MH Review

pt being discharged from psych unit and made you a card; what should the nurse do?

recognize pt thoughtfulness and accept it

a pt watches TV all day; who is the best treatment member for him to see?

recreational therapy

working with another nurse and forgot to document and wants you to document

refer to charge nurse

pt who binges/purges; nursing priority to give information

s/s of hypokalemia

home health nurse visits Alzheimer's pt; what assessment data

safety, house design, pt access to exits and stairs

40 y/o who lives with parents and works at an unchallenging job says, "I'm as happy as anyone else, even though I don't socialize much outside of work. My work is routine, but when new things come up, my boss explains things a few times to make sure I catch on. At home, my parents make decisions for me, and I go along with their ideas." The nurse should identify interventions to improve the patients's:

self-concept

mans wife is terminally ill but doesn't want to cry; what is the nurses best response?

she might find comfort in your tears

A client with ADHD feels that his parents are terrible; what is the nurses most helpful response?

-provide info on ADHA and brochemical abnormalities -it is not the parenting

SATA: Schizophrenic

-rearrange conflicting care appointments -arrange transportation -monitor basic needs and they are met

Client with PTSD

-recall that physical symptoms are related to psychological state

a pt overdosed on methamphetamine. priority nursing and medical measures include:

-reduction of fever -prevention of seizures

During an interview a client becomes verbally abusive; how can the nurse respond?

tell the client "I will return in a few minutes to continue the interview"

client requests not to see anyone other than parents and sisters; what is the nurses action?

tell them they are the only ones he wants and let them notify the others

client admitted to the psych floor and does not make eye contact; what conclusion can the nurse come to?

-more information is needed

Lithium

-most alerted for cardiac/cerebral problems -fluid/electrolytes balance

know Risperdal; severe muscle tension, increased temp, BP 150/90, trouble swalloing

-neuroleptic malignant syndrome -cover with cooling blanket -send to ICU -notify HCP

SATA: according to the values of cultures whose members use folk healing practices, features most important for a nurse to possess include:

-respect for persons -cultural skill -cultural desire -cultural knowledge

young female is urging another pt to hit someone; what should nursing staff do?

-safety issue -set limits

Female client believes her husband is having an affair, but he is not; the father tells his daughter that he can't deal with the mother; what is the nurses best response?

-they are both hurting -they both have something in common

SATA: child drowns, dies two years ago; appropriate mourning

-throwing flower in the lake on anniversary -buying life jackets -enrolled children in safety swimming

5 y/o child, lost control of himself; what is a nursing intervention?

-time out -having to sit out of activites

SATA: pt rights

-visitors -confidentiality -to complain about inadequate care

pt tells nurse that he needs to decrease stress in life; what does nurse say?

-whats going on in your life -what are some options

which remark by the nurse gives the nurse verbal tracking feedback?

-your saying you don't have a good relationship with your children

SATA: Severly withdrawn schizophrenic; nurse frustration increases daily; most helpful info?

-neurologic changes interfere with social comfort and adjustment -anxiety about emotional closeness is high and leads to avoidance -social skills not fully developed or may have regressed

A teenager is acting out and is going to throw a pool ball; what is the nurses best comment?

"Do not throw the pool ball. Set it back on the table"

need to know 4 phases of crisis

*3 trouble sleeping, withdrawal, hanging out in bars, minimum wage job

Important to teach about ECT

-advise of memory loss

SATA: adolescent mentally healthy

-describe future career -interests -believes community is a safe place to live -frequently send/receives texts from friends

SATA: hospice pt; what are nursing actions

-give pt choices -fostering personal control -support spirituality -offer interventions that include respect

SATA: nurse documents on abused women

-increased anxiety and stress -pt relies on perp for basic needs -isolated from others and community support -at risk for revenge -homicide is safety plan should be done before discharge

an example of self actualization

-it is important for the country to provide health care for everyone*???* -volunteering in the community

d. Denial

A nurse interviews a person abducted and raped at gunpoint by an unknown assailant. The person says, "I can't talk about it. Nothing happened. I have to forget!" What is the person's present coping strategy? a. Somatic reaction b. Repression c. Projection d. Denial

c. suicide potential.

A nurse uses the SAD PERSONS scale to interview a patient. This tool provides data relevant to: a. current stress level. b. mood disturbance. c. suicide potential. d. level of anxiety.

child had adapted to shelter life and formed a relationship with a supportive volunteer. The child says, "My three best friends and I got an A on our school science project." which assessment applies?

the child displays resillience

c, d, e

A college student failed two examinations. The student cried for hours and then tried to call a parent but got no answer. The student then suspended access to his social networking web site. Which suicide risk factors are present? Select all that apply.. a. History of earlier suicide attempt b. Co-occurring medical illness c. Recent stressful life event d. Self-imposed isolation e. Shame or humiliation

a. denial.

A college student who attempts suicide by overdose is hospitalized. When the parents are contacted they respond, "There must be a mistake. This could not have happened. We've given our child everything." The parents' reaction reflects: a. denial. b. anger. c. anxiety. d. rescue feelings.

a, b, c

A community health nurse visits a family with four children. The father behaves angrily, finds fault with a child, and asks twice, "Why are you such a stupid kid?" The wife says, "I have difficulty disciplining the children. It's so frustrating." Which comments by the nurse will facilitate the interview with these parents? Select all that apply. a. "Tell me how you punish your children." b. "How do you stop your baby from crying?" c. "Caring for four small children must be difficult." d. "Do you or your husband ever beat the children?" e. "Calling children 'stupid' injures their self-esteem."

c. The patient interpreted the health care worker's behavior as potentially harmful.

A confused older adult patient in a skilled care facility is in bed sleeping. The nurse enters the room quietly and touches the bed to see if it is wet. The patient awakens and hits the nurse in the face. Which statement best explains the patient's action? a. Older adult patients often demonstrate exaggerations of behaviors used earlier in life. b. Crowding in skilled care facilities increases individual tendencies toward violence. c. The patient interpreted the health care worker's behavior as potentially harmful. d. This patient learned violent behavior by watching other patients act out.

c. Report suspected sexual abuse to child protective services

A five year old is brought to the clinic for symptoms of a urinary tract infection (UTI). Your assessment reveals bruises in the child's genital and rectal areas. The mother reports that she left the child with her boyfriend the night before. Your primary priority with this client is to take which action? a. Obtain a urine sample to confirm a UTI b. Teach the mother about symptoms of a UTI c. Report suspected sexual abuse to child protective services d. Assess the child for other health problems

d. Methamphetamine

A homeless man is brought in by the police to ER. You note that he is thin, tense, jittery, has dilated pupils, halitosis, and scabs on his arms and legs. The man says, "I'm burning up. I need help." He lets you to take his oral temperature and it is 104° F. When you attempt to take his B/P he becomes suspicious, withdraws, and says, "You could be trying to kill me." You suspect he has been abusing which substance? a. PCP b. Heroin c. Barbiturates d. Methamphetamine

c. Provide one-on-one supervision.

A hospitalized patient, injured in a fall while intoxicated, believes spiders are spinning entrapping webs in the room. The patient is anxious, agitated, and diaphoretic. Which nursing intervention has priority? a. Check the patient every 15 minutes. b. Rigorously encourage fluid intake. c. Provide one-on-one supervision. d. Keep the room dimly lit.

c. "I have a plan that will fix everything."

A nurse assesses a patient who reports a 3-week history of depression and crying spells. The patient says, "My business is bankrupt, and I was served with divorce papers." Which subsequent statement by the patient alerts the nurse to a concealed suicidal message? a. "I wish I were dead." b. "Life is not worth living." c. "I have a plan that will fix everything." d. "My family will be better off without me."

a, b, c, d, e

A nurse assists a victim of spousal abuse to create a plan for escape if it becomes necessary. The plan should include which components? Select all that apply. a. Keep a cell phone fully charged. b. Have the telephone number for the nearest shelter. c. Secure a supply of current medications for self and children. d. Determine a code word to signal children that it is time to leave. e. Assemble birth certificates, Social Security cards, and licenses.

a, b, d

A nurse directs the intervention team who must take an aggressive patient to seclusion. Other patients were removed from the area. Before approaching the patient, the nurse should ensure that the staff takes which of the following actions? Select all that apply. a. Remove jewelry, glasses, and harmful items from the patient and staff members. b. Appoint a person to clear a path and open, close, or lock doors. c. Quickly approach the patient, and grab the closest extremity. d. Select the person who will communicate with the patient. e. Move behind the patient to use the element of surprise.

a, d, e

A nurse driving home after work comes upon a serious automobile accident. The driver gets out of the car with no apparent physical injuries. Which assessment findings would be expected from the driver immediately after this event? Select all that apply. a. Difficulty using a cell phone b. Long-term memory losses c. Fecal incontinence d. Rapid speech e. Trembling

b. Seeking to be assigned as the medication nurse.

A nurse worked at a hospital for several months, resigned, and then took a position at another hospital. In the new position, the nurse often volunteers to be the medication nurse. After several serious medication errors, an investigation reveals that the nurse was diverting patient narcotics for self-use. What early indicator of the nurse's drug use was evident? a. Accepting responsibility for medication errors. b. Seeking to be assigned as the medication nurse. c. Frequent complaints of physical pain. d. High sociability with peers.

b. presents a clear and present danger to others.

A patient being admitted suddenly pulls a knife from a coat pocket and threatens, "I will kill anyone who tries to get near me." An emergency code is called. The patient is safely disarmed and placed in seclusion. Justification for the use of seclusion is that the patient: a. evidences a thought disorder, rendering rational discussion ineffective. b. presents a clear and present danger to others. c. presents a clear escape risk. d. is psychotic.

b. "I see you are feeling upset. I'm going to stay and talk with you to help you feel better."

A patient comes to the clinic with superficial cuts on the left wrist. The patient paces around the room sobbing but cringes when approached and responds to questions with only shrugs or monosyllables. Select the nurse's best initial statement to this patient. a. "Everything is going to be all right. You are here at the clinic, and the staff will keep you safe." b. "I see you are feeling upset. I'm going to stay and talk with you to help you feel better." c. "You need to try to stop crying so we can talk about your problems." d. "Let's set some guidelines and goals for your visit here."

d. "What was happening just before you started to feel this way?"

A patient comes to the clinic with superficial cuts on the left wrist. The patient is pacing and sobbing. After a few minutes with the nurse, the patient is calmer. What should the nurse ask to determine the patient's perception of the precipitating event? a. "Tell me why you were crying." b. "How did your wrist get injured?" c. "How can I help you feel more comfortable?" d. "What was happening just before you started to feel this way?"

b. Help the patient identify incidents that trigger impulsive acting out.

A patient has a history of impulsively acting out anger by striking others. Which would be an appropriate plan for avoiding such incidents? a. Explain that restraint and seclusion will be used if violence occurs. b. Help the patient identify incidents that trigger impulsive acting out. c. Offer one-on-one supervision to help the patient maintain control. d. Give the patient lorazepam (Ativan) every 4 hours to reduce anxiety.

a. expresses frustration verbally instead of physically.

A patient has a history of physical violence against family members when frustrated and then experiences periods of remorse after each outburst. Which finding indicates success in the plan of care? The patient: a. expresses frustration verbally instead of physically. b. explains the rationale for behaviors to the victim. c. identifies three personal strengths. d. agrees to seek counseling.

d. Risk for other-directed violence

A patient is hospitalized after an arrest for breaking windows in the home of a former domestic partner. The history reveals childhood abuse by a punitive parent, torturing family pets, and an arrest for disorderly conduct. Which nursing diagnosis has priority? a. Risk for injury b. Post trauma response c. Disturbed thought processes d. Risk for other-directed violence

c. "I'd like to talk with you about how you're feeling right now."

A patient is pacing the hall near the nurses' station, swearing loudly. An appropriate initial intervention for the nurse would be to address the patient by name and say: a. "Hey, what's going on?" b. "Please quiet down immediately." c. "I'd like to talk with you about how you're feeling right now." d. "You must go to your room and try to get control of yourself."

d. exhibiting clues to potential aggression.

A patient sits in silence for 20 minutes after a therapy appointment, appearing tense and vigilant. The patient abruptly stands and paces back and forth, clenching and unclenching fists, and then stops and stares in the face of a staff member. The patient is: a. demonstrating withdrawal. b. working through angry feelings. c. attempting to use relaxation strategies. d. exhibiting clues to potential aggression.

a. History of family violence

A patient tells the nurse, "My husband is abusive most often when he drinks too much. His family was like that when he was growing up. He always apologizes and regrets hurting me." What risk factor was most predictive for the husband to become abusive? a. History of family violence b. Loss of employment c. Abuse of alcohol d. Poverty

c. 4 to 6

A patient visiting the crisis clinic for the first time asks, "How long will I be coming here?" The nurse's reply should consider that the usual duration of crisis intervention is _____________ weeks. a. 1 to 2 b. 3 to 4 c. 4 to 6 d. 6 to 12

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

A patient was responding to auditory hallucinations earlier in the morning. The patient approaches the nurse, shaking a fist and shouting, "Back off!" and then goes into the day room. As the nurse follows the patient into the day room, the nurse should: a. make sure adequate physical space exists between the nurse and the patient. b. move into a position that allows the patient to be close to the door. c. maintain one arm's length distance from the patient. d. sit down in a chair near the patient.

b. Hold a staff meeting to express feelings and plan the care for other patients.

A patient who was hospitalized for 2 weeks committed suicide during the night. Which initial measure will be most helpful for staff members and other patients regarding this event? a. Request the public information officer to make an announcement to the local media. b. Hold a staff meeting to express feelings and plan the care for other patients. c. Ask the patient's roommate not to discuss the event with other patients. d. Quickly discharge as many patients as possible to prevent panic.

a, d, e

A patient with a history of command hallucinations approaches the nurse, yelling obscenities. The patient mumbles and then walks away. The nurse follows. Which nursing actions are most likely to be effective in de-escalating this scenario? Select all that apply. a. State the expectation that the patient will stay in control. b. State that the patient cannot be understood when mumbling. c. Tell the patient, "You are behaving inappropriately." d. Offer to provide the patient with medication to help. e. Speak in a firm but calm voice.

b. Acknowledge and validate the patient's distress and ask, "What would you like to have happen?"

A patient with burn injuries has had good coping skills for several weeks. Today, a newly assigned nurse is poorly organized. The patient's usual schedule was not followed. By mid-afternoon, the patient is angry and loudly complains to the nurse manager. Which is the nurse manager's best response? a. Explain the reasons for the disorganization, and take over the patient's care for the rest of the shift. b. Acknowledge and validate the patient's distress and ask, "What would you like to have happen?" c. Apologize and explain that the patient will have to accept the situation for the rest of the shift. d. Ask the patient to control the anger and explain that allowances must be made for new staff members.

c. Continue the dressing change, saying, "Do you know this dressing change is needed so your wound will not get infected?"

A patient with severe injuries is irritable, angry, and belittles the nurses. As a nurse changes a dressing, the patient screams, "Don't touch me! You are so stupid. You will make it worse!" Which intervention uses a cognitive technique to help the patient? a. Wordlessly discontinue the dressing change, and then leave the room. b. Stop the dressing change, saying, "Perhaps you would like to change your own dressing." c. Continue the dressing change, saying, "Do you know this dressing change is needed so your wound will not get infected?" d. Continue the dressing change, saying, "Unfortunately, you have no choice in this because your doctor ordered this dressing change."

b. Risk of domestic abuse

A person at the emergency department is diagnosed with a concussion. The individual is accompanied by a spouse who insists on staying in the room and answering all questions. The patient avoids eye contact and has a sad affect and slumped shoulders. Assessment of which additional problem has priority? a. Phobia of crowded places b. Risk of domestic abuse c. Migraine headaches d. Major depression

c. Risk for suicide

A person intentionally overdoses on antidepressant drugs. Which nursing diagnosis has the highest priority? a. Powerlessness b. Social isolation c. Risk for suicide d. Compromised family coping

a, b, c

A person was abducted and raped at gunpoint by an unknown assailant. Which interventions should the nurse use while caring for this person in the emergency department? Select all that apply. a. Allow the patient to talk at a comfortable pace. b. Pose questions in nonjudgmental, empathic ways. c. Place the patient in a private room with a caregiver. d. Invite family members to the examination room and involve them in taking the history. e. Put an arm around the patient to offer reassurance that the nurse is caring and compassionate.

d. Severe

A person was abducted and raped at gunpoint. The nurse observes this victim is confused, talks rapidly in disconnected phrases, and is unable to concentrate or make simple decisions. What is the patient's level of anxiety? a. Weak b. Mild c. Moderate d. Severe

b. explain that washing would destroy evidence.

A rape victim tells the emergency department nurse, "I feel so dirty. Please let me take a shower before the doctor examines me." The nurse should: a. arrange for the patient to shower. b. explain that washing would destroy evidence. c. give the patient a basin of hot water and towels. d. instruct the victim to wash above the waist only.

c. "You believe this would not have happened if you had not been alone?"

A rape victim tells the nurse, "I should not have been out on the street alone." Which is the nurse's most therapeutic response? a. "Rape can happen anywhere." b. "Blaming yourself only increases your anxiety and discomfort." c. "You believe this would not have happened if you had not been alone?" d. "You are right. You should not have been alone on the street at night."

d. Designate zones according to the alphabet, and direct students to the zones based on their surnames to facilitate reuniting them with their parents.

A troubled adolescent opened fire in a high school cafeteria, fatally shooting three people and injuring many others. Hundreds of parents come to the high school after hearing the news reports. After the police arrest the shooter, which action should occur next? a. Ask the police to encircle the school campus with yellow tape to prevent parents from entering. b. Announce over the loudspeakers, "The campus is now secure. Please return to your classrooms." c. Require parents to pass through metal detectors and then allow them to look for their children in the school. d. Designate zones according to the alphabet, and direct students to the zones based on their surnames to facilitate reuniting them with their parents.

a. "Are you thinking of suicide?"

A victim of a violent rape has been in the emergency department for 3 hours. Evidence collection is complete. As discharge counseling begins, the patient says softly, "I will never be the same again. I can't face my friends. There is no sense of trying to go on." Select the nurse's most important response. a. "Are you thinking of suicide?" b. "It will take time, but you will feel the same as before." c. "Your friends will understand when you tell them." d. "You will be able to find meaning in this experience as time goes on."

a. name two community resources that can be contacted.

A victim of physical abuse by a domestic partner is treated for a broken wrist. The patient has considered leaving but says, "You stay together, no matter what happens." Which outcome should be met before the patient leaves the emergency department? The patient will: a. name two community resources that can be contacted. b. limit contact with the abuser by obtaining a restraining order. c. demonstrate insight into the abusive relationship. d. facilitate counseling for the abuser.

d. Clarifying what the patient means by, "I can't take it anymore!"

A woman says, "I can't take it anymore! Last year my husband had an affair and now we don't communicate. Three months ago, I found a lump in my breast. Yesterday my daughter said she's quitting college." What is the nurse's priority assessment? a. Identifying measures useful to help improve the couple's communication b. Discussing the patient's feelings about the possibility of having a mastectomy c. Determining whether the husband is still engaged in an extramarital affair d. Clarifying what the patient means by, "I can't take it anymore!"

c. Situational

A woman says, "I can't take it anymore! Last year my husband had an affair and now we don't communicate. Three months ago, I found a lump in my breast. Yesterday my daughter said she's quitting college." What type of crisis is this person experiencing? a. Maturational b. Adventitious c. Situational d. Recurring

9 y/o child, self blaming for divorce; what therapy is good

therapeutic drawing

a. Threat to her life

A woman was grabbed by an attacker as she walked home from work. The attacker put a gun to her head, taped her mouth, tied her hands, took her to a remote location, and raped her. Which aspect of this crisis produced the greatest amount of psychological trauma? a. Threat to her life b. Memory of the event c. Being in a remote location d. Physical pain experienced

c. "Let's develop a safety plan for repeated violence."

A young woman presents at the ER with a broken wrist and several bruises inflicted by a beating by her partner. She states that she wants to remain in the relationship for now. What is the most appropriate response by the nurse? a. "You need to leave the relationship." b. "I will call a lawyer for you if you wish." c. "Let's develop a safety plan for repeated violence." d. "Here is a list of services that can help you."

b, c, f

After assessing a victim of sexual assault, which terms could the nurse use in the documentation? Select all that apply. a. Alleged b. Reported c. Penetration d. Intercourse e. Refused f. Declined

c. Maturational

After celebrating a 40th birthday, an individual becomes concerned with the loss of youthful appearance. What type of crisis has occurred? a. Reactive b. Situational c. Maturational d. Adventitious

b. Risk for injury, related to partner's physical abuse when intoxicated

After treatment for a detached retina, a victim of domestic violence says, "My partner only abuses me when intoxicated. I've considered leaving, but I was brought up to believe you stay together, no matter what happens. I always get an apology, and I can tell my partner feels bad after hitting me." Which nursing diagnosis applies? a. Social isolation, related to lack of community support system b. Risk for injury, related to partner's physical abuse when intoxicated c. Deficient knowledge, related to resources for escape from the abusive relationship d. Disabled family coping, related to uneven distribution of power within a relationship

c. Emotional

An 11-year-old child is absent from school to care for siblings while the parents work. The family cannot afford a babysitter. When asked about the parents, the child reluctantly says, "My parents don't like me. They call me stupid and say I never do anything right." Which type of abuse is likely? a. Sexual b. Physical c. Emotional d. Economic

b. Adventitious

An adolescent comes to the crisis clinic and reports sexual abuse by an uncle. The patient told the parents about the uncle's behavior, but the parents did not believe the adolescent. What type of crisis exists? a. Maturational b. Adventitious c. Situational d. Organic

b. "Do you have access to medications?"

An adolescent tells the school nurse, "My friend threatened to take an overdose of pills." The nurse talks to the friend who verbalized the suicide threat. The most critical question for the nurse to ask would be: a. "Why do you want to kill yourself?" b. "Do you have access to medications?" c. "Have you been taking drugs and alcohol?" d. "Did something happen with your parents?"

d. Physical injuries

An adult has recently been absent from work for 3-day periods on several occasions. Each time, the individual returns wearing dark glasses. Facial and body bruises are apparent. What is the occupational health nurse's priority assessment? a. Interpersonal relationships b. Work responsibilities c. Socialization skills d. Physical injuries

b. "My fingers are tingly."

An adult patient assaults another patient and is restrained. One hour later, which statement by this restrained patient necessitates the nurse's immediate attention? a. "I hate all of you!" b. "My fingers are tingly." c. "You wait until I tell my lawyer." d. "It was not my fault. The other patient started it."

c. Chronic low self-esteem

An adult survivor of child abuse states, "Why couldn't I make him stop the abuse? If I were a stronger person, I might have been able to make him stop. Maybe it's my fault he abused me." Based on this information, what is the most appropriate nursing diagnosis? a. Ineffective family coping b. Social isolation c. Chronic low self-esteem d. Anxiety

c. Ineffective coping, related to perceived loss of daughter

An adult tells the nurse, "I can't take it anymore! Last year my husband had an affair and now we don't communicate. Three months ago, I found a lump in my breast. Yesterday my daughter told me she's quitting college and moving in with her boyfriend." What is the priority nursing diagnosis? a. Fear, related to impending surgery b. Deficient knowledge, related to breast lesion c. Ineffective coping, related to perceived loss of daughter d. Impaired verbal communication, related to spousal estrangement

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

An emergency department nurse realizes that the spouse of a patient is becoming increasingly irritable while waiting. Which intervention should the nurse use to prevent escalation of anger? a. Explain that the patient's condition is not life threatening. b. Periodically provide an update and progress report on the patient. c. Explain that all patients are treated in order, based on their medical needs. d. Suggest that the spouse return home until the patient's treatment is completed.

a stigma against mentally ill

they have no motivation

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

An intramuscular dose of antipsychotic medication needs to be given to a patient who is becoming increasingly more aggressive. The patient is in the day room. The nurse should enter the day room: a. and say, "Would you like to come to your room and take some medication your doctor prescribed for you?" b. accompanied by three staff members and say, "Please come to your room so I can give you some medication that will help you feel more comfortable." c. and place the patient in a basket-hold and then say, "I am going to take you to your room to give you an injection of medication to calm you." d. accompanied by a male nursing assistant and tell the patient, "You can come to your room willingly so I can give you this medication, or the aide and I will take you there.

a. maintaining the airway.

An unconscious person is brought to the emergency department by a friend. The friend found the person in a bedroom at a college fraternity party. Semen is observed on the person's underclothes. The priority actions of staff members should focus on: a. maintaining the airway. b. preserving rape evidence. c. obtaining a description of the rape. d. determining what drug was ingested.

b, e

From your knowledge of intimate partner violence, which of the following are true statements? Select all that apply. a. Violence is only seen in Caucasian males b. Violence crosses all cultural, ethnic, and socioeconomic boundaries c. Violence occurs with the heterosexual population d. Males are always the perpetrators e. Violence is seen in both heterosexual and homosexual relationships

pt needs to continue lithium; if they don't

they will relapse

client lost a loved one and keeps repeating the story over and over

this is a part of the grieving process and needs to be completed

what is the difference between nursing dx and mental health dx

it will effect the choice of treatment

Mexican American patient puts a picture of the Virgin Mary on the bedside table. What is the nurses best action?

leave the picture where the pt placed it

a, c, d

Because an intervention is required to control a patient's aggressive behavior, a critical incident debriefing takes place. Which topics are the primary focuses of the discussion? Select all that apply. a. Patient behavior associated with the incident b. Genetic factors associated with aggression c. Intervention techniques used by staff d. Effect of environmental factors e. Review of theories of aggression

talking to schizophrenic and they are talking back but make no sense

let them know you are not understanding them

a. Determine client's perception of crisis or disaster

During crisis or disaster intervention, your initial assessment should be to: a. Determine client's perception of crisis or disaster b. Determine the client's support system c. Determine the client's prior history with disaster d. Determine the client's ability to focus on interventions

b. "In the past, how did you handle difficult or stressful situations?"

During the initial interview at the crisis center, a patient says, "I've been served with divorce papers. I'm so upset and anxious that I can't think clearly." What could the nurse say to assess personal coping skills? a. "What would you like us to do to help you feel more relaxed?" b. "In the past, how did you handle difficult or stressful situations?" c. "Do you think you deserve to have things like this happen to you?" d. "I can see you are upset. You can rely on us to help you feel better."

a. Jumping from a 100-foot-high railroad bridge located in a deserted area late at night

Four individuals have given information about their suicide plans. Which plan evidences the highest suicide risk? a. Jumping from a 100-foot-high railroad bridge located in a deserted area late at night b. Turning on the oven and letting gas escape into the apartment during the night c. Cutting the wrists in the bathroom while the spouse reads in the next room d. Overdosing on aspirin with codeine while the spouse is out with friends

helpful resource for nurse to implement in pediatric psych unit

librarian

a. CAGE-AID

Hamilton Anxiety Rating Scale is to anxiety as ________________________ is to addiction? a. CAGE-AID b. AIMS c. CPS d. YMRS

thinking of suicide for months and then start drinking and have a gun

likelihood that there will be success in suicide

a, b, c, e

Signs of child abuse would include which of the following? Select all that apply. a. Disheveled appearance b. Fearful of parent or caregiver c. History of school absenteeism d. Bright affect e. Neglected appearance

T

T or F "Relapse is an expected complication in the recovery of addictions, and treatment includes a significant focus on teaching relapse prevention."

T

T or F The nurse's privilege to practice nursing carries with it the responsibility to practice safely, competently, and in a manner consistent with state and federal laws.

a. is experiencing a state of disequilibrium.

The assumption most useful to a nurse planning crisis intervention for any patient is that the patient: a. is experiencing a state of disequilibrium. b. is experiencing a type of mental illness. c. poses a threat of violence to others. d. has a high potential for self-injury.

a. Accept the client unconditionally

The nurse should initially focus on which of the following interventions when caring for a pregnant client with a substance abuse disorder? a. Accept the client unconditionally b. Confront the clients behaviors c. Report the client to child protective services d. Teach the effects of substance abuse

Puerto Rican pt uses dramatic body language; what is explanation

normal for his culture

a. "Genetics are associated with suicide risk. Monitoring and support are important."

The parents of identical twins ask a nurse for advice. One twin committed suicide a month ago. Now the parents are concerned that the other twin may also have suicidal tendencies. Which reply by the nurse would be most helpful? a. "Genetics are associated with suicide risk. Monitoring and support are important." b. "Apathy underlies suicide. Instilling motivation is the key to health maintenance." c. "Your child is unlikely to act out suicide when identifying with a suicide victim." d. "Fraternal twins are at higher risk for suicide than identical twins."

b. APS

What agency do you call to report elder abuse? a. CPS b. APS c. AIMS d. CAGE

b. Sympathy for the victim and anger toward the abuser

What feelings are most commonly experienced by nurses working with abusive families? a. Outrage toward the victim and sympathy for the abuser b. Sympathy for the victim and anger toward the abuser c. Unconcern for the victim and dislike for the abuser d. Vulnerability for self and empathy with the abuser

b. Report the suspected abuse or neglect according to state regulations.

What is a nurse's legal responsibility if child abuse or neglect is suspected? a. Discuss the findings with the child's teacher, principal, and school psychologist. b. Report the suspected abuse or neglect according to state regulations. c. Document the observations and speculations in the medical record. d. Continue the assessment.

d. Cocaine

What is an example of an illegal CNS stimulant? a. Propoxyphene (Darvon) b. Flurazepma (Dalmane) c. Heroin d. Cocaine

d. Desire to humiliate or control others

What is the primary motivator for most rapists? a. Anxiety b. Need for humiliation c. Overwhelming sexual desires d. Desire to humiliate or control others

d. Begin with the least restrictive measure possible.

When a patient's aggression quickly escalates, which principle applies to the selection of nursing interventions? a. Staff members should match the patient's affective level and tone of voice. b. Ask the patient what intervention would be most helpful. c. Immediately use physical containment measures. d. Begin with the least restrictive measure possible.

b. provide referral information verbally and in writing.

When a victim of sexual assault is discharged from the emergency department, the nurse should: a. arrange support from the victim's family. b. provide referral information verbally and in writing. c. advise the victim to try not to think about the assault. d. offer to stay with the victim until stability is regained.

c. Availability of means and lethality of method

When assessing a patient's plan for suicide, what aspect has priority? a. Patient's financial and educational status b. Patient's insight into suicidal motivation c. Availability of means and lethality of method d. Quality and availability of patient's social support

b. Children under 4 have the greatest risk for abuse and death

When evaluating child abuse, you remember that: a. Adolescents have the greatest risk for death from abuse b. Children under 4 have the greatest risk for abuse and death c. School-age children can speak up and are generally not victims of child abuse d. Child abuse is a vague term and is really a private matter of how parents exert discipline

c. Ask which drugs other than alcohol the patient has recently used

When intervening with a patient who is intoxicated from alcohol, it is useful for a nurse to first: a. Let the patient sober up b. Decide immediately on care goals c. Ask which drugs other than alcohol the patient has recently used d. Gain compliance by sharing personal drinking habits with the patient

b. Sit next to the child in a private setting

When preparing to speak to a possible abused child, you should: a. Sit across from the child at a table b. Sit next to the child in a private setting c. Sit next to the parents and child d. Allow the parents to speak for the child

c. helping the victim feel safe.

When working with rape victims, immediate care focuses first on: a. collecting evidence. b. notifying law enforcement. c. helping the victim feel safe. d. documenting the victim's comments.

b. has a history of spousal abuse.

Which assessment finding presents the greatest risk for violent behavior? A patient who: a. is severely agoraphobic. b. has a history of spousal abuse. c. demonstrates bizarre somatic delusions. d. verbalizes hopelessness and powerlessness.

a. Coping mechanisms the patient is using

Which assessment has priority when a nurse interviews a rape victim in the emergency department? a. Coping mechanisms the patient is using b. Patient's previous sexual experience c. Adequacy of interpersonal relationships d. Patient's history of sexually transmitted diseases

a. Stomping away from the nurses' station, going to the day room, and grabbing a pool cue from a patient standing by the pool table.

Which behavior best demonstrates aggression? a. Stomping away from the nurses' station, going to the day room, and grabbing a pool cue from a patient standing by the pool table. b. Bursting into tears, leaving the community meeting, and sitting on a bed hugging a pillow and sobbing. c. Telling the primary nurse, "I felt angry when you said I could not have a second helping at lunch." d. Telling the medication nurse, "I am not going to take that or any other medication you try to give me."

a, d, e

Which behaviors are most consistent with the clinical picture of a patient who is becoming increasingly aggressive? Select all that apply.. a. Pacing b. Crying c. Withdrawn affect d. Rigid posture with clenched jaw e. Staring with narrowed eyes into the eyes of another

b. Giving direction

Which communication technique is used more in crisis intervention than traditional counseling? a. Role modeling b. Giving direction c. Information giving d. Empathic listening

Pt with bulimia; what should the nurse teach?

not to skip meals or restrict food

pt comes into the ER and feels like hes out of body and seeing waves

pt has ingested LSD

a pt repeatedly states he is stupid; how does the nurse know that improvement has been made in cognitive behavioral therapy?

pt states "sometimes I do stupid things"

a. An unemployed husband with low self-esteem, a wife who loses her job, and a developmentally delayed 3-year-old child

Which family scenario presents the greatest risk for family violence? a. An unemployed husband with low self-esteem, a wife who loses her job, and a developmentally delayed 3-year-old child b. A husband who finds employment 2 weeks after losing his previous job, a wife with stable employment, and a child doing well in school c. A single mother with an executive position, a talented child, and a widowed grandmother living in the home to provide child care d. A single homosexual male parent, an adolescent son who has just begun dating girls, and the father's unmarried sister who has come to visit for 2 weeks

d. Emergency medical technician (EMT) who treated victims of a car bombing at a department store

Which health care worker should be referred to critical incident stress debriefing? a. Nurse who works at an oncology clinic where patients receive chemotherapy b. Case manager whose patients are seriously mentally ill and are being cared for at home c. Health care employee who worked 8 hours at the information desk of an intensive care unit d. Emergency medical technician (EMT) who treated victims of a car bombing at a department store

a. Help the patient identify a thought that increases anger, find proof for or against the belief, and substitute reality-based thinking.

Which is an effective nursing intervention to assist an angry patient to learn to manage anger without violence? a. Help the patient identify a thought that increases anger, find proof for or against the belief, and substitute reality-based thinking. b. Provide negative reinforcement such as restraint or seclusion in response to angry outbursts, whether or not violence is present. c. Use aversive conditioning, such as popping a rubber band on the wrist, to help extinguish angry feelings. d. Administer an antipsychotic or antianxiety medication.

a, b, c, e

Which of the following are theoretical characteristics of a sexual perpetrator? Select all that apply. a. High incidence of psychopathology and personality disorders (antisocial personality) b. Impulsive and hostile toward women c. Association with sexually aggressive peers d. Low socio-economic background e. Possible biological factors involving neurotransmitters

b. Strong negative feelings interfere with assessment and judgment.

Which rationale best explains why a nurse should be aware of personal feelings while working with a family experiencing family violence? a. Self-awareness protects one's own mental health. b. Strong negative feelings interfere with assessment and judgment. c. Strong positive feelings lead to underinvolvement with the victim. d. Positive feelings promote the development of sympathy for patients.

d. Riot at a rock concert

Which scenario is an example of an adventitious crisis? a. Death of a child from sudden infant death syndrome b. Being fired from a job because of company downsizing c. Retirement of a 55-year-old d. Riot at a rock concert

c. Paranoid delusions of being followed by alien monsters

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

b. Teaching stress reduction techniques to a beginning student nurse.

Which situation demonstrates the use of primary care related to crisis intervention? a. Implementing suicide precautions for a patient with depression. b. Teaching stress reduction techniques to a beginning student nurse. c. Asessing coping strategies used by a patient who has attempted suicide. d. Referring a patient with schizophrenia to a partial hospitalization program.

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

Which statement provides the best rationale for why a nurse should closely monitor a severely depressed patient during antidepressant medication therapy? a. As depression lifts, physical energy becomes available to carry out suicide. b. Suicide may be precipitated by a variety of internal and external events. c. Suicidal patients have difficulty using social supports. d. Suicide is an impulsive act.

a. speak in short, concise sentences.

While conducting the initial interview with a patient in crisis, the nurse should: a. speak in short, concise sentences. b. convey a sense of urgency to the patient. c. be forthright about time limits of the interview. d. let the patient know the nurse controls the interview.

c. Recognizing crying as an age-appropriate way to communicate

You are a home health nurse evaluating a family in which the 18 month old child has been abused by both parents. At the initial interview, the parents' state, "We spank him because he cries and cries and will not tell us what is wrong." The parents are both adolescents who are still in high school. You determine that what parental outcome would be appropriate and indicate progress. a. Less use of spanking for discipline b. Joint attendance at parenting classes c. Recognizing crying as an age-appropriate way to communicate d. Holding high expectations for their child

a. Assess for injuries, start a triage system

You are attending an IU basketball game when a section of bleachers collapses in front of you. You and your nursing school friends run to the area. Your initial action should be to: a. Assess for injuries, start a triage system b. Initiate psychological first aid c. Yell for any physicians or nurses available to help d. Console those injured and wait for EMTs and paramedics to arrive

a, d, e

You are caring for a female client in the ER with bruises on her face, a cracked tooth, and back pain. She voices concern about her children, her pets, and her ability to continue with her plans to enroll in college. You know which of the following are true. Select all that apply. a. She is correct that her pets may be at risk for injury or death from her spouse b. Her pets are safe; there is no correlation between interpersonal violence and injury to pets c. Her children are safe; there is no correlation between spousal abuse and injury to children d. It is probable that her husband may try to sabotage her career goals e. She is correct that her children may be at risk for abuse

d. "Are you comfortable discussing the abuse?"

You are caring for a patient being treated for migraine headaches. Upon physical examination you notice old scars on the patient's arms and legs. She confides childhood memories of sexual abuse by her father. What should be your immediate response? a. "Tell me more about your migraines." b. "How did you get those scars?" c. "How old were you when the abuse stopped?" d. "Are you comfortable discussing the abuse?"

a. The client will keep her scheduled appointment for a one week follow-up with the crisis therapist.

You are discharging a client who was the victim of sexual assault. Which of the following would be an appropriate outcome from a mental health standpoint for this client? a. The client will keep her scheduled appointment for a one week follow-up with the crisis therapist. b. You will give the client resource information verbally and in writing on sexual assault. c. You instruct the client on deep breathing exercises to help with anxiety. d. The client will see her primary physician in one week for physical follow-up.

a. Possible child abuse

You are working in the pre-op area of the local hospital. A two month old is scheduled for minor surgery. During your assessment you notice the child has large bruises of different stages across his back and buttocks. The mother states, "He must have fallen while playing outside" but she is a little evasive and cannot provide additional information. How would you evaluate this situation? a. Possible child abuse b. Immature parenting c. Normal findings in a two year old d. Indication of tissue fragility

b, c, d

You are working on the neurological unit caring for a patient with three children who was beaten and sexually assaulted by her spouse. Another nurse states to you, "She was stupid for staying in the relationship; she deserved it." What would be your best responses to this colleague? Select all that apply. a. "Yes, she had a lot of family and friends she could have gone to." b. "Maybe she has come to think of the violence as acceptable." c. "One reason she may have stayed is the fear of losing her children." d. "Women may stay in violent relationships due to fear, helplessness, guilt, or shame." e. "I agree. She should have packed up and left."

b, c, d, e

You recognize the following facts about elder abuse. Select all that apply. a. The perpetrators are generally strangers b. The perpetrators are usually family members or caregivers c. All states have some form of reporting system d. Individuals older than 80 have a risk 2-3x higher than other populations e. Signs of abuse are similar to those of intimate partner violence

What is a likely event that would cause grief in a community?

adolescent shoots a principal at the high school

a pt is thin, tense, jittery, and has dilated pupils. the pt says, "I'm burning up. I need help." The pt allows a temp to be taken (it is 104), then becomes suspicious and says. "You could be trying to kill me." The patient refuse further examination. Abuse of which substance is most likely?

amphetamines

pt turns call light on every 3 mins; nursing dx/outcome

anxiety, self control, using call light no more than 1 time and hour

19 y/o unable to work for 2 years due to a severe mental disorder

apply for SSI

pt leans forward and frowns, vague in answers; nurse asks?

are you having trouble hearing me?

if you're taking care of someone that has been raped; what is the nurses best response

are you thinking of harming yourself

Terminally ill client makes the comment "I know I will never get well"; how should the nurse respond?

ask what the client hopes for

nurse interviewing pt with possible PTSD, look for findings

avoids people and places that arouse painful memories

nurse can help judge see that they are mentally ill and sentence to jail would just end up back

but treatment reduces repeat offense

a client is a self mutilator, an empty feeling makes want to cut; what is the nurses best response?

choose a coping mechanism or strategy to use instead of cutting

nursing dx for Pt with manic episode

disturbed thought processes

styles of coping; pt is difficult and blames everyone else; what personality style

externalize problems

staff member assigned to HIV pt

feeling inadequate in dealing with complex needs

pt is set up for out pt therapy and tells nurse they can't come in

find someone from ACT to go get them

best intervention for nutrition for a pt with Alzheimer's?

finger foods

child adapted to shelter life. the child says, "I have three good friends at school. We talk about lots of things and sit together at lunch." select the nurses best action

foster the child's healthy characteristics and existing environmental supports

if you are tires/fatigued and need more hours to sleep

go to bed earlier and get up at the same time

pt has plan to commit suicide and has the means to do it

he is a high risk for suicide

multifamily support group; schizophrenic hasn't had a good job; nurse can best facilitate discussion of the issue

how has everyone handled painful feelings

during pt assessment

how is faith help cope with stressful situations

When documenting on a client, what is the best practice a nurse can do?

quote the client