EAQ 2 mental health 126

Which response by the nurse is appropriate for effective nurse - patient interaction when a patient diagnosed with breast cancer says , " I will discuss my illness , but you should not share the information with anyone " ? It is a part of the assessment , and you are required to inform me of your concerns I assure you that I will not share the information provided by you with anyone . " I cannot maintain your secrets because I have to follow and abide by professional ethics . " I will be sharing the information provided by you with other health care professionals involved your care , but no one else . "

" I will be sharing the information provided by you with other health care professionals involved your care , but no one else . " Rationale During the assessment , the nurse should inform the patient that the information provided by the patient will be shared with the health care professionals . This action helps safeguard the confidentiality and privacy of the patient . It also helps provide for continuity of care when the patient is discharged from the hospital . The statement that the patient should inform the nurse of all concerns may lead to angry feelings for the patient and interfere with communication ; therefore , this is not an appropriate response . The nurse should not give the patient false assurance by saying that the information provided by the patient will not be disclosed to anyone . The nurse should not rudely deny the patient's request by saying that the patient's confidential medical information cannot be kept secret : this may cause the patient to feel reiected and is not

The nurse is preparing to document information after an interaction with a patient . Which information would the nurse classify as appropriate to include ? Select all that apply . One , some , or all responses may be correct . Patient crying throughout interaction Bruises noted on right arm and lower back Safety plan discussed if abuse occurs again Restraining order filed with law enforcement Patient states " My spouse has hit me before "

All Rationale The nurse should document observations during the interaction with the patient , which would include documenting the patient crying . The nurse should also document objective data such as the location of bruises on the patient's body . Interventions such as discussing the safety plan and filing a restraining order would be documented . The nurse should also document subjective data as when the patient states that their spouse has hurt the patient before . p . 77

Which action by the nurse administrator contributes to a nursing team that is successful at building therapeutic relationships with patients ? Assigning the same nurse to each patient during each visit Instructing nurses to be strict toward patients Advising nurses to frequently interact with patients Instructing nurses to give lengthy instructions to patients action strict nurses patients so

Assigning the same nurse to each patient during each visit Rationale Consistency must be maintained while providing care to patients ; assigning the same nurse to each patient during each visit would facilitate this outcome . This action helps patients communicate effectively with nurses . Nurses should not be overly strict with patients because the patients may become aggressive . Patients may get irritated if the nurses too frequently interact with them ; nurses should interact for a short duration and give the patients space . Patients diagnosed with mental illnesses often have a reduced attention span , so nurses should avoid lengthy instructions . p . 114

In which instance would a patient benefit from telehealth services Select all that apply . One , some , or all responses may be correct . Bedridden patient Annual physical examination Patient with suicidal ideations Health care needs during a pandemic . Closest health care provider 50+ miles away

Bedridden patient Health care needs during a pandemic Closest health care provider 50+ miles away Rationale Telehealth is beneficial for a patient who is unable to come to the office such as a patient who is bedridden . Telehealth became a popular form of health care delivery during the COVID - 19 pandemic . This allowed practitioners to follow up on patients while decreasing the risk of disease spread . Patients who live in Tural areas where a health care provider is a long distance away would benefit from telehealth services . The provider would need to follow up with patients who have suicidal ideations in person in an emergency room or inpatient facility to prevent self - harm . Annual physical examinations are best done in person to allow some direct observation of the patient

Which countertransference reaction is the nurse most likely to experience toward a patient who frequently discusses family disputes and often becomes verbally aggressive ? Rescue Boredom Helplessness Overinvolvement

Boredom Rationale Because of the patient's behavior , fe nurse is at risk to experience a variety of countertransference reactions . If the patient gives repeated uninteresting information and uses an offensive style of communication , the nurse may develop boredom and become uninterested in talking to and interacting with the patient . The nurse may develop a rescue ( countertransference ) reaction if the patient shares their secrets with the nurse . The nurse may develop feelings of helplessness when treatment goals are not achieved and if the patient does not participate in the treatment effectively . Overinvolvement is experienced if the patient's behavior reminds the nurse of someone who is close to the nurse or of past patients .

How should the nurse respond to a patient with a severe mental illness who requests financial assistance to start a small business ? Contact the support groups we have told you about . " " I will give you the contact number of a friend who will help you . " Let your illness be treated first , then you can start your business . " Sorry , but I can't give any financial assistance . It is against hospital rules . "

Contact the support groups we have told you about . " Rationale The nurse should help the patient develop resources by providing information on support groups This helps increase the patient's strengths and self - esteem . The nurse should not provide direct help to the patient by contacting their friends for financial assistance . The nurse should encourage patients to act on their own ; this enhances patients ' problem - solving abilities . The nurse should not discourage the patient by saying that the patient should be treated for the illness first ; this can make the patient feel depressed and helpless . Saying that providing financial help is against hospital rules may be true , but it would not provide a solution . 115

The nurse is developing a plan of care for a patient with the following psychosocial health history and assessment data . Which patient problem would guide the nurse's actions to meet goals ? Psychosocial Health History Assessment Data 14 - year - old patient Denies pain Small noted on forearm . Reports having 1 to 2 close friends States , " I hate hearing my parents fight , so Hangs out in room at night I cut . " Body image Cooing skill Socialization Relatiinship between parents

Coping skills Rationale The patient states that they cut when hearing parents fight , which indicates that the patient has difficulty coping with the parental conflict . Therefore the nurse should gear interventions toward improving coping skills . The patient does not indicate a problem with body image . The patient reports having one to two close friends ; therefore the nurse should not address socialization . The nurse is there to address the patient's issues , not the parents ' issues . p . 83

Which response would the nurse give when a patient whose spouse recently died shares , " I think I'm losing it . I'll never be the same " ? You will eventually get back to normal . Just start doing the things that used to be fun for you . " When you find yourself starting to cry or feeling sad , distract yourself by getting busy with an activity Your spouse died , but you should not be absorbed in grief . " " Crying and the feelings you describe are normal after such a loss . It may take a long time to grieve your spouse . "

Crying and the feelings you describe are normal after such a loss . It may take a long time to grieve your spouse . " Rationale Reassuring a patient that feelings of grief are normal and that grief takes time conveys concern and empathy . It also gives information about the grieving process . Telling a patient to do what used to be fun , to distract themselves , or how they should or should not feel about the loss , are examples of ineffective responses that would hinder communication . These responses minimize the patient's feelings and demonstrate inappropriate advice and judgment by the nurse .

The nurse enters the room of a patient who underwent a mastectomy to perform an assessment . Which finding correlates to the patient having difficulty dealing with the change in body image ? Select all that apply . One , some , or all responses may be correct . Crying on a frequent basis Refusing to look at the incision Discussing future treatment Sitting in a dark hospital room Stating , " I am no longer pretty "

Crying on a frequent basis Refusing to look at the incision Sitting in a dark hospital room Stating , " I am no longer pretty " Rationale The nurse should correlate the patient's frequent crying and refusal to look at the incision as an indication of the patient having difficulty with the change in body image . Other indicators of a change in body image perception include the patient sitting in the dark and the patient stating am no longer pretty . " The patient discussing future treatment indicates hope for the future and is not related to body image .

Which intervention by the nurse would not be appropriate in a therapeutic relationship? Giving advice Actively listening Clarifying feelings Giving respect

Giving advice Rationale Giving advice is acceptable in a social relationship , but not in a therapeutic relationship . Actively listening is imperative for a therapeutic relationship . Clarifying feelings is appropriate . Giving a patient respect is appropriate .

The nurse is examining documentation made in the health record by the previous nurse . Which finding indicates a need to review legal documentation techniques ? Select all that apply . One , some , or all responses may be correct . I do not believe the patient's story about cuts found on the right arm . No injuries related to fall from chair . See incident form for details . Patient states , " If that doctor doesn't get here soon , I am leaving . " Friends visited , and an hour later the patient appears high on drugs . If the patient and spouse stopped taking drugs , they would feel better .

I do not believe the patient's story about cuts found on the right arm . No injuries related to fall from chair . See incident form for details . Friends visited , and an hour later the patient appears high on drugs . If the patient and spouse stopped taking drugs , they would feel better . Rationale The nurse should not document that the nurse does not believe the patient's story because this is the nurse's personal opinion . The nurse should not reference a completed incident form in patient's health record because the incident form is an internal tracking device and not part of the legal record . It is inappropriate for the nurse to state that the patient appears to be high on drugs following a visit by friends ; the nurse should instead document physical findings . The nurse should not record their opinion about how the patient and spouse would feel if illicit drug use stopped because this reflects the nurse's opinion . Charting the exact words of the patient using quotation marks is legally correct documentation because it is a direct quote . A p . 85

Which statement by the nurse would be therapeutic for a hospitalized patient who has made a suicide attempt after the spouse asked for a divorce ? Don't you think your life is more valuable than an unhappy marriage You should forget about your marriage and move on with your life . " Let's consider ways other than suicide to cope with your feelings When I got divorced was overwhelmed too

Let's consider ways other than suicide to cope with your feelings . " Rationale Helping a patient explore alternative solutions to problems is part of the therapeutic relationship also keeps the focus on the patient's perception and feelings . Questioning the patient's values is nontherapeutic . Telling the patient to forget the divorce is unrealistic and minimizes the patient's feelings . Bringing up the nurse's own divorce takes the focus off the patient .

Which statement is true regarding major depressive disorder ( MDD ) ? Select all that apply . One , some , or all responses may be correct . MDD affects men and women equally MDD has an 8 % prevalence rate over a 12 - month period . MDD the leading cause disability in the United States . MDD affects approximately 11 million people in the United States . MDD often co - occurring with anxiety disorders and substance - use disorders .

MDD has an 8 % prevalence rate over a 12 - month period . MDD is the leading cause of disability in the United States . MDD is often co - occurring with anxiety disorders and substance - use disorders . Rationale MDD has an 8 % prevalence rate over a 12 - month period . MDD is the leading cause of disability in the United States . MDD , along with other affective ( mood ) disorders , often co - occurs with anxiety and substance - use disorders . MDD affects almost twice as many women as men . MDD affects approximately 21.1 million people in the United States . p . 13

Which rationale supports the nurse using the following approach for documenting patient care ? Patient Notes Subjective statement : " I'm being told to do bad things " The patient paced the hall , muttering and looking in the corners . Shouted when approached . The patient was having auditory and visual hallucinations and experiencing increasing agitation . The patient was offered haloperidol as ordered and redirected to a quiet environment . Patient received 2 mg haloperidol PO prn . Sat with patient until the patient returned community lounge to watch television . Explain flow sheet findings Use common form of expression Minimizes inclusions of unnecessary data Differs in organization of information frim note to note

Minimizes inclusion of unnecessary data Rationale This documentation is problem oriented and follows the subjective data , objective data , assessment , plan , interventions , and evaluation ( SOAPIE ) method , which was developed to reduce inefficient documentation . An advantage of problem - oriented charting is that it minimizes inclusion of unnecessary data . An advantage of the narrative form of documentation is that it explains flow sheet findings . Unlike problem - oriented charting , the narrative form of documentation uses a common form of expression ( narrative writing ) . Having differing organization patterns between notes is a rationale for why SOAPIE is preferred over narrative charting not the reverse .

Which anticipated functional problems would the nurse focus initial interventions on when caring for an adult with a frontal lobe brain tumor ? Motor function and judgment Sensory and calculation abilities Interpretation of visual stimuli Hearing and emotional expression

Motor function and judgment Rationale The premotor cortex is responsible for the coordinated movement of multiple muscles , and the somatic association cortex integrates motor commands . The somatic association cortex is the area the brain responsible for coordinating ned motor skills . Cognition , memory , and analytical functions are largely functions of a third region of the frontal lobe , known as the prefrontal cortex . Damage to this area of the frontal lobe may cause changes in decision making and judgment . The parietal lobe controls sensory and calculation abilities . The occipital lobe controls interpretation visual stimuli . The temporal lobe controls hearing and emotional expression .

Which response by the nurse would be appropriate when a patient in a rehabilitation center says , " I am left alone because of my addiction " ? Why did you get addicted ? " " Everything will be all right . " " I don't agree with you . " " I would like to stay here with you . "

O " I would like to stay here with you . " Rationale Saying that the nurse will be with the patient indicates that the nurse is available for communicating with the patient and cares about their loneliness . A patient may feel criticized when asked the reason for addiction ; this can make the patient defensive . The response that everything will be all right would give false hope to the patient . The patient may feel offended and may stop sharing their feelings if the nurse indicates disagreement with the patient's feelings . helps you maintain a 107

Which finding reflects appropriate information to include when documenting the assessment and care provided in the health record of a patient admitted with bipolar disorder ? Patient states , " I do not want to talk about it . " Patient appears to be withdrawn and depressed . Patient must have no friends due to lack of visitors . Patient should follow the prescribed treatment plan .

Patient states , " I do not want to talk about it . " Rationale The nurse should include subjective data in the health record , such as when the patient states , " I do not want to talk about it . " The nurse should not document that the patient appears withdrawn and depressed because this is the nurse's opinion . The nurse is judging the patient when documenting that the patient must have no friends ; this is inappropriate to include in the health record . The nurse should document how the patient follows the plan of care but would not document what the patient should or should not do .

Which factor can affect both people involved in the communication process ? Select all that apply . One , some , or all responses may be correct . Personal bias Value system Past experience Educational level Relevance of input

Personal bias Value system Past experience Rationale When two or more people communicate , all members bring in personal biases . This can include beliefs about the others in the conversation . A person's value system can impact discussions that refer to ethical issues . Everyone has past experiences that guide how they react to messages and stimuli . A person's educational level can affect a person's employment abilities . Relevance of input refers to the transmission quality of the message .

Which phenomenon is suggested when a client says , " I like you . You remind me of my grandchild " ? Countertransference Positive transference Negative transference . Positive countertransference .

Positive transference . Rationale Transference is a phenomenon that occurs subconsciously in clients as they associate the nurse with one of their relatives . When a client effectively interacts with and follows the instruction of the nurse as a result of transference , it is called positive transference . Countertransference is a phenomenon in which the nurse associates the client with previous experience . Countertransference occurs when the nurse displaces the feelings onto the client and identifies with the nurse's past experience . In negative transference , the client avoids interaction with the nurse and becomes aggressive ; this may happen when the client associates the nurse with a tragic event or person . Countertransference is not categorized as positive or negative . p . 108

Which nursing action implemented while working with a patient demonstrates the use of active listening ? Reviewing the health record Asking introductory questions Providing observable feedback . Informing the patient about the nurse - patient relationship

Providing observable feedback . Rationale Providing observable feedback to the patient reflects active listening as it lets the patient know the nurse is hearing what the patient says . Reviewing the health record provides background information prior to meeting the patient . Asking introductory questions is the nurse initiating conversation and does not reflect active listening . Informing the patient about the nurse - patient relationship is a task in the introductory phase of the nurse - patient relationship . p . 94

During the assessment process , which patient cue would reflect conflicting verbal and nonverbal communication ? Admitted for bipolar disorder and is laughing and joking with nursing staff Reported no difficulty with sexual activity but looks away when answering Maintained eye contact when discussing noncompliance with diabetic regimen Stated pain level 8/10 with an increase in heart rate , blood pressure , and respirations

Reported no difficulty with sexual activity but looks away when answering Rationale The patient who reports no difficulty with sexual functioning to the nurse but looks away is demonstrating conflicting verbal and nonverbal communication as the patient states one thing but looks away . A patient admitted with bipolar disorder would be manic and could laugh and joke with staff . The patient who maintains eye contact when discussing health demonstrates corresponding verbal and nonverbal communication . A patient who reports a high pain level and presents with symptoms of pain would reflect congruent verbal and nonverbal communication . p . 93

Which communication technique involves the nurse repeating what the patient said using different words ? Focusing Exploring Restating Reflecting

Restating Rationale Restating is repeating what the patient stated using different words . This allows the nurse to make sure the message was understood . Focusing would allow the nurse and patient to concentrate on one point . Exploring examines ideas and experiences to get more information . Reflecting would be directing questions back to the patient . p 96

Which response would the nurse provide when a patient reports the desire to drop out of college because it is too stressful ? Don't let them beat you ! Fight back ! " " School is stressful . What do you find most stressful ? " " I know just what you are going through . The stress is terrible . " " You have only two more semesters .You will be glad if you stick it out . "

School is stressful . What do you find most stressful ? " Rationale The response " School is stressful . What do you find most stressful ? " acknowledges the patient's perception of school as difficult and asks for further information , keeping the interview focused on the patient and their feelings . This response suggests that the nurse is listening actively and is concerned . The nurse should avoid attacking the target of the patient's anxiety . Saying the nurse knows what the patient is going through would minimize the patient's experience . Saying " the stress is terrible " is an interpretation that should be avoided because it takes the focus off the patient's perception . The nurse should also avoid giving advice or false reassurance . p . 119

Which stage of Kohlberg's Stages of Moral Development focuses on individualism and exchange ? Stage 1 Stage 2 Stage 3 Stage 4

Stage 2 Rationale Kohlberg developed a theory of how people progressively develop a sense of morality . His theory helps us understand the progression from black - and - white thinking to a context - dependent decision - making process regarding the rightness or wrongness of an action . Stage 2 focuses on individualism and exchange . There is growing awareness that not everyone thinks the same and that breaking rules is a personal choice . Stage 1 focuses on obedience and punishment . There is a focus on rules and listening to aut rity to avoid punishment . Stage 3 focuses on good interpersonal relationships . Rightness or wrongness is based on individual motivations , personality , or the goodness or badness of the person . People should get along and have similar values . Stage 4 focuses on maintaining the social order . Rules are rules . Listening to authority

Which interaction would be considered countertransference ? The nurse provides community resources for alcohol abstinence . The patient admits to drinking several beers with friends every night . The patient informs the nurse that the urge to drink alcohol is too powerful . The nurse admonishes the patient for getting drunk again like their father did .

The nurse admonishes the patient for getting drunk again like their father did . Rationale Countertransference is when the nurse shifts feelings from the nurse's past onto the patient . This would be reflected by the nurse admonishing the patient for getting drunk again , just like their father did . The nurse's role is to provide community resources for the patient regarding alcohol abstinence . The patient is being open and honest when admitting to drinking patterns , as well as admitting to the powerful urge to drink being present . These are not considered countertransference . p 108

Which statement by the nurse indicates a possible problem with inappropriate boundaries and countertransference ? Select all that apply . One , some , or all responses may be correct . I've never been told that I am an ineffective or uncaring nurse . " It can be difficult to always be nice to my patients , but I always try . " The other nurses are just so hard on her because they don't know her like I do . " " I guess that the staff just wishes they could be as attuned to their patients as I am to mine " It's a good feeling to know that my patients really love me for what I do for them . "

The other nurses are just so hard on her because they don't know her like I do . " I guess that the staff just wishes they could be as attuned to their patients as I am to mine . " It's a good feeling to know that my patients really love me for what I do for them . " Rationale There may be a problem with boundaries or countertransference when the nurse feels that others are too critical of their patients and that the nurse is the only one capable of understanding a patient , and when feeling satisfaction from not only the appreciation but also the love of the patient . Stating " I've never been told that I am an ineffective or uncaring nurse " or " It can be difficult to always be nice to my patients , but I always try " may identify attempts at deflecting a sense of guilt , but they are not examples of countertransference or inappropriate boundaries . p . 108

Which information is the most useful to obtain when assessing an 18 - year - old patient for reported hallucinations ? Family psychiatric history Adverse childhood experiences ( ACES ) Relationship with parents and siblings The patient's appearance , mood , and affect

The patient's appearance , mood , and affect Rationale The nurse would use the mental status examination ( MSE ) to differentiate between a variety of systemic conditions , as well as neurological and psychiatric disorders ranging from delirium and dementia to bipolar disorder and schizophrenia . The MSE aids in collecting and organizing objective data . The nurse observes the patient's physical behavior , nonverbal communication , appearance , speech patterns , mood and affect , thought content , perceptions , cognitive ability , and insight and judgment . Family psychiatric history , quality of activities of daily living , and personal background are part of a psychosocial assessment that provides additional information from which to develop a plan of care beyond the MSE . ACES can contribute to chronic and toxic stress , as well as physical and mental illnesses . Asking about ACEs can help with efforts to prevent negative impacts on development for the patient and family ; however , this would not be the most important differential assessment data . The HEADSSS technique is used to identify risk factors with adolescents and assesses home environment , relationship with parents and siblings , school performance and activities , drug or alcohol use , sexuality , suicide risk , and savagery .

Which statement by the nurse would be considered nontherapeutic when caring for a patient who is readmitted for alcohol withdrawal ? Did you try the 12 - step program of Alcoholics Anonymous ? " Tell me what things are like for you at home with your family . " " Why do you keep drinking when you know what it does to you ? " " Was there any specific trigger to lead you to start drinking again ? "

Why do you keep drinking when you know what it does to you ? " Rationale An example of nontherapeutic communication would be the nurse asking a why question as to why the patient keeps drinking in spite of the effects . Why questions are critical and can make the patient defensive . Asking about trying Alcoholics Anonymous just get more information about attempts to try to stop drinking . When the nurse asks the patient to talk about things at home or asks about triggers , this can provide information to give the patient feedback as to what can lead to excessive drinking .

To encourage a patient diagnosed with human immunodeficiency hives to acknowledge feelings , which response would the nurse provide when observing that the patient appears depressed ? You look upset about something Don't worry about what others would say . " Are you thinking about your illness now ? " feel you are not willing to interact with me . "

You look upset about something . " Rationale Observing that the patient looks upset would invite a response while keeping the focus on the encourage sharing feelings . The nurse should not be judgmental and conclude that the patient patient's feelings . It would make the patient feel that the nurse is concerned about them and worried about what others would say . The nurse should avoid asking closed - ended questions such may interfere with further communication . It is unprofessional for the nurse to express their own as , " Are you thinking about your illness ? " It limits the conversation to a " yes " or " no " response and feelings . 107

A patient tells the nurse they are hearing voices telling them to hurt themself . Which response by the nurse would be presenting reality ? " Give an example of what the voices are saying to you . " " When did you first begin hearing the voices talk to you ? " " Can you tell me why you think the voices are talking to you ? " " I know you think the voices are real , but I do not hear them . "

know you think the voices are real , but I do not hear them . " Rationale The response , " I know you think the voices are real , but I do not hear them , " acknowledges what the patient hears but presents really that the voices are not there . When the nurse asks the patient to give an example of the voices , this is seeking clarification . Asking when the voices began is obtaining more information . Asking a why question is not a therapeutic communication technique