d. Parents of three children, age 9, 7, and 2 years, get a divorce. e. A parent retires after working at the same job for 28 years.
ANS: A, C, D Major illnesses place severe, potentially disabling stress on families. The distracters identify normal milestones in a family's development.
1. Which interventions apply to the care plan of a patient being secluded? Select all that apply. a. Seclusion instituted when verbal intervention ineffective in stopping threatening behavior b. Written medical order obtained within 2 hours c. Patient debriefed when seclusion discontinued d. Patient offered bathroom privileges hourly e. Fluids offered every 4 hours
ANS: A, C, D The correct interventions meet Medicare and Medicaid guidelines for the psychiatric setting. Other guidelines exist and should also be observed so that care can be evaluated as safe and effective. Fluids should be offered more often than every 4 hours, and a medical order must be secured within 1 hour. DIF: Cognitive level: Applying REF: p. 28 TOP: Nursing process: Planning MSC: NCLEX: Safe, Effective Care Environment
18. An acutely psychotic patient is restricted to an inpatient unit. This intervention demonstrates that which milieu element has been adapted? a. Norms b. Balance c. Therapy d. Psychopathology
ANS: B Balance refers to negotiating the line between dependence and independence. The more psychotic the individual, the less independence he or she can usually handle safely. Unit restriction with careful supervision by staff helps compensate for lack of patient judgment. Norms refers to behavioral expectations for patients. Therapy is provided by advanced-practice nurses or others with advanced education and so is not an element of milieu management. Psychopathology is not considered an environmental element.
32. Which scenario presents a high risk for violence? a. A nurse empathizes with a patient who dislikes attending exercise class. b. A nurse enforces the rule that patients must attend all scheduled activities. c. A patient spends free time with a group of other patients talking about issues in their lives. d. A patient with high anxiety is allowed to remain in a quiet room instead of attending a community meeting.
ANS: B Being forced into a treatment activity reduces trust in staff. Struggles over rules are control battles. Patients who do not feel that they have control over their lives might react violently, because they believe that they have little to lose. The other options do not exemplify control battles.
6. An adult diagnosed with paranoid schizophrenia lives with older adult parents. The patient was recently hospitalized with acute psychosis. One parent is very anxious, and the other is ill from all the stress. Select the most applicable nursing diagnosis. a. Ineffective family coping related to parental role conflict b. Caregiver role strain, related to the stress of chronic illness c. Impaired parenting, related to patient's repeated hospitalizations d. Interrupted family processes, related to relapse of acute psychosis
ANS: B Caregiver role strain refers to a caregiver's felt or exhibited difficulty in performing a family caregiver role. In this case one parent exhibits stress-related illness, and the other exhibits increased anxiety. The other nursing diagnoses are not substantiated by the information given and are incorrectly formatted (one nursing diagnosis should not be the etiology for another).
31. A staff nurse tells a peer, "I find it difficult to deal with patients who have personality disorders. They can control their behavior, whereas patients with depression truly need my services." Select the peer's most helpful response. a. "Even though it's bothering you, the patients seem to like you." b. "Our clinical nurse specialist is a good resource to help you explore those feelings." c. "Fortunately, managed care has reduced inpatient services for people with personality disorders." d. "Your comment tells me you have personal problems. Maybe psychiatric nursing is not the best practice arena for you."
ANS: B Clinical supervision can help nurses examine attitudes, reactions, and conflicts with patients on the unit and arrive at new ways of approaching patient problems. This option is the only one that recognizes that the nurse is voicing a legitimate problem for which help should be available.
15. The broadened scope of psychiatric nursing practice is attributable primarily to what factor? a. Increased use of psychotropic drugs b. Opening of community mental health centers c. Legislation that changed nurse practice acts across the country d. Recidivism of seriously mentally ill patients in public mental hospitals
ANS: B Community mental health centers were designed and organized to provide services in addition to inpatient hospitalization, thus giving nurses opportunities to practice in a variety of treatment settings (e.g., emergency rooms, partial hospitalization settings, outpatient care) and to have new roles, such as consultant, liaison, and case manager. Increased use of psychotropic drugs is not as important a factor as are community mental health centers. Legislation changing nurse practice acts broadened the scope of practice for nurse practitioners only by allowing prescriptive privileges. Recidivism is not a relevant factor.
16. Which nursing intervention will initially be most helpful for trust building with a suspicious patient? a. Enforcing rules b. Keeping appointments and promises c. Agreeing not to document the patient's disclosures d. Openly challenging unclear statements by the patient
ANS: B Consistency and honesty regarding intentions are behaviors that promote patient trust. Enforcing rules is important but not necessarily related to trust building. The other options are nontherapeutic.
16. A patient diagnosed with an acute was hospitalized for a week and is now being discharged to a halfway house, where care is managed by a community mental health nurse. Which inference applies to this community? a. Additional mental health services should be made available for the severely mentally ill. b. A seamless continuum of services is in place to serve persons with severe mental illness. c. Case management services should be expanded to care for acute as well as long-term system consumers. d. Care is effective for only a few selective psychiatric diagnoses.
ANS: B Data are sufficient to suggest that a seamless continuum of service is in place, because the individual is able to move between continuum treatment sources and is given the services of a case manager to coordinate care. Data provided are insufficient to warrant any of the other assessments.
39. During an MSE a patient says, "I am a special messenger sent to provide the world a cure for cancer." The patient's statement indicates the presence of: a. a phobia. b. a delusion. c. hypervigilance. d. loose associations.
ANS: B Delusions are false beliefs. Grandiose delusions are beliefs that one possesses greatness or special powers. A phobia is an excessive fear. Hypervigilance refers to being hyperalert and suspicious. Loose associations refer to a thought disorder in which ideas are only loosely connected.
2. A tearful patient at the mental health center says, "I should be dead." What is the most important first task for the nurse in assessing this patient? a. Ascertain the lethality of the suicide plan. b. Establish a rapport with the patient. c. Determine the risk factors for suicide. d. Encourage expression of feelings.
ANS: B Establishing rapport will allow the nurse to obtain relevant assessment data such as the presence of a suicide plan, lethality of plan, and presence of risk factors for suicide.
11. A suicide crisis line caller states, "I called to say goodbye to someone." Select the nurse's best response. a. "You seem ambivalent about committing suicide. Let's talk about that." b. "You must be feeling a lot of pain. What are you planning to do?" c. "I hope you realize how much you have to live for." d. "I think I can help you, if you'll let me."
ANS: B Expressing empathy and genuine concern while offering to work with the patient is a good beginning. Asking about the plan is appropriate and enables the nurse to assess risk. The other options fail to offer both empathy and help.
12. Bioavailability of orally administered drugs is initially associated with which physiologic phenomenon? a. Rate of renal excretion b. First-pass metabolism c. Synaptic transmission d. Blood-brain barrier
ANS: B First-pass metabolism in the liver reduces the bioavailability of orally administered drugs. The other options do not occur first.
12. Parents of a teenager recently diagnosed with serious mental illness express dismay. One parent says, "Our hopes for our child's future are ruined. We probably won't ever have grandchildren." The nurse should use interventions to assist with the parent's: a. denial. b. grieving. c. acting out. d. manipulation.
ANS: B Grief is a common reaction to having a family member diagnosed with mental illness. The grief stems from actual or potential losses such as ability to function, altered family functioning, income, and altered future prospects. Data do not support choosing any of the other options.
38. The nurse performing a mental status examination wants to assess for hallucinations. The nurse should ask: a. "Can you tell me where you are now?" b. "Do you hear or see things when others don't?" c. "Do your moods shift more than those of other people?" d. "What would you do if you found a stamped, addressed letter on the floor?"
ANS: B Hallucinations are false sensory perceptions. The correct answer directly inquires about possible hallucinations. The other options seek information about other aspects of the MSE.
8. A parent is admitted to a chemical dependency treatment unit. The patient's spouse and adolescent children participate in a family session. What is the most important aspect of family assessment? a. Spouse's co-dependent behaviors b. Interactions among family members c. Patient's reaction to the family's anger d. Children's responses to the family sessions
ANS: B Interactions among all family members are the raw material for family problem solving. By observing interactions, the nurse can help the family make its own assessments of strengths and deficits. The other options are too narrow in scope when compared with the correct option.
The nurse who uses the interpersonal model as a basis for practice will focus assessment on identifying: a. intrapsychic conflicts. b. relationship problems. c. how the environment affects behavior. d. the patient's achievement of development tasks.
ANS: B Interpersonal therapists assess for current difficulties in the patient's relationships with others. Learning new, more effective interpersonal skills becomes a goal of therapy. Psychoanalytic therapists focus on intrapsychic conflicts. The other options are not the focus of the model.
18. Which principle guides nursing intervention in the assault cycle? a. Contagiousness of violence b. Least restrictive alternative c. Containment d. Control
ANS: B It is a regulatory requirement to care for patients using the least restrictive alternatives. These efforts at treatment should be documented. Only when less restrictive alternatives prove ineffective can more restrictive alternatives be used.
13. A nurse begins working in a clinic housed in a homeless shelter. The nurse asks the clinic director, "What topic should I review to improve my effectiveness as I begin my new job?" Which topic should the clinic director suggest? a. Care of school-age children b. Psychiatric assessment c. Communicable disease prevention strategies d. Sexually transmitted disease signs and symptoms
ANS: B It is estimated that significant numbers of the homeless population have a serious mental illness and/or suffer from substance abuse or dependence. Although the other conditions may exist, the numbers are not as significant.
9. A parent is admitted to a chemical dependency treatment unit. The patient's spouse and adolescent children attend a family session. What is the priority assessment question to ask family members? a. "What changes are most important to you?" b. "How are feelings expressed in your family?" c. "What types of family education would benefit your family?" d. "Can you identify a long-term goal for improved functioning?"
ANS: B It is important to understand family characteristics in both the family of origin and the present family. The other questions are related more to outcome identification and planning intervention, neither of which should be attempted until assessment is complete.
25. A patient diagnosed with paranoid schizophrenia believes that evil spirits are being stirred by a local minister and verbally threatens to bomb a local church. The psychiatrist notifies the minister. What is the basis for this action? a. Information cannot be released without proper authorization. b. There is a duty to warn and protect. c. No action can violate the patient's confidentiality. d. Charges of malpractice must be avoided.
ANS: B It is the health care professional's duty to warn or notify an intended victim after a threat of harm has been made. Informing a potential victim of a threat is a legal responsibility of the health care professional. It is not considered a violation of confidentiality or an example of malpractice. DIF: Cognitive level: Understanding REF: pp. 21-23 TOP: Nursing process: Implementation MSC: NCLEX: Safe, Effective Care Environment
5. A patient's haloperidol dosage was reduced 2 weeks ago to decrease side effects. What assessment question demonstrates the nurse's understanding of the resulting needs of the client? a. "Will you have any difficulty getting your prescription refilled?" b. "Have you begun experiencing any forms of hallucinations?" c. "What do you expect will occur since the dosage has been reduced?" d. "What can I do to help you manage this reduction in haloperidol therapy?"
ANS: B It will be necessary for the nurse to assess for exacerbation of the patient's symptoms of psychosis as well as for a lessening of side effects. Dosage decrease might lead to the return or worsening of positive symptoms such as hallucinations and delusions, and negative symptoms such as blunted affect, social withdrawal, and poor grooming. While the other options may be appropriate assessment questions, they are not directed at the current needs of the client; the identification of emerging psychotic behaviors.
8. When considering environmental aspects of milieu management, which intervention has the highest priority for a client admitted after a failed suicide attempt? a. Sending the client's new medication prescriptions to the pharmacy b. Assigning a staff member to one-on-one observation of the client c. Orienting the client to the milieu's public and private spaces d. Having all potentially dangerous items removed from the client's belongings
ANS: B Milieu management provides a proactive approach to care. Safety overrides all other dimensions of the milieu. Initiation of suicide precautions are the priority for this client. All the remaining options are appropriate but none protect the client from the risk of another attempt to self-harm as effectively as one-on-one observation as part of suicide precautions.
8. A patient who has taken antipsychotic medication for a year presents with these signs and symptoms: jaundice, headache, pruritus, and abdominal discomfort. Which finding should be documented as objective data? a. Pruritus b. Jaundice c. Headache d. Abdominal discomfort
ANS: B Objective data are obtained by the nurse through direct observation or measurement. Jaundice is seen by the nurse. The other choices are considered subjective data.
13. A patient taking clozapine (Clozaril) says, "I get plenty of vitamin C by drinking 8 ounces of grapefruit juice each morning." Select the nurse's best response. a. "High doses of Vitamin C support the immune system and general good health." b. "Name another juice you would drink, because grapefruit juice can cause a bad reaction while taking clozapine." c. "Grapefruit juice lessens the effectiveness of your medication. You might need higher doses." d. "New research shows papaya juice is a better source of vitamin C than grapefruit juice."
ANS: B Only the correct option provides vital information based on the cytochrome P-450 enzyme system's involvement in drug metabolism. Clozapine metabolism is inhibited by the ingestion of grapefruit juice, making the likelihood of a toxic reaction to the drug more likely, because the drug accumulates in the body.
1. When a nurse assesses a family, which family task has the highest priority to healthy family functioning? a. Allocation of family resources b. Physical maintenance and safety c. Maintenance of order and authority d. Reproduction of new family members
ANS: B Physical and safety needs are given greater importance
26. Which nursing intervention for an angry, hostile patient would best contribute to prevention and management of aggression? a. Loudly calling the patient by name b. Conveying personal interest in the patient c. Positioning oneself directly in front of the patient d. Firmly directing the patient to discontinue the behavior
ANS: B Research has indicated that the nurse's ability to be with the patient as a unique person in a unique situation is essential for dealing with potentially violent patients. De-escalation techniques include listening, empathizing, using a calm voice, offering alternatives rather than ultimatums, and conveying genuine interest in the patient and his or her well-being. The other options listed are not therapeutic.
16. A patient was restrained after assaulting a staff member. Which nursing measure has priority? a. Monitor the patient every 30 minutes. b. Maintain constant supervision of the patient. c. Administer a sedating medication after applying the restraints. d. Distract the patient at frequent intervals while restraints are in use.
ANS: B Restrained patients must be constantly observed, with documentation of physical safety and comfort interventions occurring at 15-minute intervals. Medication may be administered, but this is not the priority action. Distraction is not an effective technique to use when a patient is in restraints, because minimal stimulation is preferred. DIF: Cognitive level: Analyzing REF: p. 28 TOP: Nursing process: Implementation MSC: NCLEX: Safe, Effective Care Environment
22. A patient has been placed in four-point leather restraints following a violent episode. The nurse establishing the care plan must ensure that the restraints are removed: a. after a minimum of 12 hours of seclusion. b. every 2 hours, one restraint at a time, for 10 minutes. c. to allow the patient to eat, drink, or use the bathroom. d. after the patient is sedated with antipsychotropic medication.
ANS: B Restraints must be removed at intervals specified by agency protocol (in no case less often than 2 hours) to inspect for injuries, check circulation, and provide limb range of motion. The other options do not follow regulatory policies.
21. A patient diagnosed with long-standing bipolar disorder comes to the mental health center. The patient says, "I lost my job and home. Now, I eat in soup kitchens and sleep at a shelter. I am so depressed that I thought about jumping from a railroad bridge into a river." Which factor has priority for the nurse who determines the appropriate level of care? a. Long-standing bipolar disorder b. Risk for suicide c. Homelessness d. Lack of income
ANS: B Risk assessment shows the patient to have suicidal thoughts, and a plan for the suicide that is highly lethal, executable, and with low potential for rescue. The other factors do not have as great an effect on the determination of the level of services needed since they are less related to acute safety.
16. Which observation during morning rounds should receive a nurse's priority attention? a. Breakfast is late being served. b. A sink is leaking, leaving water on the bathroom floor. c. The daily schedule has not been posted on the unit bulletin board. d. A small group of patients is complaining that one patient turned down the TV volume.
ANS: B Safety is the component of therapeutic milieu management that takes priority over the other components. A patient could be injured if he or she slipped and fell. The other problems do not pose a threat to patient safety.
17. Which scenario best illustrates scapegoating within a family? a. Messages of aggression are sent by the identified patient to selected family members. b. Family members project problems of the family onto one particular family member. c. The identified patient threatens separation to induce feelings of isolation and despair. d. Family members give the identified patient nonverbal messages that conflict with verbal messages.
ANS: B Scapegoating projects blame for family problems onto a member who is less powerful. The purpose of this projection is to distract from issues or dysfunctional behaviors in the family members.
A patient says, "This problem with my job is overwhelming. I don't know what to do." The nurse replies, "Let's role-play some work situations and try to come up with solutions." Using Lazarus's interaction model, the nurse is intervening in: a. primary appraisal. b. secondary appraisal. c. tertiary appraisal. d. reappraisal.
ANS: B Secondary appraisal is defined as the individual's evaluation of how to respond to an event. During secondary appraisal, the individual can examine possible strategies, solutions, resources, and supports. Primary appraisal refers to judgments the person makes about the event. Reappraisal occurs after new information has been received. Tertiary appraisal is not part of the model.
31. Realistic short-term goals for a patient who is newly admitted to the hospital should be achievable in: a. 1 to 2 days. b. 4 to 6 days. c. 1 to 2 weeks. d. 2 to 4 weeks.
ANS: B Short-term goals are those achievable in 4 to 6 days for hospitalized patients and somewhat longer for patients in other settings. A period of 1 to 2 days allows too little time. The other options suggest longer times than necessary.
23. An adolescent is hospitalized after a violent physical outburst and tells the nurse, "I'm going to kill my parents, but you can't tell them." Select the nurse's initial response. a. "You're right. Federal law requires me to keep information private." b. "Those kinds of threats will make your hospitalization longer." c. "You really should share this thought with your psychiatrist." d. "I am required to talk to the treatment team about your threats."
ANS: D Breach of nurse-patient confidentiality does not pose a legal dilemma for nurses in these circumstances, because a team approach to delivery of psychiatric care presumes communication of patient information to other staff members to develop treatment plans and outcome criteria. The patient should know that the team may have to warn the patient's parents of the risk for harm. DIF: Cognitive level: Analyzing REF: pp. 21-23 TOP: Nursing process: Implementation MSC: NCLEX: Safe, Effective Care Environment
29. An experienced staff nurse describes feeling emotionally burdened and yet engages actively in gossip and spreading rumors about other staff members. The clinical nurse leader can assess these behaviors as consistent with: a. antisocial personality disorder. b. mild-to-moderate depression. c. depersonalization. d. burnout.
ANS: D Burnout often produces a clinical picture similar to the one described in this question. Depression cannot be diagnosed based on this information, nor can one suggest that the behavior is antisocial. Depersonalization is a symptom of burnout.
A nurse clinician uses rational-emotive therapy with a patient who is chronically depressed. The initial step in this process is to help the patient: a. identify developmental tasks and progress. b. manage environmental stressors more effectively. c. explore childhood influences on the patient's emotional state. d. recognize how irrational beliefs are related to painful feelings.
ANS: D Cognitive therapists believe that irrational beliefs or automatic thoughts cause self-defeating behaviors to be maintained. Individuals can challenge their self-defeating behaviors once they identify irrational beliefs and see their connection to painful feelings. The other options reflect interventions that might occur later.
9. The implementation of which unit policy directed at milieu balance would reflect a need for reconsideration on the part of the treatment team? a. All clients will receive verbal and written information explaining unit rules. b. Unit clients will engage in all unit activities to assure interaction with both staff and other clients. c. All clients will be uniformly expected to present themselves in a nonviolent manner to both staff and other clients. d. At times of unit stress, client will return to their rooms.
ANS: B The situation described suggests a milieu in which patients have no time for planned therapeutic encounters with staff; hence, it is a milieu lacking balance. The remaining options address unit norms, limit setting, and environmental modifications that are reasonable and will contribute to a therapeutic milieu.
15. A patient is becoming increasingly tense, pacing the hall, alternately whispering and shouting. Other patients receive hostile, suspicious glares as they walk by. Which phase of the assault cycle is the patient demonstrating? a. Crisis phase b. Triggering phase c. Escalation phase d. Depression phase
ANS: B The triggering phase is characterized by increased tension, readiness to retaliate, pacing, irritability, suspiciousness, glaring, breathing changes, and diaphoresis. The other stages are defined by behaviors specific to the stage and are not described in the scenario.
When interacting with patients, it is important for the nurse to recognize that defense mechanisms: a. keep id impulses from gaining control. b. protect the ego from excessive anxiety. c. access unconscious feelings and memories. d. prevent conflict among the id, ego, and superego.
ANS: B Theorists widely accept the Freudian concept that ego defense mechanisms operate unconsciously to lower anxiety. The function of defense mechanisms is limited to anxiety control, so the other options are incorrect.
23. What explanation regarding the unit milieu would be most important for the nurse to give to a newly admitted patient? a. "Your behavior will be carefully monitored during your hospital stay." b. "Unit activities will help you cope with immediate needs and stressors." c. "You will be given enough medication to bring your symptoms under control." d. "I will be gathering information about you to plan your care and your discharge."
ANS: B This choice best reflects the purpose of milieu management in psychotherapeutic management as demonstrated through unit activities. Stating that behavior will be monitored creates suspicion. Discussing medication administration is a psychopharmacology issue and is not pertinent to unit milieu. Stating that assessment will take place is not directly related to milieu.
3. A patient being treated at the mental health center says, "I am having thoughts about suicide." Select the nurse's most therapeutic response. a. "Thank you for telling me, but there's nothing to worry about. We will handle it together." b. "Telling me about these feelings is a very positive action on your part." c. "It's important for you to be hospitalized as soon as possible." d. "Let's talk about the things you have to live for."
ANS: B This response gives the patient reinforcement and validation for making a positive response rather than acting out a suicidal impulse. It gives neither advice nor false reassurance, and it does not imply stereotypes such as "You have a lot to live for." It uses the patient's ambivalence and sets the stage for more realistic problem solving.
An individual with alcohol dependence will begin motivational enhancement therapy. The nurse will explain this therapy to significant others as a way of: a. altering the patient's irrational thoughts. b. enhancing the patient's willingness to change behavior. c. managing anxiety through satisfying interpersonal interactions. d. mastering critical developmental tasks not attained earlier in life.
ANS: B This variation of cognitive-behavioral therapy uses motivational interviewing to bolster the patient's readiness and willingness to change habits related to the addiction. Motivational enhancement therapy is a nonconfrontational approach that uses empathy and promotes self-efficacy. The other options are consistent with interpersonal therapy, cognitive therapy, and the use of Erikson's model.
7. Which principle is applicable to nursing care of patients with all types of psychopathology? a. Avoid competitive situations. b. Treat patients as individuals. c. Confront patients with consequences of behavior. d. Assume that patients will make self-enhancing decisions.
ANS: B Treating all patients as individuals is a key aspect of showing respect. The distracters are not universally therapeutic measures.
10. Bearing in mind the function of the blood-brain barrier, dangers associated with administering large doses of water-soluble drugs relate primarily to the: a. rapid development of tolerance. b. high risk of adverse systemic effects. c. liver's inability to metabolize water-soluble drugs. d. rapid passage into the brain increasing the risk of overdose.
ANS: B Water-soluble drugs penetrate the blood-brain barrier slowly and in insignificant amounts. A dose high enough to affect the brain would invariably cause adverse systemic side effects. The other effects are not related.
6. Which statement forms the foundation upon which a nurse should base the implementation of psychotherapeutic management to the care of a patient with mental illness? a. The nurse's role in client care is supported by the multidisciplinary team. b. Omitting any one component will compromise the effectiveness of the treatment. c. The most important element of psychotherapeutic management is drug therapy. d. A therapeutic nurse-patient relationship is the most important aspect of treatment.
ANS: B When one element is missing, treatment is usually compromised. No single element is more important than the others; however, patients' needs govern the application of the components and permit judicious use. The remaining options identify components of the psychotherapeutic management process.
2. A patient tells the nurse, "You better take good care of me or I'll sue you using the precedent established in Wyatt v. Stickney." The nurse can interpret this as: a. intellectualization. b. concern about rights to adequate treatment. c. a warning about being coerced into treatment. d. a request for immediate discharge from the facility.
ANS: B Wyatt v. Stickney was a case in which the court ruled that patients had the right to adequate treatment while hospitalized. Intellectualizing is a defense mechanism. Right to refuse treatment and commitment issues were not the focus of Wyatt v. Stickney. DIF: Cognitive level: Understanding REF: p. 21 TOP: Nursing process: Planning MSC: NCLEX: Safe, Effective Care Environment
1. Which changes in psychiatric nursing practice are directly attributable to events occurring during the Decade of the Brain? (Select all that apply.) a. Homeless shelters became practice sites. b. Nurses upgraded knowledge of psychopharmacology. c. Nurses provided psychoeducation to patients and families. d. Nurses viewed psychiatric symptoms as resulting from brain irregularities. e. Nurses were more likely to advocate for patients' rights related to involuntary commitment.
ANS: B, C, D Psychobiologic research relating to brain structure and function made it possible for psychiatric nurses to view symptoms as brain irregularities and made it necessary for them to become knowledgeable about psychotropic medications to make appropriate assessments regarding desired outcomes and side and toxic effects of therapy. With hospital stays shortened, it became necessary for nurses to provide psychoeducation to patients and families who would need to monitor outcomes, symptoms of relapse, and side and toxic effects of medication. Homeless shelters became practice sites with the onset of deinstitutionalization. Advocacy for patients' rights relating to hospitalization and commitment became an ethical issue before the Decade of the Brain.
1. What information should the nurse include in patient teaching about psychotropic medication? Select all that apply. a. Drug pharmacokinetics b. Common drug interactions c. Management of common side effects d. Descriptive list of all possible adverse effects e. Written copies of information about the drug and its effects
ANS: B, C, E Teaching about how to manage common annoying side effects, such as dry mouth and orthostatic hypotension, can promote medication compliance by the patient. Knowing what side effects to report promotes patient safety. In addition, knowing about common drug-drug interactions, such as the potentiating effects of alcohol on sedating drugs, promotes patient safety. Providing written materials is helpful to patients who can then refer to these resources rather than having to rely on memory. Pharmacokinetics and an extensive list of side effects are major aspects of the nurse's role but are not expected from patients.
1. What data should a nurse analyze when deciding to refer a patient with a psychiatric disorder to community-based care? (Select all that apply.) a. Need for PRN medication b. Severity of the patient's illness c. Need for structured formal therapy d. Presence of suicidal or homicidal ideation e. Amount of supervision required by the patient
ANS: B, D, E The decision tree for the continuum of care calls for the assessment of severity of the illness, the presence or absence of suicidal or homicidal ideation, whether or not the disability is so great that the patient is unable to provide for his or her own basic needs, and the amount of supervision required for patient safety. The frequency of need for PRN medication and the need for structured formal therapy are not considerations mentioned in the decision tree.
18. Which patient behavior would require the most immediate limit-setting? a. The patient makes self-deprecating remarks. b. At a goal-setting meeting, the patient interrupts others to express delusions. c. A patient shouts at a roommate, "You are perverted! You watched me undress." d. During dinner, a patient manipulates an older adult patient to obtain a second dessert.
ANS: C Behaviors that require the most immediate limit-setting are verbal and physical aggression, self- destructive behavior, fire setting, alcohol or drug use, manipulation, inappropriate sexual behaviors, and attempts to leave the hospital without consent. In this case the verbal aggression toward the roommate requires immediate intervention to prevent further escalation.
10. Which intervention should the nurse implement when focusing on communicating therapeutically with a client? a. Explaining to the client why they will need to ask for a razor b. Providing the client with options to help achieve smoking cessation c. Encouraging the client to identify personal stressors d. Assuring the client that they can receive telephone call on the unit telephone
ANS: C A nurse uses therapeutic communication techniques as part of the therapeutic nurse-patient relationship. An example of such communication is providing the client with an opportunity to safely identify personal stressors. The remaining options address safety, balance, and norms associated with their care.
30. A psychiatric nurse is suffering from burnout. What effect would be expected on patients under this nurse's care? Patients will probably feel: a. safe. b. empowered. c. impaired trust in the nurse. d. universality with the nurse.
ANS: C A nurse who is burned out will not spend adequate time with patients, which reduces trust. Patients feel devalued, demoralized, and powerless, and they express low levels of satisfaction with care. The patient's sense of safety and security is jeopardized. The patient looks to the nurse as a caregiver; universality is not desirable in this instance.
3. What is the most prevalent psychopathologic condition diagnosed in the United States? a. Schizophrenia b. Mood disorder c. Anxiety disorder d. Alcohol dependency
ANS: C Anxiety disorders are the most prevalent, followed by mood disorders and alcohol disorders.
3. The parent of a teen diagnosed with schizophrenia asks, "Why does schizophrenia usually appear in adolescence?" The nurse's reply would be based on which premise? a. Stimulation of neurotransmitters is unstable. b. Neuronal system complexity stabilizes. c. Dendrite branching becomes complete in adolescence. d. Amino acid production increases.
ANS: C Arborization, or branching of dendrites, is a process that continues into adolescence. Some authorities have suggested that this might account for the appearance of schizophrenia at this period in life. The other options are of no relevance.
28. For which situation would clinical supervision be most important? a. A patient asks to visit with the consumer advocate. b. A new clinical nurse leader is hired to reorganize the unit. c. A newly admitted patient makes a nearly lethal suicide attempt. d. The treatment model for the unit is changed by the psychiatrist in charge.
ANS: C Clinical supervision for staff can be a tool to facilitate improved staff cohesion, morale, and ability to maintain therapeutic relationships with patients. During clinical supervision, nurses examine attitudes, reactions, and conflicts with patients on the unit and find ways of approaching problems. Nurses often require clinical supervision when working with suicidal patients. The distracters do not pose hazards to patients' well-being.
13. Which statement by a patient would the nurse interpret as willingness to collaborate in the nurse-patient relationship? a. "I know you are here to help me, and will do whatever you tell me to do." b. "I didn't want to deal with this at first, but I'm glad you made me face it." c. "I realize that I have some issues that I need help resolving." d. "I will do anything to get out of this hospital."
ANS: C Collaboration takes place when patients recognize problems and the need for assistance. The other responses suggest coercion or simple compliance. They fail to demonstrate the element of self-reflection on the part of the patient.
10. An adult with serious mental illness is being admitted to a community behavioral health inpatient unit. Recognizing current trends in hospitalization, the nurse can reasonable assume the need to prioritize which intervention? a. Providing education regarding the need for medication adherence b. Evaluating whether the client has a clear understanding of the illness c. Implementing safety precautions to address aggressive behavior d. Counseling the client concerning risks involved in demanding discharge against medical advice
ANS: C Compared with patients of the 1960s and 1970s, today's patients are likely to display more aggressive behavior. This understanding is critical to making astute assessments that lead to planning for the provision of safety for patients and staff. Treatment compliance, understanding of the illness process, and discharge against medical advice are possible issues with which the nurse might deal, but these are less relevant when admission assessment is performed.
13. A patient tells the nurse, "This medicine makes me feel weird. I don't think I should take it anymore. Do you?" The most effective reply that the nurse could make is based on which psychotherapeutic management model? a. Psychopathology b. Milieu management c. Psychopharmacology d. Therapeutic nurse-patient relationship
ANS: C Concerns about medication voiced by patients require the nurse to have knowledge about psychotherapeutic drugs to make helpful responses. The nurse-patient relationship component is based on use of self. Milieu management is concerned with the environment of care. Psychopathology provides foundational knowledge of mental disorders but would be less relevant in framing a response to the patient than knowledge of psychopharmacology.
11. A nurse administering a selective serotonin reuptake inhibitor (SSRI) antidepressant should carefully observe the patient for symptoms related to: a. dopamine excess. b. decreased GABA level. c. increased serotonin level. d. decreased acetylcholine level.
ANS: C Depression is thought to be related to decreased amounts of the neurotransmitters norepinephrine and serotonin. SSRIs increase the reuptake of serotonin, increasing the availability of this neurotransmitter at the synapse. If the SSRI is effective, the increased serotonin will result in a decrease in symptoms of depression. The other options would not be related to SSRI administration.
After an episode of self-mutilation, a patient with borderline personality disorder will begin individual therapy and group skills training. The goals are to decrease use of dissociation, increase distress tolerance, and regulate affect. Which type of therapy is evident? a. Rational-emotive behavioral b. Motivational enhancement c. Dialectical behavioral d. Interpersonal
ANS: C Each of the components described in the scenario is a component of dialectical behavioral therapy. The scenario information is not consistent with the components of any of the other types of therapy given as options.
5. Complete this goal statement for a newly admitted patient in the orientation stage. "By the end of the orientation stage of the therapeutic relationship, the patient will demonstrate: a. greater independence." b. increased self-responsibility." c. trust and rapport with two staff members." d. ability to problem-solve one issue."
ANS: C Establishing trust is the primary task of the orientation stage of the nurse-patient relationship. The other options are too ambitious for this early stage.
1. A person says, "What mental health issues are a major concern for the general population." The nurse's reply should be based on what confirmed fact concerning mental health issues? a. Bipolar disorder is a rare diagnosis among the general population. b. A diagnosis of schizophrenia is rarely confirmed during the teenage years. c. Major depression is very prevalent among the adult population. d. Alcohol-related issues are minimal considering the entire adult population.
ANS: C Four of the top medical disorders causing disability are psychiatric disorders (i.e., major depression, schizophrenia, bipolar disorder, and alcohol abuse). About half of all mental disorders start by the midteens.
6. When assessing a patient's plan for suicide, what aspect has priority? a. Patient's cultural heritage. b. Patient's insight into suicidal motivation. c. Availability of means and lethality of method. d. Quality and access to an intact social support system.
ANS: C If a person has definite plans that include choosing a method of suicide readily available to the person, and if the method is one that is lethal (i.e., will cause the person to die with little probability for intervention), the suicide risk is considered high. These areas provide a better indication of risk than the areas mentioned in the other options.
17. Which patient should be considered for involuntary commitment for psychiatric treatment? a. A patient who is noncompliant with the treatment regimen b. A patient who sold and distributed illegal drugs c. A patient who threatens to harm self and others d. A patient who fraudulently filed for bankruptcy
ANS: C Involuntary commitment protects patients who are dangerous to themselves or others and cannot care for their own basic needs. Involuntary commitment also protects other individuals in society. The behaviors described in the other options are not sufficient to require involuntary hospitalization. DIF: Cognitive level: Understanding REF: p. 24 TOP: Nursing process: Assessment MSC: NCLEX: Safe, Effective Care Environment
14. Long- and short-term goals are documented in which part of the plan of care? a. Assessment b. Diagnosis c. Outcomes d. Interventions e. Evaluation
ANS: C Long- and short-term goals are the product of outcome identification, and documentation is appropriate only in the "outcomes" part of the plan of care.
14. A novice nurse says, "I have more important things to do than play games with patients. These activities are not a worthwhile use of my time." Select the nurse manager's best response. a. "Games are part of the therapeutic milieu." b. "Patients need a break from intensive individual therapy." c. "Informal activities help patients develop social skills and take risks." d. "Please review material on the psychotherapeutic management model."
ANS: C Nurses who engage in therapeutic activities with patients recognize that each encounter with patients is part of an overall therapeutic picture. Patients discuss real problems and solutions and practice skills needed in real-life situations. These encounters offer opportunities for assessment, for patients to process feelings, and for validation and feedback, as well as for tension relief. The correct answer is the most global response. The distracters do not educate the new nurse about the purpose of informal activities.
10. A depressed patient admitted following a suicide attempt by overdose of sedatives states, "I don't feel like signing your papers. My partner should have let me die." What level of suicide precautions should the nurse apply? a. No precautions because the patient is in a secure setting b. Routine observation that is appropriate for all patients c. One-to-one continuous supervision by staff members d. Observation by staff members every 15 minutes
ANS: C One-to-one constant supervision is appropriate for suicidal patients who are considered at high risk: those who still have suicidal ideation, those who are angry that an attempt failed, or those who refuse to participate in their own care by agreeing to talk with staff before harming themselves. The other options are not appropriate for a patient whose suicide risk is high.
9. A patient tells the nurse, "I still have suicidal thoughts, but don't tell anyone because I am supposed to be discharged today." Select the nurse's best course of action. a. Have the patient sign a "no suicide" contract. b. Respect the patient's request related to confidentiality. c. Inform the health care provider and other team members. d. Search the patient's belongings for potentially hazardous items.
ANS: C Patient right to confidentiality never includes keeping important clinical information secret, especially information related to patient safety. Patients should be informed that all relevant information will be shared with the health care team. None of the other options sufficiently address the safety issue presented by a patient who expresses suicidal thoughts. DIF: Cognitive level: Applying REF: pp. 29-30 TOP: Nursing process: Implementation MSC: NCLEX: Safe, Effective Care Environment
14. The nurse cares for a patient who was verbally aggressive upon admission. Three days later the patient says, "My family put me here. They wanted to get rid of me." When should the nurse be most vigilant for signs of escalating aggression? a. During one-on-one sessions b. During group activities c. During visiting hours d. In the early morning
ANS: C Patients are more likely to become aggressive at admission, at shift change, at mealtimes, during visiting hours, during the evening, when being transported, and during periods of change. In this case the patient will probably be increasingly upset if the family does not visit, because it will reinforce her thinking that they are against her. She is also likely to become increasingly upset if they do visit, because she accuses them of unfairly hospitalizing her. The other times are possible, but research has not supported them as being exceptionally high risk.
29. When the nurse formulates nursing diagnoses, it is necessary to be specific in describing dysfunctional behaviors so as to: a. select appropriate desirable behaviors for outcome criteria. b. analyze how the patient was feeling at the time of assessment. c. explore the context that precipitated the exacerbation of the illness. d. determine how the illness relates to the patient's total life experience.
ANS: A A goal or outcome specifies an adaptive behavior to replace one that is dysfunctional. The more specific the description of the dysfunctional behavior in the nursing diagnosis, the easier it is to specify an appropriate adaptive behavior. The other options are not relevant reasons for describing dysfunctional behaviors in nursing diagnoses.
15. Parents of a mentally ill teenager say, "We've never known anyone who was mentally ill. We have no one to talk to because none of our friends understand the problems." The nurse's most helpful intervention would be to: a. refer the parents to a support group. b. build their self-esteem as coping parents. c. teach techniques of therapeutic communication. d. facilitate achievement of normal developmental tasks.
ANS: A The need for support can be clearly identified. Referrals are made when working with families whose needs are unmet. A support group such as the National Alliance for the Mentally Ill (NAMI) will provide these parents with the support of others who have had similar experiences and with whom they can share feelings and experiences. The distracters are less relevant.
A patient has severe panic attacks and uses denial, repression, and displacement. Nursing interventions should be directed toward: a. teaching more effective coping strategies. b. setting limits on use of the defense mechanisms. c. assisting the patient to change values and beliefs. d. helping the patient uncover unconscious conflicts.
ANS: A A desired outcome would be that the patient will use more effective coping strategies. Nursing intervention would focus on helping the patient identify and use more adaptive coping strategies. Setting limits on the use of defense mechanisms is impossible. Values clarification might be unnecessary. Uncovering conflicts is not a focus of nursing intervention.
35. A student grumbles to an instructor, "I do not see the value of process recordings." The best justification of a process recording is that it is a: a. tool for analyzing communication. b. verbatim record of a patient interview. c. legal document that becomes part of the medical record. d. note written at the time of a patient interview to provide information to team members.
ANS: A A process recording is a tool for the nurse to learn about the effectiveness of communication and interventions during an interpersonal interaction. It is more than a verbatim record. It is for use by the nurse, rather than the interdisciplinary team. It is not placed into the medical record.
30. A realistic outcome for a patient with situational low self-esteem who will have a short inpatient stay would be for the patient to: a. write a list of strengths, abilities, and talents. b. role-play with others to improve social skills. c. replace a negative self-image with a positive one. d. respond with positive self-esteem in all encounters.
ANS: A A short-term goal is one that can be attained in 4 to 6 days. Identification of strengths, abilities, and talents is attainable within this time frame. The other options are long-term goals.
5. A nurse finds a psychiatric advance directive in the medical record of a patient experiencing psychosis. The directive was executed during a period in which the patient was stable and competent. The nurse should: a. ensure that the directives are respected in treatment planning. b. review the directive with the patient to ensure that it is current. c. consider the directive only if there is a cardiac or respiratory arrest. d. realize that such directives address only the use of psychotropic medication.
ANS: A Advance directives for psychiatric care might be given by competent patients. They are considered binding and should be considered in planning treatment. Advance directives address several issues including psychotropic medication. Review is not required. A psychiatric advance directive relates specifically to mental health services, not cardiac or respiratory problems. DIF: Cognitive level: Applying REF: p. 30 TOP: Nursing process: Implementation MSC: NCLEX: Safe, Effective Care Environment
27. Which characteristic of an inpatient unit organizational culture predisposes the highest risk for patient violence and aggression? a. Staff member behavior authoritarian b. High degree of structural flexibility c. Feeling of safety among patients d. Bland colors used in decor
ANS: A An important variable affecting the risk of aggression is staff attitude. A higher risk for assault is present for staff with authoritarian attitudes. Such attitudes demean patients, who might act out in anger or defense against feeling depersonalized and powerless.
3. An adult diagnosed with paranoid schizophrenia frequent experiences auditory hallucinations and walks about the unit, muttering. Which nursing action demonstrates the nurse's understanding of effective psychotherapeutic management of this client? a. Discussing the disease process of schizophrenia with the client and their domestic partner b. Minimizing contact between this patient and other patients to assure a stress free milieu c. Administering PRN medication when first observing the evidence that the client may be hallucinating d. Independently determining that behavior modification is appropriate to decrease the client's paranoid thoughts
ANS: A An understanding of psychopathology is the foundation on which the three components of psychotherapeutic management rest; it facilitates therapeutic communication and provides a basis for understanding psychopharmacology and milieu management. Minimizing contact between the patient and others and administering PRN medication indiscriminately are nontherapeutic interventions. Using behavior modification to decrease the frequency of hallucinations would need to be incorporated into the plan of care by the care team.
2. Which component of the nursing process will the nurse focus upon to address the responsibility to match individual patient needs with appropriate services? a. Planning b. Evaluation c. Assessment d. Implementation
ANS: C Proper assessment is critical for being able to determine the appropriate level of services that will provide optimal care while considering patient input and at the lowest cost. Planning and implementation utilizes the assessment data to identify and execute actions (treatment plan) that will provide appropriate care. Evaluation validates the effectiveness of the treatment plan.
12. Risk assessment for a patient shows these findings: schizophrenia but not currently; not a danger to self or others; lives in parents' home. Which decision regarding placement on the continuum of care is appropriate? a. Hospitalize the patient. b. Discharge the patient from the system. c. Refer the patient to outpatient services. d. Refer the patient to self-help resources in the community.
ANS: C Referral should be made to the least restrictive, most effective, and most cost-conscious source of services. Because the patient is not a danger to self or others, hospitalization is not needed. However, follow-up as an outpatient would be more appropriate than referral to a self-help group, in which structure might be lacking, or discharge from the system.
13. A patient is shouting loudly and is verbally aggressive. What analysis should the nurse make about this behavior? a. It is acceptable if directed toward staff but not toward another patient. b. It is not harmful and might prevent the patient from physically acting out. c. It is a significant warning sign that the patient may become physically aggressive. d. It allows the patient to vent frustration and alleviate stress without hurting anyone.
ANS: C Research findings indicate that verbally aggressive attacks on others are among the major warning signs of assault and battery, making the other answers mutually exclusive. Verbal aggression is part of the assault cycle.
11. During the risk assessment phase of care for a psychiatric patient, what is the nurse's primary goal? a. Making an initial assessment b. Confirming the patient's problem c. Assessing potential dangerousness to self or others d. Determining the level of supervision needed for the patient
ANS: C Risk assessment involves looking at dangerousness to self or others, the degree of disability, and whether or not the individual is acutely psychotic to determine the feasibility of community-based care versus hospital-based care. Risk assessment usually follows the initial assessment. Confirmation of the patient's problem is not part of the risk assessment protocol. Arranging entry into the mental health system will follow risk assessment if the patient is assessed as needing service.
3. A patient shouts, "I'm holding you responsible for mistreatment based on Rogers v. Orkin." The nurse can conclude that the patient is objecting to: a. loss of privileges to leave the unit. b. inability to make phone calls. c. taking medication. d. hospitalization.
ANS: C Rogers v. Orkin was a case in which the court ruled that nonviolent patients could not be forced to take medication. It did not have implications related to hospitalization or application of patient privileges. DIF: Cognitive level: Understanding REF: p. 21 TOP: Nursing process: Assessment MSC: NCLEX: Safe, Effective Care Environment
24. A nurse who has worked on an acute psychiatric unit for 5 years has begun describing patients in insensitive ways and is less creative when dealing with patient problems. What is the most likely explanation for the nurse's behavior? a. Marginalization b. Depersonalization c. Secondary traumatization d. Poor conflict management skills
ANS: C Secondary traumatization occurs as a result of listening to and empathizing with other people's traumas. Synonyms include compassion fatigue and helper stress. The individual becomes less able to help others. Clinical supervision is indicated.
11. During a community meeting, a patient reacts negatively about having only two patient-accessible phones on the unit. Many other patients join in, all talking at the same time. The nurse requests that only one person talk at a time. The nurse's request seeks to maintain what characteristic of a therapeutic environment? a. Norms b. Safety c. Balance d. Structure
A. norms
15. The spouse of a patient with panic attacks tells the nurse, "I am afraid my husband has a permanent disorder and will have many hospitalizations in the future. I wonder how I will be able to raise our children alone." The nurse's reply should be based on which form of nursing knowledge? a. Psychopathology b. Milieu management c. Psychopharmacology d. Nursing relationship therapy
ANS: A An understanding of psychopathology will enable the nurse to communicate reassurance to the spouse regarding the treatment of panic attacks in an outpatient setting. None of the other options has psychotherapeutic knowledge of psychiatric disorders as its focus.
19. A patient playing pool with another patient throws down the pool cue and begins swearing. The nurse should initially intervene by: a. asking other patients to leave the room. b. calling for assistance to restrain the patient. c. suggesting a time-out in the patient's room. d. restating rules of the milieu related to swearing.
ANS: C Suggesting a time-out in the patient's room is often an effective initial strategy, because it permits the patient to go to an area with fewer stimuli. It also removes the patient from other patients who are at risk for injury if the patient's behavior escalates. Restating the rules of the milieu does not help the patient diffuse the anger. Removing other patients is unnecessary unless the patient's behavior escalates.
2. What is the purpose of the DSM-V? a. It provides a detailed list of clinical psychiatric disorders. b. It details data and statistics about mental disorders in the United States. c. It serves as the official American resource manual detailing diagnostic criteria of psychiatric disorders. d. It acts as a compendium of the international demographics of substance abuse and mental disorders.
ANS: C The Diagnostic and Statistical Manual, Fifth Edition (DSM-V) is published by the American Psychiatric Association. It provides diagnostic criteria for mental and substance abuse disorders and is used throughout the United States. The other options are not descriptive of the DSM-V.
6. The greatest impact in the care of the mentally ill over the past 50 years is represented in which nursing statement to a newly admitted patient? a. "You will benefit from attending the assigned self-help groups" b. "Outpatient therapy will be prescribed as a part of your post discharge therapy." c. "Let's talk about the psychotropic drugs you've been prescribed." d. "This is a written copy of your patients' rights."
ANS: C The advent of psychotropic drugs allowed patients to normalize thinking and feeling. As psychosis diminished, the individual became accessible for psychotherapeutic interventions. Hospital stays were shortened. Hospital milieus improved. Though important, none of the other choices has had such a significant impact.
17. Which of these services is most appropriate for an older client requiring minimal mental health interventions? a. Day treatment b. Hospitalization c. Scheduled visits at a community mental health center d. Regular attendance at a senior center facility
ANS: C The continuum of care represents treatment services along a range of intensity. Hospitalization is the most intensive, progressing to day treatment, and finally to routine visits at a community mental health center. A senior center is not prepared to provide mental health interventions.
16. Select the best question to assess a family's ability to cope. a. "What strengths does your family have?" b. "Do you think your family copes effectively?" c. "Describe how you successfully handled one family problem." d. "How do you think the current family problem should be resolved?"
ANS: C The correct option is the only statement addressing coping strategies used by the family. The other options seek opinions or are closed-ended.
27. As the nurse plans care for a newly admitted patient, identification of dysfunctional behaviors will provide the focus for: a. evaluation. b. nursing diagnosis. c. nursing interventions. d. outcome identification.
ANS: C The nurse recognizes that dysfunctional behaviors are behaviors that would benefit the patient to change. These dysfunctional behaviors are written as defining characteristics in the nursing diagnosis. Nursing interventions are formulated that address changing dysfunctional behaviors to more adaptive behaviors. The focus of evaluation is patient progress; the focus of nursing diagnosis is patient problems; the focus of outcome identification is adaptive behaviors.
23. A psychotic patient tells the nurse, "Get away from me or I'll hit you. You're sucking the thoughts out of my head." To best de-escalate the situation, the nurse should: a. direct the patient to a chair. b. deny taking the patient's thoughts. c. increase the distance between nurse and patient. d. tell the patient, "You will be restrained if you hit me."
ANS: C The nurse should do as the patient requests when the request is reasonable. Patients perceiving alterations in reality often need increased personal space to feel less anxious. Denials, touching, and threatening are likely to promote escalation of violent behavior.
17. A patient shouts at a nurse who just entered the room, "You're an incompetent fool. Leave me alone." The nurse's response should be based on which rationale? a. The anger was created by a situation or significant person, not the nurse. b. The reaction probably results from transference and countertransference. c. The patient is probably reacting to fear of loss of emotional control. d. The patient has a right to openly express negative feelings.
ANS: A Anger toward the nurse is often displaced anger that has arisen from some situation or significant person in the patient's life. Nurses feel the brunt of the anger because they are "handy" and might be considered by the patient to be a safe object for the displacement. Knowing that the nurse is not the true object of the anger allows the nurse to plan a therapeutic strategy for helping the individual manage the emotion. None of the other options provides an accurate basis for planning intervention.
15. A patient's areas of strength are documented in which part of the plan of care? a. Assessment b. Diagnosis c. Outcome identification d. Interventions e. Evaluation
ANS: A Areas of strength are part of the nurse's assessment, and documentation is appropriate only in that part of the plan of care. This information is very important for the later steps of outcome identification and planning.
6. A patient constantly interferes with activities on an inpatient unit. The nurse, speaking in a loud voice, tells the patient, "If you don't go to your room immediately, I will give you medication that will make you sleep." The nurse's behavior demonstrates: a. assault. b. battery. c. negligence. d. false imprisonment.
ANS: A Assault is defined as an act that creates a reasonable apprehension of harmful or offensive contact to another without consent of the other. The nurse has threatened the patient. Battery is unwanted touching. Negligence is failure to do what is reasonably prudent under the circumstances. False imprisonment is not evident. DIF: Cognitive level: Understanding REF: p. 24 TOP: Nursing process: Implementation MSC: NCLEX: Safe, Effective Care Environment
4. To help preserve patients' rights to freedom from restraint and seclusion, the most important interventions that the nurse can use are based on which principle? a. Therapeutic management b. Reality-based communication c. Confidentiality of documentation d. Effective use of ancillary personnel
ANS: A Attention to the nurse-patient relationship, the therapeutic milieu, and principles of pharmacologic management can reduce the need for restrictive measures. The other options are important aspects of care but do not relate directly to the use of restraint and seclusion. DIF: Cognitive level: Understanding REF: p. 28 TOP: Nursing process: Implementation MSC: NCLEX: Safe, Effective Care Environment
5. A nurse reads this information in a patient's record: suffered anoxia at birth; foster home placement at age 3; taunted by peers during childhood; low self-esteem since adolescence. Which item would be classified as a biologic factor associated with the patient's mental illness? a. Anoxia at birth b. Low self-esteem c. Taunted by peers d. Trauma caused by parental death
ANS: A Biologic causes arise from nature; that is, they are organic or genetic. Anoxia is an organic etiology. The other conditions are of psychologic etiology.
2. A nurse tells a patient, "I know how you feel. My spouse can be very insensitive too. I am also considering divorce." Analysis suggests that the nurse is: a. self-disclosing inappropriately. b. experiencing countertransference. c. using empathy to establish trust with the patient. d. encouraging the patient to express negative feelings.
ANS: A Brief self-disclosure is used to help the patient clarify specific issues, to feel less vulnerable, or to feel more "normal." When used appropriately, self-disclosure benefits the patient. When used inappropriately, it benefits the nurse. In this case, the self-disclosure burdens the patient with the nurse's problems. Empathy focuses on the patient. Countertransference would result in different behaviors. Encouraging expression of negative feelings would be more direct.
2. A novice nurse asks, "What is the role of psychopharmacology in the psychotherapeutic management model?" A mentor should respond that psychopharmacology makes it possible to: a. use the least restrictive treatment alternatives. b. prevent violence against nurses. c. identify desirable outcomes. d. determine psychopathology.
ANS: A By effectively treating psychotic symptoms, the incidence of violent behaviors has been reduced. This makes possible the use of the least restrictive treatment alternative, an important facet of psychotherapeutic management. Psychopharmacology does not make the other options possible.
A patient has lung cancer, continues to smoke, and says, "I think my cancer is more the result of a bad gene than of smoking." The patient shows the use of which defense mechanism? a. Denial b. Compensation c. Intellectualization d. Reaction formation
ANS: A Denial is the unconscious refusal to admit an unacceptable idea or behavior, as shown in this example. Compensation refers to covering a weakness by overemphasizing a desirable trait. Intellectualization involves using a logical explanation without expressing emotion or affect. Reaction formation is a conscious behavior that is the opposite of an unconscious feeling.
7. An adult recently diagnosed with AIDS is hospitalized with pneumonia. The patient and family are very anxious. Select the best outcome to add to the plan of care for this family. a. Identify and describe effective coping methods. b. Describe the stages of the anticipatory grieving process. c. Recognize the ways dysfunctional communication is expressed in the family. d. Examine previously unexpressed feelings related to the patient's sexuality.
ANS: A Desired outcomes might be set for the family as a whole or for individuals within the family. The outcome most closely associated with the anxiety that each is experiencing is to focus on identifying and describing ways of coping with the anxiety. The other options are not appropriate at this time.
17. A patient has entered the escalation phase of the assault cycle. Select the most appropriate nursing intervention. a. Direct the patient to the quiet room. b. Process the incident with the patient. c. Encourage ventilation of feelings. d. Place the patient in seclusion.
ANS: A During the escalation phase the patient is still capable of cooperation when the nurse takes charge and gives calm, firm directions. This intervention observes the principle of using the least restrictive alternative. Oral PRN medication might be used if the least restrictive alternative is not effective. Ventilation of feelings would have been used in the triggering phase. Processing the incident occurs in the recovery and depression phases. Seclusion is necessary in the crisis phase.
A patient uses defense mechanisms excessively. The nurse should expect to find evidence that: a. the patient has difficulty with problem solving. b. the patient has an increased risk for psychosis. c. emotions are experienced with great intensity. d. reality is denied.
ANS: A Excessive use of defense mechanisms results in the distortion of reality. When reality is not perceived accurately, problem solving is impaired. The other options might or might not be experienced by the patient.
5. Which of Freud's contribution to psychiatry most affects current psychiatric nursing? a. The challenge to look at humans objectively b. Recognition of the importance of human sexuality c. Theories about the importance of sleep and dreams d. Discoveries about the effectiveness of free association
ANS: A Freud's work created a milieu for thinking about mental disorders in terms of the individual human mind. This called for therapists to look objectively at the individual, a principle that is basic to nursing. The correct answer is the most global response. Freud's theories of psychosexual development are an aspect of holistic nursing practice, but not the entire focus. Free association is not a pivotal issue in nursing practice.
Which argument effectively supports the importance of funding services for persons with mental illness in the United States? a. During any given year 25% of Americans are affected by mental disorders. b. Increasing toxins in the environment are increasing the incidence of mental illness. c. The high prevalence of mental illness is directly linked to increasing violence in the media. d. The incidence of mental illness is increasing because of deterioration of the American family.
ANS: A Funding is justified based on the high incidence of mental illness. The origins of mental illness are multifaceted. It is overly simplistic to associate these problems with one or two variables.
2. Which documentation of family assessment indicates a healthy and functional family? a. Members provide mutual support. b. Power is distributed equally among all members. c. Members believe that there are specific causes for events. d. Under stress, members turn inward and become enmeshed.
ANS: A Healthy families nurture and support their members, buffer against stress, and provide stability and cohesion. The distracters are unrelated or incorrect.
16. Which adjective best describes a therapeutic psychiatric nurse? a. Holistic b. Organized c. Diplomatic d. Compassionate
ANS: A Holism is crucial to knowledgeable, safe, and effective practice as a psychiatric nurse. The distracters are incomplete. Compassion is an aspect of holism.
24. The nurse caring for a hyperactive patient should be particularly concerned about assessing: a. physical safety. b. emotional trauma. c. manipulative behaviors. d. feelings about the relationship.
ANS: A Hyperactive patients are at high risk for injury and physical exhaustion, both of which compromise physical safety. Safety needs take priority over emotional needs.
16. A patient is increasingly tense, pacing the hall and glaring angrily at others. Select the nurse's best comment to this patient. a. "It looks as though you are feeling upset. Please tell me what's concerning you." b. "I can see you are on the verge of losing control. What can I do to help you?" c. "You must maintain control of your feelings even if you are feeling angry." d. "I'm going to give you an injection of your medication to prevent loss of control."
ANS: A In the triggering phase the patient's behaviors are nonviolent and present no immediate danger to others. The nurse should convey empathic support and encourage ventilation using clear, calm, and simple statements.
11. A crisis team led by a psychiatric nurse is called to a home because a patient with a history of paranoid schizophrenia is standing on the lawn shouting, "People are poisoning my water." The nurse should advise the police officer to institute procedures for: a. emergency care. b. long-term commitment. c. a probable-cause hearing. d. short-term observation and treatment.
ANS: A Individuals who are deemed to be dangerous to self, dangerous to others, or gravely disabled can be detained involuntarily for evaluation and emergency treatment for a specified period of time (often for 72 hours). Long-term commitment might be unnecessary. A probable-cause hearing is needed only for short-term observation and treatment. DIF: Cognitive level: Applying REF: p. 25 TOP: Nursing process: Implementation MSC: NCLEX: Safe, Effective Care Environment
6. A nurse assesses a newly hospitalized patient with a long history of serious and persistent mental illness. The priority assessment information to obtain regarding medication safety is: a. adverse reactions to drugs taken previously. b. history of drug compliance and noncompliance. c. level of support available from significant others. d. length of time on various psychotropic medications.
ANS: A Information related to safety is the nurse's priority. Adverse reactions to psychotropic medications can be dangerous, even life-threatening. If a patient has had an adverse reaction to a particular drug, it would be unwise to administer it again. The other options do not address a safety issue.
7. Which statement most accurately describes a nurse's role regarding psychopharmacology? a. "You will need to frequently make decisions regarding the administration of PRN medications to help the client manage anger." b. "It's a nursing responsibility to adjust a medication dose to assure effective patient responses." c. "Nurses administers medications while evaluating drug effectiveness is a medical responsibility." d. "To best assure appropriate response, a patient's questions about drug therapy should be referred to the psychiatrist."
ANS: A Nursing assessment and analysis of data might suggest the need for PRN medication as patient anxiety increases or psychotic symptoms become more acute. The nurse is the health team member who makes this determination. Nurses are responsible for monitoring drug effectiveness as well as administering medication. Nurses should assume responsibility for teaching patients about the side effects of medications. Nurses cannot alter prescribed dosages of medications unless they have prescriptive privileges.
6. A patient is withdrawn and avoids talking to the nurse. The best initial intervention for the nurse would be to: a. offer to listen and help. b. directly ask why the patient does not wish to talk. c. involve the patient in a group activity to decrease isolation. d. respect the patient's desire not to talk and leave the patient alone.
ANS: A Patients might be afraid or unable to approach nurses. Nurses must take the initiative to approach the patient, thus acknowledging the patient's worthiness and conveying acceptance. "Why" questions usually elicit rationalization. Leaving the patient alone does not foster trust. Decreasing isolation will not build trust in the nurse.
32. A patient with suicidal ideation is hospitalized. What is the priority intervention? a. Negotiating a no-harm contract b. Facilitating attendance at groups c. Administering a psychotropic drug d. Determining the precipitating situation
ANS: A Preservation of patient safety is of higher priority than any of the other interventions.
11. Prevalence rates for substance abuse disorders in the United States are: a. higher for men. b. higher for women. c. equal for both genders. d. higher than anxiety disorders.
ANS: A Prevalence rates for substance abuse disorders are highest in men. The remaining options are not true regarding substance abuse prevalence.
9. A nurse and patient agree on problems to be addressed during a brief hospital stay. Which inference is correct? a. The relationship is moving into the working stage. b. The nurse should reinforce messages about termination. c. The nurse needs to direct the patient to begin journaling. d. Management of emotions must be ensured before work can continue.
ANS: A Problems are defined and priorities for work are set as the nurse and patient collaborate during the orientation stage. This sets the stage for transition into the working stage. Management of emotions can occur during the working stage.
22. An example of a breach of a patient's right to privacy occurred when a nurse: a. released information to the patient's employer without consent. b. documented the patient's daily behaviors during hospitalization. c. discussed the patient's history with other staff during care planning. d. asked a family to share information about a patient's behavior prior to admission.
ANS: A Release of information without patient authorization violates the patient's right to privacy. The other options are acceptable nursing practices. DIF: Cognitive level: Understanding REF: p. 27 TOP: Nursing process: Implementation MSC: NCLEX: Safe, Effective Care Environment
7. Studies about psychiatric patients' understanding of psychopharmacology suggest that the nursing diagnosis most applicable is: a. deficient knowledge related to drug therapy. b. impaired memory related to drug side effects. c. impaired decision making related to drug dependency. d. disturbed thought processes related to anticipation of side effects
ANS: A Research has shown that most patients do not know important facts about the medications prescribed for them. As a result, they are often noncompliant. As knowledge deficits are removed, better compliance can be expected. Data are not present to suggest applicability of the other options.
21. The nurse in charge of a crisis team determines that a patient who has lost control requires restraint. What is the most important factor in the safe and effective use of physical restraint? a. A calm, well-trained staff b. Taking the patient off guard c. Administering an antipsychotic drug d. Talking to the patient throughout the procedure
ANS: A Six to eight staff members are required. Each must know his or her role. With training, staff can carry out the various functions smoothly and calmly. Calmness helps ensure that physical contact is protective, rather than aggressive. Hospital protocols and legal requirements must be observed. The other options are either less important elements or inappropriate.
26. Objective data obtained in an initial assessment of a patient are of particular value when: a. the patient is too ill to participate. b. the patient's admission is involuntary. c. family members have admitted the patient. d. the patient has been transferred from a subacute setting.
ANS: A Some patients are too ill to participate in or complete the assessment interview. When this is the case, the interviewer uses objective data obtained from patient observation and the reports of family or others present at the time of admission. The other options do not reflect situations in which objective data have maximal value.
6. A general psychotherapeutic management guideline nurses should apply when caring for all patients is to: a. strengthen patients' self-esteem. b. keep reality testing to a minimum. c. ignore hostile behavior when possible. d. provide unrestricted opportunities for self-expression.
ANS: A Strengthening patients' self-esteem is an important aspect of psychotherapeutic management and a key part of the nurse's role. The distracters are not always therapeutic.
A student nurse says, "I don't need to interact with my patients. I learn by observing them." The instructor can best interpret the nursing implications of Sullivan's theory to this student by responding: a. "Nurses cannot be isolated. We must interact to provide patients with opportunities to practice interpersonal skills." b. "Observing patient interactions can help you formulate priority nursing diagnoses and appropriate interventions." c. "I wonder how accurate your assessment of the patient's needs can be if you do not interact with the patient." d. "It is important to note patient behavioral changes because these signify changes in personality."
ANS: A Sullivan believed that the nurse's role includes educating patients and assisting them in developing effective interpersonal relationships. Mutuality, respect for the patient, unconditional acceptance, and empathy are cornerstones of Sullivan's theory. These cornerstones cannot be demonstrated by the nurse who does not interact with the patient. Observations provide only objective data. Priority nursing diagnoses usually cannot be accurately established without subjective data from the patient. The other distracters relate to Maslow's theory and behavioral theory.
7. A patient has identified the need for better anger management and tells the nurse, "I'm afraid that someday I might explode." The best strategy for reducing this patient's fear of losing control is to: a. talk about these feelings openly and directly. b. discuss feelings in general without reference to the patient. c. avoid talking about the feelings until the patient feels comfortable. d. reassure the patient that expressing feelings is the first step to resolving them.
ANS: A Talking openly about feelings conveys the message that feelings are natural and can be handled. Once feelings can be discussed, the focus can shift to learning to cope more effectively with them. The other options are either avoidant or nontherapeutic.
8. A nurse at a behavioral health clinic sees an unfamiliar psychiatric diagnosis on a patient's insurance form. Which resource should the nurse use to discern the criteria used to establish this diagnosis? a. The Diagnostic and Statistical Manual of Mental Disorders (DSM) b. Nursing Diagnosis Manual c. A psychiatric nursing textbook d. A behavioral health reference manual
ANS: A The DSM gives the criteria used to diagnose each mental disorder. The distracters do not contain diagnostic criteria for mental illness.
8. A gravely disabled psychiatric patient has a guardian. What is the essential implication for nursing care? a. The patient can override the guardian's judgment at any time. b. Guardianship is a legal matter that does not affect clinical care. c. The guardian's rights apply only to a patient's financial interests. d. The guardian participates in treatment planning on behalf of the patient.
ANS: D Guardians make decisions on behalf of the patient and represent the patient in treatment planning meetings. Guardianship affects clinical care, as previously mentioned. The guardian has the right to refuse treatment for the patient. The patient cannot override the guardian's judgment, because the patient is considered incompetent. DIF: Cognitive level: Understanding REF: p. 26 TOP: Nursing process: Implementation MSC: NCLEX: Safe, Effective Care Environment
12. Which individual would be the most likely candidate to have a guardian appointed? a. A patient with panic attacks b. A bipolar patient who refuses medication c. A patient with frequent admissions for drug abuse d. A gravely disabled patient with paranoid schizophrenia
ANS: D Guardians or conservators are appointed by the courts to manage the affairs of mentally ill individuals found to be incompetent and unable to manage their own affairs appropriately. A gravely disabled patient with schizophrenia would be in need of a conservator or guardian, whereas the other individuals would more likely be judged competent. DIF: Cognitive level: Analyzing REF: p. 26 TOP: Nursing process: Assessment MSC: NCLEX: Safe, Effective Care Environment
12. A nurse and patient who developed a therapeutic relationship enter into the final phase of their relationship as the patient prepares for discharge. An important nursing intervention for this stage is for the nurse to: a. provide structure and intensive support. b. inform the patient of the progress made. c. encourage the patient to describe goals for change. d. discuss feelings about termination with the patient.
ANS: D Healthy closure is facilitated when the patient discusses his or her reactions to termination and the feelings that she or he might be experiencing. The nurse serves as a role model during termination. Providing structure is related more to the orientation and working stages. Informing the patient of progress is paternalistic. The process of termination is facilitated by collaborative work. Describing goals takes place with passage from the orientation to the working stage.
14. A family expresses helplessness related to dealing with a mentally ill member's odd behaviors, mood swings, and argumentativeness. An appropriate nursing intervention for the family would be to: a. express sympathy. b. involve local social services. c. explain symptoms of relapse. d. role-play problem situations.
ANS: D Helping a family learn to set limits and deal with difficult behaviors can often be accomplished by using role-playing situations, which give family members the opportunity to try new, more effective approaches. The other options would not provide learning opportunities.
2. A nurse, preparing a community presentation, should include what information concerning the most accurate characterization of treatment of the mentally ill prior to the Period of Enlightenment? a. Large public asylums provided custodial care. b. Care for the mentally ill was more compassionate. c. Care focused on reducing stress and meeting basic human needs. d. Patients were often displayed for public amusement.
ANS: D In the 1700s it was common practice for caretakers to display mentally ill patients for the amusement of the paying public. The creation of large asylums took place during the Period of Enlightenment. Mental illness was first studied during the Period of Scientific Study. Dealing with stress and meeting basic needs are concerns of the modern era.
34. The nurse writing a discharge summary for a patient should include achievements as well as: a. care plan updates. b. a list of patient strengths. c. effective nursing interventions. d. outcomes that still need to be addressed.
ANS: D Information included in discharge summaries includes outcomes attained, outcomes still to be attained, discharge instructions, medication instructions, and follow-up appointments. The other items are not part of a discharge summary.
25. Which management practice should the clinical nurse leader of a psychiatric unit institute to enhance the therapeutic environment? a. Encourage staff efficiency and time management. b. Emphasize timely and comprehensive documentation. c. Prepare a comprehensive policy and procedure manual. d. Implement positive reinforcement for upholding professional standards.
ANS: D Institutional constraints and bureaucracy affect the caring ethic of nurses. Positive reinforcement for upholding nursing's professional standards is a management practice that supports nursing and will contribute positively to the therapeutic environment. The other options are not supportive of nursing.
13. Parents of a teenager recently diagnosed with serious mental illness express dismay. One parent says, "Our child sometimes acts so strangely that we don't invite friends to the house. Sometimes we don't get any sleep. We quit taking vacations." Which nursing diagnosis applies? a. Impaired parenting b. Dysfunctional grieving c. Impaired social interaction d. Interrupted family processes
ANS: D Interrupted family processes are evident in the face of disruptions in family functioning as a result of having a mentally ill member. Data support the possibility of this diagnosis. Data are insufficient to consider the other diagnoses.
9. A patient with low self-esteem and feelings of failure would benefit most from which activity? a. Attending a dance b. Playing board games c. Leading the chorus for a party d. Helping make favors for a party
ANS: D Making favors is a productive task that holds little opportunity for failure and ample opportunity for receiving support and positive feedback. The other options hold a greater risk for failure.
4. The primary mechanisms of action of certain antidepressants result from neurotransmitter inactivation by enzyme-based metabolism and: a. electrochemical stimulation. b. stimulation of natural precursors. c. extraction of precursors from the bloodstream. d. reuptake into the presynaptic storage vesicles.
ANS: D Neurotransmitters are inactivated in two ways: (1) they are metabolized by enzymes, and (2) they are taken back into the presynaptic storage vesicles—a process called reuptake. The other options have no physiologic basis in fact.
12. Which assessment finding should be documented as objective information? a. Rated anxiety 8 on a scale of 10 b. Reported depressed mood c. Reports of headache d. Wore layered clothing
ANS: D Objective data are measurable data obtained or observed by the nurse. Layered clothing is an example of objective data. Subjective data are what the patient relates to the nurse.
7. Which emotion experienced by a patient should be assessed by the nurse as most predictive of an increased suicide risk? a. Anger b. Elation c. Sadness d. Hopelessness
ANS: D Of the feelings listed, hopelessness is most closely associated with increased suicide risk. Depression, aggression, impulsivity, and shame are other feelings noted as risk factors for suicide.
9. A week after beginning fluoxetine (Prozac), a patient complains, "I still feel so depressed all the time." Based on pharmacodynamics, the nurse's best action is to: a. administer the medication on an empty stomach. b. advise the health care provider that the drug is ineffective. c. reassess the expected outcomes of antidepressant therapy. d. educate the patient that the drug needs more time to be effective.
ANS: D One week is probably an insufficient time for antidepressants to become effective in reducing patient symptoms. The phenomenon of receptor down-regulation develops in 2 to 4 weeks. The other options are not supported by research studies.
5. When discussing treatment of an aggressive patient with psychosis, a health care provider says, "I plan to prescribe the original antipsychotic drug." Which medication is relevant to the statement? a. Paroxetine (Paxil) b. Clozapine (Clozaril) c. Imipramine (Tofranil) d. Chlorpromazine (Thorazine)
ANS: D Only chlorpromazine and clozapine are antipsychotics. Chlorpromazine is a traditional drug, introduced in the early 1950s, whereas clozapine is a newer drug, introduced in the 1990s. Paroxetine and imipramine are antidepressants.
14. A patient taking a psychotropic medication reports, "This medicine isn't working right for me. It's causing side effects." Select the nurse's best comment to further assess the scenario. a. "Has the drug caused diaphoresis?" b. "Have you experienced urinary retention?" c. "Are you experiencing episodes of tachycardia?" d. "Tell me more about how the medication is affecting you."
ANS: D Open-ended communication techniques are important strategies for exploring the patient's concerns. It is also important for the nurse to use culturally familiar terms. Patients are unlikely to know the meaning of terms such as tachycardia, diaphoresis, and urinary retention.
14. A nurse in a community mental health center receives a call asking for information about a patient. Under which condition can the nurse release information to the caller? a. The caller is related to the patient. b. The psychiatrist approves the request. c. The caller is a mental health professional. d. The patient has given written consent for release of information.
ANS: D Patient information is privileged. Information cannot be released without consent signed by the patient. None of the other conditions is sufficient. DIF: Cognitive level: Applying REF: p. 27 TOP: Nursing process: Implementation MSC: NCLEX: Safe, Effective Care Environment
13. An involuntarily admitted inpatient with paranoid schizophrenia repeatedly calls the local mayor. The patient verbally abuses the person who answers the phone as well as the mayor. Select the most appropriate initial nursing intervention. a. Allow the patient to continue to use the phone. b. Include the patient in a social skills building group. c. Suspend the patient's phone privileges temporarily, and document the reason. d. Ask the patient advocate to review the limits of the patient's rights with the patient.
ANS: C The nurse should document that the patient's calls violated the rights of others, thus providing a basis for temporary suspension of the right to make phone calls to the mayor's office. Allowing continued calls violates the rights of others. It might require several days for the advocate to meet with the patient. DIF: Cognitive level: Analyzing REF: pp. 29-30 TOP: Nursing process: Implementation MSC: NCLEX: Safe, Effective Care Environment
A patient has delusions of persecution and hears voices saying, "You are worthless." The nurse who uses Selye's stress-adaptation model would assess these symptoms as arising from which stage? a. Alarm b. Resistance c. Exhaustion d. Reappraisal
ANS: C The scenario describes behaviors seen in the stage of exhaustion. The stage of exhaustion is characterized by exaggerated and dysfunctional defenses, personality disorganization, illogical thinking, delusions and hallucinations, and reduced orientation to reality. Alarm behaviors are demonstrated by flight-or-fight reactions. Resistance behaviors include increased use of coping and defense mechanisms. Reappraisal is not a stage of the stress-adaptation model.
A recently divorced parent attending a stress management class says, "I need to keep myself together, but I'm having difficulty thinking straight." The parent reports frequent headaches, neck tension, and a moderate level of anxiety. This patient is probably in which stage of the general adaptation syndrome? a. Panic. b. Alarm. c. Resistance. d. Exhaustion.
ANS: C The scenario is most consistent with the stage of resistance. In the stage of resistance, individuals strive to adapt to stress. Problem solving is difficult, but not impossible with assistance. Psychosomatic symptoms often appear. Anxiety is usually assessed as moderate to severe. Panic is reflected by complete disorganization and is not considered a stage of the stress-adaptation model. Alarm is characterized by flight-or-fight behaviors. Exhaustion is characterized by severe to panic level anxiety.
The parent of a 4-year-old child rewards and praises the child for helping a sibling, being polite, and using good manners. The nurse supports the use of praise because these qualities will likely be internalized and become part of the child's: a. id. b. ego. c. superego. d. preconscious.
ANS: C The superego contains the "thou shalts," or moral standards internalized from interactions with significant others. Praise fosters internalization of desirable behaviors. The id is the center of basic instinctual drives, and the ego is the mediator. The ego is the problem-solving and reality-testing portion of the personality that negotiates solutions with the outside world. The preconscious is a level of awareness from which material can be retrieved easily with conscious effort.
3. A nurse is preparing to present a discussion to a group of nursing students on meeting the needs of the mentally ill. What concerns should be identified as the focus of society's concerns during both the Period of Enlightenment and the Period of Community Mental Health? a. Moving patients out of asylums b. Studying brain structure and function c. Meeting basic human needs humanely d. Providing medication to control symptoms
ANS: C The use of asylums signaled concern for meeting basic needs of the mentally ill, who in earlier times often wandered the countryside. With deinstitutionalization, many patients who were poorly equipped to provide for their own needs were returned to the community. The current system must now concern itself with ensuring that patients have such basic needs as food, shelter, and clothing. Studying brain structure and function is more a concern of modern times, as is t
1. A patient is hospitalized for severe depression. Knowing that the patient will be discharged after a short stay, what is the nurse's first priority? a. Maximize the benefits of milieu management. b. Immediately begin to explore acute patient issues. c. Develop a goal-directed, problem-centered relationship. d. Choose a specific theoretical model as the basis for care.
ANS: C Therapeutic relationships are planned, patient-centered, and goal-directed. This is of particular importance if progress is to be made when the duration of the relationship will be brief. The other options are not the priority. Exploration of patient issues requires trust development before it can proceed.
36. Select the best outcome for a nurse to include in the care plan for a withdrawn patient who says, "I would like to have more friends." Within 3 days, the patient will: a. be more outgoing. b. develop greater independence. c. participate in one group activity. d. increase socialization with others.
ANS: C This outcome is behavioral, measurable, and related directly to the problem of social isolation. The other outcomes are neither measurable nor relevant to socialization.
15. An inpatient says, "Last time I was here, a primary nurse talked with me every day. This time, different nurses work with me. How can I make progress?" Select the nurse's best response. a. "Your comments are interesting. With your permission I will share them with the treatment team." b. "We are using a new system because of managed-care requirements. We are hopeful it will be effective." c. "Shift reports, care plans, and progress notes help different nurses work with all patients toward their individual goals." d. "It sounds like you are feeling dissatisfied with your care. After you are discharged, you will receive a form to provide feedback."
ANS: C This reply explains how many nurses are able to share responsibility and accountability for the care of patients. Good communication enables the nurses to be "on the same page" when it comes to working toward the achievement of patient-centered goals that are appropriate for each stage of the nurse-patient relationship. The other options fail to provide the information the patient needs to understand the current practices.
21. A nurse says, "What step would you like to take next to resolve this issue?" The patient stands up and shouts, "You are so controlling! You want me to do everything your way." What is the likely basis of the patient's behavior? a. Projection b. Dissociation c. Transference d. Emotional catharsis
ANS: C Transference involves a patient's emotional reaction to the nurse that is actually based on an earlier relationship or experience. In this case, the transference is negative and might be related to an earlier experience with an authority figure. Although projection is a possibility, it is less obvious. Dissociation and emotional catharsis do not apply.
19. To reduce the risk of a lawsuit based on false imprisonment, mental health nurses must give the highest priority to which intervention? a. Educating patients about unit protocols b. Providing adequate treatment during hospitalization c. Selecting the least restrictive treatment environment that will be effective d. Ensuring that patients have probable-cause hearings within 24 hours of admission
ANS: C Treating a patient in the least restrictive environment that will be effective lessens the threat of the patient bringing civil suit for false imprisonment. In the least restrictive environment the disruption to patient rights is minimized. Providing information about unit rules and providing adequate treatments are of less immediate importance than ensuring the least restrictive alternative. Probable-cause hearings are necessary only in certain cases. DIF: Cognitive level: Analyzing REF: p. 24 TOP: Nursing process: Planning MSC: NCLEX: Safe, Effective Care Environment
20. A patient whose behavior has continued to escalate despite nursing interventions begins to kick and strike out at the nurse. What is the priority nursing intervention? a. Offer an oral PRN medication. b. Have staff stand by at a distance. c. Physically control the patient's behavior. d. Allow the behavior until the patient de-escalates.
ANS: C When a patient loses control, staff must take physical control to prevent injury to the patient or others. A determination must then be made as what measures are necessary (intramuscular medication, involuntary seclusion, or restraint), keeping in mind the importance of using the least restrictive alternatives that will achieve the goal of safety.
4. As a patient and nurse move into the working stage of a therapeutic relationship, the nurse's most beneficial statement is: a. "I want to be helpful to you as we explore your problems and the way you express feelings." b. "A good long-term goal for someone your age would be to develop better job- related skills." c. "Of the problems we have discussed so far, which ones would you most like to work on at this time?" d. "When someone gives you a compliment, I notice that you become very quiet and appear uncomfortable."
ANS: C With this remark, the nurse seeks patient collaboration and offers the opportunity to set priorities for the work toward change that will be undertaken. The distracters relate to the orientation stage.
2. A patient diagnosed with bipolar disorder is admitted involuntarily during a manic phase. Lithium 300 mg PO t.i.d. is prescribed. The patient refuses the morning dose. What are the nurse's best actions? Select all that apply. a. Get the prescription changed to an elixir, and administer it in juice. b. Assemble adequate help to force the patient to take the medication. c. Educate the patient about the importance of lithium in stabilizing the mood. d. Allow the patient to refuse the medication, and document the patient's comments. e. Inform the patient that unit privileges are contingent on taking prescribed medications.
ANS: C, D Patients have the right to refuse consent to treatment, including medication administration. The courts have ruled that neither voluntary nor involuntary patients can be forced to take psychotropic medication. Hiding the medication in food or fluids is not ethical. Assembling a show of force implies that forcible administration will occur. Making privileges contingent on medication ingestion is coercion. DIF: Cognitive level: Analyzing REF: p. 29 TOP: Nursing process: Implementation MSC: NCLEX: Safe, Effective Care Environment
A student goes to a party the night before a test and then fails the exam. After seeing the score, the student slams a book on the table and says, "I have to work so much and have no time to study. It wouldn't matter anyway because the teacher is unreasonable." The nurse identifies use of which defense mechanisms? Select all that apply. a. Denial b. Compensation c. Rationalization d. Projection e. Displacement f. Reaction formation
ANS: C, D, E The student slams down the book, displacing anger, rationalizes (makes excuses), and projects blame onto the teacher. Compensation involves making up for a perceived weakness by emphasizing a desirable trait. Projection refers to blaming others or attributing unacceptable thoughts to behaviors to others. Reaction formation involves doing the opposite of an unacceptable desire.
4. An adult diagnosed with chronic depression is hospitalized after a suicide attempt. Which intervention is critical in assuring long-term, effective client care as described by psychotherapeutic management? a. Involvement in group therapies b. Focus of close supervision by the unit staff c. Maintaining effective communication with support system d. Frequently scheduled one-on-one time with nursing staff
ANS: D A critical element of psychotherapeutic management is the presence of a therapeutic nurse-patient relationship. One-on-one time with nursing staff will help in establishing this connection. While the other options are appropriate and client centered, the nurse-client relation is critical in the long-term delivery of quality effective care to this client.
10. Which situation is an example of a tort? a. The primary nurse does not complete the plan of care for a patient within 24 hours of the patient's admission. b. An advanced-practice nurse recommends that a patient who is dangerous to self and others be voluntarily hospitalized. c. A patient's admission status is changed from involuntary to voluntary after the patient's hallucinations subside. d. A nurse gives a PRN dose of an antipsychotic drug to a patient to prevent violent acting out because the unit is short staffed.
ANS: D A tort is a civil wrong against a person that violates his or her rights. Giving unnecessary medication for the convenience of staff controls behavior in a manner similar to secluding a patient; thus false imprisonment is a possible charge. The other options do not exemplify torts. DIF: Cognitive level: Understanding REF: pp. 22, 24 TOP: Nursing process: Evaluation MSC: NCLEX: Safe, Effective Care Environment
19. An individual diagnosed with schizophrenia has a history of medication nonadherence. When inpatient psychiatric care is not indicated, which service is the preferred referral? a. Primary care b. Outpatient counseling c. Apartment residential living d. A group home with 24-hour supervision
ANS: D Although inpatient hospitalization is unnecessary, the individual requires an environment in which medication compliance can be fostered. In this case, the group home would provide the best alternative. The other options do not provide adequate supervision.
20. A patient diagnosed with bipolar disorder has stabilized and is being discharged from the hospital. The patient will live independently at home but lacks social skills and transportation. Which referral would be most appropriate? a. A group home b. A self-help group c. A day treatment program d. Assertive community treatment (ACT)
ANS: D Assertive community treatment (ACT) provides intensive supervision, which includes assistance with medications and transportation that would support the goal of minimizing future hospitalizations. A group home is unnecessary, because the patient will reside at home. A day treatment program would provide a therapeutic program directed toward symptoms, but the patient's symptoms have stabilized so this service is not indicated. A self-help group would not provide the intensity of service this patient needs.
11. When a nurse working in a well-child clinic asks a parent's address, the parent responds, "My children and I are homeless." What assumption should the nurse make of this response? a. It is a common occurrence, because 1 out of 50 children are homeless. b. It signals a need to investigate the possibility that the parent has severe mental illness. c. Confirms that evidence of child abuse or neglect that should be reported to social service agencies. d. Suggests that the parent may have substance abuse problem.
ANS: A The current belief is that the homeless are people (including entire families) who have been displaced by social policies over which they have no control. One out of 50 children is homeless. Although homelessness might be associated with serious mental illness, it might also be the result of having a weak support system and of social policies over which the individual or family has no control. No assumption should be made about the existence of child or substance abuse.
A 26-month-old child displays negative behaviors. The parent says, "My child refuses toilet training and shouts 'No!' when given direction. What do you think is wrong?" Select the nurse's best reply. a. "This is normal for your child's age. The child is striving for independence." b. "The child needs firmer control. Punish the child for defiance and saying 'no.'" c. "There may be developmental problems. Most children are toilet trained by age 2." d. "Some undesirable attitudes are developing. A child psychologist can help you develop a remedial plan."
ANS: A The distracters indicate that the child's behavior is abnormal when, in fact, this behavior is typical of a child around the age of 2 years whose developmental task is to develop autonomy.
A nurse supports a patient's ego. This intervention is therapeutic because the individual's ego: a. provides rational, logical reality testing. b. is primarily concerned with right and wrong. c. uses primary process imagery to meet basic needs. d. is derived from the individual's pattern of thinking.
ANS: A The ego focuses on the reality principle and uses secondary process thinking, a logical, rational operation to maintain the well-being of the individual. The superego is concerned with right and wrong. The id uses primary process. Ego formation is influenced by heredity, environment, and maturation.
Select the goal most likely to be chosen for a patient by a nurse who uses the interpersonal model as a basis for practice. The patient will: a. develop mature, satisfying relationships that are relatively free of anxiety. b. rid self of irrational beliefs, including "shoulds," "oughts," and "musts." c. learn to meet basic needs responsibly. d. manage stress adaptively.
ANS: A The goal of interpersonal therapists is to assist the patient in developing healthy interpersonal relationships that are relatively anxiety-free. The other distracters state a goal appropriate for cognitive therapy, reality therapy, and stress management therapy, respectively.
22. When explaining risk assessment, the nurse would indicate that the highest priority for admission to hospital-based care is associated with which goal? a. Safety of self and others b. Minimal confusion and disorientation c. Successful withdrawal from harmful substances d. Management of medical illness complicating a psychi
ANS: A The highest priority is safety. In the other situations, threats to safety might or might not exist.
37. Following the admission interview, a spouse of a patient asks the nurse, "Why did you ask my partner all those questions? Some of them had nothing to do with current problems." The nurse's best response is, "Those questions help us understand: a. the patient's current status." b. the complete family history." c. the patient's past experiences." d. what the patient's prognosis will be."
ANS: A The mental status examination (MSE) is designed to provide information about the patient's current level of functioning. Other specific information might be obtained that contributes to the overall picture. The MSE does not provide information relating to the other options.
11. Two divorced people plan to marry. The man has a teenager, and the woman has a toddler. This family will benefit most from: a. guidance about parenting at two developmental levels. b. role-playing opportunities for conflict resolution. c. formal teaching about problem-solving skills. d. referral to a family therapist.
ANS: A The newly formed family will be coping with tasks associated with the stages of rearing preschool children and dealing with teenagers. These stages require different knowledge and skills. There is no evidence of a problem, so the distracters are not indicated.
21. A nurse at the mental health center prepares to administer a scheduled injection of haloperidol decanoate (Haldol depot injection) to a patient diagnosed with schizophrenia. As the nurse swabs the site, the patient shouts, "Stop, stop. I don't want to take that medicine anymore. I hate the side effects." Select the nurse's first action. a. Stop the medication administration procedure and say to the patient, "Tell me more about the side effects you've been having." b. Proceed with the injection but explain to the patient that there are medications that may help reduce the unpleasant side effects. c. Say to the patient, "Since I've already drawn the medication in the syringe, I'm required to give it, but let's talk to the doctor about delaying next month's dose." d. Notify other staff to report to the room for a show of force, and proceed with the injection, using restraint if necessary.
ANS: A The nurse, as an advocate and educator, should seek more information about the patient's decision and should not force the medication. Patients with mental illness retain their civil rights unless there is clear, cogent, and convincing evidence of dangerousness. The patient in this situation presents no evidence of dangerousness. It is not reasonable to promise a reduction in side effects without first discussing them, nor is it appropriate to pressure the patient into taking the medication. The medication cannot be given without the patient's informed consent. DIF: Cognitive level: Analyzing REF: p. 29 TOP: Nursing process: Implementation MSC: NCLEX: Safe, Effective Care Environment
16. A patient takes a psychotropic medication that affects serotonin receptors. The patient complains of anxiety, insomnia, and loss of appetite. What effect is the drug having on the serotonin receptors? a. Activation b. Antagonism c. Paradoxical d. Inhibition
ANS: A The patient's complaints indicate activation of serotonin receptors. None of the other options correctly identifies this effect.
4. Select the most appropriate comment by the nurse when a depressed patient says, "What's the use in going on?" a. "Are you thinking about suicide?" b. "I am not sure I understand what you are saying." c. "Keep your hope alive. It's always darkest just before light." d. "Tell me more about your activities before you got depressed."
ANS: A The possibility of suicide must be openly addressed. The patient often feels relieved to be able to talk about suicidal ideation. The subject must be addressed directly.
8. A realistic outcome of patient teaching about psychotropic medication is that the patient will: a. understand physiologic responses to drug therapy. b. assess effectiveness of prescribed drugs in controlling symptoms. c. describe onset, peak, and duration of action of each drug prescribed. d. state the purpose, dose, and significant side effects of each drug prescribed.
ANS: D The correct response identifies basic information that each patient should have. Because the information is basic, the outcome, as stated, is realistic. The other options are less basic and less attainable.
19. A patient's behavior has continued to escalate despite nursing interventions designed to achieve de-escalation. The patient begins to kick and strike at staff. This behavior evidences which phase of the assault cycle? a. Triggering b. Depression c. Escalation d. Crisis
ANS: D The crisis phase is characterized by a patient's loss of self-control with fighting, hitting, kicking, scratching, biting, and throwing things. Each of the other phases has selected characteristics, none of which were described in the scenario.
4. Which information is the nurse most likely to find when assessing the family of a patient with a serious and persistent mental illness? a. The family exhibits many characteristics of dysfunctional families. b. Several family members have serious problems with their physical health. c. Power in the family is maintained in the parental dyad and rarely delegated. d. The stress of living with a mentally ill individual has negatively affected family function.
ANS: D The information almost universally obtained is that the family is under stress associated with having a mentally ill member. This stress lowers the family's level of functioning in at least one significant way. Stress does not necessarily mean the family has become dysfunctional.
5. A nurse counsels a patient who made a suicide attempt 3 days ago. Select the nurse's most therapeutic comment. a. "I'm glad you voluntarily admitted yourself to the hospital. We can help you here." b. "When you have bad feelings, try to remember the good things about your life." c. "You must take control of your problems and try to find solutions." d. "Let's discuss some ways to solve your most important problem."
ANS: D The nurse helps the patient to develop effective coping skills. Assist the patient to reduce the overwhelming effects of problems by generating and testing ways to solve them. The distracters present overwhelming approaches to problem solving.
10. A patient with a history of self-mutilation says to the nurse, "I want to stop hurting myself." What is the initial step of the problem-solving process to be taken toward resolution of a patient's identified problem? a. Deciding on a plan of action b. Determining necessary changes c. Considering alternative behaviors d. Describing the problem or situation
ANS: D The nurse learns how well the patient understands the problem by asking for a detailed, in-depth description of situations, thoughts, feelings, and behaviors relevant to the identified problem. This step must be completed before moving through the problem-solving process. The other actions are premature.
3. A patient diagnosed with schizophrenia says to the nurse, "I feel really close to you. You're the only true friend I have." Select the nurse's most therapeutic response. a. "We are not friends. Our relationship is a professional one." b. "I feel sure there are other friends in your life. Can you name some?" c. "I am glad you trust me. Trust is important for the work we are doing together." d. "Our relationship is professional, but let's explore ways to strengthen friendships."
ANS: D The patient's remarks call for the nurse to remind the patient of the parameters of their relationship and take the opportunity to discuss the issue of friends. Only this option incorporates both desired elements.
A patient says, "It's my fault because I always make bad decisions. I should never have taken that job." Using a rational-emotive approach, how would the nurse respond? a. "What can you do to solve your problems at work?" b. "You're experiencing a great deal of stress right now. How can you manage it more effectively?" c. "Can you describe a time in your childhood when your parents blamed you for things you didn't do?" d. "Consider the words you are using to talk about yourself. Let's try to change those words to more positive ones."
ANS: D The therapist using rational-emotive therapy helps the patient identify irrational thoughts and replace them with new, more positive self-statements to enable the patient to think, feel, and behave differently. The other options do not make use of the combination of cognitive, emotive, and behavioral components.
5. The patient's parent asks the nurse, "Why do you want to do a family assessment? My child is the patient, not the rest of us." Select the nurse's best response. a. "Family dysfunction might have caused the mental illness." b. "Family members provide more accurate information than the patient." c. "Family assessment is part of the protocol for care of all patients with mental illness." d. "Every family member's perception of events is different and adds to the total picture."
ANS: D This response helps the family understand that the opinions of each will be valued. It allows the nurse to assess individual coping and prepares the family for the experience of working together to set goals and solve problems. The other responses are either incorrect or evasive.
9. A novice nurse on an inpatient psychiatric unit says to a colleague, "My newest patient has been diagnosed with schizophrenia. At least I won't have to monitor for a suicide risk." Select the colleague's most accurate response. a. "Our structured milieu provides a safe environment for all patients, regardless of their suicide risk." b. "Delusions usually protect a patient with schizophrenia from thinking about suicide." c. "Suicide is a higher risk for adolescents than for patients with schizophrenia." d. "Any mental illness substantially increases the risk of suicide."
ANS: D Up to 15% of patients with schizophrenia and other mental illnesses die from suicide, more than adolescents or older adults. Delusions offer no protection.
15. A patient backs into a corner of the room and shouts at the nurse, "Stay away from me." Select the best initial nursing intervention in this situation. a. Obtain an order for seclusion. b. Administer a PRN antipsychotic drug. c. Call for assistance to physically restrain the patient. d. Talk to the patient in a calm, nonthreatening manner.
ANS: D Verbal intervention provides the least restrictive alternative in this situation. Verbal intervention might halt escalation and prevent the need for medication or the use of restraint or seclusion. Seclusion, restraint, and medication usage are all more restrictive than verbal intervention. DIF: Cognitive level: Analyzing REF: p. 28 TOP: Nursing process: Implementation MSC: NCLEX: Safe, Effective Care Environment
MR 1. Which guidelines should be included by the nurse who will provide staff development training to unlicensed assistive personnel about psychotherapeutic management? Select all that apply. a. Support should be minimal to prevent development of dependence. b. Norms and limits are more important than individual needs. c. Hostility should run its course without staff interference. d. Plan opportunities to strengthen patients' self-esteem. e. Provide encouragement for patients in distress.
ANS: D, E Important guidelines include provision of encouragement, especially when patients are in distress, and strengthening patients' self-esteem. The other options are actually the opposite of accepted guidelines.
2. A patient tells the nurse, "I want to have sex with you." Which nursing responses are appropriate? Select all that apply. a. "I will forget you said that." b. "Your suggestion frightens me." c. "You must keep your distance." d. "Sex is not part of our relationship." e. "We are here to work on your problems."
ANS: D, E The correct responses provide information to the patient about the purpose of the relationship and recognize the underlying need. The other options are ineffective.
2. A community mental health nurse works in a mental health services system that is undergoing change to become a seamless system. To promote integrity of the new system, the nurse should focus on: (Select all that apply.) a. psychopathology. b. symptom stabilization. c. medication management. d. patient and family psychoeducation. e. patient reintegration into the community. f. holistic issues relating to patient care.
ANS: D, E, F A seamless system of mental health services will require new conceptualizations. Nurses will need to focus more on recovery and reintegration than on symptom stabilization and more on holistic issues such as finances and housing than on medication management. Consumers and family members will also need to be provided with extensive psychoeducation.
After being informed of a diagnosis of lung cancer, a patient says in a cheerful voice, "I feel fine. I will do some reading online about it. Right now, I want to take a nap." The nurse assesses the use of which defense mechanisms? Select all that apply. a. Repression b. Undoing c. Introjection d. Reaction formation e. Intellectualization f. Suppression
ANS: D, E, F The cheerful voice is probably the result of reaction formation. The wish to read more about the diagnosis reflects intellectualization. Taking a nap is suppression and allows the patient to avoid having to think about the problem. Repression results in unconscious forgetting. Undoing involves doing something to make up for an unacceptable act. Introjection is incorporating values and attitudes of others as if they were one's own.
7. An adult diagnosed with schizophrenia is being discharged from a state mental hospital after 20 years of institutionalization. What intervention should the nurse include in discharge planning to best manage the relapse of symptoms? a. Discuss methods to assist in the transition from hospitalization to community. b. Encourage the client to use community support services. c. Evaluate the client's ability to effectively self-administer antipsychotic medications as prescribed. d. Educate the client and family to the likely need for crisis or emergency psychiatric interventions from time to time.
ANS: D Patients with serious mental illness are rarely considered cured at the time of hospital discharge. Decompensation is likely from time to time, even when good community support is provided. While the remaining options are appropriate, none will affect relapse manage more than an understanding that relapse care will likely be necessary.
A parent said, "My child had mal ojo, so I did not give her the medicine for an ear infection." The nursing diagnosis of noncompliance was documented by the nurse who saw the child last. A culturally competent nurse would analyze that the situation occurred because of: a. lack of knowledge of therapeutic regimen. b. differences in perceptions of how illness occurs. c. evidence of unconscious hostility toward the child. d. a misunderstanding about the communicability of microbes.
B A parent who believes that his or her child's illness is the result of a spell cast on him or her will not understand the need for giving the child medication on a regular basis for several days. Diagnosing noncompliance will not help resolve the problem. Cultural negotiation and repatterning will be necessary. The other options do not present viable explanations.
A patient diagnosed with schizophrenia says, "I am a reincarnation of Jesus. I can raise the dead." The most qualified person for the nurse to refer the patient would be a: a. psychiatric nurse clinician. b. professional chaplain. c. clinical psychologist. d. community minister.
B A professional chaplain holds a ministerial degree and has had a year of special study in ministering to individuals with spiritual concerns related to health problems. The other professionals have less knowledge and experience in dealing with the dual problems of mental illness and spiritual concerns.
1. A newly licensed asks a nursing recruiter for a description of nursing practice in the psychiatric setting. What is the nurse recruiter's best response? a. "The nurse primarily serves in a supportive role to members of the health care delivery team." b. "The multidisciplinary approach eliminates the need to clearly define the responsibilities of nursing in such a setting." c. "Nursing actions are identified by the institution that distinguishes nursing from other mental health professions." d. "Nursing offers unique contributions to the psychotherapeutic management of psychiatric patients."
ANS: D Professional role overlap cannot be denied; however, nursing is unique in its focus on and application of psychotherapeutic management. Neither the facility nor the multidisciplinary team define the professional responsibilities of its members but rather utilizes their unique skills to provide holistic care. Ideally, all team members support each other and have functions within the team.
13. The nurse reads this information in a patient's record: history of agranulocytosis from antipsychotic medication; victim of childhood sexual abuse; weight loss of 27 lb in 3 months; parent diagnosed with bipolar disorder. Which item would be classified as a psychodynamic factor associated with the patient's mental illness? a. History of agranulocytosis from antipsychotic medication b. Parent diagnosed with bipolar disorder c. Weight loss of 27 lb in 3 months d. Victim of childhood sexual abuse
ANS: D Psychodynamic causes of mental illness arise from "nurture"—for example, childhood sexual abuse. The distracters are of biologic ("nature") etiology.
A patient tells the nurse, "The reason I use drugs is because everybody nags me to do things that don't interest me." The patient shows use of which defense mechanism? a. Sublimation b. Introjection c. Identification d. Rationalization
ANS: D Rationalization is an attempt to prove that one's behaviors or feelings are justifiable and involves making justifications of feelings or behaviors. Sublimation channels instinctual drives into acceptable channels. The patient is not modeling after another person or incorporating another's values.
A patient is mute, curled in a fetal position, and incontinent of urine. The patient eats small amounts only if spoon-fed. The nurse assesses this behavior as most indicative of: a. displacement. b. compensation. c. conversion. d. regression.
ANS: D Regression is defined as the return to an earlier, more comfortable developmental state—in this case, infancy. Displacement involves discharging feelings to a less threatening object. Compensation refers to covering a weakness by overemphasizing a desirable trait. Conversion refers to the unconscious expression of conflict symbolically through physical symptoms.
20. Which option describes a healthy family? a. One parent takes care of the children. The other parent earns income and maintains the home. b. A family has strict boundaries that require members to address problems inside the family. c. A couple requires their adolescent children to attend church services three times a week. d. A couple renews their marital relationship after their children become adults.
ANS: D Revamping the marital relationship after children move out of the family of origin indicates that the family is moving through its stages of development. Strict family boundaries or roles interfere with flexibility and the use of outside resources. Adolescents should have some input into deciding their activities.
12. Social-psychological models describe aggression as: a. intentional harm toward others. b. an unhealthy way of managing anxiety. c. a conflict with others expressed aggressively. d. a response to frustration in the social environment.
ANS: D Social-psychological models of aggression focus on the interaction of individuals with their environment and locate the source of anger in interpersonal requirements and frustrations. The other options are not consistent with this model.
4. Which assessment finding should be documented as subjective information? a. Flushed face b. White blood cell (WBC) count 12,000 cells/μL c. Lithium level 1.2 mEq/L d. Reports of abdominal pain
ANS: D Subjective data are what the patient relates to the nurse such as reports of pain. Objective data are measurable data obtained by the nurse.
7. A patient tells the nurse, "When I get out, I'm going to get even with a lot of people." With respect to the nurse's duty to warn, the nurse should: a. take no action on a general threat. b. notify local law enforcement officials. c. warn close relatives and significant other. d. document and discuss the threat with the clinical team.
ANS: D The Tarasoff ruling specifies that a specific threat to a readily identifiable person or persons must be made. In this situation, the threat is nonspecific. The prudent action is to document and discuss with the clinical team to determine the need for providing a warning to third parties. DIF: Cognitive level: Applying REF: pp. 23-24 TOP: Nursing process: Implementation MSC: NCLEX: Safe, Effective Care Environment
During an interdisciplinary team meeting, a nurse says, "The patient's psychological distress seems to result from automatic thoughts that cause self-defeating behaviors." The nurse is conceptualizing the patient's problem from the viewpoint of which model? a. Interpersonal b. Psychoanalytic c. Stress-adaptation d. Cognitive-behavioral
ANS: D The cognitive-behavioral model recognizes the role of automatic thoughts (irrational beliefs) in promulgating self-defeating behaviors. The information given in the scenario does not reflect conceptualization using any of the other models.
A nurse is scheduled to interview a new patient, a Muslim college professor from the Middle East. Which action by the nurse would support cultural competence? a. Serve the patient a cold beverage at the beginning of the interview. b. Review Middle Eastern cultural values before the interview. c. Avoid offering to shake hands with the patient. d. Determine if a translator is available.
B Brushing up on Middle Eastern culture would be a sensitive action that might result in a lowering of barriers between the nurse and patient. It would not be necessary to serve beverages during the interview. A translator would probably not be needed if the patient is a college professor. Shaking hands with Middle Easterners is acceptable.
Culture is defined as a group's shared: a. race and ethnicity. b. values, beliefs, and norms. c. biologic variations and psychological characteristics. d. patterned behavioral responses that developed over time.
B Culture is the internal and external manifestation of a person's, group's, or community's learned and shared values, beliefs, and norms that are used to help individuals function in life and understand and interpret life occurrences. None of the other responses provides an adequate explanation of culture, because all are too narrow in scope.
9. Which nursing intervention is associated with a shift in the psychiatric nursing focus during the community mental health period of the 1960s? a. De-emphasizing the high numbers of people seeking treatment b. Making substance abuse the primary focus of care c. Focusing services on persons with serious mental illness d. Assessing the client's potential for improvement
ANS: D The community mental health movement brought with it a broadening of areas of concern to the psychiatric nurse. It became acceptable, even desirable, for psychiatric nurses to focus on what was called the worried well, as opposed to providing care for acutely ill psychotic individuals. Neither disillusionment with the numbers seeking treatment nor providing more services to those with severe mental illness occurred.
A Korean-American patient showed rare eye contact. This nursing diagnosis was formulated: Chronic low self-esteem related to shame and guilt as evidenced by lack of eye contact. Interventions were sought to improve the patient's self-esteem, but after 3 weeks the patient's eye contact was unchanged. Select the accurate analysis of this scenario. a. The patient's poor eye contact indicated anger and hostility that did not resolve. b. The nurse should have assessed the patient's culture before formulating this diagnosis and plan. c. Resolution of shame and guilt cannot be expected to occur in 3 weeks. The nurse should allow more time. d. The patient's eye contact should have been directly addressed by role-playing to increase comfort with eye contact.
B The amount of eye contact a person engages in is often culturally determined. In some cultures eye contact is considered insolent, whereas in others eye contact is expected and valued. Korean-Americans often prefer not to engage in direct eye contact.
On the admission papers, a patient checked the box labeled "No religious affiliation." What meaning can the nurse draw from this information? The patient: a. is not religious. b. is probably monotheistic. c. has conventional religious values. d. is probably experiencing spiritual distress.
B The correct answer is consistent with the beliefs of 80% of Americans: there is one Supreme Being. The distracters offer misinformation and misinterpretation about the meaning of "No religious affiliation."
A patient diagnosed with schizophrenia complains of demon voices coming through the television. Which statement by the nurse providing spiritual care would be most comforting to the patient? a. "Rest assured that God will fill your heart with peace." b. "I am concerned about your spiritual distress." c. "God will hold you in the palm of His hand." d. "God knows your every thought."
B The correct answer shows compassion and caring on the part of the nurse and contributes to trust building. The nurse has offered concerns, which reassures the individual that he or she will not be abandoned. The other options each include abstract concepts that are difficult for someone who thinks concretely to interpret correctly. They might even be frightening to patients who think concretely.
A patient with major depression shows the nurse a passage in the Bible and says, "How do you think this verse relates to me?" The nurse is unfamiliar with the verse and unsure how to respond. Select the nurse's best action. a. Ask the patient, "What do you think the verse means?" b. Invite professional clergy to join the dialogue with the patient. c. Explain to the patient, "I'm not familiar with that passage. It would be better for me not to comment." d. Say to the patient, "Would you bring that up in the group session? You can get input from several people about what the verse means."
B The correct answer shows that the nurse recognizes personal limits but remains engaged in the interaction with the patient. The distracters reject the patient's concerns.
A nurse cares for patients who recently immigrated to the United States. The nurse would expect patients from which countries to hold relational worldviews? Select all that apply. a. Germany b. Panama c. Mexico d. Ghana e. France
B, C, D Persons of Hispanic and African-American cultures often hold relational worldviews. Mexico and Panama are predominantly Hispanic cultures. Ghana is African. Immigrants from Germany and France (European countries) would more likely have analytic worldviews.
What information about a patient's perceptions and values would the nurse obtain by using questions from the HOPE tool? Select all that apply. a. Healthy spirituality versus sick religiosity b. That which gives the patient hope and meaning in life c. Important personal spiritual practices d. Role of religion in the patient's life e. Sources of strength and comfort
B, C, D, E The HOPE questions gather information about sources of hope, strength, comfort, meaning, peace, love, and connection; the role of organized religion for the patient; personal spirituality and practices; and effects on medical care and end-of-life decisions.
A patient moans, "God wants me to suffer, but I don't know why. I feel like an outcast. I should have never been born." Which nursing diagnosis applies? a. Potential for enhanced spiritual well-being b. Disturbed personal identity c. Spiritual distress d. Powerlessness
C Defining characteristics for the nursing diagnosis of spiritual distress are present. They include concern with the meaning of life, anger toward God, questioning the meaning of suffering, conflict about beliefs, and questions about the morality of the therapeutic regimen. Spiritual distress is more applicable to the patient's comments than the other diagnoses.
3. Sequence these expressions of suicidality from least to most acute. a. Threat b. Gesture c. Ideation d. Attempt e. Completion
C, A, B, D, E Suicidality exists on a continuum, beginning with ideation and then progressing to threats, gestures, attempts, and finally completed suicide.
An African-American patient tells a nurse with a European-American worldview, "There's no sense talking. You wouldn't understand because you live in a white world." Select the nurse's best response. a. "Nurses are educated to care for people from all cultures. It is a required component of nursing education." b. "It would be helpful if you described an example of something you think I would not understand." c. "Your mental illness is causing you to view me with prejudice. We are all here to help you." d. "Yes, I do understand. Everyone goes through the same experiences."
B Having the patient speak in specifics rather than globally will help the nurse understand the patient's perspective. This approach will help the nurse establish rapport with the patient. False reassurances will not facilitate communication with the patient.
A patient of Cuban descent is hospitalized with depression. Which factor is most applicable to care planning? a. The nurse should confer with the family's oldest woman, who will serve as the primary decision maker. b. With the patient's permission, the nurse should consult with family and religious advisors to plan care. c. The plan of care should incorporate use of meditation and contemplation techniques. d. Western medical treatment will be readily accepted by the patient.
B Patients of Hispanic cultures often have relational worldviews. Individuals who have a relational worldview usually desire the involvement of family, religious advisors, and even friends during health care visits and the planning of interventions. The patient's consent is required for this involvement. The other options reflect alternative worldviews.
An African-American caregiver says, "Both of my parents have dementia. I find it so difficult to care for them because of their disabilities. I get depressed and hopeless thinking about it. Can you give me any suggestions for coping?" Before making suggestions, the nurse should assess: a. the parents' stage of dementia. b. the caregiver's religious ideology. c. whether or not the parents' medications are helping. d. if financial resources are sufficient to provide a health care aide.
B Serious illness of loved ones often presents difficult dilemmas and problems in adjustment for caregivers. It is known that religious activities are important coping mechanisms for many African-American caregivers of older adults. The correct answer is the only option directly concerned with caretaker coping. The foci of the other options are on the parents.
A nurse cares for a first-generation American whose family emigrated from Germany one generation ago. This patient would probably have which worldview about the source of knowledge? a. Knowledge is acquired through use of affective or feeling senses. b. Knowledge is acquired according to proof of existence. 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 The European-American perspective of acquiring knowledge evolves through acquiring proof that something exists using the personal senses. The distracters describe the beliefs of other cultural groups.
A Hispanic parent says, "An old woman gave my baby the evil eye." The health care provider determines that the infant is physically healthy. The most culturally competent intervention would be to: a. tell the parent that the baby is healthy and needs no treatment. b. explain that the evil eye is a superstition and not a cause of illness. c. encourage the parent to immerse the baby in cool water baths daily. d. bring a root doctor into the consultation to restore the baby's lost soul.
D An individual who believes in mal ojo will also believe that Western medicine is ineffective to treat it. This person will believe that because the illness has an unnatural cause, treatment is best conducted by a native healer who can remove the spell. The parent would not view offering no treatment or casting doubt on evil eye as a superstition as helpful, making these options culturally insensitive. A cool water bath could destabilize an infant's body temperature.
A nurse begins work at 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 Cultural competence is dependent on understanding the beliefs and values of members of a different culture. A nurse who works with an individual or group of a culture different from his or her own must be open to learning about the culture. The other options have little to do with cultural competence or represent only a portion of the answer.
Which therapeutic intervention should the nurse suggest for a patient with panic attacks and problems with concentration? a. Occupational therapy b. Medication education c. Recreational therapy d. Group therapy
a. Occupational therapy Occupational therapists prescribe activities that can help the patient increase concentration and focus. The other activities are not designed to increase concentration and attention span.
17. Regarding effective milieu management, the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) standards mandate what intervention? a. Orientation programs detail safety issues and precautions. b. Patients' room doors remain open during hours of sleep. c. Safety precautions are simple and apply commonsense behaviors. d. Patients' personal belongings are kept in secure areas under staff control.
a. Orientation programs detail safety issues and precautions.
18. Which adjective best characterizes custodial care? a. Paternalistic b. Beneficent c. Essential d. Safe
a. Paternalistic
Which research findings about the therapeutic environment of an inpatient psychiatric unit have implications for nursing practice? (Select all that apply.) a. Patients valued interactions with other patients. b. Patients perceived other patients as dissimilar from self. c. Hospitalization interferes with planning for the future. d. Patients failed to experience bonding with other patients. e. Hospitalization creates feelings of safety from self-destructiveness.
a. Patients valued interactions with other patients. e. Hospitalization creates feelings of safety from self-destructiveness.
A nurse prepares to lead an anger management group, which is what type of group? a. Psychoeducational b. Self-help c. Activity d. Support
a. Psychoeducational
The nurse administers a medication that potentiates the action of GABA. Which finding would be expected? a. Reduced anxiety. b. Improved memory. c. More organized thinking. d. Fewer sensory perceptual alterations
a. Reduced anxiety
A patient is withdrawn, suspicious, and maintains physical distance from staff and other patients. Which intervention demonstrates appropriate use of touch with this patient? a. Refraining from touch b. Patting the patient's arm when fear is expressed c. Reaching out to shake the patient's hand as an initial greeting d. Placing an arm around the patient's shoulders while walking down the hall
a. Refraining from touch
A nurse working on a geropsychiatric unit designs new clinical protocols. Which potential problems have the highest priority? a. Risks for falls b. Cognitive errors c. Memory deficits d. Nutritional deficits
a. Risks for falls Patients in geropsychiatric units have an especially high risk for falls. Safety is the nurse's priority concern.
A patient is diagnosed with severe depression. The nurse will prepare a plan to teach the patient about medications that improve brain availability of which neurotransmitter? Select all that apply. a. Serotonin b. Dopamine c. Norepinephrine d. Acetylcholine e. Substance P
a. Serotonin c. Norepinephrine Two neurotransmitters believed to be in low concentration at brain synapses of patients with depression are norepinephrine and serotonin. Most antidepressants act to increase availability of one or both of these neurotransmitters. Dopamine is implicated in schizophrenia; acetylcholine is implicated in Alzheimer's disease. Substance P modulates pain.
A patient has visual aphasia. The nurse can project that there is dysfunction in which cerebral lobe? a. Temporal b. Parietal c. Occipital d. Frontal
a. Temporal Temporal lobe lesion of the visual association area would result in visual aphasia, the inability to recognize previously known words
What is the best analysis of this described nurse-patient interaction? Patient: I get discouraged when I realize I've been struggling with my problems for over a year. Nurse: Yes you have, but many people take even longer to resolve their issues. You shouldn't be so hard on yourself. a. The nurse has responded ineffectively to the patient's concerns. b. The patient is expressing lack of willingness to collaborate with the nurse. c. The patient is offering the opportunity for the nurse to revise the plan of care. d. The nurse is using techniques that are consistent with the evaluation step of the nursing process.
a. The nurse has responded ineffectively to the patient's concerns
1. Which aspects of the environment of a psychiatric unit comply with JCAHO environment-of-care standards? (Select all that apply.) a. Visitor badges b. Identification badges for employees c. Telephones located in enclosed booths d. Requiring patients to wear hospital-issue clothing e. Guidelines for staff interaction with media representatives
a. Visitor badges b. Identification badges for employees c. Telephones located in enclosed booths
A patient in a support group says, "I'm tired of being sick. Everyone always helps me, but I'll be glad when I can help someone else." This statement reflects: a. altruism. b. universality. c. cohesiveness. d. corrective recapitulation.
a. altruism.
When assessing a patient, the nurse elicits the Babinski reflex on the left foot. The nurse can determine the existence of: a. an upper motor neuron lesion on the right side. b. an upper motor neuron lesion on the left side. c. a lower motor neuron lesion on the right side. d. a lower motor neuron lesion on the left side.
a. an upper motor neuron lesion on the right side. The Babinski sign is the result of an upper motor neuron lesion on the opposite contralateral side of the body
A patient sustained a severe injury to the temporal lobe auditory association area. Which nursing diagnosis should be considered for the patient? Impaired verbal communication
Damage to the auditory association area will result in the individual being unable to associate words that he or she hears with their meaning, thus making verbal communication difficult
3. Sequence the following historical events beginning with the evolution of psychotropic medications: a. SSRI antidepressants were developed. b. Drugs became available to treat patients diagnosed with Alzheimer's disease. c. Clozapine (Clozaril), the first atypical antipsychotic drug, was marketed. d. Chlorpromazine (Thorazine) was discovered.
Evolutionary events in the development of psychotropic drugs changed the care environment for patients with mental illness and had significant effects on the nurse's role.
The parent of an adopted infant tells the nurse, "Our baby was abused before the adoption. I read an article online that said this experience causes problems as a child grows up. What we should be alert for?" Select the nurse's best response. a. "Early trauma sometimes causes learning difficulties, anxiety, and difficulty handling stress later in life." b. "Early abuse causes the myelin covering of the nerves to overgrow, which leads to high anxiety and mood instability." c. "Many individuals who experience early trauma and abuse develop symptoms of schizophrenia." d. "Your child will be normal. Information in online articles is not reliable."
a. "Early trauma sometimes causes learning difficulties, anxiety, and difficulty handling stress later in life."
3. Which statements indicate that a patient understands the unit norms? (Select all that apply.) a. "I need quiet time after art therapy today." b. "I will not yell during the community meeting." c. "I realize that I need help with my problems." d. "I will show up on time to take my medication." e. "I will talk to staff if I get angry instead of punching somebody."
a. "I need quiet time after art therapy today." b. "I will not yell during the community meeting." d. "I will show up on time to take my medication." e. "I will talk to staff if I get angry instead of punching somebody."
During a one-on-one interaction with the nurse, a patient frequently looks nervously at the door. Select the best comment by the nurse to this nonverbal cue. 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 leader begins the discussion at the first meeting of a new group. Which comment should be included? a. "It is important for everyone to arrive on time for our group." b. "Talking to family members about our group will help us achieve our goals." c. "Everyone is expected to share a personal experience at each group meeting." d. "Groups provide more cost-effective treatment in this time of budget constraints."
a. "It is important for everyone to arrive on time for our group."
A patient says to the nurse, "I dreamed I could not breathe and was being attacked. When I woke up, I felt emotionally drained, as though I hadn't rested well." Which comment would be appropriate if the nurse seeks to interpret? a. "It sounds as though you were uncomfortable with the content of your dream." b. "So you are saying that you were not able to breathe and felt in danger?" c. "I understand. Thank you for telling me about your bad dream." d. "So, you feel as though you had a poor night's sleep?"
a. "It sounds as though you were uncomfortable with the content of your dream."
A leader begins the discussion at the first meeting of a new group. Which comment would be most appropriate? a. "Let's start by establishing some rules for our group." b. "Let's begin with each person here defining his or her problem." c. "I want each person to explain why he or she is attending this group." d. "Talking to family about our group will help us achieve our goals."
a. "Let's start by establishing some rules for our group."
Which diagnosis meets criteria for admission to a co-occurring inpatient unit? a. Bipolar disorder, manic phase, patient has abused alcohol daily to self-medicate b. Undifferentiated schizophrenia and hallucinations of angels playing harps c. Major depression, suicidal intent, and a highly lethal suicide plan d. Anorexia nervosa and 30% underweight
a. Bipolar disorder, manic phase, patient has abused alcohol daily to self-medicate The patient experiencing a bipolar episode and abusing alcohol would meet criteria for such a diagnosis unit, since its focus is on the treatment of substance abuse and mental illness in a psychiatric hospital setting. The other three patients require acute psychiatric care but do not meet the admitting criteria.
3. Which nursing action best supports maintenance of a therapeutic environment? a. Creating therapeutic relationships with patients b. Providing purposeful structured activities c. Maintaining patient records and care plans d. Administering medication
a. Creating therapeutic relationships with patients
An individual is experiencing problems associated with speech and communication. Which cerebral structures are most likely to be involved in this deficit? Select all that apply. a. Frontal lobe b. Parietal lobe c. Occipital lobe d. Temporal lobe e. Basal ganglia
a. Frontal lobe d. Temporal lobe The frontal and temporal lobes of the cerebrum play a key role in the reception of messages and speech. The occipital lobe is predominantly involved with vision. The basal ganglia influence integration of physical movement as well as some thoughts and emotions, whereas the parietal lobe is involved with sensory reception.
A patient has frequent panic attacks and asks the nurse, "Why does this happen to me?" The nurse should explain that the problem might relate to a deficit of a brain chemical called: a. GABA b. Serotonin c. Dopamine d. Glutamate
a. GABA Gamma-aminobutyric acid (GABA) is a neurotransmitter thought to exert a braking force on anxietyA GABA deficit is implicated in generalized anxiety disorder and panic attacks.
9. Which statement about balance provides a basis for a nurse's management of the therapeutic environment? a. Independence is best gained in increments. b. Independence is a fundamental right of all patients. c. Independence jeopardizes safety in an inpatient setting. d. Dependence is a characteristic of most persons with mental illness.
a. Independence is best gained in increments.
When assessing a patient's social skills, which remark would serve the nurse best? a. "It sounds as if you need to develop some assertiveness skills." b. "Describe an example of a time when you felt uncomfortable in a social situation." c. "It is not easy to be assertive. We can role-play some situations to give you practice." d. "What do you plan to do the next time you find yourself in an uncomfortable social situation?"
b. "Describe an example of a time when you felt uncomfortable in a social situation."
A patient's plan of care includes this nursing diagnosis: Impaired verbal communication related to lack of assertiveness skills. To include the patient in prioritizing this problem, the nurse should say: a. "Who are the people with whom you are most passive?" b. "How important is it for you to become more assertive?" c. "Let's look at how we can address this problem together." d. "Are you interested in attending the assertiveness class?"
b. "How important is it for you to become more assertive?"
A patient scheduled to attend various group sessions complains, "I'm really mad about having to attend all those groups. No one else spends all day in a circle in a little room." Select the nurse's best response. a. "Why are you upset?" b. "I can hear that you are upset. Let's talk about it." c. "Just go along with the plan, even if you do not agree." d. "The groups are carefully planned by staff to benefit patients."
b. "I can hear that you are upset. Let's talk about it."
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 your friend is very painful for you." d. "Crying is a way of expressing the hurt you're experiencing." e. "Let's talk about something else, since this subject is upsetting you."
b. "I can see that you feel sad about this situation." c. "The loss of your friend is very painful for you." d. "Crying is a way of expressing the hurt you're experiencing."
A newly admitted patient asks the nurse, "Can you hear those people laughing at me? They are making fun of me." Select the nurse's best response. a. "You are mistaken. No one is laughing at you." b. "I know the sound of laughter is real to you, but I don't hear it." c. "Your mind is playing tricks on you, making you think you hear laughter." d. "When people are mentally ill, they often experience things that others cannot relate to."
b. "I know the sound of laughter is real to you, but I don't hear it."
Select the best description of therapeutic use of self to provide to a new psychiatric nurse. a. "Most nurses have caring personalities that equip them to be helpful to patients." b. "It's mostly about using good verbal and nonverbal communication, objectivity, genuineness, and empathy." c. "It means that you keep yourself at a distance so you are not affected by patients' problems and emotions." d. "The most important aspect of practice is when and how much to touch, as well as when to listen and give advice."
b. "It's mostly about using good verbal and nonverbal communication, objectivity, genuineness, and empathy."
A male patient is diagnosed with mitochondrial encephalopathy. The patient's daughter asks, a. "Since this is a genetic disorder, am I at risk for having it too?" Select the nurse's best response. a. "Your risk is related to exposure to environmental toxins." b. "No, this problem is only passed on by the mother." c. "You must be feeling very worried." d. "Your risk is not predictable."
b. "No, this problem is only passed on by the mother." Mitochondria are passed to the ovum only by the mother, so the patient is not at risk for receiving it from the father
What is the best way to support the need for physical activity when the patient moves from acute care into community-based care? a. Use video-based exercise programs on television. b. Enroll in a swim class at the community center. c. Attend outpatient psychoeducational groups. d. Join a social club.
b. Enroll in a swim class at the community center. The key combination affords the patient physical exercise as well as opportunities for social interaction at a community center. Exercise on television is solitary. Psychoeducational and social interaction do not achieve the goal.
A nurse works in a geropsychiatric unit. Which intervention will be most helpful for patients experiencing confusion and disorientation? a. Door locks b. Environmental cues c. Community meetings d. Psychoeducational groups
b. Environmental cues Environmental cues can be helpful to patients with cognitive impairment, such as signs with names or graphic images, orientation boards, and color-coding locations. These elements are usually present on dementia units and geropsychiatric units. Community meetings and psychoeducational groups may be helpful but may also overstimulate patients with dementia. Door locks help the staff rather than patients.
13. In a therapeutic environment, which norm exists? a. Opportunities for self-expression that relieve stress b. Expectations for socially acceptable behavior c. The behaviors most people display daily d. Shared experiences among patients
b. Expectations for socially acceptable behavior
A patient denies hunger despite ingesting less than 400 calories daily. The patient's problem might be associated with dysfunction of which structure? a. Parietal lobe b. Hypothalamus c. Medulla oblongata d. Reticular activating system
b. Hypothalamus Research has shown that the hypothalamus is involved with eating and satiety, so dysfunction might be a factor in anorexia nervosa
A psychiatric nurse clinician on an inpatient unit plans to lead a special-problems group for withdrawn patients. Which information will be of most assistance as the nurse prepares for this assignment? a. Inpatient groups rarely have a lasting beneficial effect. b. Inpatient groups have short-term, goal-oriented sessions. c. Inpatient groups are helpful for patients with verbal skills. d. Inpatient groups facilitate insight into deeply rooted life issues.
b. Inpatient groups have short-term, goal-oriented sessions.
An adolescent has an autism spectrum disorder. Which psychoeducational group topic would best meet the patient's needs? a. Signs of relapse b. Interpersonal skills c. Anger management d. Medication management
b. Interpersonal skills Individuals with autism spectrum disorders almost universally have impaired relationships and need help learning effective social skills to support relationships. Anger and medication management might or might not be needs of such individuals. Deficits are constant, so relapse is not an issue.
4. While nurses are engaged in shift change report, one patient becomes loud and aggressive. This patient verbally harasses and frightens another patient. Which element of the therapeutic environment has been jeopardized? a. Norms b. Safety c. Balance d. Structure
b. safety
As members disperse at the conclusion of a productive group meeting, one member says, "Let's have a big group hug." Select the leader's most appropriate response. a. "Hugging is not permitted." b. "I am glad you found the meeting so helpful." c. "Thanks for that suggestion, but not everyone may be comfortable with hugs." d. "The group is over now. Members may not have continued contact with each other."
c. "Thanks for that suggestion, but not everyone may be comfortable with hugs."
A patient has difficulty expressing anger appropriately. The nurse encourages the patient to set realistic goals by stating: a. "You seem to have problems expressing anger in a nonaggressive way." b. "I thought you sounded angry when I told you it was time for group." c. "What do you think needs to change about how you express anger?" d. "What bothers you about your actions when you get angry?"
c. "What do you think needs to change about how you express anger?"
1. During orientation the clinical nurse leader tells a novice nurse, "You will be involved in purposeful creation of corrective learning experiences for all patients so as to provide a healing atmosphere." The clinical nurse leader is explaining aspects of milieu-related concept? a. Balance b. Limit-setting c. A therapeutic environment d. Establishing behavioral norms
c. A Therapeutic environment
6. Which element of therapeutic environmental management has the highest priority? a. Clearly establishing norms and designating limits b. Scheduling purposeful activities throughout the day c. Creating an environment of psychological and physical safety d. Promoting a balance between patient dependence and independence
c. Creating an environment of psychological and physical safety
What is the primary purpose of referring a patient to an activity group? a. Assess the patient's social skills. b. Provide cognitive and sensory stimulation. c. Encourage socialization and communication. d. Educate the patient about use of leisure time.
c. Encourage socialization and communication.
The nurse asks members of a group for recovering alcoholics how they handle the urge to drink. Which communication technique is the nurse using? a. Summarizing b. Presenting reality c. Encouraging comparison d. Seeking consensual validation
c. Encouraging comparison
16. Which treatment setting would necessitate the most restrictive environment? a. Partial hospitalization b. Geropsychiatric unit c. Forensic hospital d. Group home
c. Forensic hospital Patients in forensic hospitals have mental illness as well as conviction or charges for criminal activity. These settings must be therapeutic but also confine patients from society. Rules, regulations, and restrictions have similarities to those of prisons
A patient excitedly tells the nurse, "Look what I made in arts and crafts! I did a good job. I want to make some other things too." The nurse may conclude that the part of the patient's nervous system responsible for processing this reaction is the: a. Brainstem b. Occipital lobe c. Limbic system d. Corpus callosum
c. Limbic system The nurse may conclude that the part of the patient's nervous system responsible for processing this reaction is the: limbic system. Feelings of pleasure are generated in the brain's limbic system
Which type of group is a staff nurse with 2 months' psychiatric experience best qualified to conduct? a. Social skills group b. Family therapy group c. Medication education group d. Insight-oriented psychotherapy group
c. Medication education group
Although a patient appears to have recovered from a head injury from an auto accident 3 months ago, the family reports changes in the patient's personality and behavior. The nurse should explain that these changes are likely associated with injury to the: a. Pons b. Parietal lobe c. Prefrontal area d. Caudate nucleus
c. Prefrontal area The prefrontal area is the seat of personality It is responsible for thought, goal-oriented behavior, and inhibition.
A patient admitted to an inpatient unit after a suicide attempt says, "I feel so overwhelmed. There are so many issues I have to deal with." The nurse should schedule the patient to attend which type of group? a. Social skills b. Psychodrama c. Problem-solving d. Medication information
c. Problem-solving
8. A newly admitted patient is withdrawn and does not seek out interaction with staff or patients. Nursing interventions should focus on which element of the treatment environment? a. Norms b. Safety c. Structure d. Limit-setting
c. Structure
An anxious, withdrawn patient is experiencing auditory hallucinations. This patient could benefit most at this time from participation in: a. a recreation group. b. an insight-oriented group. c. a reality orientation group. d. a stress management group.
c. a reality orientation group.
A patient diagnosed with schizophrenia, paranoid type, frequently gets up and walks away during interactions with a nurse. The nurse can best increase the patient's comfort level by: a. arranging the chairs side by side, about 2 feet apart. b. sitting at eye level across the table from the patient. c. standing a few feet away from where the patient sits. d. talking in the patient's room with the door closed.
b. sitting at eye level across the table from the patient.
A common mistake nurses make when developing therapeutic communication techniques is: a. using too many different techniques during an interaction. b. allowing patients to become too anxious before responding. c. giving advice rather than encouraging patients to solve problems. d. focusing on what patients say rather than on communication techniques.
c. giving advice rather than encouraging patients to solve problems.
The nurse plans discharge teaching for a patient who had a stroke involving the hippocampus. The nurse should adapt the teaching plan to account for possible problems with: a. visual acuity. b. expressive aphasia. c. short-term memory. d. balance and coordination.
c. short-term memory. The limbic system is crucial to memory Damage to the hippocampus, a part of the limbic system, causes problems converting short-term to long-term memory, making learning difficult.
A patient asks, "Who will be at the community meeting?" The nurse responds: a. "Patient representatives and staff" b. "Members of the mental health team" c. "All patients and the nurse manager" d. "All patients, nursing staff, and students"
d. "All patients, nursing staff, and students" Typically, all patients, students assigned to the unit, and all nursing staff attend community meetings. Members of other disciplines might or might not attend.
A patient says to the nurse, "My family was mean to me when they visited today. They have no right to treat me like that." Select the nurse's best initial response. a. "Why do you think they were mean?" b. "Perhaps you overreacted to what they said." c. "How do you feel about your family treating you that way?" d. "Describe what happened when your family visited you today."
d. "Describe what happened when your family visited you today."
A patient states, "I'm tired of all these therapy sessions. It's just too much for me." Using supportive confrontation, the nurse should reply: a. "It will get better if you just keep trying." b. "You are doing fine. Don't be so hard on yourself." c. "Tell me more about how the therapy sessions are too much." d. "I know you find this difficult, but I believe you can get through it."
d. "I know you find this difficult, but I believe you can get through it."
A positive outcome from attending a special-problems group is evidenced by which statement by a patient? a. "You're a great group leader and kept things moving smoothly." b. "This experience wasn't as bad as I thought it would be." c. "I rely on the group to help me make decisions." d. "I learned how my anger affects other people."
d. "I learned how my anger affects other people."
After attending a group, which statement by a patient shows evidence of benefits associated with universality? a. "I've learned to identify my anxious feelings." b. "The group really gave me the support to change." c. "I've learned that I can be helpful to others." d. "My problems are not unique. I'm not alone."
d. "My problems are not unique. I'm not alone."
A nurse realizes that the comment just made to a patient was inconsiderate. Select the nurse's most therapeutic statement in this situation. a. "How do you feel about what I just said?" b. "See, even nurses say stupid things sometimes." c. "Sorry about that. Let's continue where we left off." d. "That was an insensitive remark. I'm sorry if it hurt you."
d. "That was an insensitive remark. I'm sorry if it hurt you."
These comments are made by patients in a support group. Which comment best contributes to group cohesiveness and effectiveness? a. "Talking about my problems helps me think of ways to solve them. Let me explain them to everyone." b. "We aren't making progress because our group leader has as many problems as we do." c. "No one in this group wants to hear anything else about your financial problems." d. "We started out talking about guilt, but we wandered off from that subject."
d. "We started out talking about guilt, but we wandered off from that subject."
A nurse working in an intensive inpatient psychiatric unit should place emphasis on which area of care? a. Behavior modification principles b. Personality restructuring and insight c. Improving interpersonal relationships d. Symptom stabilization and daily living skills
d. Symptom stabilization and daily living skills The nurse will emphasize symptom stabilization and daily living skills, because the length of stay will be short. Behavior modification principles are not used in all settings. Developing insight, restructuring personality, and improving interpersonal relationships are lengthy endeavors.
19. A psychiatric facility is "accredited by JCAHO." Which asset would be expected? a. A 4:1 patient-to-staff ratio b. Private rooms for all patients c. Use of a therapeutic milieu treatment model d. Telephones for private patient conversations
d. Telephones for private patient conversations
A talkative member of a support group for patients diagnosed with bipolar disorder has monopolized the group discussion for 15 minutes. The nurse leading the group would best intervene by: a. maintaining silence. It is important for group members to give feedback to each other. b. encouraging the patient to continue. Patients learn from each other in group sessions. c. saying, "You must allow some of the other members of the group to talk. You cannot monopolize the conversation." d. addressing the patient by name and saying, "I'm glad you shared your thoughts with us. Let's hear what others think."
d. addressing the patient by name and saying, "I'm glad you shared your thoughts with us. Let's hear what others think."
10. A patient demonstrating manic behaviors gathered other patients in the dayroom and gave a sales talk, pressuring others to purchase shares of stock in a gold mine. Which element of a therapeutic environment is jeopardized? a. Connection b. Exploration c. Structure d. Balance
d. balance
Ventricular enlargement noted in brain studies of patients with Alzheimer's disease is most likely attributable to: a. narrowing of the subarachnoid space. b. overproduction of cerebrospinal fluid. c. blockage of cerebrospinal fluid outflow. d. brain atrophy associated with cellular degeneration.
d. brain atrophy associated with cellular degeneration In Alzheimer's disease, when brain cells degenerate, the brain atrophies and the ventricles enlarge to fill the existing space
The patient is tense, hypervigilant, and complains, "My heart is racing." The nurse understands that the primary neurotransmitter associated with these complaints is: a. serotonin. b. glutamate. c. acetylcholine. d. norepinephrine.
d. norepinephrine. It is released in response to sympathetic stimulation and causes increased heart rate and blood pressure and other symptoms of anxiety.
The priority treatment goal for a patient with severe and persistent mental illness being treated in a community-based facility will be to: a. form new relationships. b. self-administer medications. c. participate in community activities. d. independently attend to activities of daily living.
d. independently attend to activities of daily living. Priority outcomes for community treatment focus on the individual being able to function at his or her optimal level by attending to activities of daily living. The other options have a lower priority or can be managed by others.
2. Four nurses describe their unit environments. Which description can most clearly be identified as therapeutic? a. "My unit uses behavior modification to enhance patients' social skills." b. "My unit allows patients to test new behaviors in a secure environment." c. "My unit helps patients deal with childhood issues by providing a safe setting." d. "My unit allows patients to deal with personal issues without interpersonal stressors."
"My unit allows patients to test new behaviors in a secure environment."
24. A patient's insurance will not pay for continuing hospitalization at a private facility, so the family considers transferring the patient to a public psychiatric hospital. They express concern that the patient will "never get any treatment." Select the nurse's most helpful reply. a. "Under the law, treatment must be provided. Hospitalization without treatment violates patients' rights." b. "That's a justifiable concern, because the right to treatment extends only to provision of food, shelter, and safety." c. "Much will depend on other patients, because the right to treatment for a psychotic patient takes precedence over the right to treatment of a patient who is stable." d. "All patients in public hospitals have the right to choose both a primary therapist and a primary nurse."
ANS: A The right to medical and psychiatric treatment was conferred on all patients hospitalized in public mental hospitals under federal law. The remaining statements do not accurately describe that right. DIF: Cognitive level: Applying REF: pp. 22, 30-31 TOP: Nursing process: Implementation MSC: NCLEX: Safe, Effective Care Environment
28. A patient tells the nurse, "I was raped a month ago. Since then I've felt anxious and have been unable to talk normally to my husband. I've had frequent thoughts about cutting my wrists." What is the priority nursing concern regarding this patient? a. The risk for self-directed violence b. The development of rape traumatic syndrome c. The damage that could result in poor self-esteem d. The demonstration of signs and symptoms of acute anxiety
ANS: A The risk for self-injury is of highest priority, because patient safety is involved.
8. The nurse believes that a patient is having emotional pain. Which remark is most therapeutic? a. "I hear how painful this is for you. I would like to help you deal with it." b. "I'm so sorry this has happened to you. You don't deserve it." c. "What would you like me to do to help you through this?" d. "I don't think this is as serious as you believe it is."
ANS: A This remark uses empathy to acknowledge the patient's feelings and then offers help. Using empathy tells the patient that his or her feelings are understood. Offering help implies hope for a positive resolution. Empathy, rather than sympathy, is a useful tool. Asking what to do for the patient implies helplessness on the part of the nurse. Minimizing the problem is demeaning to the patient.
14. Which skill is most important to a nurse working as a member of a community mental health team that strives to use a seamless continuum of care? a. Case management b. Diagnostic ability c. Physical assessment skills d. Patients' rights advocacy
ANS: A To effectively use a seamless continuum of care, a nurse must have case management skills with which he or she can coordinate care using available and appropriate community resources. Psychosocial assessment and physical assessment are functions that can be fulfilled by another health care worker. Patients' rights advocacy is one aspect of case management.
23. Staff members take an aggressive patient to seclusion. Before leaving the patient in the room, the priority action should be: a. remove potentially harmful objects from the patient. b. require the patient to use the bathroom. c. have the patient lie on the bed. d. offer the patient fluids.
ANS: A Use of seclusion promotes safety, so removal of harmful objects is necessary. Seclusion is also designed to decrease stimulation. The patient might be asked if he or she needs to go to the bathroom but will not be forced to do so. In some facilities there is no bed in the room, only a mattress on the floor.
33. A patient hospitalized for 6 days has made little progress toward outcomes written at the time of admission. The nurse decides that the lack of progress toward goals indicates that: a. needs for reassessment exist. b. discharge should be delayed. c. nursing diagnoses were incorrect. d. nursing interventions were inadequate.
ANS: A When the evaluation is made that goals are not being attained, reassessment should take place. Nursing diagnoses might need to be reformulated, more realistic outcomes identified, or nursing interventions changed, but none of these measures can be determined to be appropriate until the reassessment has been completed.
2. A patient with suicidal impulses is placed on suicide precautions. Which measures will the nurse incorporate into the plan of care? Select all that apply. a. Allow no glass or metal on meal trays. b. Remove all potentially harmful objects. c. Maintain continuous one-on-one nursing observation. d. Check the patient's whereabouts every 15 minutes, and make frequent verbal contacts. e. Keep the patient within visual range while he or she is awake, and check every 15 to 30 minutes while asleep.
ANS: A, B, C One-on-one observation is necessary for anyone who has limited control over suicidal impulses. Plastic dishes on trays and the removal of potentially harmful objects from the patient's possession are measures included in any level of suicide precautions. The distracters are insufficient to assure the patient's safety.
1. A psychiatric aide asks, "Can you give me some examples of how we provide structure for patients?" The nurse should offer which suggestions? Select all that apply. a. Set limits on destructive behavior. b. Direct a patient to go to a quiet place. c. Sit with a withdrawn, isolated patient. d. Distract a patient who is hallucinating. e. Help a patient contemplate needed change.
ANS: A, B, C, D Providing structure means that staff members meet patient needs for organizing elements in the environment to produce specific outcomes. Contemplating change is the only option that would not be considered an example of structuring.
1. A parent was recently hospitalized with severe depression. Family members say, "We're falling apart. Nobody knows what to expect, who should make decisions, or what to do to keep the family together." Which interventions should the nurse use when working with this family? Select all that apply. a. Help the family set realistic expectations. b. Provide empathy, acceptance, and support. c. Empower the family by teaching problem solving. d. Negotiate role flexibility among family members. e. Focus on the family rather than on the patient in planning.
ANS: A, B, C, D The correct answers address expressed needs of the family. The other option is inappropriate.
3. A newcomer to a community support meeting asks a nurse, "Why aren't people with mental illnesses treated at state institutions anymore?" What would be the nurse's accurate responses? (Select all that apply.) a. "Funding for treatment of mental illness now focuses on community treatment." b. "Psychiatric institutions are no longer accepted because of negative stories in the press." c. "There are less restrictive settings available now to care for individuals with mental illness." d. "Our nation has fewer people with mental illness; therefore, fewer hospital beds are needed." e. "Better drugs now make it possible for many persons with mental illness to live in their communities."
ANS: A, C, E Deinstitutionalization and changes in funding shifted care for persons with mental illness to the community rather than large institutions. Care provided in a community setting, closer to family and significant others, is preferable. Improvements in medications to treat serious mental illness made it possible for more patients to live in their home communities. Prevalence rates for serious mental illness have not decreased. Although the national perspectives on institutional care did become negative, that was not the reason many institutions closed.
2. Which intervention demonstrates that a nurse is functioning within the scope of psychotherapeutic management? (Select all that apply.) a. Structuring meaningful unit activities b. Administering electroconvulsive therapy c. Encouraging a patient to express feelings d. Interpreting the results of psychological testing e. Assessing a patient for medication side effects
ANS: A, C, E Milieu management, patient communication, and medication administration are all within the scope of nursing practice. Electroconvulsive therapy is a medical treatment and, therefore, should be administered by a physician. Psychological testing is interpreted by a psychologist.
1. What common themes apply to persons who have suicidal ideation? Select all that apply. a. Belief that life is meaningless b. Absolute intention to die c. Existence of cognitive impairment d. Experiencing hopelessness e. Feeling out of control
ANS: A, D Hopelessness, meaninglessness, and feeling out of control are the most common themes underlying suicidal ideation. The other options reflect myths about suicide. Not all who attempt suicide are intent on dying. Not all are cognitively impaired.
10. How does a multiaxial diagnostic and classification tool contribute to successful treatment of persons with mental illness? a. It provides for consistency and continuity in formulation of diagnoses. b. It assesses more dimensions of illness than simply the medical diagnosis. c. It establishes prevalence rates for psychiatric disorders across various cultural groups. d. It provides treatment algorithms for psychotherapeutic management of persons with mental illness.
ANS: B A multiaxial tool looks more holistically at the individual. The DSM-V-TR axes consider medical conditions, presence of personality and developmental disorders, relevant psychosocial and environmental factors, and global assessment of functioning. The other options listed are not advantages that contribute to treatment success.
18. A patient who is admitted involuntarily with bipolar disorder, manic phase, refuses a prescribed dose of lithium. The nurse assembles a show of force and intimidates the patient into taking the medication. As an outcome of this action, the patient: a. will experience lessened mania. b. can bring civil suit for assault and battery. c. can sue the hospital for false imprisonment. d. has no recourse, because the medication is in the interest of the patient's welfare.
ANS: B A nurse who forces a patient to accept treatment or take medication in a nonemergency situation against the patient's wishes can be found liable for assault (threatening) and battery (nonconsenting touching) in civil court, even if the nurse had the best interest of the patient in mind. Diminished symptoms of mania are not likely to be related to a single dose of lithium. The scenario does not describe the conditions of false imprisonment. Actions taken in the best interest of the patient that violate the patient's rights are cause for civil action. DIF: Cognitive level: Applying REF: p. 24 TOP: Nursing process: Evaluation MSC: NCLEX: Safe, Effective Care Environment
When the nurse conducts a developmental assessment with a new patient, the assessment can be expected to yield information: a. regarding use of defense mechanisms. b. about the degree of mastery of critical tasks. c. that will help the patient make rational decisions. d. about mobilization of defenses against stressors.
ANS: B According to Erikson's developmental theory, a developmental assessment is conducted for the purpose of determining the extent to which an individual has successfully mastered the critical task of each stage of development up to his or her chronologic age. Lack of mastery or partial mastery will yield clues about issues to be addressed in working with the patient. Because of its focus, the developmental assessment might yield only minimal information about defense mechanism use and defenses used to cope with stress. Rational decision making is not expected to be fostered as a result of developmental assessment.
Which statement by an adult would lead a nurse to suspect deficits in mastery of the developmental task of infancy? a. "I have many warm and close friendships." b. "I am afraid to let anyone really get to know me." c. "I am always right. Keep your opinion to yourself." d. "I am ashamed I did that wrong. Please forgive me."
ANS: B According to Erikson, the developmental task of infancy is the development of trust. The key is the only statement clearly showing the lack of ability to trust others. The distracters suggest that the developmental task of infancy was successfully completed: rigidity rather than mistrust, and failure to resolve the crisis of initiative versus guilt.
The nurse using the Lazarus Interactional Model should make it an early priority to assess the individual's response to stress and: a. physical condition. b. appraisal of the threat. c. ability to use relaxation techniques. d. childhood experiences in dealing with stress.
ANS: B According to Lazarus, the significance of the threat or what it means to the individual is of primary importance in determining the individual's response. This personal evaluation is based on cognitive appraisal. The other options are of lesser importance initially.
A 26-year-old woman has a realistic sense of self, a commitment to reasonable career goals, a satisfying intimate partner relationship, and a circle of loyal friends. This person says, "I volunteer for important projects in my community." The nurse can draw which conclusion? a. There is lack of mastery of critical tasks associated with the stage of industry versus inferiority. b. Mastery of critical tasks associated with the stage of identity versus role diffusion is evident. c. Fear of criticism and affection affect mastery of critical tasks associated with intimacy. d. The person vacillates between dependence and independence.
ANS: B Adult behavior reflecting mastery of the critical tasks associated with the stage of identity versus role diffusion includes confident sense of self, emotional stability, commitment to career planning, sense of having a place in society, establishing a relationship with the opposite sex, fidelity to friends, and development of personal values. The behaviors given in the scenario are not indicators of any of the other options.
A 25-year-old man complains of overwhelming guilt about minor social errors, feels self-pity, and says, "I stay on the sidelines of life so I can avoid the embarrassment of being noticed." The nurse can assess deficits in mastery of critical tasks associated with which developmental stage? a. Trust versus mistrust b. Industry versus inferiority c. Autonomy versus shame and doubt d. Generativity versus self-absorption
ANS: B Adult behaviors reflecting developmental problems associated with the stage of industry versus inferiority include excessive guilt and embarrassment, passivity, apathy, rumination and self-pity, assumption of the victim role, and underachievement of potential. The behaviors given in the scenario reflect the critical tasks of industry versus inferiority. Tasks of the other stages are entirely different.
A 75-year-old retired executive complains, "I am unable to say 'no' when asked to help with community causes. These projects overtax my strength, but if I don't do them, who will?" The nurse can assess that this person is having difficulty with critical tasks related to which developmental stage? a. Trust versus mistrust b. Integrity versus despair c. Identity versus role diffusion d. Autonomy versus shame and doubt
ANS: B Adult behaviors reflecting problems associated with the developmental stage of integrity versus despair include inability to reduce activities, overtaxing strength, and feeling indispensable, or the opposite: feeling helpless, useless, or lonely; focusing on past mistakes; and inability to occupy oneself with satisfying activities. Tasks of the other stages are not described in the scenario.
25. Assessment findings by the multidisciplinary team after a patient-intake interview are used primarily to: a. confirm ongoing discharge planning. b. expand and confirm the initial assessment. c. verify the appropriateness of nursing diagnoses. d. analyze the patient's feelings about hospitalization.
ANS: B As members of the multidisciplinary team interact with the patient, their impressions might support or differ slightly from the initial assessment. The findings are synthesized and used in planning ongoing treatment. The other options have less relevance or are not applicable.
14. A patient tells the nurse, "This medication makes me feel weird. I don't think I should take it anymore. Do you?" What is the nurse's best response? a. "I wonder why you think that." b. "Tell me how the medication makes you feel." c. "One must never stop taking medication." d. "You need to discuss this with your psychiatrist."
ANS: B As part of the psychopharmacology component of psychotherapeutic management, the responsibility of the nurse is to gather data about patients' responses to medication and to be alert for side and adverse effects of the medication. The other responses are tangential to the real issue.
4. Which statement made by a nurse demonstrates an understanding of the issue affecting the delivery of care to the mentally ill that motivated passage of the Community Mental Health Centers Act in 1963? a. "Involuntary hospitalized occurs only if a client demonstrated violent behavior." b. "We attempt to address the issues that occur when a client is geographically isolated from family and community." c. "Legally a voluntarily admitted client can demand to be discharged before receiving adequate treatment." d. "Mental ill clients must give informed consent before being used as subjects in pharmacologic research."
ANS: B State hospitals were often located a great distance from the patients' homes, making family visits difficult during hospitalization. The Community Mental Health Centers Act in 1963 served as the impetus for deinstitutionalization, allowing patients and families to receive care close to home. Admission only for behavior that endangers self or others is more consistent with current admission criteria. Early discharge rarely occurred before the community mental health movement. Unethical pharmacologic research was not a major issue leading to community mental health legislation.
1. Considering that a state uses the M'Naghten Rule when an individual is on trial for a crime, what would be most important to document for a nurse caring for a patient who will soon be tried on murder charges? a. The patient's participation in treatment planning b. The patient's comments about commission of the crime c. Examples of behaviors that support psychiatric diagnoses d. The patient's perceptions of the need for hospitalization and treatment
ANS: B The M'Naghten Rule states that to be held legally accountable for his or her actions, a person with mental illness must be able to understand the nature and implications of the crime. Although each of the options refers to data that should be documented, the patient's comments about the crime would be of most importance to the trial. DIF: Cognitive level: Applying REF: p. 21 TOP: Nursing process: Implementation MSC: NCLEX: Psychosocial Integrity
12. Which individual should the nurse assess as having the highest risk for homelessness? a. An older adult woman with mild dementia who lives alone in an apartment b. An adult with serious mental illness and no family c. An adolescent with an eating disorder d. A married person with alcoholism
ANS: B The adult has both a serious mental illness and a potentially weak support system. Both are risk factors for homelessness. The other individuals have psychiatric disorders but have better established support systems.
22. A nurse considers interventions for a diabetic patient who needs to change eating habits and lose weight. The nurse will base strategies on which principle? a. The nurse's primary responsibility is to encourage the change. b. Patient-initiated change is more successful than imposed change. c. For successful change, both the benefit and the risk to the patient must be high. d. Patients value advice from nurses because of the trusting dimensions of the relationship.
ANS: B The answer indicates that the patient is invested in the change process. Nurses have multiple responsibilities in the change process, including education and reinforcement. Nurses should avoid giving advice.
17. A community mental health nurse assessing a person with a psychiatric disorder, should refer this person to services based on which basic concept? a. Focus on interventions is on the least costly initially. b. Initial interventions are the least restrictive. c. Initial interventions offer a form of psychoeducation. d. Rapid symptom stabilization is the primary goal.
ANS: B The concept of least restrictive treatment environment preserves individual rights to freedom. Many patients are healthy enough to receive community-based treatment. Hospitalization is reserved for short periods when patients are assessed as being a danger to self or others. Cost is a consideration but is of lesser concern than safety. All facets of the continuum should offer psychoeducation as needed by patients and families. Some aspects of the care continuum are more concerned with a patient's need for symptom stabilization than others (e.g., hospitals versus psychiatric rehabilitation programs). The outcome of symptom stabilization is not a need for some patients, so it is not a correct answer.
11. A patient says, "I went out drinking only one time last week. At least I'm trying to change." The nurse responds, "I appreciate your effort, but you agreed to abstain from alcohol completely." The nurse is: a. using cognitive restructuring. b. preventing manipulation. c. showing empathy. d. using flooding.
ANS: B The correct comment prevents the nurse from being manipulated by the patient. The nurse should address what happened, along with the expectations. The remaining options do not attempt to address the patient's manipulation of the situation.
10. A nurse interviews a homeless parent with two teenage children. To best assess the family's use of resources, the nurse should ask: a. "Can you describe a problem your family has successfully resolved?" b. "What community agencies have you found helpful in the past?" c. "Do you feel you have adequate resources to survive?" d. "What is one thing you dislike about this family?"
ANS: B The correct option asks about resource use in an open, direct fashion. It will give information about choices that the family has made to use other family members or resources in the community. The other questions do not address prior use of resources.
8. Four individuals have suicide plans. Which plan evidences the highest risk for completed suicide? a. Drinking dishwashing detergent before a family meal. b. Jumping from a suspension bridge in a rural location late at night. c. Cutting the wrists in the bathroom while a patient's spouse reads in the next room. d. Overdosing on acetaminophen (Tylenol) 1 hour before the patient's spouse is expected home from work.
ANS: B The correct response presents a highly lethal method with little opportunity for rescue. The other options are lower lethality methods with higher rescue potential.
3. A 15-year-old patient is hospitalized after a suicide attempt. The adolescent lives with his mother, stepfather, and several siblings. When performing a family assessment, the nurse must first determine: a. how the family expresses and manages emotion. b. the names and relationships of the patient's family members. c. the communication patterns between the patient and parents. d. the meaning the patient's suicide attempt has for family members.
ANS: B The names and relationships of the patient's family members constitute the most fundamental information and should be obtained first. Without this, the nurse cannot fully process the other responses.
1. A student tells the school nurse, "My friend threatened to take an overdose of pills." The nurse talks to the friend who verbalized the suicidal threat. Select the most critical question for the nurse to ask. 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?"
ANS: B The nurse must assess the patient's access to a means to carry out the plan and, if there is access, alert the parents to remove the medications from the home. The information in the other questions is important to ask, but it is not the most critical.
1. A nurse administers a highly protein-bound medication. Which patient would have the most immediate and powerful effect from this drug? a. A healthy adolescent b. A 76-year-old patient with malnutrition c. A woman in the second trimester of pregnancy d. An adult with a fractured femur from a sporting accident
ANS: B The older malnourished patient would have fewer serum proteins to bind the drug; therefore, higher amounts of free drug would be available to act immediately. The patients described in the distracters would have normal protein levels, so the drug would be bound.
A 29-year-old lives with his parents, has few interpersonal relationships, and says, "Most people can't be trusted." This person makes decisions only after consulting with his parents. Using Erikson's developmental theory, the nurse can draw which conclusion? a. The patient has evidence of inferiority and lacks a sense of direction. b. Developmental deficits in early life have impaired the patient's adult functioning. c. The patient's developmental problems will probably lead to a serious mental illness. d. It is impossible for the patient to proceed to the next developmental stage until mastering earlier stages.
ANS: B The patient achieved only partial mastery of the trust versus mistrust stage. Deficits in development carried from one stage to the next interfere with functioning at the adult level. Individuals do progress from stage to stage when mastery is not attained, however adjustment is usually impaired. Developmental problems might lead to a serious mental disorder, but might also produce less serious results.
17. A patient takes a psychotropic medication that affects norepinephrine receptors. The patient reports, "It feels like my heart is pounding in my chest." What effect is the drug having on the norepinephrine receptors? a. Inhibition b. Activation c. Paradoxical d. Antagonism
ANS: B The patient's complaints indicate activation of norepinephrine receptors. The medication has stimulated the action of 1-receptors. None of the other options correctly identifies this outcome.
15. A patient takes a psychotropic medication that affects acetylcholine receptors. The patient complains of dry mouth and constipation. What effect is the drug having on the acetylcholine receptors? a. Activation b. Antagonism c. Stimulation d. Paradoxical
ANS: B The patient's complaints indicate suppression of the parasympathetic nervous system, which is associated with antagonism of the action of acetylcholine.
20. How many violations of Medicare and Medicaid guidelines are evident in this documentation? Patient assaulted nurse in hall at 1730. Staff provided verbal intervention, but patient continued to strike out. Patient placed in seclusion at 1745. Observation instituted at hourly intervals. Order received from physician at 1930. Patient sleeping soundly at 2100. Patient released from seclusion at 2230 and returned to own room. a. Two b. Three c. Four d. Five
ANS: D Constant observation of a secluded individual is necessary, with attention given at frequent intervals for safety and comfort interventions. No mention is made of providing fluids or bathroom privileges. Seclusion requires a written order posted within 1 hour. Seclusion must be terminated when patient behavior permits. If the patient is calm enough to sleep, the need for seclusion should be reevaluated. The patient should be debriefed after the seclusion. DIF: Cognitive level: Analyzing REF: p. 28 TOP: Nursing process: Evaluation MSC: NCLEX: Safe, Effective Care Environment
18. A parent has become verbally abusive toward the spouse and oldest child since losing a job 6 months ago. The child ran away twice, and the spouse has become depressed. What is the most appropriate nursing diagnosis for this family? a. Impaired parenting, related to verbal abuse of oldest child b. Impaired social interaction, related to disruption of family bonds c. Ineffective individual coping, related to fears about economic stability d. Disabled family coping, related to insecurity secondary to loss of family income
ANS: D Disabled family coping refers to the behavior of a significant family member that disables his or her own capacity as well as another's capacity to perform tasks essential to adaptation. The distracters are inaccurate because more than one individual is affected by the stressors.
20. A newly admitted patient tells the nurse, "The voices are bothering me." The nurse should first: a. ignore the patient's reference to voices. b. distract the patient from the hallucinations. c. tell the patient that the voices do not exist. d. seek a description of the voices and identify themes.
ANS: D Early assessment of hallucinations is based on the content of the messages. Content often reveals the dynamics of the patient's symptoms and typically revolves around a theme such as powerlessness, hate, guilt, or loneliness. Ignoring the reference is nontherapeutic and thwarts assessment. Distraction is a possible strategy after the nurse understands the content of the hallucinations. Saying that the voices do not exist negates the patient's experience. Saying you do not hear them is preferable.
24. Referral to a psychiatric extended-care facility would be most appropriate for which of the following patients? a. An adult with generalized anxiety disorder b. A severely depressed 70-year-old retiree c. A patient with personality disorder who frequently self-mutilates d. A severely ill person with schizophrenia who is regressed and withdrawn
ANS: D Extended care often serves those with severe and persistent mental illness and those with a combination of psychiatric and medical illnesses. The patient demonstrating the signs and symptoms described in the correct option is at risk for developing psychotic behaviors that increases the risk for self and other directed harm. Patients with anxiety disorders can be referred to outpatient services. Severely depressed patients would need more intensive care, as would a self-mutilating individual.
19. A parent says, "My son and I argue constantly since he started using drugs. When I talk to him about not using drugs, he tells me to stay out of his business." What is the nurse's most appropriate action? a. Educate the parent about the stages of family development. b. Report the son to law enforcement authorities. c. Refer the son for substance abuse treatment. d. Make a referral for family therapy.
ANS: D Family therapy is indicated, and the nurse should provide a referral. Reporting the child to law enforcement would undermine trust and violate confidentiality. The other distracters may occur later.
A patient asks, "Why it is important to uncover memories and conflicts hidden in the unconscious?" A Freudian therapist would explain that bringing unconscious information to consciousness will: a. resolve developmental issues, fears, and crises. b. allow an individual control over the id and superego. c. suppress painful feelings and increase rational thinking. d. provide insight into behavior and allow meaningful change to occur.
ANS: D Freud believed that uncovering unconscious material generates an understanding of behavior that enables individuals to make choices about behavior and thus improve mental health. It will not, however, automatically resolve issues, give the patient control over id and superego strivings, or result in rational thinking.
A group of nurses disagrees about whether or not to make spirituality a part of the assessment. Which statement provides a compelling argument in favor of including spiritual assessment? a. Research clearly demonstrates that spiritual interventions by nurses are a cost-effective practice. b. Accrediting organizations regard spiritual care as a patient right. c. Spirituality is better addressed by nurses than by clergy. d. Prayer consistently improves mental health outcomes.
B There is a lack of agreement as to whether or not spiritual care should be a legitimate concern of nurses, despite a large body of research evidence citing its advantages to patients. Among the major deterrents to including spiritual care is the concern that already overburdened nurses will not find time to perform the assessment. It should be noted, however, that when an accrediting body considers a facet of care to be a right of patients, it will look for evidence of attention to that right. A spiritual assessment documented in the medical record provides such evidence. The other options are of lesser importance when weighed against the standards set by an accrediting agency.
A patient says, "I am a Christian." The nurse understands that Christianity includes which groups? Select all that apply. a. Judaism b. Mormonism c. Buddhism d. Catholicism e. Greek Orthodox
B, D, E Christianity accounts for 78% of the U.S. population and includes Protestant, Mormon, Catholic, and some orthodox groups. Judaism and Buddhism are not Christian religions.
14. A patient has been bumping and pushing other patients. The nurse carefully explains to the patient that such behavior is unacceptable. The nurse has provided what characteristic of a therapeutic environment? a. Balance b. Limit-setting c. Personal control d. Environmental modification
B. Limit-setting
16. The nurse leading a social skills group is engaged in managing which environmental element? a. Balance b. Structure c. Accountability d. Risk management
B. Structure
A patient diagnosed with schizophrenia, paranoid type, has been suspicious of staff since admission. The patient visits with a chaplain but then tells the nurse, "Don't send any more preachers." What is the most likely reason for the patient's reaction? a. Hostility b. Distractibility c. Inability to trust d. Inability to find meaning in suffering
C Individuals with paranoid schizophrenia often have an inability to trust. Inability to trust may be related to inadequate nurturing in infancy and to later difficulty recognizing a connection with God. The other options are less clearly related to issues of paranoia and trust.
A patient says, "I know I need religion in my life, but I don't know how to find God. I feel I have been abandoned." The nurse should assess for a childhood history of: a. recurrent losses. b. overindulgence. c. lack of nurturing. d. poor school performance.
C Loder has hypothesized that early developmental experiences set the stage for later spiritual dynamics. Inadequate nurturing may result in lack of establishment of trust. Later, spiritual issues of abandonment and shame might surface. None of the other options have been advanced as explanations for feelings of abandonment by God.
At the time of discharge, a patient with a European-American worldview demands copies of all medical records. Which analysis most accurately explains the patient's behavior? The patient: a. continues to experience mistrust of the team's truthfulness. b. is probably planning to see an attorney about poor care. c. values the written evidence of illness and treatment. d. probably wants to edit the records for accuracy.
C Members of European-American cultures have analytic worldviews and value information that is written because it lends proof. The distracters offer more remote reasons for the behavior.
A clinic nurse encounters many patients who request acupuncture, nutritional therapies, moxibustion, cupping, and coining. The nurse understands that these patients are seeking to restore: a. chi. b. meridians. c. equilibrium. d. divine relationships.
C Patients who view illness as disequilibrium or lack of balance may seek alternative therapies to restore balance. Chi is an energy force. Meridians are lines in the body representing body functions. Divine relationships are an aspect of balance, but equilibrium is a broader concept.
The nurse can expect the parent of a child with mal ojo (evil eye) to believe that the effects of the spell can be broken after: a. ignoring the child. b. feeding the child warm foods. c. looking deeply into the child's eyes. d. a root doctor or native healer intervenes.
D Individuals who believe in culture-bound illnesses usually also believe that the cure for the illness is found in treatment by a native healer or roots doctor. The parent would not believe that any of the other options are effective.
A nurse is assigned to an outreach program on a Native-American reservation. Which tenet should the nurse consider when communicating with these consumers? a. Silence is considered a social error. b. Touching is an accepted part of conversation. c. Important topics are always preceded by polite social conversation. d. Rules regarding roles and status are important and must be observed.
D Relationships are based on the idea that the Supreme Being is present in each person and that all persons must be valued and treated with dignity. This is particularly true of treatment received by tribal elders, healers, and others perceived to be in positions of importance. The other options are not consistent with the ecologic worldview.
The spouse of a psychiatric patient says, "This mental illness should not have happened. I tried to teach the importance of professing faith in God and getting converts, but my partner rejected them. Those practices keep me well. It's the only way to live." The nurse can assess that the spouse is demonstrating: a. atheism. b. humanism. c. agnosticism. d. sick religiosity.
D Sick religiosity is marked by a lack of openness to other possibilities, a sense of exclusiveness, and absolutism. The scenario does not give evidence of any of the other options.
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 or not an interpreter is needed.
D The assessment depends on communication. The nurse should first determine whether or not an interpreter is needed. The other information can be subsequently assessed when communication is effective.
When a Mexican-American woman and nurse interact, the patient often holds the nurse's hand or links arms with the nurse. The nurse is uncomfortable with this behavior. Which analysis is most accurate? a. The patient is using touch to make the nurse uncomfortable and manipulate the relationship based on that factor. b. An energy field disturbance has occurred. Touch rebalances the energy between the patient and nurse. c. The patient is afraid of being alone. When touching the nurse, the patient is reassured and comforted. d. The patient is accustomed to and comfortable with touch, as are members of many Hispanic cultures.
D The most likely answer is that the patient's behavior is culturally influenced. Hispanic women frequently touch women they consider to be their friends. Although the other options are possible, they are much less likely.
A nurse leads a psychoeducational group for patients diagnosed with residual schizophrenia. A realistic outcome for group members is that they will: a. discuss ways to manage their illness. b. develop a high level of trust and cohesiveness. c. understand unconscious motivation for behavior. d. demonstrate insight about development of their illness.
a. discuss ways to manage their illness.
Effective use of the nursing process is dependent on communication that: a. is structured and goal-directed. b. meets the needs of both patient and nurse. c. is spontaneous and affords mutual self-disclosure. d. fosters emotional distance between patient and nurse.
a. is structured and goal-directed.
12. The framework of schedules, rules, and activities around which a therapeutic environment revolves is related to which associated term? a. Structure b. Balance c. Norms d. Safety
a. structure
When a patient voices a delusion during a group session, the nurse can effectively handle the situation by (select all that apply): a. using empathy. b. presenting reality. c. exploring the delusional content. d. focusing on the underlying need expressed. e. asking the group what they think about the delusion.
a. using empathy. b. presenting reality. d. focusing on the underlying need expressed.
A large mental health facility has several specialized units. A patient admitted for alcohol withdrawal asks, "Will I be with patients who have schizophrenia or dementia while I'm here?" Select the nurse's best answer. a. "No. Patients with alcoholism often become violent and must be isolated from our general psychiatric population." b. "No. Patients with needs for alcohol detoxification are treated on our acute substance abuse unit." c. "Yes. Our patients often help each other, so they are all on the same unit." d. "Your question leads me to wonder if you're feeling frightened."
b. "No. Patients with needs for alcohol detoxification are treated on our acute substance abuse unit." Specialty units serve specific populations of patients. The patient in need of alcohol detoxification will receive care on an acute substance abuse unit. It's important to answer the patient's question. Afterward, the nurse can explore the patient's feelings. Violence is a risk during alcohol withdrawal, but the risk alone is not a reason to isolate the patient from others.
During the community meeting a patient says, "I'm having problems in my sex life." The leader of the meeting will make which response? a. "Go on. We are here to listen." b. "That's a topic to discuss with your therapist today." c. "How does everyone else feel about discussing this topic?" d. "Perhaps you should leave the meeting until you are in better control."
b. "That's a topic to discuss with your therapist today." Individual problems are not dealt with in community meetings. It is suggested to patients that individual issues be discussed with one's therapist. The focus of community meetings is on matters of general concern to the group at large. When the patient is informed of when and where to address the individual problem, it should be done in a nonpunitive manner.
A patient at the crisis intervention clinic states, "When I got up this morning, I realized I could not go on any longer." Select the nurse's best response to facilitate analyzing the problem and making a nursing diagnosis. a. "How long have you been feeling this way?" b. "What is different about your feelings today?" c. "We are here to help you. I'm glad you decided to come to the center." d. "You said you felt like you could not go on. Tell me more about that."
b. "What is different about your feelings today?"
A leader begins the discussion at the first meeting of a new group. Which comments should be included? Select all that apply. a. "We use groups to provide treatment, because it's a more cost-effective use of staff in this time of budget constraints." b. "When someone shares a personal experience, it's important to keep the information confidential." c. "Talking to family members about our group discussions will help us achieve our goals." d. "Everyone is expected to share a personal experience at each group meeting." e. "It is important for everyone to arrive on time for our group."
b. "When someone shares a personal experience, it's important to keep the information confidential." e. "It is important for everyone to arrive on time for our group."
Which intervention would be most appropriate for the nurse to use when conducting a maintenance group? a. Helping patients identify better coping strategies b. Accepting, empathizing, and showing concern c. Asking patients to identify topics for the group d. Confronting ingrained behaviors and defenses
b. Accepting, empathizing, and showing concern
Which patient would benefit most from a group that focuses on reality orientation? a. Adolescent with mixed drug and alcohol abuse b. Adult with undifferentiated schizophrenia c. Older adult with depression d. Young adult in crisis
b. Adult with undifferentiated schizophrenia
5. Which nursing action best supports the maintenance of psychological safety for a patient with mental illness? a. Helping a depressed patient to inventory personal flaws b. Assisting a patient to change clothes after an episode of incontinence c. Allowing an anxious patient to pace in isolation and without interruptions d. Requiring a restrained patient to remain silent until restraints are removed
b. Assisting a patient to change clothes after an episode of incontinence
Which patient would benefit most from closed, process-oriented group therapy? a. Adult with disorganized schizophrenia admitted to an acute psychiatric unit b. Outpatient living independently with chronic low self-esteem and anxiety c. Patient receiving treatment in an assertive community treatment program d. Resident of a group home attending a partial hospitalization program
b. Outpatient living independently with chronic low self-esteem and anxiety Group therapy is seldom an option during short-term treatment. The individual with low self-esteem, anxiety, and living independently meets criteria for being able to develop plans for change and coping, and is able to attend group sessions long enough to benefit from group therapy's curative features. A patient in an assertive community program is someone who receives care from a team that seeks him or her out in the community. Group home residents might or might not be suitable for inclusion in group therapy sessions.
A patient diagnosed with depression has a need for divisional activities. Which team member is best qualified to assess the patient's leisure needs and plan the interventions? a. Occupational therapist b. Recreational therapist c. Exercise physiologist d. Chaplain
b. Recreational therapist Recreational therapists are qualified to assist patients to find leisure interests that will enable the patient to learn to balance work and play. The other professionals do not have this focus.
A nurse wants to provide opportunities for a patient to try out new, more assertive behaviors. Which technique should the nurse use? a. Clarifying b. Role-playing c. Giving feedback d. Encouraging evaluation
b. Role-playing
Which outcome of hospital-based psychiatric care should the nurse consider a priority for a patient to achieve before discharge? a. Referral for vocational rehabilitation b. Safe level of functioning c. Medication stabilization d. Problem resolution
b. Safe level of functioning Safe level of functioning is of paramount importance before a patient returns to the community. Work toward problem resolution and medication stabilization can continue in the community. Referral for aftercare might or might not be necessary, depending on a patient's needs.
A patient says, "I wish I could express my depressed feelings rather than keeping them inside." The nurse should schedule the patient to attend which type of group? a. Social skills b. Special problems c. Reality orientation d. Relapse prevention
b. Special problems
A patient says, "I'm like a wind-tossed leaf. My goal is to find meaning in life." The nurse should consider referring the patient to which group? a. Self-help b. Spirituality c. Reality orientation d. Psychoeducational
b. Spirituality Lack of meaning in one's life is a spiritual concern. Referral to a spirituality group has potential for helping the client. The other options do not address the patient's expressed concern.
A patient is recovering from surgery to remove a tumor in the cerebellum. Which assessment finding is most attributable to this diagnosis? a. The patient complains of limited taste and smell. b. The patient demonstrates poor balance and coordination. c. The patient has limited ability to learn and poor memory. d. The patient has poor emotional control and low motivation.
b. The patient demonstrates poor balance and coordination The cerebellum coordinates muscle synergy and is responsible for the maintenance of equilibrium The limbic system plays a role in taste, smell, memory, learning, emotional control, and motivation.
7. In which instance would it be most important for the nurse to set limits? a. An involuntarily hospitalized patient insists on being discharged. b. Two patients are found kissing in an obscure area of the unit. c. A patient with suicidal ideation asks to leave the unit. d. A depressed patient seeks daily telephone privileges.
b. Two patients are found kissing in an obscure area of the unit.
Which techniques are therapeutic when interacting with a patient? Select all that apply. a. Avoiding direct questions b. Validating and clarifying c. Using empathy sparingly d. Assuming an attending posture e. Maintaining constant eye contact
b. Validating and clarifying d. Assuming an attending posture
The nurse assesses a patient with Parkinson's disease. Tremors will be most pronounced when the patient is: a. When sleeping b. When sitting quietly c. When focusing intently d. When reaching for something
b. When sitting quietly The tremor of Parkinson's disease, a disease that affects the extrapyramidal system, is most pronounced when the patient is at rest In Parkinson's disease, tremor is absent during sleep and diminished when concentrating or with intentional movement.
A patient in a detoxification unit asks, "What good will it do to go to Alcoholics Anonymous and talk to other people with the same problem?" The nurse's best response would be to explain that self-help groups such as AA provide opportunities for: a. newly discharged alcoholics to learn about the disease of alcoholism. b. people with common problems to share their experiences with alcoholism and recovery. c. patients with alcoholism to receive insight-oriented treatment about the etiology of their disease. d. professional counselors to provide guidance to individuals recovering from alcoholism.
b. people with common problems to share their experiences with alcoholism and recovery.
While a member of a group shares painful feelings of guilt, another member begins humming and tapping the side of the chair. Select the leader's best initial action with the disruptive patient. a. Recognize that the behavior is an expression of anxiety, and do not interrupt it. b. Say, "Please stop humming and tapping. It is disruptive to our group." c. Say, "Please leave the group now. Your behavior is inappropriate." d. Say, "You seem uncomfortable with our discussion."
d. Say, "You seem uncomfortable with our discussion."
Dysfunction in which structure should lead to the nurse to consider the institution of fall precautions? a. Wernicke's area b. Hippocampus c. Amygdala d. Cerebellum
d. Cerebellum The cerebellum is responsible for the maintenance of equilibrium. When equilibrium is impaired, fall prevention becomes a priority
15. A nurse plans ways to promote patient safety and security. A proactive approach would include which intervention? a. Restricting psychotic patients' rights b. Enforcing consequences of limit-setting c. Setting limits when a patient acts out aggressively d. Clearly communicating expectations for patients' behavior
d. Clearly communicating expectations for patients' behavior
A patient with split-brain syndrome has damage to which structure of the brain? a. Amygdala b. Hippocampus c. Pyramidal tract d. Corpus callosum
d. Corpus callosum When this communication pathway is severed, split-brain syndrome develops.
After a patient's first group session, the nurse asks, "How was the experience of participating in group for you?" Which communication technique is the nurse using? a. Summarizing b. Seeking clarification c. Making observations d. Encouraging evaluation
d. Encouraging evaluation
A patient has disorganized thinking associated with schizophrenia. Neuroimaging studies will most likely show dysfunction in which part of the brain? a. Temporal lobe b. Cerebellum c. Brainstem d. Frontal lobe
d. Frontal lobe
The nurse tells a patient, "I noticed that you frowned when we discussed your relationship with your family." Which communication technique is the nurse using? a. Clarifying b. Interpreting c. Giving information d. Making observations
d. Making observations
During a support group meeting focusing on strategies to manage symptoms, a patient asks the nurse leader how to deal with angry outbursts from a supervisor. Select the nurse's best action. a. Answer the question, and then move on to another topic. b. Offer to answer the question privately after the group session. c. Inform the patient that only illness-related problems can be discussed in the group. d. Matter-of-factly explain that the topic being discussed is the importance of medication.
d. Matter-of-factly explain that the topic being discussed is the importance of medication.
When observing and interpreting a patient's nonverbal communication, which nursing consideration is important? a. Patients are usually aware of their nonverbal cues. b. Verbal responses are more important than nonverbal cues. c. Nonverbal cues have obvious meaning and are easily interpreted. d. Nonverbal cues provide significant information but must be validated.
d. Nonverbal cues provide significant information but must be validated.
What is the primary purpose of a community meeting? a. Making assignments for patients' chores for the day b. Determining patients' eligibility for increases in privileges c. Encouraging patients to share their feelings and individual problems d. Providing a forum for patients to have input into daily program operations
d. Providing a forum for patients to have input into daily program operations An emphasis of community meetings is on democratic aspects of unit life. The meeting serves as a forum for patients to voice opinions about the environment and to initiate discussion of community concerns. Making assignments and sharing are only some of the issues addressed in a community meeting. Privilege eligibility would not be discussed in a community meeting.
A patient complains of an inability to sleep because of too much noise and light, even though the environment is quiet with soft lighting. This patient might be experiencing dysfunction of the: a. Basal ganglia b. Pituitary gland c. Substantia nigra d. Reticular activating system
d. Reticular activating system The reticular activating system (RAS) serves as a screen that allows individuals to tune out some stimuli and attend to others Lack of sleep can produce psychotic symptoms
Which skill is most important for a nurse preparing to work in the psychiatric setting? a. Helpful transference b. Sympathetic listening c. Supportive confrontation d. Therapeutic communication
d. Therapeutic communication
During an interview with a depressed patient, the nurse sits with folded arms and fidgets when long silences occur. When the patient expresses hopelessness about getting better, the nurse replies, "You will feel better when your medication takes effect." This interaction: a. shows therapeutic use of limit-setting. b. is minimally therapeutic but effective. c. evidences therapeutic use of self. d. is nontherapeutic and ineffective.
d. is nontherapeutic and ineffective.
A nurse could anticipate that the treatment plan for a patient experiencing memory difficulties might include medications designed to: a. inhibit GABA. b. increase dopamine at receptor sites. c. decrease dopamine at receptor sites. d. prevent destruction of acetylcholine.
d. prevent destruction of acetylcholine
A patient who used heroin and became addicted says, "I have willpower to manage my life in other areas, but I feel helpless to control my craving for heroin." The nurse's response should be based on research findings suggesting that addictive behavior is related to changes in: a. cortisol secretion. b. the substantia nigra. c. mitochondrial DNA. d. the nucleus accumbens.
d. the nucleus accumbens
When a nurse administers an anticholinergic drug, it is important to assess for symptoms associated with inhibition of: a. spinal nerve function. b. the central nervous system. c. the sympathetic nervous system. d. the parasympathetic nervous system.
d. the parasympathetic nervous system. Drugs with anticholinergic properties block parasympathetic function of certain cranial nerves, resulting in dilated pupils, decreased tearing, dry mouth, tachycardia, and a slowed GI system