PassPoint - Foundations of Pychiatric Nursing

A nurse is assessing a client taking tranylcypromine sulfate. Which client statement requires immediate follow up from the nurse?

"I accidentally cut my finger with a knife, and it took 2 hours to stop bleeding."

The client exhibits a flat affect, psychomotor deficits, and depressed mood. The nurse attempts to engage the client in an interaction but the client does not respond to the nurse. Which response by the nurse is most appropriate?

"I'll sit here with you for 15 minutes."

The nurse working at the site of a severe flood sees a woman, standing in knee-deep water, staring at an empty lot. The woman states, "I keep thinking that this is a nightmare and that I'll wake up and see that my house is still there." Which crisis intervention strategies are most needed at this time? Select all that apply.

-Ask the client about any physical injuries she may have. -Determine if any of her family are injured or missing. -Allow the client to talk about her fears, anger, and other feelings. -Assess her for risk of suicide and other signs of decompensation.

A 75-year-old female client was brought to the crisis center by their spouse. The spouse reports that the client has been in shock and anxious since their purse was stolen outside of their home. The client blames themself for being robbed, is worried about their stolen wallet and credit cards, and is afraid to go home. What nursing action(s) would be indicated? Select all that apply.

-Encourage the client to talk about the robbery and their feelings. -Discuss what changes at home would help them feel safe. -Investigate if the client has physical injuries from the robbery.

A spouse brings the client to the emergency department. The spouse reports that since the death of their 7-month-old daughter 8 weeks earlier, the client has been neglecting the housework and family, has lost 20 lb (9.1 kg), and has not left the house. Which additional assessment findings would indicate to the nurse that the client may be experiencing extreme depression? Select all that apply.

-obvious neglect of personal hygiene -speaking in soft monotone voice -inconsolable weeping

A nurse is teaching a client stress management. Which techniques would be considered adaptive coping skills? Select all that apply.

-set realistic goals for each day -practice relaxation techniques -balance sleep, rest, and exercise

A client with psychosis is prescribed quetiapine 400 mg by mouth daily in two divided doses. The pharmacy dispenses 200-mg tablets. How many tablets should the nurse administer with each dose? Record your answer using a whole number.

1

A client who comes to the emergency department with multiple bruises on the face and arms, a black eye, and a broken nose says that these injuries occurred when they fell down the stairs. The nurse suspects that the client may have been physically assaulted. What should the nurse do next?

Ask the client directly about the possibility of physical abuse.

A nurse working at an outpatient mental health center primarily with chronically mentally ill clients receives a telephone call from the parent of a client who lives at home. The parent reports that the client has not been taking their medication and now is refusing to go to the work center where she they have worked for the past year. What action should the nurse take first?

Ask to speak to the client directly on the phone.

When preparing to present a community program about women who are victims of physical abuse, the nurse should stress what information about the incidence of battering?

Battering is a major cause of injury to women.

A nurse assesses a client with psychotic symptoms and determines that the client likely poses a safety threat and needs vest restraints. The client is adamantly opposed to this. What would be the best nursing action?

Contact the physician and obtain necessary orders.

A 5-year-old child exhibits signs of extreme restlessness, short attention span, and impulsiveness. Which intervention by the nurse would be therapeutic for this child?

Define behaviors that are acceptable and behaviors that are not permitted.

A teenage client is a high school wrestler who fasts before every wrestling tournament and then binges immediately after the tournament. On the way to each tournament, the client walks rapidly up and down the bus aisle and spits repeatedly into a cup. Which is the best initial intervention for this client?

Discuss secondary gains that are unconsciously driving the client's behavior.

A nurse is explaining medication benefits and adverse effects to a client with a history of psychosis. The client's sibling states that explaining things to the client is a waste of the nurse's time. What information about informed consent should the nurse use to respond to the sibling's negative statement?

Informed consent is an important part of effective client care that helps accomplish treatment goals.

After 2 days on a psychiatric unit, a client is still isolating himself in his room, except for meals. The client says he is uncomfortable around crowds of people. Which nursing intervention is the most appropriate initially?

Invite the client to go for a walk with the nurse and one other client.

The nurse plans care for a client with schizophrenia who lacks the motivation to shower and dress. Which outcome should the nurse expect the client to achieve by the end of 4 days?

Perform showering and dressing.

A nurse is caring for a client who has been hospitalized with schizophrenia. The client has had this disorder for 8 years and is now displaying regression, increased disorganization and inappropriate social interactions. Which nursing intervention will best help this client meet self-care needs?

Provide client with assistance in hygiene, grooming, and dressing.

A nurse in a psychiatric care unit finds that a client with psychosis has become violent and has struck another client in the unit. What action should the nurse take in this case?

Restrain the client, as they are harmful to the other clients.

A client is complaining to other clients about not being allowed by staff to keep food in their room. What action should the nurse take?

Set limits on the behavior.

Assessment of a client who has just been admitted to the inpatient psychiatric unit reveals an unshaven face, noticeable body odor, visible spots on the shirt and pants, slow movements, gazing at the floor, and a flat affect. Which of the following should the nurse interpret as indicating psychomotor retardation?

Slow movements.

The client is suspicious of staff members and other clients. To help establish a therapeutic relationship with the client, which plan would be best?

Spend brief intervals with the client each day.

A psychiatric treatment team is planning care for a client who was involuntarily admitted for treatment of depression and suicide ideation. When planning the client's care, what legal parameters of care should the nurse be aware of?

The client is able to refuse medications.

Despite education and role-play practice of restraint procedures, a staff member is injured when actually restraining a client. When helping the other staff members deal with the incident, the nurse should address which factor?

The emotional responses may be similar to those of other crime victims.

A client receives the diagnosis they are HIV positive. Which reaction to the diagnosis would put the client in greatest need of intervention by the nurse?

a client who says, "I've found a solution for this mess"

An experienced nurse is precepting a new nurse in a psychiatric emergency room and is discussing criteria for involuntary commitment. Which client would signal to the experienced nurse that the new nurse understands the criteria?

a person who threatens to kill their spouse of 38 years

A nurse documents, "The client described the partner's abuse in an emotionless tone and with a flat facial expression." This statement describes the client's:

affect

A client is taking clozapine and complains of a sore throat. This symptom may be an indication of which adverse reaction?

agranulocytosis

The nurse is planning an education for new nurses on psychiatric units. Which topic should be given priority?

breach of confidentiality

At an emergency shelter, a client who has experienced an earthquake that damaged their home tells the nurse that they are going to spend the night in their own bed at home. Which defense mechanism is the client exhibiting?

denial

A client who has experienced the loss of their spouse through divorce, the loss of their job and apartment, and the development of drug dependency is experiencing situational low self-esteem. Which outcome is most appropriate initially?

discuss their feelings related to their losses.

A client changes topics quickly while relating past psychiatric history. This client's pattern of thinking is called:

flight of ideas.

A client exhibits psychomotor deficits, withdrawal, minimal eye contact, and unresponsiveness to the nurse's questions. Which outcome should the nurse include in the initial plan of care?

interact with the nurse.

A nurse is reviewing home medications for a client recently admitted to a long-term psychiatric unit. The charge nurse asks why this client has frequent blood draws over the next few weeks. The nurse would be correct to state which home medication dosages vary according to the blood levels of the drug?

lithium carbonate

A nurse is obtaining a history from a client. The client reports being a waiter. When asked about the work environment, the client says, "If customers confront me for not being attentive enough, I just spit on their food." The nurse suspects the client is prone to which type of behavior?

passive-aggressive

What client behaviors would be most important for the nurse to consider in deciding to institute suicide precautions because of high-risk behavior?

recently attempted suicide with a lethal method.

Nursing implications for a client taking central nervous system (CNS) stimulants include monitoring the client for which conditions?

tachycardia, weight loss, and mood swings

The terms "judgment" and "insight" are sometimes used incorrectly. Insight is the ability to:

understand the nature of one's problem or situation.

When a client expresses feelings of unworthiness, which response by the nurse would be most appropriate?

"As you begin to feel better, your feelings of unworthiness will begin to disappear."

A nurse is explaining electroconvulsive therapy (ECT) to members of a depression support group. Which statement would indicate understanding?

"ECT treatments are given for severe depression when other meds have failed."

A nurse is working with an adolescent who has reported low self-esteem. When developing a plan of care, the nurse considers the adolescent's psychosocial needs. Which question will best assist the nurse in assessing the adolescent's psychosocial development?

"How did you come to understand your feelings about yourself?"

In the process of dealing with the intense feelings about being raped, victims commonly verbalize that they were afraid they would be killed during the rape and wish that they had been. The nurse should decide that further counseling is needed if the client makes which statement?

"I get so angry at times that I have to have a couple of drinks before I sleep."

The nurse assesses the progress of a client who has behavioral manifestations of stress. Which client statement indicates that the client has gained insight into the use of the defense mechanism of displacement?

"Now when I am mad at my spouse, I talk to them instead of taking it out on the kids."

An emergency department nurse is conducting an assessment interview with an elderly client. The client states, "I was so frightened when I fell while crossing the street." Which statement would be the best response?

"That must have been frightening for you."

A client with substance abuse and bipolar disorder has recently stabilized after experiencing a crisis resulting from a psychotic episode. The client tells the nurse, "I want to live in the community again." What is most important for the nurse to communicate with the healthcare provider if advocating for the client's discharge into the community?

"There's extensive documentation to support the client's improved functioning level."

The nurse encourages client evaluation of their own behavior. Which probe should the nurse use?

"What did you do differently with your coworker this time?"

A client was experiencing marital discord with a spouse of 4 years. When the spouse walked out, the client became angry and began to throw things and break dishes. A friend talked the client into seeking help at the local mental health center. Which of these questions should the nurse ask initially to begin to assess this client's immediate problem?

"What led you to come in for help today?"

A client in an acute care center lacerates the wrists. The client has a history of conflicts and acting out and asks the nurse, "I did a good job, didn't I?" Which response by the nurse is best?

"What were you feeling before you hurt yourself?"

A client with bipolar disorder is taking lithium carbonate 300 mg t.i.d. The client's lithium level is 2.7 mEq/L. In assessing the client, the nurse finds no evidence of lithium toxicity. The first assessment question the nurse should ask before ordering another blood test is:

"When did you take your last dose of lithium?"

A client tells the nurse at the outpatient clinic that they do not need to attend groups because they are "not a regular like these other people here." How should the nurse respond to the client?

"You say you're not a regular here, but you're experiencing what others are experiencing."

A nurse is leading a group on medication management. One of the group members is beginning to monopolize the session, talking about experiences with medications. Which statement by the nurse would be best?

"You're doing well in contributing to the group, but I'd like to hear what others are thinking."

A client who is dying from AIDS is admitted to the inpatient psychiatric unit because they attempted suicide. Their close friend recently died from AIDS. The client states to the nurse, "What's the use of living? My time's running out." What is the nurse's best response?

"You're in a lot of pain. What are you feeling?"

A client is admitted to the psychiatric unit following a suicide attempt. The client experienced identity theft through the internet and states, "My savings, checking, and retirement accounts are empty. I have nothing left to pay my bills or buy food and medicines. The only thing left is to die." After 1 week, the nurse would conclude that the client's condition has improved upon hearing which statement(s)? Select all that apply.

-"I realize that I still can get monthly public assistance benefits." -"I filed identity theft claims with the bank, my retirement account, and the government authorities." -"With all the help I got here, I think I may be able to survive after all."

The stigma related to having a mental illness, especially a chronic illness, persists despite improvements in the management of illnesses and an increase in public education. Which view most perpetuates the stigma?

Clients can recover from mental illness if they have willpower.

A client is escorted to the psychiatric unit from the emergency department (ED) by staff and a security officer. The client's shoulder is bandaged, and their arm is in a sling because of a self-inflicted gunshot wound to the shoulder. Later, the client's spouse follows with a bag of the client's belongings. Which nursing action is most appropriate at this time?

Inspect the bag and its contents in the presence of the client and spouse.

The nurse notes that a client is too busy investigating the unit and overseeing the activities of other clients to eat dinner. To help the client obtain sufficient nourishment, which plan would be best?

Serve foods that the client can carry with them.

A nurse is evaluating a family in which chronic child abuse has occurred and the parents have experienced chronic alcohol and drug abuse. Significant social supports have been established by social services and the parents have both received drug and alcohol treatment and parenting classes. Which indicates that the parents have progressed in their treatment??

The parents report an understanding of normal growth and development.

Two days after a client's spouse and child were found dead in a flood, the client returns to the crisis center and says they think it would be better to "end it all right now and join my spouse and kid, wherever they are." The nurse has already determined that the client has no history of psychiatric problems. What should the nurse consider this client's risk for suicide to be?

The risk is high; the client's suicide threat can be considered a call for help and should be taken seriously.

A client with a diagnosis of bipolar disorder is energetic, impulsive, and verbalizing loudly in the community room. To prevent injury while complying with the principle of the least-restrictive environment, which action should the nurse take to prevent escalation of the client's mood?

Try to channel the client's energy into appropriate activities.

During the mental status examination, a client may be asked to explain such proverbs as "Don't cry over spilled milk." The purpose of this is to evaluate the client's ability to think:

abstractly

One of the myths about sexual abuse of young children is that it usually involves physically violent acts. Which behavior is more likely to be used by the abusers?

coercion as a result of the trusting relationship

Which approach by the nurse would most likely foster a therapeutic relationship with a client who tries to manipulate people?

consistency

A client with antisocial personality disorder smokes in prohibited areas and refuses to follow other unit and facility rules. The client persuades others to do the client's laundry and other personal chores, splits the staff, and will work only with certain nurses. The care plan for this client should focus primarily on:

consistently enforcing unit rules and facility policy.

A client in an acute care mental health program refuses a morning dose of an oral antipsychotic medication and believes it contains poison. The nurse should respond by taking which action?

consulting with the physician about a care plan.

The nurse is helping a client deal with personal issues and painful feelings. What does the nurse identify as a crucial goal of therapeutic communication?

conveying client respect and acceptance even if not all of the client's behaviors are tolerated

The nurse teaches a group of unlicensed assistive personnel (UAP) about providing care to clients with depression. Which approach by one of the UAPs indicates an understanding of the most effective approach to a depressed client?

empathetic

A client is transferred from the emergency department to the locked psychiatric unit after attempting suicide by taking 200 acetaminophen tablets. The client is now awake and alert but refuses to speak with the nurse. In this situation, the nurse's first priority is to:

ensure safety by initiating suicide precautions.

An older adult client was prescribed lorazepam 1 mg three times a day to help calm anxiety after their spouse's death. The next day, the client calls their adult child asking when they are to be picked up to go to the graveside. The client says they have been walking up and down the driveway for the past hour waiting for their child. Noting the client's agitation, hyperactivity, and insistence, the adult child calls the nurse to report their parent's behavior. Which finding would the nurse suspect as the cause of the client's behavior, and what action would the nurse suggest?

experiencing a paradoxical reaction to the lorazepam and should stop the new medication immediately.

The nurse develops the plan of care for a client with acute stress disorder who lost their sibling in a boating accident. Which intervention should the nurse initiate?

facilitating a progressive review of the accident and its consequences

An adolescent is brought to the hospital emergency department in a state of unconsciousness after having swallowed "a bottle of pain pills" 45 minutes earlier. The pills are identified as oxycodone. A suicide note is found that asks for forgiveness. Which measure should the nurse be prepared to carry out when this client is admitted?

giving naloxone IV

When planning the care of a client experiencing aggression, the nurse incorporates the principle of "least restrictive alternative," meaning that less restrictive interventions must be tried before more restrictive measures are employed. Which measure should the nurse consider to be the most restrictive?

haloperidol given intramuscularly

The nurse plans care for a client who is being abused. Which measure is most important to include?

helping the client develop a safety plan

A client with a chronic mental illness who does not always take their medications is separated from their spouse and receives public assistance funds. The client lives with their parent and older sibling and manages their own medication. The client's parent is in poor health and also receives public assistance benefits. The client's sibling works outside the home, and the client's other parent is dead. Which issue should the nurse address first?

medication compliance

A client who has lost control has been put into restraints. Which nursing intervention is the highest priority when a client is placed in restraints?

monitoring the client every 15 minutes

The nurse assesses an aggressive client. Which behavior warrants the nurse's prompt reporting and use of safety precautions?

naming another client as their adversary

A married female client has been referred to the mental health center because they are depressed. The nurse notices bruises on their upper arms and asks about them. After denying any problems, the client starts to cry and says, "My spouse did not really mean to hurt me, but I hate for the kids to see this. I am so worried about them." What is the most crucial information for the nurse to determine?

potential of immediate danger to the client and their children

The nurse is performing an assessment on a client after the client's third electroconvulsive therapy (ECT). Which finding should the nurse anticipate most frequently?

short-term memory loss

Assertive behavior involves:

standing up for one's rights while respecting the rights of others.

A client is using biofeedback to manage pain. The nurse can explain to the client that biofeedback will enable the client to exert control over physiologic processes by which mechanism?

translating the signals of body processes into observable forms

A client has a history of violence toward others and an inability to cope with anger. What should the nurse use as the most important indicator of goal achievement before discharge?

verbalization of feelings in an appropriate manner