NUR 326 Psych/MH Exam 1
1. A suicidal patient is found by the nurse as he tries to hang himself from the shower in the bathroom. What nursing intervention would address the patient's need for safety while maintaining his self-esteem? a. Assign a staff member to remain with him at all times. b. Place him in the seclusion room with 15 minute checks c. Request that he remain with the patient group at all times. d. Tell him he may use the bathroom only with staff supervision.
A
A nurse is caring for a client who has acute stress disorder and is experiencing severe anxiety. Which of the following statements should the nurse make? a) "Tell me how you are feeling right now" b) "you should focus on the positive things in your life to decrease your anxiety" c) "Why do you believe you are experiencing this anxiety?" d) "Let's discuss the medications your provider is prescribing to decrease your anxiety."
A
A nurse is preparing to provide an educational seminar on stress to other nursing staff. Which of the following information should the nurse include in the discussion? a) excessive stressors cause the client to experience distress b) the body's initial adaptive response to stress is denial c) absence of stressors results in homeostasis d) negative, rather than positive, stressors produce a biological response
A
A nurse is teaching a client about stress-reduction techniques. Which of the following indicates understanding of the teaching? a) "Cognitive reframing will help me change my irrational thoughts to something positive" b) "Progressive muscle relaxation uses a mechanical device to help me gain control over my pulse rate" c) "Biofeedback causes my body to release endorphins so that I feel less stress and anxiety" d) "mindfulness allows me to prioritize the stressors that I have in my life so that I have less anxiety"
A
A nurse is working on an acute mental health unit and caring for a client who has PTSD. Which of the following findings should the nurse expect? select all that apply a) Difficulty concentrating on tasks b) obsessive need to talk about the traumatic event c) negative self image d) recurring nightmares e) diminished reflexes
A,C,D
A nurse is assessing a client who has generalized anxiety disorder. Which of the following findings should the nurse expect? (select all that apply) a) excessive worry for 6 months b) impulse decision making c) delayed reflexes d) restlessness e) need for reassurance
A,D,E
4. A nursing interview for a patient being admitted for depression reveals that the patient has been taking a benzodiazepine for anxiety for 3 years. Which actions by the nurse reflect an understanding of the effects of this classification of drugs? Select all that apply. a. The nurse asks how much of the drug the patient takes daily. b. The admitting physician is notified of the patients medication history. c. The nurse prepares to discuss the process of detoxification with the patient. d. The nurse suggests to the patient that the dosage is likely to be increased. e. The patient is interviewed regarding how well the anxiety has been controlled.
ABC Benzodiazepines are relatively safe and effective for short-term use to control the debilitating symptoms of anxiety. However, longer-term treatment with these drugs raises issues of tolerance, abuse, and dependence. The medication dosage would not be increased. The effectiveness of the medication is irrelevant but rather the length of the therapy is the prime concern.
The patients daughter was murdered while they were customers in a local bank. Which statements would support the patients diagnosis of posttraumatic stress disorder (PTSD)? Select all that apply: a. I feel numb, like a robot going through the motions of existing. b. Im so nervous and jump at the slightest noise. c. I have not slept very well at all since I lost her. d. I cant stop reliving the last time I saw her alive. e. Id love nothing better than to kill that murderer.
ABCD
1. A patient is being evaluated for a possible diagnosis of panic disorder with agoraphobia. Which nursing assessment findings support this diagnosis? Select all that apply. a. Patient states, Ive had these fears for more than 6 years. b. Patient describes having a panic attack several times a month. c. Patient is embarrassed by the limitations the disorder causes. d. Stated, I never even think about going shopping in a crowded mall. e. Condition began after beginning treatment for a chronic intestinal problem.
ABCD To meet the first DSM-IV-TR criterion for panic disorder with agoraphobia, the person must experience recurrent, unexpected panic attacks, with at least one attack followed by one of the following for a month: (1) persistent concern about having additional attacks; (2) worry about the implications of the panic attacks; or (3) a significant change in behavior as a result of the attacks. The second criterion is that the individual experiences agoraphobia. Agoraphobic fears typically involve being in a crowd. The third criterion is that the person avoids agoraphobic situations or has anxiety about having a panic attack. This person will not go to an area or event where he or she has experienced an agoraphobic reaction. The fourth criterion states that panic attacks are not caused by the direct effects of a substance, a medication, or a medical condition.
5. A patient comes to the ED exhibiting severe physical and emotional symptomology. When no physical cause can be found for the symptoms, the patient is diagnosed with severe anxiety with panic attack symptoms. Which assessment data supports this diagnosis? Select all that apply. a. Blood pressure 158/90; 15 minutes later 130/80 b. Claims that she feels like she going to die c. Random but controlled thoughts d. Unable to follow instructions e. Dry, flushed skin
ABD Blood pressure will begin to drop in a panic attack as the sympathetic nervous system release occurs; the patient may express an emotional sensation of doom and the patient will not be able to concentrate and so will be unable to follow instructions. Thoughts during a panic attack are uncontrolled and the skin is diaphoretic.
3. Which lifestyle changes should the nurse incorporate in the nursing care plan for a patient with generalized anxiety disorder? Select all that apply. a. Stop smoking. b. Limit caffeine intake. c. Eliminate stress from your life. d. Practice a relaxation technique daily. e. Limit worrying to specific times each day.
ABDE CNS stimulants, including caffeine and nicotine, increase anxiety symptoms such as heart rate and muscle tension. Relaxation techniques are invaluable in the management of stress and anxiety. Limiting the time to allow worrying will help control the invasive thoughts. One cannot avoid stressful situations and attempting to do so does not help in managing its affects.`
When assessing a patient diagnosed with a mood disorder, which abnormal diagnostic tests would be considered a possible factor in the manifestation of the disorder? Select all that apply a. RBC (red blood cell) b. ECG (electrocardiogram) c. BUN ( blood urea nitrogen) d. TSH (thyroid stimulating hormone) e. Blood glucose
ADE
A client says she is experiencing increased stress because her significant other is "pressuring me and my kids to go live with him. I love him, but I'm not ready to do that." She also states that her significant other "keeps nagging at my oldest son, which makes me mad, since he's my son, not his." Which of the following should the nurse recommend to promote a change in the client's situation? A. Learn to practice mindfulness. B. Use assertiveness techniques. C. Exercise regularly. D. Rely on the support of a close friend.
B
A nurse is caring for a client who has bipolar disorder. The client states, "I am very rich, and I feel i must give my money to you." Which of the following responses should the nurse make? a) "Why do you think you feel the need to give money away?" b) "I am here to provide care and I cannot accept this from you." c) "I can request that your cause manager discuss appropriate charity options with you." d) "You should know that giving away your money is inappropriate."
B
A nurse is providing preoperative teaching for a client who was just informed that she requires emergency surgery. The client, has a respiratory rate 30/min and says "this is difficult to comprehend. I feel shaky and nervous" The nurse should identify that the client is experiencing which of the following levels of anxiety? a) mild b) moderate c_) severe d) panic
B
A nurse is discussing acute vs prolonged stress with a client. Which of the following effects should the nurse identify as an acute stress response? Select all that apply a) chronic pain b) depressed immune system c) increased blood pressure d) panic attacks e) unhappiness
B,C,E
A nurse is planning care for a client who has bipolar disorder and is experiencing a manic episode. Which of the following interventions should the nurse include in the plan of care? Select all that apply a) provide flexible client behavior expectations b) offer concise explanations c) establish consistent limits d) disregard client complains e) use a firm approach with communication
B,C,E
A nurse is caring for a client who is experiencing moderate anxiety. Which of the following actions should the nurse take when trying to give necessary information to the client? (select all that apply) a) reassure the client that everything will be okay b) discuss prior use of coping mechanisms with the client c) ignore the client's anxiety so she will not feel embarrassed d) demonstrate a calm manner while using simple and clear directions e) gather information from the client using close-ended questions
B,D
A nurse is involved in a serious and prolonged mass casualty incident in the emergency department. Which of the following strategies should the nurse use to help prevent developing a stress-related disorder? select all that apply a) avoid thinking about the incident when it is over b) take breaks during the incident for food and water c) debrief with others following the incident d) hold emotions in check in the days following the incident e) take advantage of offered counseling
BC,E
A nurse is caring for a client who has derealization disorder. Which of the following findings should the nurse identify as an indication of derealization? a) the client explains that her body seems to be floating above the ground. b) the client has the idea that someone is trying to kill her and steal her money c) the client states that the furniture in the room seems smell and far away. d) the client cannot recall anything that happened within the last 2 weeks.
C
A nurse in an acute mental health facility is caring for a client who has bipolar disorder. Which of the following is the priority nursing action? a) set consistent limits for expected client behavior" b) administer prescribed medications as scheduled c) provide the client with step by step instructions during hygeine activities. d) monitor the client for escalating behavior
D
A nurse is caring for a client who is experiencing a panic attack. Which of the following actions should the nurse take? a) Discuss new relaxation techniques b) Show the client how to change his behavior. c) Distract the client with a television show d) Stay with the client and remain quiet
D
A nurse is caring for a client who states, "I'm so stressed at work because of my coworker. He expects me to finish his work because he's too lazy!" When discussing effective communication, which of the following statements by the client to his coworker indicates client understanding? a) "you really should complete your own work. I don't think it's right to expect me to complete your responsibilities" b) "why do you expect met o finish your work? You must realize that I have my own responsibilities." c) "It's not fair to expect me to complete your work. If you continue, then I will report your behavior to our supervisor." d) "When I have to pick up your extra work, I feel very overwhelmed. I need to focus on my own responsibilities."
D
A nurse is collecting an admission history for a client who has acute stress disorder. Which of the following should the nurse expect? a) The client remembers many details about the traumatic incident b) The client expresses heightened elation about what is happening c) the client states he first noticed manifestations of the disorder 6 weeks after the traumatic incident occurred d) the client expresses a sense of unreality about the traumatic event
D
1. A patient was the driver of a car that struck and killed a child. The patient tells a nurse, "I killed a child! I'm haunted by the sight of the body being thrown into the air. If I hadn't been drinking I might have been able to stop. I don't know how I can go on living with myself!" The crisis nurse should give priority to assessing the patient's: a. suicidal risk. b. physical condition. c. recent drug dependency. d. current alcohol consumption.
a
1. A voluntary patient mutilates herself whenever she leaves the unit. The nurse suggests use of four-point restraint to prevent the patient from further harming herself. What question should be considered before this measure is undertaken? a. Is this the least restrictive measure possible? b. Can four-point restraint be used for voluntary patients? c. What litigation is likely to follow from this action? d. What documentation will be necessary after restraint application?
a
1. The nurse using cognitive behavior techniques when working with patients knows that attributions are meanings the patient gives to events or circumstances that: a. may or may not be objectively accurate b. support a sense of autonomy c. promote rigidity and chaos d. isolate family members from each other
a
1. The nursing student learned of a high school classmate who recently committed suicide. The classmate's death surprised the student, because the classmate had always seemed very confident and popular. The student knows, however, that suicide is usually: a. An act with a message and purpose b. An impulsive act without meaning c. A random act of selfishness d. A random act without meaning or purpose
a
A nurse planning teaching for a parent group concerned with preventing family violence can discuss the fact that exposure to violence in the media: a. Desensitizes people to the violence around them b. Has no effect on the increase of violence in society c. Broadens the viewers knowledge about world happenings d. Helps to distinguish appropriate behaviors from inappropriate behaviors
a
The nurse is planning care for a patient who was admitted to the hospital after threatening to harm himself when he was stopped by the police for speeding. He was intoxicated at the time of admission and was assessed as being depressed, anxious, and hostile. Which patient outcome is the priority? a. Patient will remain free from self-harm although hospitalized. b. Patient will report suicidal ideation or desire to harm self to the staff. c. Patient will accept referral to the hospital-based substance abuse program. d. Patient will recognize and interrupt unconscious intentions to harm self.
a
Which outcomes would be appropriate to determine early favorable response to antidepressant medication? a. The patient will complete own self-care activities. b. The patient will demonstrate assertive communication skills. c. The patient will describe signs and symptoms of major depression. d. The patient will make plans to attend one community social activity a week.
a
5. A patient is admitted for treatment for persistent, severe anxiety. Which nursing diagnosis would help effectively direct patient care? a. Disturbed sensory perception related to narrowed perceptual field b. Risk for injury related to closed perception c. Hopelessness related to total loss of control d. Risk for other-directed violence related to combative behavior
a A narrowed perceptual field occurs with severe anxiety; therefore this diagnosis should be considered. Data are not present to support the other diagnoses.
8. Which question would assist the nurse in determining whether the patient has been experiencing anxiety? a. Have you had difficulty concentrating lately? b. Have you been feeling sad and especially lonely? c. Do you have a history of failed personal relationships? d. Do you frequently experience difficulty controlling your anger?
a Concentration difficulties occur when moderate or greater levels of anxiety are present. Loneliness is more related to mood. A failed personal relationship is more related to poor self-esteem. Inability to control anger is related to poor impulse control.
17. A nurse is reprimanded by the nurse manager. Shortly thereafter, a patients family member reports that the nurse curtly told them You cant come in now. You know you need to wait until visiting hours. The incidence should be discussed based on the knowledge that the defense mechanism the nurse used was: a. Displacement b. Projection c. Sublimation d. Suppression
a Displacement is transferring a response or feeling toward one person onto another less threatening person. Projection is attributing strong faults to another and is not displayed in this scenario. Sublimation is channeling maladaptive thoughts into socially acceptable behaviors. Suppression is intentionally avoiding thinking about problem areas.
A patient who is experiencing a manic episode approaches the nurse and with pressured speech states, I hate oatmeal. Lets get everybody together to do exercises. Im thirsty and Im burning up. Get out of my way; I have to see that guy. The priority nursing action is to: a. Measure the patients temperature and pulse. b. Offer to have the dietitian visit to discuss his diet. c. Tell the patient he can lead exercises at the community meeting. d. Show relief when the patient ends the interaction and walks away.
a During a manic episode, the patient may be inattentive to physical needs or illness. The brief remark about burning up could suggest fever. Thirst may accompany fever, be a sign of dehydration, or be related to lithium administration. More information is needed. Because hyperactive patients have difficulty remaining still, taking the temperature and pulse will give priority information. If necessary, BP can be taken later. A nutritional consult is not a priority intervention. It is not appropriate to foster increased hyperactivity. To show relief would be disrespectful on the part of the nurse.
The nurse determines that the most effective point of intervention for bereavement is: a. Promotion of mental and spiritual health across the life span b. At the time a newly discovered loss is impending c. Immediately after the loss has occurred d. When requested by the patient
a Effective health promotion before stress and loss regardless of age is most helpful. The remaining options provide help around the time of loss, which is helpful but not as effective as long-term help throughout a persons life.
10. The nurse has been working with a patient who experiences anxiety. Which intervention should the nurse implement initially when the patient is observed pacing and wring her hands? a. Asking how she has managed anxiety effectively in the past b. Distracting her by offering to help her make a telephone call c. Asking her what she believes is causing her increased anxiety d. Teaching her to take deep, relaxing breaths to manage the anxiety
a First help the patient to build on the coping methods that the patient used to manage anxiety in the past. Coping methods that were previously successful will generally be effective in subsequent situations. Distraction is not usually successful initially. Assessing for the cause of the anxiety will not, in this situation, be helpful in managing it; often times patients are not aware of the cause. Teaching will not be effective while the patient is experiencing anxiety but should be done when the patient is relaxed and able to focus.
Which statement by the patient would indicate the need for additional education regarding the prescribed lithium treatment regimen? a. I will restrict my daily salt intake. b. I will take my medications with food. c. I will have my blood drawn on schedule. d. I will drink 8 to 12 glasses of liquids daily.
a Patients taking lithium must maintain a normal sodium intake or risk symptoms of lithium toxicity. The patient should have 2 to 3 liters of fluid daily. Taking lithium with food minimizes gastrointestinal side effects. Regular monitoring of lithium levels is important to prevent toxicity.
. An inappropriately dressed patient has not slept for 3 days while making excessive, expensive long-distance phone calls. When the patient can be heard singing loudly in the examining room, the nurse makes initial plans to focus on: a. Assessing needs for food, liquids, and rest b. Setting strict limits on dress and behavior c. Conducting an in-depth suicide assessment d. Obtaining a complete psychosocial assessment
a Patients with mania frequently ignore their basic physiologic needs, as evidenced by not sleeping for 3 days, thus making these assessments the priority. Limits, although appropriate to consider, are not the priority. The manic state precludes a thorough assessment initially. Suicide assessment is not a priority at this time but reckless behavior could result in personal injury.
19. A young, married female patient is attracted to a male nurse. When the nurse sets clear boundaries, the patient falsely accuses him of sexual harassment. The nursing supervisor recognizes the defense mechanism of: a. Projection b. Splitting c. Suppression d. Displacement
a Projection is attributing strong conflicting feelings to another person. Splitting is seeing others and oneself as all good or all bad. Suppression is incorrect because the person avoids thinking about problem areas. Displacement, or transferring a feeling to a less threatening person, is not being used in this scenario.
3. What is the priority nursing diagnosis for a patient exhibiting signs of acute mania that include exaggerated physical activity, agitation, insomnia, and anorexia? a. Risk for injury b. Chronic low self-esteem c. Noncompliance d. Insomnia
a Risk for injury is the priority diagnosis. Possible injuries include dehydration, which may result from not drinking and trauma, which may result from bumping into objects or from physical altercations. The other options are valid diagnoses, but not of highest priority.
An outcome for a patient experiencing anticipatory grieving for a spouse diagnosed with terminal cancer would be that the patient will: a. Continue to be emotionally involved with the dying spouse b. Develop protective mental mechanisms to allay the pain of spousal loss c. Not voice threats of physical violence that is either self or others directed d. Agree to stay at home and care for the spouse with appropriate assistance
a Some families who are experiencing anticipatory grieving withdraw prematurely from the ill member, so this is an important outcome. There are no protective mechanisms to prevent loss experiences. Anticipatory grieving does not imply violence. A contract to stay home and care for the spouse even with assistance is not helpful.
Which symptom reported by an adult patient, who was sexually abused as a child, reflects the diagnosis of posttraumatic stress disorder (PTSD)? a. A history of substance abuse b. Refusing to go to public places from which escape may be difficult c. Seeking advice and guidance prior to making any significant decision d. Ruminating easily concerning the abuse with friends and acquaintances
a Substance abuse to help manage the unpleasant symptoms is characteristic of PTSD. Being uncomfortable in certain locations refers to agoraphobia. Seeking extensive support characterizes a dependent person. Ease in talking about the experience is uncharacteristic of PTSD
The nurse in the Emergency Department is taking a history from a family accompanying a child with suspicious traumatic injuries. The nurse should: a. Be open, concerned, and honest. b. Obtain information as covertly as possible. c. Avoid responding to hints that abuse has occurred. d. Separate the family from the child during the interview.
a The nurse serves as a role model for the parents and the child. Being open and honest and showing appropriate concern for the child is the most appropriate approach. Direct questioning is necessary to obtain the history. Concerns about the possibility of abuse must be addressed in a sensitive manner. The family will be able to remain with the child during history taking. It is helpful for the nurse to observe family interactions.
A patient has been physically abused by her boyfriend frequently since moving in together. During her last discussion with the nurse, the patient stated, I probably should not keep going back to him, because he continues to abuse me. The nurse is aware that the final decision to leave a batterer is: a. Usually a gradual process that occurs over time b. Likely to occur after the victim suffers a serious injury c. More likely if the patient has approval from her family d. Made when the batterer gives her permission to do so
a The victim usually moves slowly when making the decision to leave the batterer because of many self-imposed constraints and many environmental factors that must be considered. It is unlikely that a batterer will give permission for the victim to leave. The remaining options are not supported by current research.
1. Which of the following symptoms indicates Neuroleptic Malignant Syndrome (NMS), a potentially fatal side effect of an antipsychotic medication such as Haldol (haloperidol)? a) Photosensitivity and an itchy rash on face, neck, chest and extremities b) Hyperthermia and muscle rigidity c) Blurred vision, constipation, and urinary retention d) Tongue protrusion, lip smacking, and grimacing
b
A child was admitted to the childrens unit, having been sexually abused by an acquaintance of her family. The child refuses to talk and participate in unit activities, choosing to stay in her room with her stuffed animals. Which therapeutic intervention will best help the child release pent-up feelings about the abuse? a. Family therapy b. Play therapy c. Individual communication with the nurse d. Role-play with other children on the unit
b
An appropriate nursing strategy to assist a patient who was involuntarily admitted after a suicide attempt is:: a. Avoiding any focus on the topic of suicide b. Encouraging patient to verbalize personal feelings c. Supporting patient focus on others rather than self d. Discussing the impact of suicidal thoughts on the family
b
Because of the cognitive disturbances associated with schizophrenia, which technique will be useful as the nurse teaches a patient about self-management? a. Use only verbal instruction. b. Teach material in small segments. c. Offer opportunities for making numerous choices. d. Plan the teaching for a time when the patient has been recently medicated.
b
The community health nurse is visiting a patient diagnosed with dysfunctional grieving since the death of his wife and child over a year ago. Which actions should the nurse implement first? a. Promote interaction with others. b. Assess risk of self-directed violence. c. Facilitate expression of feelings related to the loss. d. Determine the degree of ambivalence toward the loss.
b
The nurse caring for a school-age child who has been sexually abused by a close family member demonstrates an understanding of communication barriers in this situation by: a. Realizing that repeated questioning by others will occur b. Assuring the child that the story they are telling is believed c. Reinforcing that the child will not be in trouble with the police d. Promising to tell only those who need to know about the incident
b
The nurse is leading a support group for women who have experienced interpersonal violence. When a patient asks about the characteristics of the perpetrators of interpersonal violence, the nurse accurately responds that they are: a. Usually under the influence of alcohol b. Most often someone the victim knows c. A stranger to the victim in most cases d. Often in a psychotic state during the act
b
What is the basis for the reduction in disturbed thought processes when a patient is administered haloperidol (Haldol)? a. Reduction in the number of brain cells that crave dopamine b. Dopamine receptors are blocked, making dopamine less available c. Dopamine receptors are enhanced, making more dopamine available d. Medication causes an increased cellular production of dopamine
b
Which nursing action best addresses the needs of a paranoid patient who believes the food is poisoned? a. Explaining that others eat the food and are not harmed b. Allowing the patient to select food from vending machines c. Encouraging the patient to discuss why someone would poison the food d. Taking steps to prevent the patient from verbalizing the delusional thoughts
b
Which principle should the nurse apply when planning nursing care for a patient who was voluntarily admitted after a suicide attempt? a. Patients who attempt suicide and fail will not try again. b. The more specific the plan, the greater the risk for suicide. c. Patients who talk about suicide are less likely to attempt it. d. Patients who attempt suicide and fail do not really want to die.
b
When differentiating between bereavement symptoms and depression, the nurse will base the formulation on knowledge that in bereavement: a. Suicide thoughts are common. b. Symptoms remit and exacerbate. c. Guilt feelings are overwhelming. d. Psychomotor retardation is obvious.
b Acute exacerbations are common especially around holidays and significant milestones. The remaining options are more common with depression.
3. What is the basis for assessing a male patient who is agoraphobic for panic attacks? a. Men are more likely to experience panic attacks. b. An overwhelming number of agoraphobic patients also have panic attacks. c. Patients are often unaware that the symptoms they are experiencing are those of panic. d. Panic attacks are generally the cause of a patient developing phobias like agoraphobia.
b Almost all patients who present with agoraphobia in clinical samples have a current diagnosis or history of panic disorder. Males are not more likely than females to experience panic attacks. Patients are not usually unaware of panic attack symptoms. Panic attacks dont cause, but are often triggered by, phobias.
The nurse learns at report that a newly admitted manic patient is demonstrating grandiosity. Which statement would be most consistent with this symptom? a. I cant do anything anymore. b. Im the worlds most astute financier. c. I can understand why my wife is upset that I overspend. d. I cant understand where all the money in our family goes.
b An individual who is demonstrating grandiosity has an exaggerated view of his abilities. The other options are more moderate statements and lack that element of exaggeration.
The common element seen in every type of bereavement is: a. Bereavement is a predictable process that is a result of loss. b. The individual has experienced the loss of something of importance. c. Acute depression is generally experienced by all who grieve for a loss. d. The course of the grieving will be determined by the seriousness of the loss.
b Each type of loss means that something meaningful has been taken away, whether it is physical, psychological, social, or symbolic. The remaining options are not true statements regarding bereavement.
9. The nurse working with patients diagnosed with posttraumatic stress disorder (PTSD) is aware of the need to intervene early in order to de-escalate a patients increasing anxiety level. Which patient behavior is likely an early indication of escalating anxiety? a. Talking rapidly b. Pacing around the unit c. Staring out the window d. Refusing to go to therapy
b Recognize the patients use of relief behaviors (e.g., pacing, wringing of hands) as indicators of anxiety. Talking rapidly is an indicator of manic behavior. Staring is more likely seen in depression. Refusing to attend therapy is seen in aggressive, defiant patients.
A patient returned from attending the service memorializing his wife, who died after a sudden illness. Although those around him were visibly saddened, he smiled and remained in control. He refused support from friends, stating, I can handle anything that comes my way. The patients behavior is an example of _____ grief. a. Normal b. Inhibited c. Distorted d. Conflicted
b The statement indicates inhibited grief that is characterized by minimal emotional expression of grief. There is not enough data to support conflicted grief, which involves ambivalence in the relationship with the departed. Distorted grief is not one of the standard types, and normal grief is not characterized by this behavior.
What measure will facilitate communication with a patient who is depressed and evidencing psychomotor retardation and withdrawal? a. Ask the patient to indicate yes or no with finger signals. b. Arrange to spend time with the patient at prearranged intervals. c. Give concrete and concise directions rather than asking questions. d. Speak loudly and rapidly to the patient to focus his or her attention.
b This measure will promote the establishment of rapport and demonstrate respect and acceptance of the patient. It will facilitate patient willingness to communicate thoughts and feelings without making unnecessary demands on the patient; a headshake or nod would work as well. Patients should not simply be ordered about; they should be asked to respond without placing excessive demands. Patients with psychomotor retardation have the ability to hear, but their ability to process information may be slowed, requiring well-paced simple communication.
A young child is being evaluated in the Emergency Department for injuries her mother reports resulted from a fall down the stairs. Which of these findings indicates that physical abuse may be a chronic problem for the child? a. The mothers description of the child as being clumsy b. Several fractures revealed on x-ray in varying degrees of healing c. Clinging to her mother as she attempted to leave the examining room d. Struggling with the staff when attempts to obtain a blood specimen were made
b Unhealed fractures indicate both numerous injuries and that medical intervention was not sought at the time of injury. Although unkind, the mothers description of the child is not reason to believe chronic abuse has occurred. The remaining options reflect normal behavior, especially if pain or separation is suspected.
1. A patient, who has recently lost a spouse, calls the crisis line stating the occurrence of suicidal ideations that involve jumping off a bridge over the river when no one is around. What level of lethality would a nurse assess for this plan? a. Low b. Moderate c. High d. Lethality cannot be determined from this data
c
A family member of a suicidal patient asks, Are there any medications that can prevent a person from committing suicide? Which statement best answers the question? a. If people want to harm themselves, they eventually will. b. Antipsychotic medications are used primarily for suicide prevention. c. Antidepressants treat mood disorders that accompany suicidal ideation. d. There are no medications available that specifically affect suicidal behavior.
c
A new nurse asks the experienced nurse, Why did you ask about culture when it was obvious you needed to focus on the battering? The experienced nurse should respond: a. Its just a habit I got into awhile ago. b. It helps me focus on whether to do a complete physical assessment. c. Culture is a determinant of how women interpret and respond to violence. d. If I know more I can refer her to a shelter that caters to her cultural group.
c
A nurse is teaching a newly licensed nurse about the use of electroconvulsive therapy for the treatment of bipolar disorder. Which of the following statements by the newly licensed nurse indicates understanding? A) "ECT is the recommended initial treatment for bipolar disorder" b) "ECT is contraindicated in clients who have suicidal ideation" c) "ECT is effective for clients who are experiencing severe mania" d) "ECT is prescribed to prevent relapse of bipolar disorder"
c
A patient admits to having been battered by her live-in boyfriend several times over the past 2 years. She states to the nurse, We plan to get married next June, and I think things will be better then. He is always so sorry afterward, that I think I can trust him to change. Which intervention should be included in the patients teaching plan? a. Discourage her hope that the battering will end after they are married. b. Assist her in enrolling in a class to learn techniques of self-defense. c. Assist her in developing an emergency plan, because the pattern of violence is likely to continue. d. Emphasize that the battering pattern usually remains the same in frequency and severity over time.
c
A patient was admitted and prescribed antidepressants for severe depression with feelings of hopelessness, helplessness, and suicidal ideation. When would the patient be at greatest risk for suicide during hospitalization? a. Within the first hour after admission and when family leaves b. At night after visitors leave and patients are allow in their room c. Within the first 24 hours after admission and as discharge approaches d. Within 48 hours of first expressing suicidal ideation and as therapy progresses
c
A patient who has been battered by her partner sobs, It was my own fault. Which of the following would be the priority response by the nurse? a. Why do you think he does it? b. What did you do to deserve this? c. No one has the right to abuse another. d. Tell me about when you were growing up.
c
An older adult is admitted to the hospital for severe depression. The nurse, gathering data for a medical and psychiatric history, learns of a suicide attempt 4 years ago after the death of a spouse. Based on this information, it is likely that the patient: a. Will avoid attempting suicide again after the past experience b. Will try to minimize the seriousness of the suicide attempt c. May express suicidal ideation or make a suicide attempt d. Will report that he has recently written a will
c
The nurse administering an antidepressant to a suicidal patient understands that the brain abnormality the medication addresses is: a. Atrophy of the brain b. Enlarged lateral ventricles c. Irregularities in the serotonin system d. Abnormal electroencephalogram (EEG) readings
c
The nurse who sees a number of battered elderly females each year decides to put together a set of guidelines for nurses. An appropriate guideline to include would be to: a. Make protective services aware of the abuse. b. Take at least two photographs of each trauma area. c. Begin the interview by asking the least sensitive questions. d. Assess for the presence of sexually transmitted diseases.
c
The nurse would evaluate that patient education regarding lithium therapy for an individual with bipolar disorder as effective if the patient states: a. I can stop my lithium when I feel better. b. I can continue with my diuretic and cardiac medications. c. I will probably need to take the lithium for the rest of my life. d. I will taper my lithium when a therapeutic serum level is achieved.
c
Which nursing intervention will assist a patient being treated in the Emergency Department for extensive soft tissue injuries to disclose an experience of domestic violence? a. Allowing the patient to initiate the topic of violence b. Speaking with the patient in the absence of her husband c. Providing a safe, nonintimidating, and supportive environment d. Interviewing her in the presence of another healthcare professional
c
16. The head nurse in the ED has received word that a major fire in a high-rise office tower will result in many injured persons being brought to the hospital within the next few minutes. The head nurse tells the staff, You will need to assess for acute stress reactions as well as treating physical problems. Which patient is exhibiting symptoms characteristic of acute stress reaction? a. A male whose moods swing between mania and depression b. A female who reports still hearing her daughters pleas for help c. A male who keeps repeating I dont understand whats going on? d. A female who is rocking her young son and repeating it will be okay.
c Acute stress reactions are characterized by indications of dissociation, such as dissociative amnesia. Mood swings are more reflective of a mood disorder. Auditory hallucinations would be consistent with re-living a traumatic event. Comforting and reassuring a child in this manner is not characteristic of an acute stress reaction.
Which physical disturbance is commonly assessed in patients experiencing acute grief? a. Hypersomnia b. Increased appetite c. Tightness in the chest d. Cardiovascular problems
c Chest discomfort is common with the bereaved person. Anorexia is more common. There is no research to support the connection with cardiovascular involvement. Insomnia is more frequent than sleepiness.
Which measure consistent with the use of cognitive therapy could the nurse incorporate into the treatment plan of a chronically depressed patient? a. Approach the patient with cheerful affect and optimistic remarks. b. Ignore the patients pessimistic statements; give attention for positive thinking. c. Identify negative evaluations and challenge pessimistic beliefs. d. Seek to uncover unconscious conflicts about significant relationships.
c Cognitive therapy addresses symptom removal by identifying and correcting distorted negative thinking. An overly cheerful mannerism is an insensitive nontherapeutic approach that will reinforce patient negative thinking about self. To ignore negative statements while reinforcing positive thinking is considered a behavioral approach. Seeking to uncover unconscious conflicts is a psychodynamic approach.
1. A patient who was savagely attacked by a bear has no memory of the event. Which statement best explains the patients inability to remember the attack? a. The woman lost consciousness and was not cognitively aware of what happened during the attack b. The brain has produced a chemical anemia that will repress the memories of the attack indefinitely. c. The patient is unconsciously using a defense mechanism to protect against the repeated memory of the attack. d. It is a temporary suppression of the attack; her memory will return when she is physically and emotionally ready to handle the memories.
c Defense mechanisms are used unconsciously to protect us from threats to the physical, mental, and social aspects of ourselves. The memory of the event may or may not come back but this is not generally related to the patients ability to handle the memories. Memory may be lost or impaired as a result of brain trauma but not as likely from a chemical alteration.
The nurse will base a discussion of dysthymia on the fact that the condition: a. Typically has an acute onset b. Involves delusional thinking c. Is chronic low-level depression d. Does not include suicidal ideation
c Dysthymia is identified as a chronic low-level depression frequently lasting over a period of several years without remitting. Dysthymia has a slow, insidious onset. Delusional thinking is not a common manifestation of dysthymia. Suicidal thoughts are seen among dysthymic patients.
20. A college-aged patient complains that, when I begin to take a test, I freeze up and my mind goes blank. The nurse will react based on the understanding that this patients anxiety level is: a. Mild b. Moderate c. Severe d. Panic
c In severe anxiety, a person may freeze and problem solving is difficult. A person is relatively relaxed and comfortable in mild anxiety. A person in moderate anxiety may feel energized and focused. A person at panic level has total loss of control.
Which statement best explains how a mother of several children should prepare to help them cope with the loss of a dear aunt? a. Children are resilient and simply need love as they grieve. b. People regardless of age or gender experience stages of grief. c. Each child will grieve in a unique way and on their own timetable. d. Extreme reactions are more commonly observed in the young griever.
c No two people regardless of age will grieve the same way, even in the same family. Each persons grief has unique characteristics and a timetable all its own. It is not necessarily true that young grievers experience severe reactions to loss and require only love during this experience. Although most individuals do experience the various stages of grief, that information is not the most instructive for the mother.
2. Which assessment finding exhibited by a patient being assessed for posttraumatic stress disorder (PTSD) would be considered a defining behavior and support such a diagnosis? a. Can describe the attack in great detail b. Experiences dramatic swings in affect c. Describes vivid flashbacks of being attacked d. Is preoccupied with the need to tell someone about the attack
c One defining behavior that is seen when an individual has PTSD is that the person re-experiences the traumatic event. This takes place by having recurrent and intrusive disturbing recollections of the trauma, including thoughts, images, or perceptions about the incident. The person sometimes experiences recurrent dreams of the incident and acts or feels as though the event was recurring in the present (flashback). Generally the PTSD patient cannot remember all the details of the trauma nor are they particularly interested in re-telling the events of the trauma. The patient generally has a very limited range of affect.
14. A patient is ordered medication therapy to manage the symptoms of anxiety disorder. Which statement by the patient indicates an understanding of the typical classification of medication prescribed for this disorder? a. Tricyclic antidepressants are particular good for panic attacks. b. I have to give up beer while taking monamine oxidase inhibitors (MAOIs). c. Selective serotonin reuptake inhibitors (SSRIs) help with panic attacks as well. d. Benzodiazepines are usually effective when taken for chronic anxiety like mine.
c SSRIs are the most widely prescribed medication to treat panic disorder. They are effective and have a low side-effect profile. Tricyclic antidepressants are not effective for panic attacks and have more side effects than SSRIs. MAOIs are effective but require knowledge of and compliance with a special diet and are not the first choice in this situation. Benzodiazepines are effective but produce alterations in sensorium and other side effects and are not used for long-term management.
4. Discharge preparation for a patient includes the administration of the Hamilton Anxiety Scale (HAS). When asked by the patient to explain the purpose of the assessment the nurse responds: a. It is an assessment tool used to evaluate the symptoms of anxiety. b. The tool is used to help confirm the diagnosis of anxiety disorder. c. This tool helps determine if your symptoms have improved with treatment. d. It helps identify the presence of any other disorder associated with anxiety.
c The HAS is a valid and time-tested tool that gives the most objective measure of the degree to which anxiety has been effectively treated. The HAS does not evaluate for symptoms of anxiety or act as a diagnosis tool for anxiety or another other associated disorder.
A patient in her early teens who is being treated for irritable bowel syndrome has just disclosed that she has been the victim of child abuse for 8 years. For what other condition should the nurse assess this patient? a. Schizophrenia b. Agoraphobia c. Posttraumatic stress disorder d. Obsessive-compulsive disorder
c The state of chronic hyperarousal caused by the abuse is the basis for three common outcomes of childhood abuse: PTSD, depression, and irritable bowel syndrome. The conditions mentioned in the other options are not related to child abuse.
A patient experiences intrusive, insulting auditory hallucinations. Which independent behavioral technique can the nurse teach the patient to employ when the voices are troublesome? a. Introduce a distraction like reading. b. Use positive talk to offset the insults. c. Sing or whistle to compete with the voices. d. Increase the daily dose of an antipsychotic medication.
c This action provides an alternative to listening to the voices and gives the patient a sense of control. The patient should not adjust medication independently. Reading will not be particularly effective, because the voices are uncontested in a quiet atmosphere. Positive talk is generally used to positively affect self-esteem.
A newly admitted patient has the diagnosis of catatonic schizophrenia. Which behavior observed in the patient supports that diagnosis? a. Uses a rhyming form of speech b. Refuses to eat any unwrapped foods c. Laughs when watching a sad movie d. Maintains an immobilized state for hours
d
The nurse presenting a suicide prevention lecture would decide who the target population is based on what fact? a. Females have the highest risk for suicide. b. Children are considered a high-risk group for committing suicide. c. The highest suicide rate is among the Caucasian middle-age population. d. Rates of suicide are highest among the older population, age 80 and older.
d
When an elderly patient is brought into the Emergency Department by family members who reported a fall the nurse became suspicious that the patient had suffered physical abuse. The patient denied that she had been abused. Her denial is most likely based on her: a. Feeling that she deserved the physical abuse b. Strong belief that nothing could be done to help her c. Lack of trust that the situation could ever be changed d. Fear of the possibility of being removed from her family
d
Which nursing diagnosis is appropriate for a patient who insists being called Your Highness and demonstrates loosely associated thoughts? a. Risk for violence b. Defensive coping c. Impaired memory d. Disturbed thought processes
d
Which principle should the nurse apply when planning care for a patient who is diagnosed with bipolar disorder and currently in the manic phase? a. Manic patients respond well to peer pressure. b. Decreasing stimulation tends to diminish symptoms. c. Increasing stimulation tends to encourage the patient to focus. d. Detailed activities will facilitate the patients ability to self control behavior.
d
Which patient behavior would support the diagnosis of residual schizophrenia with negative symptoms? a. Communicating using only rhyming phases b. Claims that worms are crawling in my brain c. Maintaining both arms suspended awkwardly overhead d. Shows no emotion when telling the story of a sisters recent death
d Blunted affect is considered a negative symptom. The other symptoms would be classified as positive symptoms.
Which initial short-term outcome would be appropriate for a patient who was admitted expressing delusional thoughts? a. Accept that delusion is illogical. b. Distinguish external boundaries. c. Explain the basis for the delusions. d. Engage in reality-oriented conversation.
d Delusions are not reality oriented; thus an appropriate outcome would be that patient will engage in reality-oriented conversation rather than discussing delusional beliefs. Delusions are fixed, false beliefs. Patients rarely accept anyone using logic to dispute them. Data are not present to suggest boundary disturbance. Explaining the delusion is not progress; it suggests the patient still holds to the belief.
Which statement made by the patient who attempted suicide best indicates that the criterion for discharge has been met? a. I know who to call if I get depressed again. b. Ive learned that there is hope and I dont have to hurt. c. I have good friends who are willing to help me with my problems. d. I do not feel like harming myself anymore and that feels so comforting.
d Denying a need to harm oneself is a clear statement from the patient that he or she is feeling more positive. The remaining options although positive are not as good an indicator for discharge because they do not address the issue of self-harm.
Which of the following interventions should the nurse plan to use to reduce patient focus on delusional thinking? a. Confronting the delusion b. Refuting the delusion with logic c. Exploring reasons the patient has the delusion d. Focusing on feelings suggested by the delusion
d Focusing on feelings suggested by the delusion will help meet patient needs and help the patient stay based in reality. This technique fosters rapport and trust while discouraging the belief without challenging or refuting it.
To provide nursing care to abused children and their families, the nurse must first: a. Recommend removal of the children from the family. b. Complete a comprehensive physical and mental assessment. c. Refer each case to the appropriate social worker for follow-up. d. Examine personal feelings regarding the trauma of child abuse and neglect.
d Self-examination is required in order for the nurse to be objective and therapeutic in providing care. Although important, an assessment is not the initial step in this situation. Removal is not always recommended. A social service referral may not be required, depending on the situation.
Which statement regarding the various types of child offender is correct? a. The physical offender lacks remorse, although the sexual offender usually shows guilt and shame. b. The physical offender has diverse characteristics, although the sexual offender has lack of remorse. c. The physical offender has a mature ego, although the sexual offender has a rigid, overdeveloped superego. d. The physical offender has poor self-esteem and unrealistic expectations of children, although the sexual offender has diverse characteristics.
d The child physical offender often is assessed as having poor self-esteem, poor impulse control, unrealistic expectations of children, immaturity, and minimal external supports. The child sexual offender has diverse characteristics, with no profile becoming apparent. The child sexual offender often does not show remorse for the acts.
A patient is being seen for symptoms of insomnia and significant weight loss that has occurred during the 2 months since her husbands death. What is the purpose of the query, Describe how it has been for you since your husband died? a. To display an attitude of concern and sympathy to the patient b. To learn whether the patient has a significant support system c. To rule out factors that may interfere with diagnosing her illness d. To determine the risk for pathologic grief and the need for grief therapy
d The question is a common assessment question to determine the grief work that has been done. The query does not ask about support systems or specific factors, and the query is more than a display of concern.
The nurse is interviewing a patient who presents with a dislocated shoulder and demonstrates signs of anxiety although relying on her partner for answers. Although the partner is out of the room, which question is most important to ask? a. Have you been with your partner long? b. Are you being abused by your partner? c. Shall I notify the police that you would like to press charges? d. Have you ever been physically or emotionally hurt by someone?
d When the victim is alone, the nurse must seek information about abuse. Phrasing the question to avoid use of such terms as abuse or battered is essential. These terms are too emotionally charged, and patients often respond in the negative. The length of the relationship is not a priority. Asking to call the police is premature.
