Test 4

After formulating the nursing diagnoses for a new patient, what is the next action a nurse should take? a. Design interventions to include in the plan of care. b. Determine the goals and outcome criteria. c. Implement the nursing plan of care. d. Complete the spiritual assessment.

b. Determine the goals and outcome criteria.

The acronym QSEN refers to: a. Qualitative Standardized Excellence in Nursing. b. Quality and Safety Education for Nurses. c. Quantitative Effectiveness in Nursing. d. Quick Standards Essential for Nurses.

b. Quality and Safety Education for Nurses.

Which statement shows a nurse has empathy for a patient who made a suicide attempt? a. "You must have been very upset when you tried to hurt yourself." b. "It makes me sad to see you going through such a difficult experience." c. "If you tell me what is troubling you, I can help you solve your problems." d. "Suicide is a drastic solution to a problem that may not be such a serious matter."

A - "you must have been very upset when you tried to hurt yourself."

What information is conveyed by nursing diagnoses? Select all that apply. a. Medical judgments about the disorder b. Goals and outcomes for the plan of care c. Unmet patient needs currently present d. Supporting data that validate the diagnoses e. Probable causes that will be targets for nursing interventions

c, d, e

A newly admitted patient who is acutely psychotic is a private patient of the senior psychiatrist. To whom does the psychiatric nurse who is assigned to this patient owe the duty of care? a. Health care provider b. Profession c. Hospital d. Patient

d. Patient

A patient says, "I've done a lot of cheating and manipulating in my relationships." Select a nonjudgmental response by the nurse. a. "How do you feel about that?" b. "It's good that you realize this." c. "That's not a good way to behave." d. "Have you outgrown that type of behavior?"

A - "How do you feel about that?"

A patient says, "Please don't share information about me with the other people." How should the nurse respond? a. "I won't share information with others without your permission, but I will share information about you with other staff members." b. "A therapeutic relationship is just between the nurse and the patient. It's up to you to tell others what you want them to know." c. "It really depends on what you choose to tell me. I will be glad to disclose at the end of each session what I will report to others." d. "I cannot tell anyone about you. It will be as though I am talking about my own problems, and we can help each other by keeping it between us."

A - "I won't share information with others without your permission, but I will share information about you with other staff members."

A nurse explains to the family of a patient who is mentally ill how the nurse-patient relationship differs from social relationships. Which is the best explanation? a. "The focus is on the patient. Problems are discussed by the nurse and patient, but solutions are implemented by the patient." b. "The focus shifts from nurse to patient as the relationship develops. Advice is given by both, and solutions are implemented." c. "The focus of the relationship is socialization. Mutual needs are met, and feelings are openly shared." d. "The focus is the creation of a partnership in which each member is concerned with the growth and satisfaction of the other."

A - "The focus is on the patient. Problems are discussed by the nurse and patient, but solutions are implemented by the patient."

A nurse ends a relationship with a patient. Which actions by the nurse should be included in the termination phase? Select all that apply. a. Focus dialog with the patient on problems that may occur in the future. b. Help the patient express feelings about the relationship with the nurse. c. Help the patient prioritize and modify socially unacceptable behaviors. d. Reinforce expectations regarding the parameters of the relationship. e. Help the patient identify strengths, limitations, and problems.

A - Focus dialog with the patient on problems that may occur in the future. B - Help the patient express feelings about the relationship with the nurse.

Which descriptors exemplify consistency regarding therapeutic nurse-patient relationships? Select all that apply. a. Having the same nurse care for a patient on a daily basis b. Encouraging a patient to share initial impressions of staff c. Providing a schedule of daily activities to a patient d. Setting a time for regular sessions with a patient e. Offering solutions to a patient's problems

A - Having the same nurse care for a patient on a daily basis C - Providing a schedule of daily activities to a patient D - Setting a time for regular sessions with a patient

As a nurse discharges a patient, the patient gives the nurse a card of appreciation made in an arts and crafts group. What is the nurse's best action? a. Recognize the effectiveness of the relationship and patient's thoughtfulness. Accept the card. b. Inform the patient that accepting gifts violates the policies of the facility. Decline the card. c. Acknowledge the patient's transition through the termination phase but decline the card. d. Accept the card and invite the patient to return to participate in other arts and crafts groups.

A - Recognize the effectiveness of the relationship and patient's thoughtfulness. Accept the card.

A new psychiatric nurse has a parent diagnosed with bipolar disorder. This nurse angrily recalls embarrassing events concerning the parent's behavior in the community. Select the best ways for this nurse to cope with these feelings. Select all that apply. a. Seek ways to use the understanding gained from childhood to help patients cope with their own illnesses. b. Recognize that these feelings are unhealthy, and try to suppress them when working with patients. c. Recognize that psychiatric nursing is not an appropriate career choice, and explore other nursing specialties. d. Begin new patient relationships by saying, "My own parent had mental illness, so I accept it without stigma." e. Recognize that the feelings may add sensitivity to the nurse's practice, but supervision is important.

A - Seek ways to use the understanding gained from childhood to help patients cope with their own illnesses. E - Recognize that the feelings may add sensitivity to the nurse's practice, but supervision is important.

A community mental health nurse has worked with a patient for 3 years but is moving out of the city and terminates the relationship. A new nurse who begins work with this patient will: a. begin at the orientation phase. b. resume the working relationship. c. enter into a social relationship. d. return to the emotional catharsis phase.

A - begin at the orientation phase

A nurse says, "I am the only one who truly understands this patient. Other staff members are too critical." The nurse's statement indicates: a. boundary blurring. b. sexual harassment. c. positive regard. d. advocacy.

A - boundary blurring

At what point in the nurse-patient relationship should a nurse plan to first address termination? a. In the orientation phase b. During the working phase c. In the termination phase d. When the patient initially brings up the topic

A - in the orientation phase

11. A Mexican-American patient puts a picture of the Virgin Mary on the bedside table. Under which section of the assessment should the nurse document this behavior? a. Culture b. Ethnicity c. Verbal communication d. Nonverbal communication

ANS: A Cultural heritage is expressed through language, works of art, music, dance, ethnic clothing, customs, traditions, diet, and expressions of spirituality. This patient's prominent placement of the picture is an example of expression of cultural heritage.

9. While talking with a patient with severe depression, a nurse notices the patient is unable to maintain eye contact. The patient's chin lowers to the chest while the patient looks at the floor. Which aspect of communication has the nurse assessed? a. Nonverbal communication b. A message filter c. A cultural barrier d. Social skills

ANS: A Eye contact and body movements are considered nonverbal communication. Insufficient data are available to determine the level of the patient's social skills or whether a cultural barrier exists.

18. A patient is having difficulty making a decision. The nurse has mixed feelings about whether to provide advice. Which principle usually applies? Giving advice: a. Is rarely helpful. b. Fosters independence. c. Lifts the burden of personal decision making. d. Helps the patient develop feelings of personal adequacy.

ANS: A Giving advice fosters dependence on the nurse and interferes with the patient's right to make personal decisions. Giving advice also robs patients of the opportunity to weigh alternatives and to develop problem-solving skills. Furthermore, it contributes to patient feelings of personal inadequacy. It also keeps the nurse in control and feeling powerful.

5. Which technique will best communicate to a patient that the nurse is interested in listening? a. Restate a feeling or thought the patient has expressed. b. Ask a direct question, such as "Did you feel angry?" c. Make a judgment about the patient's problem. d. Say, "I understand what you're saying."

ANS: A Restating allows the patient to validate the nurse's understanding of what has been communicated. Restating is an active listening technique. Judgments should be suspended in a nurse-patient relationship. Closed-ended questions such as, "Did you feel angry?" ask for specific information rather than show understanding. When the nurse simply states that he or she understands the patient's words, the patient has no way of measuring the understanding.

14. When a female Mexican-American patient and a female nurse sit together, the patient often holds the nurse's hand. The patient also links arm and arm with the nurse when they walk. The nurse is uncomfortable with this behavior and thinks the patient is homosexual. Which alternative is a more accurate assessment? a. The patient is accustomed to touch during conversations, as are members of many Hispanic subcultures. b. The patient understands that touch makes the nurse uncomfortable and controls the relationship based on that factor. c. The patient is afraid of being alone. When touching the nurse, the patient is reassured and comforted. d. The nurse is homophobic.

ANS: A The most likely answer is that the patient's behavior is culturally influenced. Hispanic women frequently touch women they consider to be their friends. Although the other options are possible, they are less likely.

2. Which benefits are most associated with the use of telehealth? Select all that apply. a. Cost savings for patients b. Maximization of care management c. Access to services for patients in rural areas d. Prompt reimbursement by third-party payers e. Rapid development of trusting relationships with patients

ANS: A, B, C Use of telehealth technologies has shown that it can maximize health and improve disease management skills and confidence with the disease process. Many rural patients have felt disconnected from services; telehealth technologies can solve these problems. Although telehealth's improved health outcomes regularly show cost savings for payers, one significant barrier is the current lack of reimbursement for remote patient monitoring by third-party payers. Telehealth is not associated with rapid development of trusting relationships.

12. An African-American patient says to a Caucasian nurse, "There's no sense talking. You wouldn't understand because you live in a white world." The nurse's best action would be to: a. explain, "Yes, I do understand. Everyone goes through the same experiences." b. say, "Please give an example of something you think I wouldn't understand." c. reassure the patient that nurses are in contact with people from all cultures. d. change the subject to one that is less emotionally disturbing.

ANS: B Having the patient speak in specifics rather than globally helps the nurse understand the patient's perspective. This approach helps the nurse engage the patient.

2. A patient with paranoid schizophrenia tells the nurse, "The CIA is monitoring us through the fluorescent lights in this room. Be careful what you say." Which response by the nurse would be most therapeutic? a. "Let's talk about something other than the CIA." b. "It sounds like you're concerned about your privacy." c. "The CIA is prohibited from operating in health care facilities." d. "You have lost touch with reality, which is a symptom of your illness."

ANS: B It is important not to challenge the patient's beliefs, even if they are unrealistic. Challenging undermines the patient's trust in the nurse. The nurse should try to understand the underlying feelings or thoughts the patient's message conveys. The correct response uses the therapeutic technique of reflection. The other comments are nontherapeutic. Asking to talk about something other than the concern at hand is changing the subject. Saying that the CIA is prohibited from operating in health care facilities gives false reassurance. Stating that the patient has lost touch with reality is truthful but uncompassionate.

3. The patient says, "My marriage is just great. My spouse and I usually agree on everything." The nurse observes the patient's foot moving continuously as the patient twirls a shirt button. What conclusion can the nurse draw? The patient's communication is: a. clear. b. mixed. c. precise. d. inadequate.

ANS: B Mixed messages involve the transmission of conflicting or incongruent messages by the speaker. The patient's verbal message that all is well in the relationship is modified by the nonverbal behaviors denoting anxiety. Data are not present to support the choice of the verbal message being clear, explicit, or inadequate.

20. A patient with acute depression states, "God is punishing me for my past sins." What is the nurse's best response? a. "Why do you think that?" b. "You sound very upset about this." c. "You believe God is punishing you for your sins?" d. "If you feel this way, you should talk to a member of your clergy."

ANS: B The nurse reflects on the patient's comment, a therapeutic technique to encourage sharing for perceptions and feelings. The incorrect responses reflect probing, closed-ended comments, and giving advice, all of which are nontherapeutic.

10. During the first interview with a parent whose child died in a car accident, the nurse feels empathic and reaches out to take the patient's hand. Select the correct analysis of the nurse's behavior. a. It shows empathy and compassion. It will encourage the patient to continue to express feelings. b. The gesture is premature. The patient's cultural and individual interpretation of touch is unknown. c. The patient will perceive the gesture as intrusive and overstepping boundaries. d. The action is inappropriate. Patients in a psychiatric setting should not be touched.

ANS: B Touch has various cultural and individual interpretations. Nurses should refrain from using touch until an assessment can be made regarding the way in which the patient will perceive touch. The other options present prematurely drawn conclusions.

19. The relationship between a nurse and patient as it relates to status and power is best described by which term? a. Symmetric b. Complementary c. Incongruent d. Paralinguistic

ANS: B When a difference in power exists, as between a student and teacher or between a nurse and patient, the relationship is said to be complementary. Symmetrical relationships exist between individuals of like or equal status. Incongruent and paralinguistic are not terms used to describe relationships.

1. A patient cries as the nurse explores the patient's relationship with a deceased parent. The patient says, "I shouldn't be crying like this. It happened a long time ago." Which responses by the nurse will facilitate communication? Select all that apply. a. "Why do you think you are so upset?" b. "I can see that you feel sad about this situation." c. "The loss of your parent is very painful for you." d. "Crying is a way of expressing the hurt you're experiencing." e. "Let's talk about something else because this subject is upsetting you.

ANS: B, C, D Reflecting ("I can see that you feel sad" or "This is very painful for you") and giving information ("Crying is a way of expressing hurt") are therapeutic techniques. "Why" questions often imply criticism or seem intrusive or judgmental, and they are difficult to answer. Changing the subject is a barrier to communication.

6. A patient discloses several concerns and associated feelings. If the nurse wants to seek clarification, which comment would be appropriate? a. "What are the common elements here?" b. "Tell me again about your experiences." c. "Am I correct in understanding that...?" d. "Tell me everything from the beginning."

ANS: C Asking, "Am I correct in understanding that...?" permits clarification to ensure that both the nurse and patient share mutual understanding of the communication. Asking about common elements encourages comparison rather than clarification. The remaining responses are implied questions that suggest the nurse was not listening.

7. A patient tells the nurse, "I don't think I'll ever get out of here." Select the nurse's most therapeutic response. a. "Don't talk that way. Of course you will leave here!" b. "Keep up the good work and you certainly will." c. "You don't think you're making progress?" d. "Everyone feels that way sometimes."

ANS: C By asking if the patient does not believe that progress has been made, the nurse is reflecting by putting into words what the patient is hinting. By making communication more explicit, issues are easier to identify and resolve. The remaining options are nontherapeutic techniques. Telling the patient not to "talk that way" is disapproving. Saying that everyone feels that way at times minimizes feelings. Telling the patient that good work will always result in success is falsely reassuring.

A nurse wants to enhance the growth of a patient by showing positive regard. The action consistent with this wish is: a. making rounds daily. b. staying with a tearful patient. c. administering daily medication as prescribed. d. examining personal feelings about a patient.

B - staying with a tearful patient

17. Which principle should guide the nurse in determining the extent of silence to use during patient interview sessions? a. Nurses are responsible for breaking silences. b. Patients withdraw if silences are prolonged. c. Silence provides meaningful moments for reflection. d. Silence helps patients know that what they have said is understood.

ANS: C Silence can be helpful to both participants by giving each an opportunity to contemplate what has transpired, weigh alternatives, and formulate ideas. A nurse breaking silences is not a principle related to silences. Saying that patients withdraw during long silences or that silence helps patients know that they are understood are both inaccurate statements. Feedback helps patients know they have been understood.

8. Documentation in a patient's chart shows, "Throughout a 5-minute interaction, patient fidgeted and tapped left foot, periodically covered face with hands, and looked under chair while stating, 'I enjoy spending time with you.'" Which analysis is most accurate? a. Patient is giving positive feedback about the nurse's communication techniques. b. Nurse is viewing the patient's behavior through a cultural filter. c. Patient's verbal and nonverbal messages are incongruent. d. Patient is demonstrating psychotic behaviors.

ANS: C When a verbal message is not reinforced with nonverbal behavior, the message is confusing and incongruent. Some clinicians call it a "mixed message." It is inaccurate to say that the patient is giving positive feedback about the nurse's communication techniques. The concept of a cultural filter is not relevant to the situation; a cultural filter determines what a person will pay attention to and what he or she will ignore. Data are insufficient to draw the conclusion that the patient is demonstrating psychotic behaviors.

A nurse wants to demonstrate genuineness with a patient diagnosed with schizophrenia. The nurse should: a. restate what the patient says. b. use congruent communication strategies. c. use self-disclosure in patient interactions. d. consistently interpret the patient's behaviors.

B - use congruent communication strategies

4. A nurse interacts with a newly hospitalized patient. Select the nurse's comment that applies the communication technique of "offering self." a. "I've also had traumatic life experiences. Maybe it would help if I told you about them." b. "Why do you think you had so much difficulty adjusting to this change in your life?" c. "I hope you will feel better after getting accustomed to how this unit operates." d. "I'd like to sit with you for a while to help you get comfortable talking to me."

ANS: D "Offering self" is a technique that should be used in the orientation phase of the nurse-patient relationship. Sitting with the patient, an example of "offering self," helps build trust and conveys that the nurse cares about the patient. Two incorrect responses are ineffective and nontherapeutic. The other incorrect response is therapeutic but an example of "offering hope."

15. A Puerto Rican-American patient uses dramatic body language when describing emotional discomfort. Which analysis most likely explains the patient's behavior? The patient: a. Has a histrionic personality disorder. b. Believes dramatic body language is sexually appealing. c. Wishes to impress staff with the degree of emotional pain. d. Belongs to a culture in which dramatic body language is the norm.

ANS: D Members of Hispanic-American subcultures tend to use high affect and dramatic body language as they communicate. The other options are more remote possibilities.

13. A Filipino-American patient had this nursing diagnosis: Situational low self-esteem, related to poor social skills as evidenced by lack of eye contact. Interventions were used to raise the patient's self-esteem; however, after 3 weeks, the patient's eye contact did not improve. What is the most accurate analysis of this scenario? a. The patient's eye contact should have been directly addressed by role-playing to increase comfort with eye contact. b. The nurse should not have independently embarked on assessment, diagnosis, and planning for this patient. c. The patient's poor eye contact is indicative of anger and hostility that remain unaddressed. d. The nurse should have assessed the patient's culture before making this diagnosis and plan.

ANS: D The amount of eye contact in which a person engages is often culturally determined. In some cultures, eye contact is considered insolent, whereas in other cultures, eye contact is expected. Asian Americans, including persons from the Philippines, often prefer not to engage in direct eye contact.

1. A patient says to the nurse, "I dreamed I was stoned. When I woke up, I felt emotionally drained, as though I hadn't rested well." Which comment would be appropriate if the nurse seeks clarification? a. "It sounds as though you were uncomfortable with the content of your dream." b. "I understand what you're saying. Bad dreams leave me feeling tired, too." c. "So, all in all, you feel as though you had a rather poor night's sleep?" d. "Can you give me an example of what you mean by 'stoned'?"

ANS: D The technique of clarification is therapeutic and helps the nurse examine the meaning of the patient's statement. Asking for a definition of "stoned" directly asks for clarification. Restating that the patient is uncomfortable with the dream's content is parroting, a nontherapeutic technique. The other responses fail to clarify the meaning of the patient's comment.

16. During an interview, a patient attempts to shift the focus from self to the nurse by asking personal questions. The nurse should respond by saying: a. "You've turned the tables on me." b. "Nurses direct the interviews with patients." c. "Do not ask questions about my personal life." d. "The time we spend together is to discuss your concerns."

ANS: D When a patient tries to focus on the nurse, the nurse should refocus the discussion back onto the patient. Telling the patient that interview time should be used to discuss patient concerns refocuses discussion in a neutral way. Telling patients not to ask about the nurse's personal life shows indignation. Saying that nurses prefer to direct the interview reflects superiority. Saying "You've turned the tables on me" states the fact but does not refocus the interview.

A new nurse tells a mentor, "I want to convey to my patients that I am interested in them and that I want to listen to what they have to say." Which behaviors are helpful in meeting the nurse's goal? Select all that apply. a. Sitting behind a desk, facing the patient. b. Introducing self to a patient and identifying own role. c. Using facial expressions that convey interest and encouragement. d. Assuming an open body posture and sometimes mirror imaging. e. Maintaining control of the topic under discussion by asking direct questions.

B - Introducing self to a patient and identifying own role. C - Using facial expressions that convey interest and encouragement. D - Assuming an open body posture and sometimes mirror imaging.

As a patient diagnosed with mental illness is being discharged from a facility, a nurse invites the patient to the annual staff picnic. What is the best analysis of this scenario? a. The invitation facilitates dependency on the nurse. b. The nurse's action blurs the boundaries of the therapeutic relationship. c. The invitation is therapeutic for the patient's diversional activity deficit. d. The nurse's action assists the patient's integration into community living.

B - The nurse's action blurs the boundaries of the therapeutic relationship.

A nurse assesses a confused older adult. The nurse experiences sadness and reflects, "The patient is like one of my grandparents . . . so helpless." What feelings does the nurse describe? a. Transference b. Countertransference c. Catastrophic reaction d. Defensive coping reaction

B - countertransference

What is the desirable outcome for the orientation stage of a nurse-patient relationship? The patient will demonstrate behaviors that indicate: a. great sense of independence. b. rapport and trust with the nurse. c. self-responsibility and autonomy. d. resolution of feelings of transference.

B - rapport and trust with the nurse

A nurse should introduce the matter of a contract during the first session with a new patient because contracts: a. specify what the nurse will do for the patient. b. spell out the participation and responsibilities of each party. c. indicate the feeling tone established between the participants. d. are binding and prevent either party from prematurely ending the relationship.

B - spell out the participation and responsibilities of each party.

As a nurse escorts a patient being discharged after treatment for major depressive disorder, the patient gives the nurse a gold necklace with a heart pendant and says, "Thank you for helping mend my broken heart." Which is the nurse's best response? a. "Accepting gifts violates the policies and procedures of the facility." b. "I'm glad you feel so much better now. Thank you for the beautiful necklace." c. "I'm glad I could help you, but I can't accept the gift. My reward is seeing you with a renewed sense of hope." d. "Helping people is what nursing is all about. It's rewarding to me when patients recognize how hard we work."

C - "I'm glad I could help you, but I can't accept the gift. My reward is seeing you with a renewed sense of hope."

A patient says, "I'm still on restriction, but I want to attend some off-unit activities. Would you ask the doctor to change my privileges?" What is the nurse's best response? a. "Why are you asking me when you're able to speak for yourself?" b. "I will be glad to address it when I see your doctor later today." c. "That's a good topic for you to take up with your doctor." d. "Do you think you can't speak to a doctor?"

C - "That's a good topic for you to take up with your doctor."

Which issues should a nurse address during the first interview with a patient diagnosed with a psychiatric disorder? a. Trust, congruence, attitudes, and boundaries b. Goals, resistance, unconscious motivations, and diversion c. Relationship parameters, the contract, confidentiality, and termination d. Transference, countertransference, intimacy, and developing resources

C - Relationship parameters, the contract, confidentiality, and termination

Termination of a therapeutic nurse-patient relationship with a patient has been successful when the nurse: a. avoids upsetting the patient by shifting focus to other patients before the discharge. b. gives the patient a personal telephone number and permission to call after discharge. c. discusses with the patient changes that have happened during the relationship and evaluates the outcomes. d. offers to meet the patient for coffee and conversation three times a week after discharge.

C - discusses with the patient changes that have happened during the relationship and evaluates the outcomes.

After several therapeutic encounters with a patient who recently attempted suicide, which occurrence should cause the nurse to consider the possibility of countertransference? a. The patient's reactions toward the nurse seem realistic and appropriate. b. The patient states, "Talking to you feels like talking to my parents." c. The nurse feels unusually happy when the patient's mood begins to lift. d. The nurse develops a trusting relationship with the patient.

C - the nurse feels unusually happy when the patient's mood begins to lift

During which phase of the nurse-patient relationship can the nurse anticipate that identified patient issues will be explored and resolved? a. Preorientation b. Orientation c. Working d. Termination

C - working

Which remark by a patient indicates passage from the orientation phase to the working phase of a nurse-patient relationship? a. "I don't have any problems." b. "It is so difficult for me to talk about my problems." c. "I don't know how talking about things twice a week can help." d. "I want to find a way to deal with my anger without becoming violent."

D - "I want to find a way to deal with my anger without becoming violent."

A patient says, "People should be allowed to commit suicide without interference from others." A nurse replies, "You're wrong. Nothing is bad enough to justify death." What is the best analysis of this interchange? a. The patient is correct. b. The nurse is correct. c. Neither person is totally correct. d. Differing values are reflected in the two statements.

D - Differing values are reflected in the two statements.

A nurse caring for a withdrawn, suspicious patient recognizes the development of feelings of anger toward the patient. The nurse should: a. suppress the angry feelings. b. express the anger openly and directly with the patient. c. tell the nurse manager to assign the patient to another nurse. d. discuss the anger with a clinician during a supervisory session.

D - discuss the anger with a clinician during a supervisory session.

Which behavior shows that a nurse values autonomy? The nurse: a. sets limits on a patient's romantic overtures toward the nurse. b. suggests one-on-one supervision for a patient who is suicidal. c. informs a patient that the spouse will not be in during visiting hours. d. discusses available alternatives and helps the patient weigh the consequences.

D - discusses available alternatives and helps the patient weigh the consequences.

During the first interview, a nurse notices that the patient does not make eye contact. The nurse can correctly analyze that: a. the patient is not truthful. b. the patient is feeling sad. c. the patient has a poor self-concept. d. more information is needed to draw a conclusion.

D - more information is needed to draw a conclusion.

A nurse is talking with a patient, and 5 minutes remain in the session. The patient has been silent for most of the session. Another patient comes to the door of the room, interrupts, and says to the nurse, "I really need to talk to you right now." The nurse should: a. say to the interrupting patient, "I am not available to talk with you at the present time." b. end the unproductive session with the current patient and spend time with the patient who has just interrupted. c. invite the interrupting patient to join in the session with the current patient. d. tell the patient who interrupted, "This session is 5 more minutes; then, I will talk with you."

D - tell the patient who interrupted, "This session is 5 more minutes; then, I will talk with you."

Before assessing a new patient, a nurse is told by another health care worker, "I know that patient. No matter how hard we work, there isn't much improvement by the time of discharge." The nurse's responsibility is to: a. document the other worker's assessment of the patient. b. assess the patient based on data collected from all sources. c. validate the worker's impression by contacting the patient's significant other. d. discuss the worker's impression with the patient during the assessment interview.

b. assess the patient based on data collected from all sources.

A patient with paranoid schizophrenia believes evil spirits are being summoned by a local minister and verbally threatens to bomb a local church. The psychiatrist notifies the minister. The psychiatrist has: a. released information without proper authorization. b. demonstrated the duty to warn and protect. c. violated the patient's confidentiality. d. avoided charges of malpractice.

b. demonstrated the duty to warn and protect.

A nurse performing an assessment interview for a patient with a substance use disorder decides to use a standardized rating scale. Which scales are appropriate? Select all that apply. a. Addiction Severity Index (ASI) b. Brief Drug Abuse Screen Test (B-DAST) c. Abnormal Involuntary Movement Scale (AIMS) d. Cognitive Capacity Screening Examination (CCSE) e. Recovery Attitude and Treatment Evaluator (RAATE)

a, b, e

When a nurse assesses an older adult patient, answers seem vague or unrelated to the questions. The patient also leans forward and frowns, listening intently to the nurse. An appropriate question for the nurse to ask would be: a. "Are you having difficulty hearing when I speak?" b. "How can I make this assessment interview easier for you?" c. "I notice you are frowning. Are you feeling annoyed with me?" d. "You're having trouble focusing on what I'm saying. What is distracting you?"

a. "Are you having difficulty hearing when I speak?"

The family of a patient whose insurance will not pay for continuing hospitalization considers transferring the patient to a public psychiatric hospital. The family expresses concern that the patient will "never get any treatment." Which reply by the nurse would be most helpful? a. "Under the law, treatment must be provided. Hospitalization without treatment violates patients' rights." b. "That's a justifiable concern because the right to treatment extends only to the provision of food, shelter, and safety." c. "Much will depend on other patients because the right to treatment for a psychotic patient takes precedence over the right to treatment of a patient who is stable." d. "All patients in public hospitals have the right to choose both a primary therapist and a primary nurse."

a. "Under the law, treatment must be provided. Hospitalization without treatment violates patients' rights."

Which action by a psychiatric nurse best supports patients' rights to be treated with dignity and respect? a. Consistently addressing each patient by title and surname. b. Strongly encouraging a patient to participate in the unit milieu. c. Discussing a patient's condition with another health care provider in the elevator. d. Informing a treatment team that a patient is too drowsy to participate in care planning.

a. Consistently addressing each patient by title and surname.

A nurse assesses an older adult patient brought to the emergency department by a family member. The patient was wandering outside, saying, "I can't find my way home." The patient is confused and unable to answer questions. Select the nurse's best action. a. Document the patient's mental status. Obtain other assessment data from the family member. b. Record the patient's answers to questions on the nursing assessment form. c. Ask an advanced practice nurse to perform the assessment interview. d. Call for a mental health advocate to maintain the patient's rights.

a. Document the patient's mental status. Obtain other assessment data from the family member.

A patient with major depression has lost 20 pounds in one month has chronic low self-esteem and a plan for suicide. The patient has taken an antidepressant medication for 1 week. Which nursing intervention is most directly related to this outcome: "Patient will refrain from gestures and attempts to harm self"? a. Implement suicide precautions. b. Frequently offer high-calorie snacks and fluids. c. Assist the patient to identify three personal strengths. d. Observe patient for therapeutic effects of antidepressant medication.

a. Implement suicide precautions.

A nurse at the mental health center prepares to administer a scheduled injection of haloperidol decanoate (Haldol depot injection) to a patient with schizophrenia. As the nurse swabs the site, the patient shouts, "Stop, stop! I don't want to take that medicine anymore. I hate the side effects." Select the nurse's best initial action. a. Stop the medication administration procedure and say to the patient, "Tell me more about the side effects you've been having." b. Say to the patient, "Since I've already drawn the medication in the syringe, I'm required to give it, but let's talk to the doctor about skipping next month's dose." c. Proceed with the injection but explain to the patient that other medications are available that may help reduce the unpleasant side effects. d. Notify other staff members to report to the room for a show of force and proceed with the injection, using restraint if necessary.

a. Stop the medication administration procedure and say to the patient, "Tell me more about the side effects you've been having."

Several nurses are concerned that agency policies related to restraint and seclusion practices are inadequate. Which statement about the relationship of substandard institutional policies and individual nursing practice should guide nursing practice? a. The policies do not absolve an individual nurse of the responsibility to practice according to the professional standards of nursing care. b. Agency policies are the legal standard by which a professional nurse must act and therefore override other standards of care. c. In an institution with substandard policies, the nurse has a responsibility to inform the supervisor and leave the premises. d. Interpretation of policies by the judicial system is rendered on an individual basis and therefore cannot be predicted.

a. The policies do not absolve an individual nurse of the responsibility to practice according to the professional standards of nursing care.

A patient being treated in an alcohol rehabilitation unit reveals to the nurse, "I feel terrible guilt for sexually abusing my 6-year-old child before I was admitted." Based on state and federal law, the best action for the nurse to take is to: a. anonymously report the abuse by telephone to the local child abuse hotline. b. reply, "I'm glad you feel comfortable talking to me about it." c. respect nurse-patient relationship of confidentiality. d. file a written report on the agency letterhead.

a. anonymously report the abuse by telephone to the local child abuse hotline.

A patient is very suspicious and states, "The FBI has me under surveillance." Which strategies should a nurse use when gathering initial assessment data about this patient? Select all that apply. a. Tell the patient that medication will help this type of thinking. b. Ask the patient, "Tell me about the problem as you see it." c. Seek information about when the problem began. d. Tell the patient, "Your ideas are not realistic." e. Reassure the patient, "You are safe here."

b, c, e

A nurse assesses a patient who reluctantly participates in activities, answers questions with minimal responses, and rarely makes eye contact. What information should be included when documenting the assessment? Select all that apply. a. Uncooperative patient b. Patient's subjective responses c. Only data obtained from the patient's verbal responses d. Description of the patient's behavior during the interview e. Analysis of why the patient is unresponsive during the interview

b, d

A voluntarily hospitalized patient tells the nurse, "Get me the forms for discharge against medical advice so I can leave now." What is the nurse's best initial response? a. "I can't give you those forms without your health care provider's knowledge." b. "I will get them for you, but let's talk about your decision to leave treatment." c. "Since you signed your consent for treatment, you may leave if you desire." d. "I'll get the forms for you right now and bring them to your room."

b. "I will get them for you, but let's talk about your decision to leave treatment."

A nurse's neighbor asks, "Why aren't people with mental illness kept in state institutions anymore?" What is the nurse's best response? a. "Many people are still in psychiatric institutions. Inpatient care is needed because many people who are mentally ill are violent." b. "Less restrictive settings are now available to care for individuals with mental illness." c. "Our nation has fewer persons with mental illness; therefore fewer hospital beds are needed." d. "Psychiatric institutions are no longer popular as a consequence of negative stories in the press."

b. "Less restrictive settings are now available to care for individuals with mental illness."

Which entry in the medical record best meets the requirement for problem-oriented charting? a. "A: Pacing and muttering to self. P: Sensory perceptual alteration, related to internal auditory stimulation. I: Given fluphenazine (Prolixin) 2.5 mg at 0900, and went to room to lie down. E: Calmer by 0930. Returned to lounge to watch TV." b. "S: States, 'I feel like I'm ready to blow up.' O: Pacing hall, mumbling to self. A: Auditory hallucinations. P: Offer haloperidol (Haldol) 2 mg . I: (Haldol) 2 mg at 0900. E: Returned to lounge at 0930 and quietly watched TV." c. "Agitated behavior. D: Patient muttering to self as though answering an unseen person. A: Given haloperidol (Haldol) 2 mg and went to room to lie down. E: Patient calmer. Returned to lounge to watch TV." d. "Pacing hall and muttering to self as though answering an unseen person. haloperidol (Haldol) 2 mg administered at 0900 with calming effect in 30 minutes. Stated, 'I'm no longer bothered by the voices.'"

b. "S: States, 'I feel like I'm ready to blow up.' O: Pacing hall, mumbling to self. A: Auditory hallucinations. P: Offer haloperidol (Haldol) 2 mg . I: (Haldol) 2 mg at 0900. E: Returned to lounge at 0930 and quietly watched TV."

Which nursing intervention demonstrates false imprisonment? a. A confused and combative patient says, "I'm getting out of here and no one can stop me." The nurse restrains this patient without a health care provider's order and then promptly obtains an order. b. A patient has been irritating, seeking the attention of nurses most of the day. Now a nurse escorts the patient down the hall saying, "Stay in your room or you'll be put in seclusion." c. An involuntarily hospitalized patient with suicidal ideation runs out of the psychiatric unit. A nurse rushes after the patient and convinces the patient to return to the unit. d. An involuntarily hospitalized patient with suicidal ideation attempts to leave the unit. A nurse calls the security team and uses established protocols to prevent the patient from leaving.

b. A patient has been irritating, seeking the attention of nurses most of the day. Now a nurse escorts the patient down the hall saying, "Stay in your room or you'll be put in seclusion."

A nurse asks a patient, "If you had fever and vomiting for 3 days, what would you do?" Which aspect of the mental status examination is the nurse assessing? a. Behavior b. Cognition c. Affect and mood d. Perceptual disturbances

b. Cognition

An adolescent asks a nurse conducting an assessment interview, "Why should I tell you anything? You'll just tell my parents whatever you find out." Select the nurse's best reply. a. "That isn't true. What you tell us is private and held in strict confidence. Your parents have no right to know." b. "Yes, your parents may find out what you say, but it is important that they know about your problems." c. "What you say about feelings is private, but some things, like suicidal thinking, must be reported to the treatment team." d. "It sounds as though you are not really ready to work on your problems and make changes."

c. "What you say about feelings is private, but some things, like suicidal thinking, must be reported to the treatment team."

A nurse works with a patient to establish outcomes. The nurse believes that one outcome suggested by the patient is not in the patient's best interest. What is the nurse's best action? a. Remain silent. b. Educate the patient that the outcome is not realistic. c. Explore with the patient possible consequences of the outcome. d. Formulate an appropriate outcome without the patient's input.

c. Explore with the patient possible consequences of the outcome.

A new staff nurse completes orientation to the psychiatric unit. This nurse will expect to ask an advanced practice nurse to perform which action for patients? a. Perform mental health assessment interviews. b. Establish therapeutic relationships. c. Prescribe psychotropic medications. d. Individualize nursing care plans.

c. Prescribe psychotropic medications.

A newly admitted patient with major depression has lost 20 pounds over the past month and has suicidal ideation. The patient has taken an antidepressant medication for 1 week without remission of symptoms. Select the priority nursing diagnosis. a. Imbalanced nutrition: Less than body requirements b. Chronic low self-esteem c. Risk for suicide d. Hopelessness

c. Risk for suicide

When a new patient is hospitalized, a nurse takes the patient on a tour, explains the rules of the unit, and discusses the daily schedule. The nurse is engaged in: a. counseling. b. health teaching. c. milieu management. d. psychobiologic intervention.

c. milieu management.

A patient should be considered for involuntary commitment for psychiatric care when he or she: a. is noncompliant with the treatment regimen. b. sold sells and distributes illegal drugs. c. threatens to harm self and others. d. fraudulently files for bankruptcy.

c. threatens to harm self and others.

Which individual with a mental illness may need emergency or involuntary hospitalization for mental illness? The individual who: a. resumes using heroin while still taking methadone. b. reports hearing angels playing harps during thunderstorms. c. throws a heavy plate at a waiter at the direction of command hallucinations. d. does not show up for an outpatient appointment with the mental health nurse.

c. throws a heavy plate at a waiter at the direction of command hallucinations.

Two hospitalized patients fight when they are in the same room. During a team meeting, a nurse asserts that safety is of paramount importance and therefore the treatment plans should call for both patients to be secluded to prevent them from injuring each other. This assertion: a. reveals that the nurse values the principle of justice. b. reinforces the autonomy of the two patients. c. violates the civil rights of the two patients. d. represents the intentional tort of battery.

c. violates the civil rights of the two patients.

An adolescent hospitalized after a violent physical outburst tells the nurse, "I'm going to kill my father, but you can't tell anyone." Select the nurse's best response. a. "You're right. Federal law requires me to keep that information private." b. "Those kinds of thoughts will make your hospitalization longer." c. "You really should share this thought with your psychiatrist." d. "I am obligated to share information with the treatment team."

d. "I am obligated to share information with the treatment team."

Which statement made by a patient during an initial assessment interview should serve as the priority focus for the plan of care? a. "I can always trust my family." b. "It seems like I always have bad luck." c. "You never know who will turn against you." d. "I hear evil voices that tell me to do bad things."

d. "I hear evil voices that tell me to do bad things."

Which scenario is an example of a tort? a. The primary nurse does not complete the plan of care for a patient within 24 hours of the patient's admission. b. An advanced practice nurse recommends that a patient who is dangerous to self and others be voluntarily hospitalized. c. A patient's admission status is changed from involuntary to voluntary after the patient's hallucinations subside. d. A nurse gives an as-needed dose of an antipsychotic drug to a patient to prevent violent acting-out because a unit is short staffed.

d. A nurse gives an as-needed dose of an antipsychotic drug to a patient to prevent violent acting-out because a unit is short staffed.

A nurse assessing a new patient asks, "What is meant by the saying, 'You can't judge a book by its cover'?" Which aspect of cognition is the nurse assessing? a. Mood b. Attention c. Orientation d. Abstraction

d. Abstraction

A nurse documents: "Patient is mute, despite repeated efforts to elicit speech. Makes no eye contact. Is inattentive to staff. Gazes off to the side or looks upward rather than at the speaker." Which nursing diagnosis should be considered? a. Defensive coping b. Decisional conflict c. Risk for other-directed violence d. Impaired verbal communication

d. Impaired verbal communication

A patient begins a new program to assist with building social skills. In which part of the plan of care should a nurse record the item "Encourage patient to attend one psychoeducational group daily"? a. Assessment b. Analysis c. Planning d. Implementation e. Evaluation

d. Implementation

In a team meeting a nurse says, "I'm concerned whether we are behaving ethically by using restraint to prevent one patient from self-mutilation while the care plan for another patient who has also self-mutilated calls for one-on-one supervision." Which ethical principle most clearly applies to this situation? a. Beneficence b. Autonomy c. Fidelity d. Justice

d. Justice

A patient's nursing diagnosis is Insomnia. The desired outcome is: "Patient will sleep for a minimum of 5 hours nightly by October 31." On November 1, a review of the sleep data shows the patient sleeps an average of 4 hours nightly and takes a 2-hour afternoon nap. Which evaluation should be documented? a. Consistently demonstrated b. Often demonstrated c. Sometimes demonstrated d. Never demonstrated

d. Never demonstrated

A patient's nursing diagnosis is Insomnia. The desired outcome is: "Patient will sleep for a minimum of 5 hours nightly by October 31." On November 1, a review of the sleep data shows the patient sleeps an average of 4 hours nightly and takes a 2-hour afternoon nap. What is the nurse's next action? a. Continue the current plan without changes. b. Remove this nursing diagnosis from the plan of care. c. Write a new nursing diagnosis that better reflects the problem. d. Revise the target date for outcome attainment and examine interventions.

d. Revise the target date for outcome attainment and examine interventions.

Select the most appropriate label to complete this nursing diagnosis: ___________, related to feelings of shyness and poorly developed social skills as evidenced by watching television alone at home every evening. a. Deficient knowledge b. Ineffective coping c. Powerlessness d. Social isolation

d. Social isolation

A patient states, "I'm not worth anything. I have negative thoughts about myself. I feel anxious and shaky all the time. Sometimes I feel so sad that I want to go to sleep and never wake up." Which nursing intervention should have the highest priority? a. Self-esteem-building activities b. Anxiety self-control measures c. Sleep enhancement activities d. Suicide precautions

d. Suicide precautions

Nursing behaviors associated with the implementation phase of the nursing process are concerned with: a. participating in the mutual identification of patient outcomes. b. gathering accurate and sufficient patient- centered data. c. comparing patient responses and expected outcomes. d. carrying out interventions and coordinating care.

d. carrying out interventions and coordinating care.

At what point in an assessment interview would a nurse ask, "How does your faith help you in stressful situations?" During the assessment of: a. childhood growth and development. b. substance use and abuse. c. educational background. d. coping strategies.

d. coping strategies.

A psychiatric nurse best implements the ethical principle of autonomy when he or she: a. intervenes when a self-mutilating patient attempts to harm self. b. stays with a patient who is demonstrating a high level of anxiety. c. suggests that two patients who are fighting be restricted to the unit. d. explores alternative solutions with a patient, who then makes a choice.

d. explores alternative solutions with a patient, who then makes a choice.

A nurse cares for an older adult patient admitted for the treatment of depression. The health care provider prescribes an antidepressant medication, but the dose is more than the usual adult dose. The nurse should: a. implement the order. b. consult a drug reference. c. give the usual geriatric dosage. d. hold the medication and consult the health care provider.

d. hold the medication and consult the health care provider.

The spouse of a patient who has delusions asks the nurse, "Are there any circumstances under which the treatment team is justified in violating the patient's right to confidentiality?" The nurse must reply that confidentiality may be breached: a. under no circumstances. b. at the discretion of the psychiatrist. c. when questions are asked by law enforcement. d. if the patient threatens the life of another person.

d. if the patient threatens the life of another person.

An example of a breach of a patient's right to privacy occurs when a nurse: a. asks a family to share information about a patient's prehospitalization behavior. b. discusses the patient's history with other staff members during care planning. c. documents the patient's daily behaviors during hospitalization. d. releases information to the patient's employer without consent.

d. releases information to the patient's employer without consent.

Select the best outcome for a patient with the nursing diagnosis: Impaired social interaction, related to sociocultural dissonance as evidenced by stating, "Although I'd like to, I don't join in because I don't speak the language very well." The patient will: a. demonstrate improved social skills. b. express a desire to interact with others. c. become more independent in decision making. d. select and participate in one group activity per day.

d. select and participate in one group activity per day.