BH Exam 2
A patient tried for the murder of a spouse and child was found guilty but mentally ill (GBMI). A psychiatric nurse is asked, "Does that mean this patient will be walking the streets after a short hospitalization?" Which reply shows the best understanding of GBMI?
"A person found guilty but mentally ill will be treated while serving the sentence."
A psychiatric technician states, "This patient has frequently threatened suicide but has never attempted it. The patient should be sent home instead of encouraging the threats." The nurse supports admitting the patient by responding:
"Any suicide threat deserves serious attention and concern for safety."
A nurse performing an admission interview identifies a need for one-to-one supervision when the patient admits to having suicidal ideations with a plan. The best way to inform the patient of the planned intervention is to say:
"I understand your impulse to harm yourself. A staff member will stay with you to help you control that impulse."
A patient is acutely psychotic, withdrawn, claims to be a robot, and cannot think of how to take a shower. Which response by the nurse is best?
"I will turn on the water for you and provide you with step-by-step directions."
A patient who was abused as a child tells a nurse of the abuse in a stilted, unemotional manner. Which intervention would encourage the patient to examine feelings associated with childhood abuse?
"If I experienced that as a child, I would feel betrayed, confused, and frightened."
Which statement made by an adolescent patient represents an indirect expression of low self-esteem?
"If I had only gotten that job, then I could certainly experience happiness in life."
A patient's husband is distraught over his wife's behavior since their child died in a car accident 1 month ago. He says, "She still cries herself to sleep each night. Help my wife control herself." The nurse's most therapeutic response would be:
"It's hard to see her so upset, but crying is one way of expressing her feelings."
While talking with a nurse, a patient remarks, "My father's been dead for months. I think Mom needs to get on with her life." The most appropriate response by the nurse is:
"It's possible that she still needs more time. Grieving often takes 1 year or more."
A patient being treated for severe depression shows resistance to involvement in the nurse-patient relationship by being withdrawn and unresponsive. There is also preoccupation with guilt and hopelessness. When interacting with the patient, which response would have the greatest therapeutic impact?
"It's very likely that you will feel better as your treatment continues."
When a nurse shares that "caring for the manic client is less stressful than caring for a depressed one since they aren't at risk for injury," the nurse manager responds:
"Let's consider the ways that acute mania can also cause injuries."
A patient is acutely psychotic and withdrawn. The patient claims to be a robot, stating, "I can't relate to others. I have no feelings. I can't talk because I have no ideas in my head." Acceptance is shown when the nurse remarks to this patient:
"May I sit here with you for a while?"
During occupational therapy a patient diagnosed with schizophrenia sits staring at a piece of paper. Which response is most therapeutic at this time?
"Rub the glue stick on the back of the paper."
During discharge planning, a patient whose manic symptoms are remitting asks, "Do I have to take lithium even though I'm not high any longer?" The most appropriate response is:
"Taking the medication daily will help you avoid relapses and recurrences."
Which remark by a nurse best represents an attempt to assess the patient's current ability to organize and enact a suicide wish?
"What plan do you have for committing suicide?"
A patient who is seeking help at the mental health clinic states, "I know my work has gone downhill. I'm a poor spouse, parent, and teacher. I should be able to do better." The best response by the nurse would be:
"You have very high expectations for yourself."
A person calls the crisis hotline and says, "Nobody can help me now. I just want to say goodbye to somebody before I do it." The best response to this statement would be:
"You sound very discouraged. What are you planning to do?"
The nursing diagnosis for a patient who is depressed and suicidal at admission is "risk for suicide." The most appropriate outcome for this diagnosis at discharge from the hospital is, "The patient will:
"not harm self while hospitalized."
Which individual is most in need of measures to reduce the risk for self-concept disturbance associated with health-illness transition?
A 15-year-old with Crohn disease who states, "An ileostomy will mean I won't be able to do stuff with my friends."
Which individual would be at greatest risk for self-esteem disturbance?
A 16-year-old high school junior
Based on current sociocultural risk factors for mental illness, a nurse assesses that which patient is at highest risk for depression?
A 26-year-old female
While making a home visit, a community health nurse sees evidence that the child of a patient has been abused. What rationale should be the basis for the nurse's nursing action?
A federal ruling requires that the nurse report the suspected abuse.
Which patient has best achieved the desired outcome of therapy to improve self-concept?
A patient who states, "I understand that no one else can make me happy. I'm using my strengths and making my wishes become realities."
According to the Stuart Stress Adaptation Model, which person can be assessed as being the closest to the maladaptive responses end of the continuum of emotional responses?
A patient whose spouse died 2 years ago, who states, "Strong people don't mourn. I've kept busy and focused on supporting the kids."
The emergency department calls to say a patient experiencing symptoms of mania is being admitted. Which room placement should a nurse choose for the patient?
A single room near the nurse's station
A patient, who is homeless and known to be schizophrenic, was arrested after vandalizing parked cars while naked. Which behaviors will be considered when determining if the patient should be involuntarily committed for care? Select all that apply. a. The patient is a possible danger to others. b. The patient is a diagnosed schizophrenic. c. The patient is a disruptive factor to the community. d. The patient is unable to provide for his or her own basic needs. e. The patient is in need of either physical or mental health treatment.
A,D,E
A person who has been fired from a job calls the mental health clinic and tells a nurse, "I feel so overwhelmed that I don't see any other answer but to die." Another voice can be heard in the background. Which action should the nurse take?
Ask to speak to the other person and alert them to the caller's suicide threat.
A suicidal patient was found attempting to hang himself in the bathroom shower. What nursing intervention would best address the patient's current need for safety while maintaining his self-esteem?
Assign a staff member to remain with the patient at all times.
A priority for nurses working with psychiatric patients would be the assessment of suicide risk for individuals who have the tendency to be: (Select all that apply.) a. blaming. b. hostile. c. hopeless. d. impulsive. e. controlling.
B,C,D
Which patient is apt to display violent behavior directed at others? (Select all that apply.) a. A patient with a history of obsessive compulsive behaviors who displays signs of severe depression after the loss of a job held for 20 years b. A patient who has a history of assaulting people when commanded to do so by "the voices" c. A patient who has been noncompliant with prescribed psychotropic medication and whose manic behavior has escalated d. A patient who has an antisocial personality disorder and who has been abusing amphetamines for 3 years e. A patient who was diagnosed with posttraumatic stress disorder (PTSD) who recently lost a limb in an automobile accident
B,C,D
An assessment has been made that a patient is highly suicidal. One-to-one constant supervision with unit restriction has been ordered. How will this order be implemented?
By observing the patient at all times while revoking any off-unit privileges
A nurse is attempting to help a patient alter negative self-concept. What is the correct order in which these nursing interventions should be implemented? A. Assisting the patient in the process of self-evaluation. B. Encouraging the patient's attempts at self-exploration. C. Introducing skills that expand the patient's ability to be self-aware. D. Helping the patient formulate a plan of action. E. Supporting the patient in the achievement of goals.
C, B, A, D, E
What nursing diagnosis should be considered when caring for a patient who has engaged in direct or indirect self-destructive behavior?
Chronic low self-esteem
A nurse is working with a patient to improve self-concept using an intervention directed toward self-evaluation. Which intervention is best?
Clarifying that the patient's beliefs affect the patient's feelings and behaviors
The nurse can expect to find which assessment findings in a patient who is hypomanic?
Clinical symptoms less severe than those of a manic state
A patient with low self-esteem has begun making behavior changes. A nurse positively reinforces these changes during a therapy session. The patient and nurse are actively engaged in which level of intervention?
Commitment to action
A nurse is working with a patient to improve self-concept by expanding self-awareness. Which intervention is best?
Creating a climate of acceptance toward the patient
Two nurses are discussing the rights of hospitalized psychiatric patients. Which of their beliefs requires follow-up by the nurse manager?
Disclosure of patient information to law enforcement agencies is permitted without patient consent.
What is the new staff nurse's immediate duty when a patient discloses a plan to kill a family member upon release from the hospital?
Document the information in the patient's medical record, and notify the nursing supervisor of the statement.
A patient with severe depression and suicidal ideation has not improved after trials with selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants. Which treatment option can a nurse expect the health care provider will now consider?
Electroconvulsive therapy
When working with a patient with self-concept disturbance, which type of communication would initially be most useful?
Empathic
A nurse is working with a patient to improve self-concept using an intervention directed toward self-exploration. Which intervention is best?
Encouraging the patient to examine behaviors related to a stressor
A patient is about to receive electroconvulsive therapy (ECT) when a nurse sees that a consent form for treatment has not been signed. Which fact should determine the nurse's immediate action?
Failure to obtain the patient's written consent constitutes battery.
A patient who has recently lost a spouse calls the crisis line and reports 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?
High.
Which coping mechanism should a nurse expect to see a patient initially use to mourn the death of a spouse?
Introjection
Patients of which demographic group have the highest suicide rate in the United States?
Male age 50 years or older
A patient is extremely hyperactive, distractible, and rarely sleeps. The patient eats little, resulting in a loss of 6 pounds since admission 3 days ago. Which measure is a priority when developing a plan for the patient's care?
Offer high-calorie "portable" finger foods and nutritionally fortified fluids hourly.
A patient was admitted after an unsuccessful suicide attempt. The patient is overheard saying, "Next time, I'll make sure no one interrupts me." Which level of suicide precautions should be ordered?
One-to-one supervision for safety
The staff members notify the police that a court-committed patient has eloped. What is the initial action for the staff to take when the patient is returned to the hospital?
Readmit the patient under the original court-ordered commitment.
Which action by a nurse violates the rights of a psychiatric patient?
Refusing to mail letters to the local newspaper written by a committed patient
How does a nurse's use of sympathetic communication sometimes hinder a patient's work in developing a more realistic self-concept?
Sympathy can reinforce self-pity.
When a patient begins fluoxetine (Prozac), what information should be included in the plan for patient education?
The onset of action is 2 to 6 weeks.
A nurse was sued for malpractice but not convicted. Which fact from the case would have been decisive in determining its outcome?
The patient did not suffer any physical or any emotional harm.
Which findings indicate that the goal of returning to appropriate emotional responsiveness has been attained by a patient with mania?
The patient identifies two attainable personal goals and offers a realistic (nongrandiose) self-appraisal.
Select the best goal when working with a patient who has an alteration in self-concept.
The patient will attain the maximum level of self-actualization to realize his or her potential.
Regardless of the type of commitment, which right is guaranteed to a hospitalized psychiatric patient?
The right to consult a lawyer
An individual is advised to seek psychiatric hospitalization and agrees to receive treatment and abide by hospital rules. What type of admission is this?
Voluntary
A patient paces continuously while repeatedly mumbling, "I'm worthless. It's all hopeless." Which nursing measure would be most helpful in establishing a relationship with this patient?
Walk with the patient, and make occasional empathic observations.
A patient was admitted involuntarily. What assumption can the nurse make about the patient?
When admitted, the patient was an imminent danger to self or others or was deemed unable to provide for his or her own basic needs.
The critical element a nurse must consider when completing a behavioral assessment of a patient with a mood disturbance is:
a change in usual patterns and responses.
A patient was admitted voluntarily to the psychiatric unit. A nurse must understand that voluntary status confers the right of the patient to:
accept or refuse any recommended treatment modalities.
A patient hospitalized 3 weeks ago with major depressive disorder presented with suicidal ideations but no suicide plan. Sertraline (Zoloft) was prescribed, and the patient now reports that the feelings of depression have somewhat lessened. The guiding factor the nurse considers when planning care is that there is:
an increased risk for suicide as the depression lifts.
During an admission a nurse suspects a patient is having suicidal ideations. The best course of action is to:
ask the patient if thoughts of suicide have occurred.
A patient tells a nurse, "I am a weak person." The patient feels inadequate and vulnerable and states often feeling helpless and
chronic low self-esteem.
A patient who is acutely psychotic and withdrawn claims to be a robot. An early intervention designed to help this patient expand self-awareness would be to:
confirm the patient's identity.
A nurse assessing a patient who has been noncompliant with the prescribed diabetic diet and exercise regimen should consider planning strategies to overcome patient use of:
denial.
A patient was widowed 8 months ago. The patient has never cried and speaks of the spouse as if they were still together. Theprominent defense mechanism exhibited by the patient is:
denial.
A patient reports feeling detached and says, "It feels as though I'm watching a movie as life unfolds. I'm isolated, on the outsid and not involved. I really don't feel anything. I don't know if I'm alive or dead, awake or sleeping." The nurse can determine that the patient is describing:
depersonalization.
When a patient who immigrated to the United States tells a nurse that consent to electroconvulsive therapy (ECT) was only given because the patient's spouse said, "They will deport you if you didn't do what they said to do," the nurse should initially:
document the comment and notify the health care provider immediately.
A patient who _____ should be assessed as using indirect self-destructive behavior.
drinks nearly 1 quart of whiskey per day
A patient claims to have been denied the right to confidentiality. To best preserve the patient's rights, the treatment team must:
educate the patient about the process required for the filing of a formal complaint.
A patient displaying symptoms of mania has spent the entire morning pacing in the dayroom and now has begun verbally intimidating other patients. The nurse manages the milieu by:
escorting the patient out of the dayroom.
A nurse caring for a hospitalized suicidal patient on one-to-one supervision should initially focus on:
facilitating awareness, expression, and labeling of feelings.
A nurse is working with a patient to improve self-concept. To best assist the patient in realistic goal planning, the nurse will:
help the patient understand that the patient alone can bring about personal change.
When working with a patient experiencing an alteration in self-concept resulting from dissociative amnesia, a nurse should begin by:
identifying and supporting the patient's ego strength.
A patient tells a nurse, "My children had me ruled incompetent. I'm going to ask the doctor to reverse that ruling." The nurse's reply should be based on the fact that:
incompetency may only be reversed by a court.
When evaluating the effectiveness of the care provided for a self-destructive patient, the best approach is to:
involve the patient in the process of evaluation.
A nurse is working with a patient with depression whose identical twin committed suicide. In assessing this patient for suicidal risk, the nurse should consider that this patient:
is at increased risk for suicide.
A patient who was hospitalized after a serious suicide attempt is scheduled to be discharged to home. During the hospitalization, the patient has been compliant with all aspects of the treatment plan. It is reasonable to believe the patient will continue to comply with treatment because the patient:
is beginning to demonstrate positive behavioral changes.
During the process of self-exploration, it is important for a nurse to convey the message that the patient:
is responsible for his or her own behavior, including maladaptive coping responses.
A patient with mania is displaying elation, hyperactivity, grandiosity, verbosity, disturbed sleep pattern, and poor judgment. The plan of care should take into consideration the need to:
maintain physiological equilibrium.
A person was arrested for writing thousands of dollars of worthless checks. After acting out sexually in court, the patient explained in rapid-fire speech to the judge, "I'm going to expand my outlook, shape-up, sail away, and be a bird in paradise." These behaviors are consistent with a diagnosis of:
mania.
A patient diagnosed with severe depression exhibits psychomotor retardation and a sense of worthlessness manifested in poor personal hygiene. The patient refuses to shower, stating, "I can't." The nurse should:
matter-of-factly assist the patient to shower and dress in clean clothes.
The parents of a patient with schizophrenia ask whether their child is likely to become violent. The best answer the nurse can give is that the vast majority of mentally ill individuals are:
no more dangerous than other individuals in the population.
The initial response of a steelworker who was fired from a job was disbelief. At home the steelworker told family members about the firing but retreated to the bedroom, saying, "I'm too choked up to talk about it right now." These behaviors are characteristic of:
normal grief reaction.
Which relationships most significantly affect a 3-year-old child's development of self-concept? Relationships with:
parents.
A patient hospitalized for depression demonstrates dysfunctional thinking as evidenced by persistent pessimism and predictions of disastrous outcomes. A nurse using cognitive therapy will focus on:
patient recognition and replacement of automatic negative evaluations.
A patient diagnosed with schizophrenia has difficulty completing tasks and seems forgetful and disinterested in activities. A nurse can best select successful strategies by understanding that these behaviors are due to:
problems in cognitive functioning.
A patient in the process of being involuntarily committed demands to be evaluated by his own private psychiatrist. To preserve the patient's rights, the treatment team must:
provide access to the private psychiatrist.
Although not assessed to be dangerous to self or others, a patient diagnosed with borderline personality disorder has created many problems on the unit and consistently refuses to accept prescribed medication. Nursing actions must be guided by the realization that legally this patient may:
refuse any type of treatment.
A patient diagnosed with schizophrenia is standing naked after showering and appears dazed and indecisive. The nursing intervention that will be most helpful to promote dressing would be:
saying, "These are your underpants. I'll help you put them on.
A patient shares, "My mood is really low, and even though I get plenty of sleep, I'm tired all the time. It seems like it happens every fall and winter." This patient is most likely experiencing:
seasonal affective disorder.
A patient states, "Ever since I was a kid, I knew I should study, get good grades, and go to medical school. I wanted to be helpful and do good for others." From this statement, the nurse obtains information to assess this patient's:
self-ideal.
A nurse is caring for a patient who has been noncompliant with the prescribed diabetic diet and exercise regimen. The nurse promotes compliance by enhancing the patient's:
sense of control.
A patient with depression recently lost 8 pounds. After only a few bites the patient refuses to eat more, saying, "I'm full. All that food makes me sick just to look at it." The most effective way for the nurse to help increase the patient's dietary intake would be to:
serve six small, calorie-dense meals daily.
A psychiatric nurse working in a community health center receives a call asking whether a family friend has been a patient in the facility. The nurse should:
state that he or she is unable to give any information to the caller.
A patient signed a sales contract to purchase a new home and 1 week later was voluntarily hospitalized for treatment of depression. The sales contract is now most likely:
still valid.
A patient with severe depression signed permission for electroconvulsive therapy (ECT). Later, the patient tells the nurse, "I signed permission for treatment after my spouse told me I could be deported if my depression can't be cured." The nurse assesses that:
the patient's consent may have been coerced.
A patient with a history of assaulting several family members is voluntarily admitted for alcohol detoxification. A nurse suggests use of physical restraints to minimize the risk to the milieu and to manage the patient's anticipated aggressive behavior. The primary principle guiding the manager's response is:
the right to the least restrictive measure of restriction possible.
The major difference between self-injury and suicide lies in whether the patient has:
the wish to relieve tension or the wish to die.
A patient with depression tells a nurse, "I hope someone will make sure my family gets my jewelry when I'm gone." This statement can be assessed as a suicide:
threat.
