Ch 11: The Psychiatric-Mental Health Nursing Process

c) To assess the client's mental capacity d) To assess the client's current emotional state e) To assess the client's behavioral function Pg. 158-159 The purpose of the psychosocial assessment is to construct a picture of the client's current emotional state, mental capacity, and behavioral function. This assessment serves as the basis for developing a plan of care to meet the client's needs. However, it is not conducting for the purpose of assessing the client's care plan. The client's physical health status would need to be addressed in a physical assessment.

27. When assessing a client's mental health status, which describes the purpose of the psychosocial assessment? Select all that apply. a) To assess the client's plan of care b) To assess the client's physical health status c) To assess the client's mental capacity d) To assess the client's current emotional state e) To assess the client's behavioral function

b) Assessment Pg. Statements such as "the client is depressed" or "the client has poor insight" are interpretations or inferences. Their accuracy depends on supportive data such as "the client manifests a sad affect, reports feeling depressed, and has stopped participating in usual activities" or " the client states he takes his medications even though he doesn't know what they are for," respectively.

32. After conducting an interview with a psychiatric-mental health client, the nurse documents in the client chart that "the client is depressed." The nurse is engage in which part of the nursing process? a) Data collection b) Assessment c) Evaluation d) Planning

a) Avoid stimulating drinks such as coffee or tea in the evening c) Limit fluid intake before bedtime f) Establish a consistent bedtime routine Pg. 155 Establishing a consistent bedtime routine, limiting fluids and particularly those such as coffee and tea that are stimulants are all important non-pharmacological measures to help with insomnia. The client should not go to bed until ready to sleep and should eat a lighter meal in the evening. Use of prescription medicine should not be tried until nonpharmacological measures are used.

4. A client states "I am having trouble going to sleep." Which interventions would the nurse recommend that will be most beneficial to assist with sleep? Select all that apply. a) Avoid stimulating drinks such as coffee or tea in the evening b) Ask the healthcare provider for a prescription for a sleep aid c) Limit fluid intake before bedtime d) Go to bed early to have more time to relax e) Eat a heavy meal to limit hunger f) Establish a consistent bedtime routine

d) Asking whether the client often feels cold Pg. 152 Dress is typically appropriate for occasion and weather, and dress varies considerably from person to person. Some older adults may wear excess clothing because of slowed metabolism and loss of subcutaneous fat resulting in cold intolerance. The nurse needs to determine this first before performing any other assessments.

40. The nurse notes that an older adult client is wearing layers of clothing on a warm, fall day. Which would be the priority assessment at this time? a) Reviewing the client's culture for possible influence b) Observing the client's overall hygiene c) Assessing the client's developmental level d) Asking whether the client often feels cold

c) Validated data and suspected problems Pg. Diagnoses are written using validated data and are a mechanism for conveying to the care team what the suspected problems will be or are.

46. When evaluating care plans as a part of peer review, the nurse knows that the best nursing diagnoses are written in terms of what? a) Judgments and advice b) Cues, inferences, and goals c) Validated data and suspected problems d) Client and nursing needs

a) Hobbies c) Family d) Occupation f) Activities Pg. The number and type of roles may vary, but they usually include family, occupation, and hobbies or activities. It is useful for the nurse to know the client's racial and ethnic identity, but these do not constitute roles or relationships.

9. Which are the types of roles that are usually included when assessing roles and relationships? Select all that apply. a) Hobbies b) Race c) Family d) Occupation e) Ethnicity f) Activities

B) Lithium

A group of nursing students are reviewing information related to drug therapy for mood disorders. The students demonstrate an understanding of the information when they identify which agent as the gold standard for treating bipolar disorder? A) Carbamazepine B) Lithium C) Valproate D) Lamotrigine

B) Lorazepam C) Buspirone

A group of nursing students are reviewing the various drug classes used to treat psychiatric disorders. The students demonstrate understanding when they identify which of the following as examples of antianxiety medications? Select all that apply. A) Selegiline B) Lorazepam C) Buspirone D) Zolpidem E) Methylphenidate

A) Give the antacid 1 hour before the antipsychotic medication.

A nurse is caring for a psychiatric patient who is receiving an antacid that contains aluminum salts. Which action by the nurse would be most appropriate? A) Give the antacid 1 hour before the antipsychotic medication. B )Give the antacid at the same time as the antipsychotic medication. C)Administer the antacid 1 hour after the antipsychotic medication D) Administer the antacid just before the patient goes to sleep.

B) Bioavailability

A nurse is reviewing information about a psychiatric medication that describes the amount of the drug that actually reaches systemic circulation unchanged. The nurse identifies this as which of the following? A) First-pass effect B) Bioavailability C) Solubility D) Biotransformation

Ans: A, B, C, D Feedback: When planning a medication group, the nurse should assess a member's medication knowledge to determine what the individual would like to learn. People with mental illnesses may have difficulty remembering new information, so assessment of cognitive abilities is important. Assessing attention span, memory, and problem-solving skills gives valuable information that nurses can use in designing the group. The nurse should determine the member's reading and writing skills to select effective client education materials. Although an ideal group is one in which all members use the same medication, in reality, this situation is rare, and usually the group members are using various medications.

A psychiatric-mental health nurse is preparing to lead a medication group. Which of the following would be most important for the nurse to assess? Select all that apply. A) Cognitive abilities B) Medication knowledge C) Reading skills D) Writing abilities E) Use of a specific medication

Ans: A Feedback: Avoiding naps in the late afternoon or evening, eating lightly before retiring, and limiting fluid intake before retiring are nonpharmacologic sleep interventions that should be tried before administering sleep medications because of side effects associated with many pharmacologic sleep interventions.

A staff nurse on a psychiatric unit knows that clients often have trouble sleeping because of their psychiatric conditions. Which of the following reflects a psychiatric nursing intervention to appropriately address this problem? A) Limiting amounts of evening snacks and beverages B) Involving clients in a volleyball game immediately before bedtime C) Enforcing the rule that all patients be in bed with lights out by 10:30 p.m. D) Encouraging clients to take short naps in the afternoons

A) I need to be careful because the drug can make me sleepy.

After teaching a patient who is prescribed imipramine about the drug, the nurse determines that the teaching was effective when the patient states which of the following? A) I need to be careful because the drug can make me sleepy. B) I don't have to worry about getting dizzy when I get up from lying down. C) I might notice some excess saliva in my mouth at different times. D) I need to avoid foods with fiber because diarrhea can occur.

C) History of depression

The nurse is reviewing the medical records of several patients receiving antipsychotic agents. Which factors, if noted, would the nurse identify as placing a patient at greater risk for tardive dyskinesia? A) Male gender B) Age 30 to 45 years C) History of depression D) Short duration of treatment

Ans: A, C, E Feedback: The roles of self-confessor, dominator, and playboy are individual roles that members play to meet personal needs. These roles have nothing to do with the group's purpose or cohesion and can detract from the group's functioning. If individual roles predominate, the group may be ineffective. Follower and compromiser are maintenance roles. Elaborator is a task role.

When leading a group, the nurse determines that several of the group members have assumed roles that may be interfering with the group's function. Which roles might be involved? Select all that apply. A) Self-confessor B) Follower C) Dominator D) Elaborator E) Playboy F) Compromiser

c) Encourage the client to help with meal preparation Pg. 154-155 The client who demonstrates paranoia about food being poisoned should be encouraged to help with food preparation so that there is certainty about food being not poisoned. Discussing nutrition, taking vitamins and adding favorite foods will not address the feeling of paranoia the client has about the food being poisoned.

1. A client states, "I don't want to eat anything because I am afraid that my food is poisoned." Which intervention is best for the nurse to perform to encourage the client to eat? a) Tell the client to take vitamins on a daily basis b) Ask the client about favorite foods to add for meals c) Encourage the client to help with meal preparation d) Discuss the importance of proper nutrition with the client

a) "You have had several stressful events occur" Pg. 144 The nurse is summarizing by stating that several stressful events have occurred. Noting symptoms such as shaking hands relates to objective data. Discussing the stress level is stating the consequence of these events that have occurred versus summarizing the reasons. The nurse statement regarding the need to relax is a solution to the discussion on stress and events causing this instead of summarizing what the client has said.

10. The nurse is interviewing a client who has a diagnosis of panic disorder. Which statement by the nurse indicates the use of summarizing? a) "You have had several stressful events occur" b) "I can see that your hands are shaking" c) "You may need to find ways to relax" d) "Your stress level seems really high right now"

b) Obtain permission from the client to speak with the family Pg. Many psychiatric symptoms are beyond a patient's awareness. Family members, friends, and other health care professionals are important sources of information. Before seeking information from others, the nurse must obtain permission from the patient. The nurse needs to provide the patient with a clear explanation of why the information is needed and how it will be used. Calling without the patient's permission is a breach of confidentiality. There is no need to contact the health care provider; the client is the person who must give consent. Having the client contact the family to obtain the information would be inappropriate.

11. A psychiatric-mental health nurse is conducting an assessment and needs to gather additional information from the client's family. Which action would be most appropriate? a) Have the client call the family to obtain the information b) Obtain permission from the client to speak with the family c) Contact the client's family immediately after the session d) Call the health care provider to obtain approval to contact the family

c) Incongruent Pg. 161-162 The correct answer is incongruent affect or lack of harmony between one's voice and movements with one's speech or verbalized thoughts. Blunted affect is a severe reduction or limitation in the intensity of one's affective responses to a situation. Flat affect describes absence or near absence of any signs of affective responses. Labile affect is the abnormal fluctuation of one's expressions.

12. A mental health nurse is caring for a client with schizophrenia. The nurse observes the client laughing about the recent death of the client's father. The nurse would correctly document this mood as what? a) Labile b) Flat c) Incongruent d) Blunted

a) Labile mood Pg. 147 Moods that shift rapidly, displaying a range of emotions, are termed labile.

13. In the space of five minutes, the client has been laughing and euphoric, then angry, and then crying for no reason that is apparent to the nurse. This behavior would be best described as... a) Labile mood b) Flight of ideas c) Tangential thinking d) Lack of insight

b) "What is your definition of health?" Pg. 152 The nurse is asking an appropriate assessment question with culture in determining a client's health beliefs. The nurse would not assume a client has certain beliefs, such as medicine men, and it is best also not to assume a person with a different ethnicity came from another country- instead the nurse can ask what cultural group a person belongs to. Asking about seeking help will not elicit the best response to health beliefs and behaviors- it is best to ask how illness is defined and what a patient would do to get better if ill to determine this information.

14. The nurse is performing a cultural assessment on a client admitted with depression. What question would obtain the most detailed assessment information? a) "Are you from another country?" b) "What is your definition of health?" c) "Do you believe in medicine men?" d) "Do you seek help when you are ill?"

d) Perception of the problem Pg. The question will elicit information about the client's view or perspective of the problem.

15. During the assessment, the nurse asks the client to describe his problems. The purpose of this question is to obtain information about the client's... a) Admitting diagnosis b) Personal needs c) Communication skills d) Perception of the problem

b) Evaluating the effectiveness of the treatment Pg. 139 The evaluation phase is the final phase of the nursing process, and it focuses on the client's status, progress toward goal achievement, and ongoing reevaluation of the care plan.

16. A 22-year-old client who has been diagnosed with paranoid personality disorder has been receiving treatment. The final stage of the nursing process in the care of this client should focus on what? a) Encouraging the client to develop coping skills and life skills b) Evaluating the effectiveness of the treatment c) Selecting specific interventions d) Engaging the client's friends and family

a) Affect Pg. 147 Affect refers to a person's emotional expression (in this case, the manner in which the client talks about the client's experiences). Feelings are emotional states or perceptions. Blocking is the interruption of thoughts. Moods are prolonged emotional states expressed by the affect.

17. A nurse documents that "the client describes the recent breakup of a dating relationship with an emotionless tone and a flat facial expression." In which section of the mental status exam would the nurse have documented this statement? a) Affect b) Mood c) Blocking d) Feelings

c) Chronological age and developmental level Pg. 153 The client's chronological age and developmental level are important factors in the psychosocial assessment. The nurse evaluates the client's age and developmental level for congruence with expected norms. For most clients, this will have a greater bearing on care and treatment than issues related to finances, transportation and previous utilization of health care.

18. What factor is most important in the psychosocial assessment of the mental health client in order to formulate a plan of care? a) History of multiple physicians b) Ability to obtain transportation c) Chronological age and developmental level d) Financial support

d) Assessment of history Pg. 140 When the client is being admitted to inpatient setting, the nurse first obtains the client's psychiatric history. In the inpatient setting, a thorough psychiatric history would be more important to address early, rather than educational level, social status, and insurance information.

19. A client is being admitted to an inpatient setting. It is important for the nurse to first obtain which information about the client? a) Educational level b) Social status c) Insurance information d) Assessment of history

d) Thinking Pg. A delusion is a fixed false idea or thought.

2. A delusion represents a problem in which of the following areas? a) Memory b) Orientation c) Motivation d) Thinking

d) Presenting reality Pg. 161-162 By replying with facts when the client makes a statement that is not true and is likely a delusion, the nurse is using the technique of presenting reality. The nurse focuses the interview by bringing the conversation back on topic if the client goes off on a tangent (e.g., by telling a very involved narrative of how the client had arrived at the health care provider). Restating means repeating what the client has said to invite clarification (e.g, by responding, "You are the king of a magical land?"). The nurse would give recognition through active listening, verbally encouraging the patient to continue and nonverbally presenting an open, interested demeanor.

20. A client with a history of schizophrenia states "I am the ruler of a magical land." When the nurse replies by stating who and where the client is, which interview behavior is the nurse using? a) Restating b) Giving recognition c) Focusing d) Presenting reality

b) "Where were you when this happened?" Pg. 148 Ideas of reference are the client's inaccurate interpretation that general events are personally directed to him or her, such as hearing a speech on the news and believing the message had personal meaning. "Where were you when this happened," would relate to the place and might give the nurse more information to validate the client's previous comments. "Why do you think that," may be interpreted as the nurse challenging the client. "Are you sure," is a closed-ended question and does not encourage the client to elaborate. "That is unbelievable," is a statement rather than a question and could be interpreted as the nurse's opinion of the information provided by the client.

21. The client spoke of a current event in the national news and described it as it relates to the client. Then the client spoke of a historical event and described it as being directly related to the client. Which question might the nurse ask to determine if the client is experiencing ideas of reference? a) "Why do you think that?" b) "Where were you when this happened?" c) "Are you sure?" d) "That is unbelievable!"

c) Recognizing that these areas may also be uncomfortable for the client to discuss Pg. Two areas that may be uncomfortable or difficult for the nurse to assess are sexuality and self-harm behaviors. The nurse needs to remember that it may be uncomfortable for the client to discuss these topics as well. However, it would be inappropriate to share these feelings of comfort explicitly with the client. A nurse must perform difficult assessments and is not justified in delegating them because of discomfort. Assessments must be thoughtfully individualized to each client.

22. Sexuality and self-harm behaviors are often difficult areas for nurses to assess. An effective way for nurses to deal with this discomfort includes what? a) Deferring assessing these areas to a more experienced nurse b) Developing a standard question to ask of all clients during this area of assessment c) Recognizing that these areas may also be uncomfortable for the client to discuss d) Sharing feelings of discomfort with the client

a) Validation Pg. 161 The nurse is practicing validation which demonstrates respect for clients and their human rights. Containment involves setting the right environment or milieu for a client's food and shelter needs but this was a more global statement made by the nurse to help with any needs. Psychoeducation involves teaching a client lacking skills due to a psychiatric disorder- there is not a skill defined with this statement by the client. Conflict resolution is an intervention used in disagreements or disputes but there is no evidence there has been one.

23. The nurse states to a client who calls out for help, "I am happy to help you. Please let me know what I can do." Which process is the nurse using with this statement? a) Validation b) Conflict resolution c) Psychoeducation d) Containment

a) The anxious client Pg. 159 The nurse should not choose an isolated location such as a conference room for the interview, if the client is unknown to the nurse or has a history of any threatening behavior either to themselves or to others. The anxious client by diagnosis does not present a threat and so is the one best suited for the nurse to use the conference room for the interview.

24. When considering where to conduct a psychosocial assessment, the nurse can effectively interview which client in the unit's conference room? a) The anxious client b) The aggressive client c) The suicidal client d) The paranoid client

d) Quality of life Pg. 163 Components of the social assessment include functional status, social systems, and quality of life. Mental status is part of the psychological assessment. The biologic assessment includes current and past health status, physical examination with review of body systems, review of physical function, and pharmacologic assessment. A risk factor assessment is part of the psychological assessment.

25. What is part of the social component in a psychiatric-mental health nursing assessment? a) Risk factor assessment b) Mental status c) Pharmacologic assessment d) Quality of life

b) Look for patterns reflected in the overall assessment Pg. 140 After completing the psychosocial assessment, the nurse analyzes all the data that he or she has collected. Data analysis involves thinking about the overall assessment rather than focusing on isolated bits of information. The nurse looks for patterns or themes in the data that lead to conclusions about the client's strengths and needs, and to a particular nursing diagnosis. No one statement or behavior is adequate to reach such a conclusion. Normal findings can be as significant as abnormal findings. The nurse should analyze data before presenting it formally.

26. The nurse has completed the psychosocial assessment. Which is the best approach toward analysis of the data to identify nursing diagnoses and develop an appropriate plan of care? a) Focus individually on each piece of information obtained from the client b) Look for patterns reflected in the overall assessment c) Present all data obtained in the treatment team meeting d) Consider only the abnormal findings in the assessment

a) Judgment d) Short-term memory e) Attention and concentration Pg. 143 Attention and concentration, as well as judgment and memory will test the client's cognition or ability to think and know. Support system is part of assessing the client's social domain, and stress level is not related to cognition.

28. In assessing the client's cognition in a mental health assessment, which area(s) would be tested? Select all that apply. a) Judgment b) Support system c) Stress level d) Short-term memory e) Attention and concentration

c) "The client will refrain from cutting or self-mutilation" Pg. 150 An expected outcome is a measurable, client-oriented goal, such as the goal of abstaining from self-harm. "Resolution of her psychiatric diagnosis" and "better coping skills" do not meet these criteria of attainability and measurability. An expected outcome should not be framed in terms of the care providers' actions or interventions.

29. A client's nursing diagnosis of "risk for self-directed violence" has been identified because of her recent history of cutting and self-mutilation. Which of the following expected outcomes is most appropriate for this client's plan of care during inpatient treatment? a) "The client will demonstrate better coping skills" b) "Staff will observe the client for signs of self-mutilation" c) "The client will refrain from cutting or self-mutilation" d) "The client will demonstrate resolution of her psychiatric diagnosis"

d) Delusion Pg. 150-152 The client has a delusion (a fixed false belief not based in reality) about his superiority over others. Flight of ideas is excessive amount and rate of speech composed of fragmented or unrelated ideas. Thought broadcasting is a delusional belief that others can hear or know what the client is thinking. Loose associations are disorganized thinking that jumps from one idea to another with little or no evident relation between the thoughts.

3. A client is admitted to the psychiatric unit and states, "I am president of the largest corporation in the world. Everyone comes to me for advice." The nurse knows the client is exhibiting what? a) Flight of ideas b) Thought broadcasting c) Loose associations d) Delusion

c) Inconsistent with the nursing process, because assessment always comes first Pg. 155 The five steps of the nursing process supply an organized approach for providing quality psychiatric-mental health nursing care. The five steps of the nursing process are assessment, diagnosis, planning, implementation, and evaluation.

30. A nurse awaits the arrival of a client who is being transferred from a nursing home. The client has a history of schizophrenia and has been behaving bizarrely. The nurse begins preparing the plan of care by outlining expected outcomes. The nurse's actions are which of the following? a) Consistent with the nursing process, because the goals generally will be applicable to all clients with schizophrenia b) Inconsistent with the nursing process, because the nurse should establish goals with the client c) Inconsistent with the nursing process, because assessment always comes first d) Consistent with the nursing process, because goals should be identified before interventions

b) Concentration Pg. 163 The nurse assesses the client's ability to concentrate by asking the client to perform certain tasks such as repeating the days of the week backward. The nurse directly assesses memory, both recent and remote, by asking questions with verifiable answers. Orientation refers to the client's recognition of person, place, and time. Abstract thinking is making associations or interpretations about a situation or comment.

31. The nurse asks a client to list the days of the week in reverse order. The nurse is assessing what? a) Memory b) Concentration c) Abstract thinking d) Orientation

c) Labile Pg. 147 A client who exhibits intense, frequently shifting emotional extremes has a labile affect. Mobile affect is considered a stable normal affect. A restricted affect is one in which the individual expresses few emotions. Euphoric is a term used to describe mood, not affect. It indicates an elated mood.

33. A psychiatric-mental health nurse is assessing a client's affect. The client demonstrates extremes, going from laughing and joking one moment to crying and tears a few minutes later. This pattern occurs throughout the interview. The nurse documents this as which type of affect? a) Euphoric b) Mobile c) Labile d) Restricted

b) Emphasize the importance of truthful information using a nonjudgmental approach Pg. 154-155 Noncompliance with prescribed medications is an important area. If the client has stopped taking medication or is taking medication other than as prescribed, the nurse must help the client feel comfortable enough to reveal this information. A collaborative approach is more effective and therapeutic than imposes more supervision. The nurse also explores the client's use of alcohol and over-the-counter or illicit drugs. Such questions require nonjudgmental phrasing; the nurse must reassure the client that truthful information is crucial in determining the client's plan of care. The client has a right to self-determination, but this does not oblige the nurse to ignore harmful behaviors.

34. A nurse suspects that a client is abusing alcohol while taking prescribed medications. The nurse plans to educate the client on the dangers of mixing medicine with alcohol. Which would be the most effective way for the nurse to approach this subject with the client? a) Firmly inform the client of the dangers of mixing medications with alcohol b) Emphasize the importance of truthful information using a nonjudgmental approach c) Recommend a higher level of care so the client can be more closely supervised d) Recognize the client's right to self-determination and avoid addressing the subject

b) Implement nursing actions that have been identified Pg. 143-145 The steps of the nursing process include assessment, diagnosis, planning, implementation, and evaluation. Following the development of the plan, the plan should be implemented.

35. A nurse develops a plan of care for a client with an eating disorder. The plan includes developing a contract with the client to modify behavior. What is the next step? a) Diagnose the client with ineffective coping as evidenced by need to binge and purge to manage stress b) Implement nursing actions that have been identified c) Assess the client's current weight d) Evaluate the effectiveness of the contract

b) Physical appearance Pg. 149 When assessing a client suspected of being depressed, the psychiatric nurse pays close attention to the client's affect and physical appearance. An ability to describe a problem, recall details, and use fine motor skills are not typically the first things to pay attention to when assessing a client suspected of being depressed.

36. When assessing a client who has been referred to the outpatient mental health clinic with symptoms of depression, the psychiatric nurse should closely observe the client's affect and which assessment component? a) Recollection of the problem's related details b) Physical appearance c) Ability to describe the problem d) Fine motor skills

d) "Can you tell me what this object is?" Pg. 163 The nurse is assessing the client's comprehension when asking the client to name a common object such as a pen or watch. The client is demonstrating judgment by describing what to do with a wallet found on the ground. Being able to discuss where the client went on the last vacation is a test of the client's memory. The ability to subtract numbers is demonstrating the client's attention and concentration.

37. The nurse is performing a mental health assessment. Which question would be best to ask the client to determine comprehension? a) "Can you subtract the number 5 from 22?" b) "Where did you go on your last vacation?" c) "What would you do if you found a wallet on the ground?" d) "Can you tell me what this object is?"

a) Evaluation of insight and judgment Pg. 143-145 The mental status examination is a central aspect of the psychiatric assessment process that assesses current cognitive and affective functioning through data collection on appearance, behavior, level of consciousness, speech, thought content and processes, cognitive ability, mood and affect, insight, and judgment. This assessment relies almost exclusively on observation rather than inquiry and is expected to change during treatment.

38. A nurse has been asked to complete a mental status examination of a psychiatric-mental health client. Which is a necessary component of this assessment? a) Evaluation of insight and judgment b) Evaluation of medication compliance c) A review of systems d) Questions regarding past behaviors

d) "Who is the current president?" Pg. 147 The nurse directly assesses memory, both recent and remote, by asking questions with verifiable answers such as "What is the name of the current president?" The nurse may not be able to verify the accuracy of the client's responses to questions such as "Do you have any memory problems?" or "What did you do yesterday?" Orientation refers to the client's recognition of person, place, and time. Asking the client why he or she is here assesses perception and insight.

39. The nurse best assesses a client's memory by asking which question? a) "Do you know why you are here?" b) "Do you have any problems with memory?" c) "What did you have for lunch yesterday?" d) "Who is the current president?"

d) Identification of previously effective coping skills Pg. Reminiscence encourages patients, either in individual or group settings, to discuss their past and review their lives. Through reminiscence,individuals can identify past coping strategies that can support them in current stressful situations. None of the other options are outcomes of this form of therapy.

41. What is the expected outcome of therapeutic reminiscence? a) Improvement of minor cognitive deterioration b) Maintaining both short and long term memory c) Distraction from recurring fears d) Identification of previously effective coping skills

a) Milieu therapy Pg. 161 Examples of nursing interventions used in the social domain include behavior therapy, milieu therapy, and various home and community interventions. Counseling is a nursing intervention related to the psychological domain. Self-care and nutrition are related to the biologic domain.

42. What is a nursing intervention used in the social domain? a) Milieu therapy b) Nutrition promotion c) Counseling d) Self-care education

b) The length and quality of relationships Pg. 160 Social assessment also includes identification of the person's social network. The nurse should elicit the information about the size and extent of the network, both relatives and nonrelatives, and the length and quality of the relationships.

43. When conducting a psycho-social assessment, the nurse inquires about the client's social supports. In order to effectively do this, which does the nurse need to explore? a) Challenges faced with social networks b) The length and quality of relationships c) The number of networks d) The proximity of the networks to the client

b) The nurse should recognize the incongruity between content and behavior and find ways of exploring further Pg. 150 An apparent disconnect between content and the client's behavior should prompt the nurse to explore the matter more deeply. While grieving is indeed an individual process, it would be imprudent for the nurse to deny the incongruity between the topic and the behavior. The client's statement heightens the relevance of mental status in the assessment, but the priority would be to explore the matter more deeply and ask follow-up questions. It would be presumptuous to conclude that the client is depersonalizing the spouse's death.

44. The nurse is assessing an older adult client with lower back pain. In the course of assessment, the nurse learns that the client lost a spouse 10 weeks ago. The client laughs inappropriately and states, "My spouse just up and left me!" Which is the nurse's best response? a) The nurse should recognize that the client is depersonalizing the death of the spouse b) The nurse should recognize the incongruity between content and behavior and find ways of exploring further c) The nurse should recognize that the grieving process is highly individual, and responses need not match societal or cultural norms d) The nurse should redirect the assessment toward mental status assessment

d) Measurable and realistic Pg. 163 Explanation: Outcomes can be measured immediately after the nursing intervention or after time passes. Expected outcomes must be measurable and realistic. Evaluation of client outcomes involves assessing cost-effectiveness of the interventions, benefits to the client, and the client's level of satisfaction. Client plans of care and outcomes are individualized, not specific to the diagnosis, but to the client's ability to learn, barriers to learning, and other factors. The client's input is valuable in establishing goals as well as the collaboration of the healthcare team, but this does not measure outcomes. Outcomes are measured as being met or unmet; being flexible and accomodating does not measure outcomes.

45. For a psychiatric client's expected outcomes to be appropriate they must be... OR The psychiatric nurse is caring for a client with mental illness. What statement from the client indicates that teaching on expected outcomes has been effective? a) Mutually agreed upon by client and care team b) Closely aligned with the psychiatric diagnosis c) Flexible and abstract d) Measurable and realistic

b) Assess the client's knowledge of the medication and identify the client's learning style d) Develop mutually agreed on goals with the client for learning about the medication c) Instruct the client on administration needs and side effects of the medications a) Ask the client to explain how to administer the medication and side effects to observe for Pg. 139 Health teaching is an important part of the psychiatric-mental health nurse's role and the nurse would do this according to the nursing process with assessing, planning, intervening and evaluating the client's teaching. The nurse would first assess the client's knowledge and learning style. The nurse and client would develop mutual goals for what the client will learn. Interventions are completed that help with reaching the mutually agreed upon goals. The nurse would then evaluate the client's knowledge to determine if learning has occurred.

47. The nurse is teaching a client about a new psychotropic medication that the client will begin. Place the following steps in order for performance of the client's education. a) Ask the client to explain how to administer the medication and side effects to observe for b) Assess the client's knowledge of the medication and identify the client's learning style c) Instruct the client on administration needs and side effects of the medications d) Develop mutually agreed on goals with the client for learning about the medication

a) Self-concept c) Roles and relationships e) Cognition Pg. For this client, there has been a recent major loss of significant relationships and of the role of caregiver. As a result of the loss of the client's role as caregiver, the client's personal view of self or personal qualities/attributes will also be altered. The history includes the recent death of the client's mother as well as the fact that the client has lost the role of primary caregiver. This part of the assessment can to helpful in understanding the nature of the client's depressive symptoms. The client is neatly dressed, so it does not appear that self-care is an issue. Judgment would be reflected by problems involving decision making. Cognition would be reflected by problems involving the ability to think or know.

48. The nurse is interviewing a client who has been experiencing symptoms of depression over the past month. The client is clean and neatly dressed. During the interview, the client describes recent stresses, including the death of the client's mother, for whom the client was a primary caregiver. The nurse interprets this information as reflecting potential problems with which area? Select all that apply. a) Self-concept b) Judgment c) Roles and relationships d) Self-care considerations e) Cognition

a) "Clients feel more secure when working with us when we are dressed in our regular clothes" Pg. 161 The nursing staff may not wear uniforms as a way to promote a therapeutic milieu for clients on the unit. This can decrease the formalized nature of the unit and make clients feel more secure and able to bond with nursing staff. Clients may have physical needs, even on a mental health unit, and typically nurses are not hampered with moving quickly when in a uniform. The staff would follow whatever rules are set for the unit with employment and dress so this is not a part of wearing regular clothes versus a uniform.

49. The nursing student on a mental health unit asks a nurse why they don't wear a uniform when coming to work. What is the nurse's best response? a) "Clients feel more secure when working with us when we are dressed in our regular clothes" b) "We can move more quickly when wearing our regular clothes if we have an emergent situation" c) "We are not working with clients who have physical needs so we can wear our regular clothes" d) "The staff is happier to not buy special clothes so this is a way to promote our job satisfaction"

d) Hyperthyroidism Pg. 143 An elevated serum thyroxine concentration is indicative of hyperthyroidism. Hypothyroidism, anemia, and muscle tissue injury are not typically associated with an elevated thyroxine concentration.

5. The client has an elevated serum thyroxine concentration. This finding indicates which disease processes? a) Muscle tissue injury b) Hypothyroidism c) Anemia d) Hyperthyroidism

d) Initial and ongoing interviews with the client and family Pg. The client and family are the most direct and comprehensive source of patient data.

50. The single most important source of information in the nurse's psychosocial assessment of the client is... a) The family's knowledge about the client and his or her behaviors b) The client's understanding of his or her difficulties c) The client's chart, containing past history d) Initial and ongoing interviews with the client and family

b) "Tell me what a routine day would be for you?" Pg. 143-145 Asking a client what a routine day looks like is an open-ended question that allows the nurse to establish rapport and show interest in what a client's life is like. The other questions can elicit information but would be closed questions which would likely just have a short answer or one that would not encourage further discussion with the client.

51. The nurse is interviewing a client admitted with a diagnosis of depression. What question asked by the nurse best indicates interest and establishes rapport with the client? a) "What is your name and date of birth?" b) "Tell me what a routine day would be for you?" c) "Are you feeling stressed right now?" d) "What type of coping mechanisms do you use?"

b) Warn the client's neighbor and report to the authorities Pg. When the client makes specific threats or has a plan to harm another person, health care providers are legally obligated to warn the target of the threats. Legally this is called duty to warn. Although the nurse must document the session thoroughly and can meet with the client again the next day, this should not be the nurse's first action. The nurse should eventually review coping strategies for anxiety and set new therapeutic goals; however, duty to warn is the priority.

6. A nurse is seeing a client for a weekly therapeutic session in an outpatient psychiatric clinic. The client discloses to the nurse that the client often has thoughts about killing a neighbor. What should be the nurse's first response? a) Review the client's history to determine presence of past of violent behavior b) Warn the client's neighbor and report to the authorities c) Document the session thoroughly and meet with the client again the next day d) Review coping strategies for anxiety and set new therapeutic goals

b) The client's ability to use abstract thinking Pg. 148 When the nurse states, "A stitch in time saves nine," and asks the client to restate it in his or her own words, the nurse is assessing the client's ability to use abstract thinking. The client's orientation is recognizing person, place, and time. The client's memory, both recent and remote, can be assessed by asking the client questions that have verifiable answers. The client's ability to concentrate can be assessed by asking the client to perform certain tasks, including spelling the word "world" backward.

7. The nurse asks the client to restate the following in his own words, "A stitch in time saves nine." which sensorium and intellectual process is the nurse attempting to identify? a) The client's orientation b) The client's ability to use abstract thinking c) The client's memory d) The client's ability to concentrate

b) "What day of the week is it?" c) "What is your name?" e) "Can you tell me where you are?" Pg. 147 Asking the client to give the client's name, identify the client's location, and name the day of the week assess orientation. Asking the client to relate what the client ate for breakfast assesses short memory, and asking the client to count backward assesses intellectual abilities, neither of which is a reflection of orientation.

8. When assessing orientation, the nurse completes the assessment by asking which questions? Select all that apply. a) "Would you count from 1 to 10 backward, please?" b) "What day of the week is it?" c) "What is your name?" d) "What did you eat for breakfast today?" e) "Can you tell me where you are?"

Ans: C Feedback: Learning how to manage a medication regimen or control angry outbursts is often the aim of teaching (psychoeducation) groups. Psychoeducation groups are formally planned, and members are purposefully selected so that the focus of the group will help them work on a specific problem or knowledge deficit. Psychotherapy groups treat individuals' emotional problems and can be implemented from various theoretic perspectives, including psychoanalytic, behavioral, and cognitive. These groups focus on examining emotions and helping individuals face their life situations. Self-help groups are led by people who are concerned about coping with a specific problem or life crisis. These groups do not explore psychodynamic issues in depth. Supportive therapy groups are usually less intense than psychotherapy groups and focus on helping individuals cope with their illnesses and problems.

A client has been placed in an anger management group because he has trouble controlling his angry outbursts. The nurse interprets this type of group as an example of which of the following? A) Psychotherapy B) Self-help C) Psychoeducation D) Supportive therapy

Ans: C Feedback: The statement, "This must be a very difficult time for you" reflects empathy, which is one of the nursing behaviors that can enhance the effectiveness of an assessment interview. The focus needs to be on the client. Therefore, asking about his wife or other children would be less appropriate. Telling the client how the nurse feels is an inappropriate use of self-disclosure.

A client is being admitted to a psychiatric unit. While explaining his reason for seeking admission, he describes how his 32-year-old son recently died of a heart attack. Which response by the nurse would enhance the effectiveness of this interview? A) "How is your wife handling your son's death?" B) "Do you have any other living children that can help you cope with this loss?" C) "This must be a very difficult time for you." D) "I know exactly how you're feeling; my 23-year-old son died unexpectedly last year."

Ans: D Feedback: The response about making a serious attempt on his life and not being ready to go home by tomorrow addresses the client's unrealistic assumption and presents him with the reality of his situation. Presenting reality is one assessment interview behavior that enhances the effectiveness of an assessment interview. Asking the client to tell the nurse about his daughter changes the subject and focus of the client's statement. Telling the client that he is right is false reassurance. The response, "As good as new?," although a reflective and clarifying statement, shifts the focus of the interaction.

A client was admitted to the hospital after a suicide attempt following his daughter's death in an automobile accident; the client had been driving and survived with only minor injuries. Even though the accident was unavoidable, he feels responsible. During the assessment interview, the client begins to describe the last conversation he had with his daughter before he lost control of the automobile. As he speaks about his daughter, his voice trembles, and a tear rolls down his face. He makes a visible attempt to "straighten up" and smiles superficially at the nurse, stating, "I'll get over this. I just need to keep a stiff upper lip. I think all I need to do is stay overnight. I'll be as good as new by tomorrow." Which response by the nurse would be most appropriate? A) "Tell me about your daughter. How would you describe the relationship you had with her?" B) "I'm sure you are right; a good night's rest should make a big difference." C) "As good as new?" D) "You made a serious attempt on your life; you will not be ready go home by tomorrow."

Ans: D Feedback: Because the duration of client hospitalization is relatively short, open groups are typical on inpatient units, such as an inpatient anger management group. Closed groups are more typical of outpatient groups that have a sequential curriculum, or psychotherapy groups. Examples include outpatient smoking cessation, psychotherapy, and psychoeducation groups.

A group of nursing students is reviewing information about open and closed groups. The students demonstrate understanding of the information when they identify which of the following as an example of an open group? A) Outpatient smoking cessation group B) Community clinic psychoeducation group C) Ambulatory psychotherapy group D) Inpatient anger management group

Ans: B Feedback: Self-help groups are led by people who are concerned about coping with a specific problem or life crisis. These groups do not explore psychodynamic issues in depth. Professionals usually do not attend these groups nor serve as consultants. Psychiatric nurses lead supportive therapy groups. Both types of groups focus on a specific problem.

A group of nursing students is reviewing information about the different types of group. The students demonstrate understanding of the information when they identify which of the following as a characteristic of a self-help group that differentiates it from a supportive therapy group? A) The group is led by a professional. B) The group is led by a consumer. C) There is no identified leader. D) The group is focused on a specific problem.

Ans: A, B, D Feedback: Yalom described 11 primary factors through which therapeutic changes occur in group psychotherapy. These include, among others, altruism, catharsis, imitative behavior, universality, and instillation of hope.

A group of nursing students is reviewing the factors associated with group psychotherapy, through which therapeutic changes occur. The students demonstrate understanding when they identify which of the following as a factor? Select all that apply. A) Altruism B) Catharsis C) Repressed behavior D) Universality E) Hopelessness

D) Akathisia

A hospitalized patient who has been taking an antipsychotic medication for 2 weeks begins pacing and walking throughout the unit. He tells the nurse that he cannot sit still. The nurse documents this finding as which of the following? A) Akinesia B) Dystonia C) Pseudoparkinsonism D) Akathisia

D) 8 AM

A nurse administers a prescribed dose of lithium at 8 PM. The nurse would schedule a specimen to be obtained for a blood level at which time? A) 10 PM B) 12 AM C) 4 AM D) 8 AM

Ans: A Feedback: To encourage group cohesiveness, the nurse should use team-building exercises or encourage socialization with minimal supervision. Task completion helps to promote achievement of the group's work but does not necessarily foster group cohesiveness. Spending time with each member may be important to facilitate communication and develop a relationship, but this would not promote group cohesiveness. Each group develops its own group themes.

A nurse has begun group counseling sessions for several hospitalized clients in the psychiatric facility. Which of the following would be most effective for the nurse to do to promote group cohesiveness? A) Use team-building exercises. B) Encourage task completion by members. C) Spend time with each member individually. D) Be consistent with the group themes.

Ans: A, B Feedback: In the beginning stage of development, the nurse acknowledges each member; constructs a working environment; develops rapport with the members; begins to build a therapeutic relationship; and clarifies outcomes, processes, and skills related to the group's purpose. Members also begin to test whether they can trust one another and the leader. Working to develop norms, promoting sharing of feelings, and facilitating communication occur during the working phase.

A nurse is acting as the leader of a newly formed group that is in the beginning stage of development. Which of the following would the nurse expect to do? Select all that apply. A) Develop rapport with the group members B) Anticipate members testing one another C) Work with members to develop norms D) Promote sharing of feelings E) Facilitate verbal and nonverbal communication

Ans: D Feedback: Large groups (more than 8 to 10 members) are effective for specific problems or issues, such as smoking cessation or medication information, and are often used in the workplace. Transference and countertransference issues usually do not develop in large groups. Group cohesiveness is less in larger groups. Larger groups also can be challenging because of the increased number of potential interactions and relationships that can form.

A nurse is deciding about the size of the group. The nurse determines that a large group would be best based on which of the following? A) Transference and countertransference issues will be moderate to minimal. B) Group cohesiveness will be strong with greater interpersonal experiences. C) The number of potential interactions and relationships is limited. D) The group is effective for dealing with a specific issue.

Ans: D Feedback: An effective group leader recognizes the effects of an individual's mood on the total group. Thus, an effective leader would realize that the client's intense anger could set the emotional tone of the entire group. If the purpose of the group is to deal with emotions, then choosing to discuss the member's problem at the beginning of the session would help to limit the intense anger to the one person experiencing it. Keeping the focus off the client or asking the client to leave could disrupt the functioning of the group because the client's emotions can affect the entire group. Suggesting the client make a private counseling appointment may be appropriate later, after discussing the client's problem at the beginning of the session.

A nurse is leading a group in which members are encouraged to discuss their feelings and emotions. The group session is just starting when a client stomps into the room, slams his notebook on a table, and sits down. His affect is one of anger and hostility. Which response by the nurse would be most appropriate? A) Keep the focus off the client so his anger has time to de-escalate. B) Suggest the client make a private counseling appointment to address his anger issues. C) Ask the client to leave the group until he is calmer. D) Encourage the client to discuss his anger with the group.

Ans: C Feedback: In some groups, members clearly dislike one particular member. This situation can be challenging for the leader because it can result in considerable tension and conflict. This person could become the group's scapegoat. The group leader may have made a mistake by placing the person in this particular group, and another group may be a better match. One solution may be to move the person to a better-matched group. Whether the person stays or leaves, the group leader must stay neutral and avoid displaying negative verbal/nonverbal behaviors that indicate that there is dislike for this specific member (or that indicate displeasure with the other members for their behavior). Often, the group leader can manage the situation by showing respect for the disliked member and acknowledging his or her contribution. Skipping the client nonverbally indicates negative feelings. Allowing the client to talk last isolates the client from the group. Demanding that the other group members tell why they dislike the client would demonstrate displeasure with the rest of the group for their behavior.

A nurse is leading a group on an adolescent psychiatric unit. A new member in the group is from out of state. His accent and his way of dressing set him apart from the other clients and it is obvious that the group, for the most part, dislikes this client. During the group session, the nurse has the members draw the emotion they are feeling and then has them present their drawings and explain them to the group. Which of the following would be the most effective way to address the group's dislike for the new member? A) Skip him when it is his turn to present his drawing. B) Let the client talk last so the others will not have time to make fun of him. C) Compliment the client when he presents his drawing. D) Demand that each member of the group tell the client why they dislike him.

Ans: D Feedback: With a client who agrees initially then continually says, "Yes, but . . .," the nurse should encourage that person to formulate his or her own solutions. The leader can serve as a role model of the problem-solving behavior for the other members and encourage them to let the member develop a solution that would work specifically for him or her. Telling the client to join a different group is demeaning and does not address the client's problem. Asking the client if he or she realizes the response, or telling the client to stop and think about why, could be threatening to the client's self-esteem.

A nurse is leading a small group of hospitalized clients diagnosed with psychiatric disorders. One group member has asked for advice and often agrees with suggestions by other group members, but then adds, "Yes, but . . ." to every suggestion offered. Which response by the nurse would be most appropriate? A) "Things would probably work out better if you joined a different group." B) "Do you realize you say, 'Yes, but . . .' to every suggestion the group has for you?" C) "I suggest you stop and think about why you always respond to suggestions with 'Yes, but . . .'" D) "What solution do you think would work best for you?"

B.) Tolerance

A nurse is performing an admission assessment. The patient complains that it has been taking larger and larger amounts of medication to get the desired effect. Based on this information, the nurse interprets this as suggesting which of the following? A) Desensitization B )Tolerance C.) Therapeutic index D) Toxicity

A) Fluoxetine, C) Sertraline

A nurse is preparing a continuing education presentation for a group of psychiatric-mental health nurses about various psychopharmacologic agents. The nurse is planning to discuss selective serotonin reuptake inhibitors. Which agents would the nurse include in this group? Select all that apply. A) Fluoxetine B) Duloxetine C) Sertraline D) Venlafaxine E) Bupropion F) Amoxapine

A) Ensuring that there is a signed informed consent on the patient's chart C) Alerting the patient to the possibility of confusion after the treatment E) Ensuring that the patient is closely supervised for at least the first 12 hours afterward

A nurse is preparing a patient for electroconvulsive therapy. Which of the following would the nurse include in the patient's plan of care? Select all that apply. A) Ensuring that there is a signed informed consent on the patient's chart B) Telling the patient he can have fluids but no food before the procedure C) Alerting the patient to the possibility of confusion after the treatment D) Informing the patient that he can leave his dentures in place for the treatment E) Ensuring that the patient is closely supervised for at least the first 12 hours afterward

Ans: C Feedback: An ideal size for a small group is seven to eight clients. Clients with challenging behaviors should be carefully screened and assigned to smaller groups. Small groups (usually no more than seven to eight members) become more cohesive, are less likely to form subgroups, and can provide a richer interpersonal experience than large groups. Even though small groups cannot easily withstand the loss of members, they are ideal for clients who are highly motivated to deal with complex emotional problems (e.g., sexual abuse, eating disorders, or trauma) or for those who have cognitive dysfunction and require a more focused group environment with minimal distractions.

A nurse is preparing to form a group in an inpatient psychiatric setting for clients who have experienced trauma. In addition to the group leader, the nurse would anticipate including how many clients? A) 3 or 4 B) 5 or 6 C) 7 or 8 D) 9 or 10

Ans: B Feedback: When working with older adult groups, the nurse needs to slow the pace of the group meetings and place greater emphasis on using wisdom and experience, rather than learning new information. The nurse should also encourage the group to use life-review strategies such as autobiography and reminiscence. When teaching new skills, the nurse should place them within the context of previous attempts to resolve issues and problems.

A nurse is preparing to lead an older adult group. Which of the following would the nurse need to keep in mind when leading this group? A) Focusing the group to promote learning of new information B) Keeping the pace of the group meetings slow C) Discouraging the use of life-review strategies D) Teaching entirely new methods for coping

C) Phase III

A nurse is working as part of a team involved with the testing of a new psychiatric medication. The drug is currently being used in multiple clinical trials at various different sites. The nurse is engaged in which phase of testing? A) Phase I B) Phase II C) Phase III D) Phase IV

C) Neurotransmitters

A nursing instructor is teaching a class on the pharmacodynamics of psychiatric medications. The instructor determines that additional teaching is needed when the students identify which of the following as a site of action? A) Receptor B) Ion channels C) Neurotransmitters D) Enzymes

D) You may experience noticeable weight gain while taking this medication.

A patient has been prescribed clozapine for treatment of schizophrenia. Which of the following would the nurse include in the teaching plan for this patient and family? A) You may experience hypertension while taking this medication. B) One of the side effects of this medication is breast engorgement. C) People taking this medication often experience dermatitis. D) You may experience noticeable weight gain while taking this medication.

C) Serotonin syndrome

A patient is brought to the emergency department by her brother, who reports that the patient became very agitated and started hallucinating. Further assessment reveals tachycardia, incoordination, vomiting, and diarrhea. The brother states that the patient is taking paroxetine for depression. Which of the following would the nurse most likely suspect? A) Neuroleptic malignant syndrome B) Acute dystonic reaction C) Serotonin syndrome D) Hypothyroidism

B) Antipsychotic

A patient is experiencing hallucinations and delusions. The nurse would expect the physician to order which class of drug? A) Mood stabilizer B) Antipsychotic C) Antianxiety agent D) Stimulant

B You need to eat more fruits and vegetables and drink more water

A patient is prescribed medication for a psychiatric disorder. After 3 days, the patient tells the nurse that he or she has been constipated. Which instruction would the nurse give the patient? A You need to eat more high-protein foods such as meat and peanut butter B You need to eat more fruits and vegetables and drink more water C' Ask your psychiatrist to prescribe a stool softener for you. D.This side effect should disappear within a week or so.

C) These are the results of the drug that can be treated; your illness is not getting worse.

A patient receiving an antipsychotic agent develops acute extrapyramidal symptoms. Which response by the nurse would be most appropriate? A) These symptoms are not real; the medication makes your brain think they are real. B) You have developed an allergy to the medication, so we need to change it. C) These are the results of the drug that can be treated; your illness is not getting worse. D) The sunlight together with the medication has caused these symptoms; just stay indoors.

D) Agranulocytosis

A patient who has been taking clozapine for 6 weeks visits the clinic complaining of fever, sore throat, and mouth sores. The nurse notifies the patient's physician because the nurse suspects which of the following? A) Severe anemia B) Neuroleptic malignant syndrome C) Encephalitis D) Agranulocytosis

B.) St. Johns Wort

A patient with depression asks the nurse about possible herbal supplements. Which of the following would the nurse identify as being commonly used? A) Valerian B.) St. Johns Wort C) Kava D) Melatonin

Ans: C Feedback: The client's history of a recent suicide attempt in conjunction with his signs of depression, such as difficulty sleeping, lack of appetite, and inability to concentrate, put him at risk for suicide. The information described in the nurse's observations does not support ineffective role performance, infection, or self-mutilation.

After assessing a client, a nurse noted the following: "He was tearful, he tried to kill himself before coming into the hospital, he had no immediate plan for another suicide attempt, he was unable to concentrate, and he reported having trouble sleeping and having little or no appetite." The nurse also noted that the client's appearance was unkempt, that he spoke in a low monotone, and that he was unable to establish and maintain eye contact. Based on this information, which nursing diagnosis would be the most appropriate? A) Ineffective Role Performance B) Risk for Infection C) Risk for Suicide D) Risk for Self-Mutilation

Ans: B, C Feedback: Formal group roles include the leader and each member. Coordinator and information seeker, which are task roles, and harmonizer, which is a maintenance role, are considered informal roles.

After educating a class about formal and informal roles of group members, the instructor determines that the education was successful when the class identifies which of the following as a formal role? Select all that apply. A) Coordinator B) Leader C) Member D) Harmonizer E) Information seeker

C) Tap beers

After teaching a patient who is receiving phenelzine, the nurse determines that the teaching was successful when the patient states the need to avoid which of the following? A) Fresh cottage cheese B) Cooked sliced ham C) Tap beers D) Soy milk

Ans: B Feedback: The statement reflects the role of the gatekeeper, who attempts to keep communication channels open by encouraging or facilitating the participation of others, or proposes regulation of the flow of communication through limiting time. The group observer keeps records of various aspects of the group processes and interprets data to the group. The encourager praises, agrees with, and accepts the contributions of others. The energizer attempts to stimulate the group to action or decision.

During a group session, one of the members states, "Let's keep this discussion going so that everyone can participate, but let's keep the time each person speaks to about 3 minutes." The leader interprets this member as acting in which role? A) Group observer B) Gatekeeper C) Encourager D) Energizer

D) Assessing the patient for target symptoms and side effects

During the stabilization phase of drug therapy for a patient who is hospitalized with a psychiatric disorder, which action would be most appropriate? A) Discussing the timing of tapering the medication B) Instructing the patient about relapse prevention C) Determining if the medication is losing its effect D) Assessing the patient for target symptoms and side effects

Ans: A Feedback: When one group member continually tries to monopolize the conversation in an initial session, the client is most likely experiencing anxiety. The monopolizer does not reflect anger, rebellion, or fear.

In an initial group therapy session, a nurse observes that one group member continually tries to monopolize the conversation. The nurse interprets this behavior as reflecting which of the following in the client? A) Anxiety B) Anger C) Rebellion D) Fear

C) Because of your age and related changes in liver functioning, you may have medication levels in your system with the potential to be toxic.

The nurse is caring for a 70-year-old psychiatric patient who has been prescribed a number of medications. When teaching the patient about the medications, which explanation would be most appropriate? A) Your stomach empties more quickly as you age; therefore, you may feel the effect of your medications almost immediately. B) Your entire GI system speeds up, so your medications are digested much more quickly. Therefore, it is important that you not drive after you take your medications. C) Because of your age and related changes in liver functioning, you may have medication levels in your system with the potential to be toxic. D) Because of age-related circulation changes, your body will be able to deliver therapeutic doses of your medication to select body sites more quickly

C) Document the patient's symptoms of tardive dyskinesia.

The nurse observes an older adult patient who has been taking antipsychotic medications for 8 months. The patient is smacking her lips and blinking her eyes rapidly. The nurse also observes a protruding tongue. Which action by the nurse would be most appropriate? A) Ask if the patient has been experiencing side effects. B) Contact the patient's physician for a different medication order. C) Document the patient's symptoms of tardive dyskinesia. D) Instruct the patient to begin tapering off the medication.

Ans: B Feedback: Open-ended questions are most helpful when beginning an interview because they allow the nurse to observe how the client responds verbally and nonverbally. They also convey caring and interest in the person's well-being, which helps to establish rapport. Asking about previous hospitalization, thoughts of self-harm, and a spousal relationship would be questions asked later in the assessment.

Which of the following questions would be most helpful in beginning an initial assessment interview for a client who has just been admitted to a psychiatric inpatient unit? A) "Have you had any previous psychiatric admissions?" B) "What brings you into the hospital today?" C) "Have you had any thoughts about trying to harm yourself? D) "How would you describe your relationship with your spouse?"

Ans: B Feedback: The nurse's statement reflects confrontation, which helps individuals learn something about themselves, helps to reduce some forms of disruptive behavior, and helps members deal more openly and directly with one another. Support would be reflected in a statement such as, "We really appreciate your sharing that experience with us." Summarizing would be reflected in a statement such as, "So far we've discussed problems with . . . ." Clarification would be reflected in a statement such as, "What I heard you say was that you were feeling very angry right now. Is that correct?"

While leading a group, a nurse leader says to a client, "This is the fourth time that you've changed the subject when we have talked about child abuse. Is something going on?" The nurse is using which technique? A) Support B) Confrontation C) Summarizing D) Clarification

Ans: A Feedback: Norms establish acceptable group behaviors and encourage conformity of behavior among group members. Group cohesion is the closeness or sticking together of the group. Group think is the tendency of group members to avoid conflict and adopt a normative pattern of thinking that is often consistent with the ideas of the group leader. Group process is the development and culmination of the session-to-session interactions of the members that move the group toward its goals.

While leading a small group, a nurse sets up the ground rules at the beginning of the first meeting. One of the rules established is that the group will always start at the specified time, rather than waiting until everyone has arrived to begin. This rule reflects which of the following? A) Group norms B) Group cohesion C) Group think D) Group process

Ans: C Feedback: For any group to be successful, it must have members who assume task roles. The task role of information seeker is one in which the group member asks for clarification. The coordinator shows or clarifies the relationships among various ideas and suggestions. The recorder writes suggestions, keeps minutes, and serves as the group memory. The standard setter expresses the standards for the group to achieve.

While participating in a group therapy session, one group member consistently asks for clarification of the topic the group is discussing. The nurse leading the group interprets this behavior as reflecting which group role? A) Coordinator B) Recorder C) Information seeker D) Standard setter