MS II quiz 13 Psych Responses to Illness & Psychiatric Disorders

A nurse is caring for a client who has obsessive compulsive disorder (OCD) and is constantly picking up after others and cleaning in the day room. The nurse should recognize the client's action as which of the following?

decreasing anxiety to a tolerable level

A patient is brought in from the emergency department after telling the physician that he is a relative of the president of the United States. He says he should not be detained because he has important business to attend to that involves national security. He is dressed in a bright coat with plain pants and gets very angry when you question him. What is the patient experiencing?

manic episode

Laboratory work is prescribed for a client who has been experiencing delusions. When the laboratory technician approaches the client to obtain a blood specimen of the client's blood, the client begins to shout, "You're all vampires. Let me out of here!" The nurse present at the time should respond by stating which?

"Are you fearful and think perhaps that others might want to hurt you?"

A patient says, "I just don't think I can keep going on. I just want it all to end." The nurse assesses that this patient has suicidal ideation. What is the nurse's best response?

"do you have any thoughts about harming yourself?"

A nurse is evaluating the outcomes for a client who has depression following the death of his wife 3 months ago. Which of the following client statements indicates a need for further intervention?

- "I just (don't) feel like eating, because I have never liked eating alone."

A client is admitted to the in-patient unit and is being considered for electroconvulsive therapy (ECT). The client appears calm, but the family is hyper-vigilant and anxious. The client's mother begins to cry and states, "My child's brain will be destroyed. How can the doctor do this?" The nurse should make which therapeutic response?

- "It sounds as though you have some concerns about the ECT procedure. Why don't we sit down together and discuss any concerns you may have?"

A charge nurse overhears another nurse talking with a client who has schizophrenia. Suddenly the client yells, "I am the devil! I am God! Open the gate for me!" Which of the following responses by the nurse requires the charge nurse to intervene?

- "there is no gate."

A nurse in an acute care mental health facility is caring for a hospitalized client who has agoraphobia. The nurse observes that the client is making progress when he is able to participate in which of the following activities?

- A picnic at a local park

A nurse is caring for a client who has obsessive-compulsive disorder (OCD). Which of the following actions is appropriate for the nurse to take?

- Determine client's level of anxiety

A nurse is caring for a client who has schizophrenia and begins to talk about fantasy subjects. Which of the following is an appropriate intervention by the nurse?

- Encourage client to focus on reality-based issues

A nurse is collecting data from a client who has posttraumatic stress disorder (PTSD) following a sexual assault. Which of the following is an expected finding?

- Increased feelings of anger

The nurse is assigned to care for a client admitted to the hospital after sustaining an injury from a house fire. The client attempted to save a neighbor involved in the fire, but despite the client's effort, the neighbor died. Which action should the nurse take to enable the client to work through the meaning of the crisis.

- Inquiring about the client's feelings that may affect coping.

A nurse is reinforcing teaching with a group of adolescents regarding identifying behavioral indicators of depression. Which of the following manifestations should the nurse include? (Select all that apply.)

- Irritability - Decreased energy - Isolation from peers

The nurse in the mental health unit reviews the therapeutic and nontherapeutic communication techniques with a nursing student. Which are therapeutic communication techniques? (Select all that apply)

- Restating - Listening - Maintaining neutral responses - Providing acknowledgment and feedback

Which is not considered as a probable cause of mood disorders?

- Traumatic event during childhood.

A patient with low back pain confesses that he heavily drinks each night to help him sleep and control pain. What does this behavior exemplify?

- Using a maladaptive coping method

A nurse assesses that a 42-year-old patient lives with her parents and is dependent on them for decisions about her life. Which mental health characteristic is the patient lacking?

Autonomous Behavior

A patient who has a history of episodes of road rage thinks that she is a very good driver and does not understand why she keeps being told she is a poor driver. She is losing her license now, and she tells the nurse that she is feeling very unhappy and abandoned. She feels like she might hurt herself. The nurse realizes that the patient is exhibiting which personality disorder?

Borderline (Difficulty controlling anger and an unstable sense)

A client is admitted to a psychiatric unit for treatment of a psychotic disorder. The client is at the locked exit door and is shouting, "Let me out! There's nothing wrong with me! I don't belong here!" The nurse identifies this behavior as which?

Denial

A manic client announces to everyone in the dayroom that a stripper is coming to perform that evening. When the psychiatric nurse's aide firmly states that the client's behavior is not appropriate, the manic client becomes verbally abusive and threatens physical violence to the nurse's aide. Based on the analysis of this situation, the nurse determines that the appropriate action should be which?

Escort the manic client to their own room.

A nurse is caring for a client who has bipolar disorder and states that his latest computer project is "revolutionizing the industry." Which of the following behaviors is the client exhibiting?

Grandiosity

What is the goal of nursing care for the patient with a chronic illness?

Help the patient manage the illness

A nurse is caring for a client who witnessed her brother's homicide and has posttraumatic stress disorder (PTSD). Which of the following findings should the nurse expect?

High sensitivity to loud voices or noises

A co-worker is noted to be very organized. However, you see that he is always making lists and citing the rules of the organization. He wants all his projects to be perfect and gets very upset when things happen that make him miss his deadlines. The co-worker is exhibiting signs of which personality disorder?

OCD

The nurse is assigned to care for a client experiencing disturbed thought processes. The nurse is told that the client believes that the food is being poisoned. Which communication technique should the nurse plan to use to encourage the client to eat?

Open-ended questions and silence

The nurse observes that a client is psychotic, pacing, and agitated and is making aggressive gestures. The client's speech pattern is rapid, and the client's affect is belligerent. Based on these observations, the nurse's immediate priority of care is which?

Provide safety for the client and all the clients on the unit

When a patient is given a diagnosis of cancer, his first statement is, "What did I ever do to deserve God punishing me?" What does this exemplify?

Spiritual distress

A client has reported that crying spells have been a major problem over the past several weeks and that the doctor said depression is probably the reason. The nurse observes that the client is sitting slumped in the chair, and the clothes that the client is wearing do not fit well. The nurse interprets that further data collection should focus on which?

Weight loss

A nurse in an acute care mental health facility is sitting with a client who has schizophrenia. The client whispers to the nurse, "I'm being kept in this prison against my will. Please try to get me out." Which of the following responses should the nurse make?

You feel that you do not belong here?"

A client was admitted to a medical unit with acute blindness. Many tests are performed, and there seems to be no organic reason why this client cannot see. The nurse later learns that the client became blind after witnessing a hit-and-run car crash in which a family of three was killed. The nurse suspects that the client may be experiencing which?

conversion disorder