Exam 1 - Test Bank questions

What is the purpose of a nurse providing appropriate feedback? A. To give the client good advice B. To advise the client on appropriate behaviors C. To evaluate the clients behavior D. To give the client critical information

ANS: D The purpose of providing appropriate feedback is to give the client critical information. Feedback should not be used to give advice or evaluate behaviors.

Which client statement should alert a nurse that a client may be responding maladaptively to stress? A. Ive found that avoiding contact with others helps me cope. B. I really enjoy journaling; its my private time. C. I signed up for a yoga class this week. D. I made an appointment to meet with a therapist.

ANS: A Reliance on social isolation as a coping mechanism is a maladaptive method to relieve stress. It can prevent learning appropriate coping skills and can prevent access to needed support systems.

If an individual is two-faced, which characteristic essential to the development of a therapeutic relationship should a nurse identify as missing? A. Respect B. Genuineness C. Sympathy D. Rapport

ANS: B The nurse should identify that genuineness is missing in the relationship. Genuineness refers to an individuals ability to be open and honest and maintain congruence between what is felt and what is communicated. Genuineness is essential to establishing trust in a relationship.

Two clients get into a heated argument regarding TV program selections. The nurse turns off the TV and asks the clients to go to their rooms to cool off, after which they will discuss and attempt to resolve the problem. The nurses action is promoting which assertive technique? A. Defusing B. Clouding or fogging C. Responding as a broken record D. Shifting from content to process

ANS: A Defusing is a technique that delays further discussion with an angry individual until a calm demeanor has been achieved. In the situation presented, the nurse is allowing the clients to calm down prior to addressing their issues.

Most cultures label behavior as mental illness on the basis of which of the following criteria? A. Incomprehensibility and cultural relativity B. Strength of character and ethics C. Goal directedness and high energy D. Creativity and good coping skills

ANS: A Incomprehensibility and cultural relativity are most often the criteria used to define whether something is labeled mental illness. The other identified behaviors would be more associated with health than illness.

According to Peplau, which nursing intervention is most appropriate when the nurse is functioning in the role of a surrogate? A. The nurse functions as a nurturing parent in order to build a trusting relationship. B. The nurse plays cards with a small group of clients. C. The nurse discusses childhood events that may affect personality development. D. The nurse provides a safe social environment.

ANS: A According to Peplau, when a client is acutely ill, he or she may incur the role of infant or child, while the nurse is perceived as the mother surrogate.

A nurse should assess a patient taking a drug with anticholinergic properties for inhibited function of the: A. parasympathetic nervous system. B. sympathetic nervous system. C. reticular activating system. D. medulla oblongata.

ANS: A Acetylcholine is the neurotransmitter found in high concentration in the parasympathetic nervous system. When acetylcholine action is inhibited by anticholinergic drugs, parasympathetic symptoms such as blurred vision, dry mouth, constipation, and urinary retention appear. The functions of the sympathetic nervous system, the reticular activating system, and the medulla oblongata are not affected by anticholinergics.

A nurse administers a medication that potentiates the action of GABA. Which finding would be expected? A. Reduced anxiety B. Improved memory C. More organized thinking D. Fewer sensory perceptual alterations

ANS: A Increased levels of GABA reduce anxiety, thus any potentiation of GABA action should result in anxiety reduction. Memory enhancement is associated with acetylcholine and substance P. Thought disorganization is associated with dopamine. GABA is not associated with sensory perceptual alterations.

A client is diagnosed with generalized anxiety disorder. In order to maximize the learning process prior to discharge teaching, which assessment should be performed by the nurse? A. Assessing the clients level of anxiety B. Assessing and documenting the clients vital signs C. Assessing suicide risk D. Assessing availability of support systems

ANS: A Anxiety at a moderate or higher level will interfere with the learning process.

What is the legal significance of a nurses action when a nurse threatens a demanding client with restraints? A. The nurse can be charged with assault. B. The nurse can be charged with negligence. C. The nurse can be charged with malpractice. D. The nurse can be charged with beneficence.

ANS: A Assault is an act that results in a persons genuine fear and apprehension that he or she will be touched without consent.

Two clients are roommates on an inpatient psychiatric unit. At breakfast, client A, who had been missing her gold locket, notices client B wearing it. Which should a nurse recognize as a nonassertive or passive behavioral response from client A? A. Client A ignores the situation. B. Client A discusses the situation with her nurse and develops a plan of action. C. Client A immediately approaches client B and pulls the necklace off her neck. D. Client A offers to wash client Bs clothes and accidentally spills bleach in the water.

ANS: A By ignoring the situation, client A avoids conflict, denies her feelings, and does not assertively resolve the problem. This is an example of nonassertive behavior.

A 40-year-old female client has never experienced an intimate relationship. A nursing student tells an instructor that this client remains in Eriksons developmental stage of intimacy versus isolation. What is the instructors most appropriate reply? A. Eriksons stages of development are assessed by chronological age, not task achievement. This client is in the generativity versus stagnation stage, which occurs from 30 to 65 years of age. B. Eriksons stages of development are assessed by task achievement, not chronological age. This client is in the intimacy versus isolation stage, which occurs from 20 to 30 years of age. C. Eriksons stages of development are assessed by task achievement, not chronological age. This client is in the generativity versus stagnation stage, which occurs from 30 to 65 years of age. D. Eriksons stages of development are assessed by chronological age, not task achievement. This client is in the intimacy versus isolation stage, which occurs from 20 to 30 years of age.

ANS: A Eriksons stages of development are assessed by chronological age, not task achievement. This client is in Eriksons stage of generativity versus stagnation because she is 40 years old. The student has failed to recognize that even though the client did not successfully achieve the intimacy task of the intimacy versus isolation stage, the client must now be assessed at the age-appropriate developmental stage of generativity versus stagnation.

During an assertiveness training group, a nurse suggests using I statements. The group questions the usefulness of this communication technique. Which explanation by the nurse is most appropriate? A. When I statements are used, opinions are communicated without blaming others. B. When I statements are used, anger is displaced by using indirect means. C. When I statements are used, responsibility for ones behavior is attributed to another. D. When I statements are used, eye contact is promoted.

ANS: A I statements clearly state ones feelings and needs without blaming or demeaning others.

The therapeutic action of monoamine oxidase inhibitors (MAOIs) blocks neurotransmitter reuptake, causing: A. increased concentration of neurotransmitter in the synaptic gap. B. decreased concentration of neurotransmitter in the synaptic gap. C. destruction of receptor sites. D. limbic system stimulation.

ANS: A If the reuptake of a substance is inhibited, it accumulates in the synaptic gap and its concentration increases, permitting ease of transmission of impulses across the synaptic gap. Normal transmission of impulses across synaptic gaps is consistent with normal rather than depressed mood. The other options are not associated with blocking neurotransmitter reuptake.

When an individuals stress response is sustained over a long period of time, which physiological effect of the endocrine system should a nurse anticipate? A. Decreased resistance to disease B. Increased libido C. Decreased blood pressure D. Increased inflammatory response

ANS: A In a general adaptation syndrome, prolonged exposure to stress leads to the stage of exhaustion at which time the bodys compensatory mechanisms no longer function effectively and diseases of adaptation occur. A decreased immune response is seen at this stage.

An adolescent client has problems expressing anger appropriately. Which nursing statement would encourage the client to set realistic goals? A. What do you think needs to change about how you express anger? B. How did you feel after attending the anger management session? C. On a scale of 1 to 10, please rate your current level of anger. D. What bothers you about the actions of others when you get angry?

ANS: A In the planning phase of the nursing process, the nurse works with the client to identify expected outcomes for a plan individualized to the client or to the situation.

A client has continual problematic relationships and rejects others before possibly being rejected. The client states, I am afraid of failing in my job responsibilities. Which correctly written nursing diagnosis should be prioritized for this client? A. Poor self-esteem R/T negative self-image AEB fear of failure B. Altered thought processes R/T anxiety AEB delusions C. Role confusion R/T rejection and poor job productivity D. High risk for violence: self-directed R/T rejection of others

ANS: A Individuals with low self-esteem perceive themselves to be incompetent, unlovable, insecure, and unworthy. A correctly written actual nursing diagnosis must have a related to (R/T) and an evidenced by (AEB) statement. A risk for nursing diagnosis does not contain an AEB statement because the problem has not yet occurred.

A client diagnosed with schizophrenia receives fluphenazine decanoate (Prolixin Decanoate) from a home health nurse. The client refuses medication at one regularly scheduled home visit. Which nursing intervention is ethically appropriate? A. Allow the client to decline the medication and document. B. Tell the client that if the medication is refused, hospitalization will occur. C. Arrange with a relative to add medication to the clients morning orange juice. D. Call for help to hold the client down while the injection is administered.

ANS: A It is ethically and legally appropriate for the nurse to allow the client to decline the medication and provide accurate documentation. The clients right to refuse treatment should be upheld unless the refusal puts the client or others in harms way.

A nurse cares for four patients who are receiving clozapine, lithium, fluoxetine, and venlafaxine, respectively. For which patient should the nurse be most alert for alterations in cardiac or cerebral electrical conductivity as well as fluid and electrolyte imbalance? The patient receiving: A. lithium (Lithobid) B. clozapine (Clozaril) C. fluoxetine (Prozac) D. venlafaxine (Effexor)

ANS: A Lithium is known to alter electrical conductivity, producing cardiac dysrhythmias, tremor, convulsions, polyuria, edema, and other symptoms of fluid and electrolyte imbalance. Patients receiving clozapine should be monitored for agranulocytosis. Patients receiving fluoxetine should be monitored for acetylcholine block. Patients receiving venlafaxine should be monitored for heightened feelings of anxiety.

A patient taking medication for mental illness develops restlessness and an uncontrollable need to be in motion. A nurse can correctly analyze that these symptoms are related to which drug action? A. Dopamine-blocking effects B. Anticholinergic effects C. Endocrine-stimulating effects D. Ability to stimulate spinal nerves

ANS: A Medication that blocks dopamine often produces disturbances of movement such as akathisia because dopamine affects neurons involved in both thought processes and movement regulation. Anticholinergic effects include dry mouth, blurred vision, urinary retention, and constipation. Akathisia is not caused by endocrine stimulation or spinal nerve stimulation.

Meditation has been shown to be an effective stress management technique. When meditation is effective, what should a nurse expect to assess? A. An achieved state of relaxation B. An achieved insight into ones feelings C. A demonstration of appropriate role behaviors D. An enhanced ability to problem-solve

ANS: A Meditation produces relaxation by creating a special state of consciousness through focused concentration.

An inpatient client, whom the treatment team has determined to be a danger to self, gives notice of intention to leave the hospital. What information should the nurse recognize as having an impact on the treatment teams next action? A. State law determines how long a psychiatric facility can hold a client. B. Federal law determines if the client is competent. C. The clients family involvement will determine if discharge is possible. D. Hospital policies will determine treatment team actions.

ANS: A Most states commonly cite that in an emergency a client who is dangerous to self or others may be involuntarily hospitalized.

A community health nurse is planning a health fair at a local shopping mall. Which middle-class socioeconomic cultural group should the nurse anticipate would most value preventive medicine and primary health care? A. Northern European Americans B. Native Americans C. Latino Americans D. African Americans

ANS: A Northern European Americans, especially those who achieve middle-class socioeconomic status, place the most value on preventative medicine and primary health care. This value is most likely related to this groups educational level and financial capability. Many members of the Native American, Latino American, and African American subgroups value folk medicine practices.

Which of the following are behavioral components of assertive communication? A. Listening B. You statements C. Closed posture D. Continuous direct eye contact

ANS: A One part of assertiveness communication and behavior is to listen and take time to understand what is being said before giving a response.

A nurse is assessing 15-year-old identical twins who respond very differently to stress. One twin becomes anxious and irritable, while the other withdraws and cries. How should the nurse explain these different responses to stress to the parents? A. Reactions to stress are relative rather than absolute; individual responses to stress vary. B. It is abnormal for identical twins to react differently to similar stressors. C. Identical twins should share the same temperament and respond similarly to stress. D. Environmental influences weigh more heavily than genetic influences on reactions to stress.

ANS: A Responses to stress are variable among individuals and may be influenced by perception, past experience, and environmental factors in addition to genetic factors.

A nurse is running a group on self-esteem. A client asks, Where does self-esteem come from? Which is the most appropriate nursing reply? A. Many factors, over the life span, influence development and maintenance of self-esteem. B. Self-esteem is determined by factors outside of an individuals control. C. Self-esteem is established in childhood and remains relatively fixed throughout life. D. Genetics are the single largest contributor to an individuals self-esteem.

ANS: A Self-esteem refers to the degree of regard or respect that individuals have for themselves and is a measure of worth that they place on their abilities and judgments. Many factors influence the development of self-esteem over a persons life span.

Which is an appropriate initial nursing intervention for a client with chronic low self-esteem? A. Assessing the content of negative self-talk B. Administering anxiolytic medications C. Using reassurance and physical touch D. Using distraction techniques

ANS: A Self-negating verbalizations and internal self-talk undermine self-esteem. Assessing and then intervening to limit or eliminate these negative communications will help improve self-esteem.

Which of the following are identified as psychoneurotic responses to severe anxiety as they appear in the DSM-5? A. Somatic symptom disorders B. Grief responses C. Psychosis D. Bipolar disorder

ANS: A Somatic symptom disorder is characterized by preoccupation with physical symptoms for which there is no demonstrable organic pathology. One of the diagnostic criteria is a high level of anxiety about health concerns or illness.

Which behavior displayed by a patient receiving a typical antipsychotic medication would be assessed as displaying behaviors characteristic of tardive dyskinesia (TD)? A. Grimacing and lip smacking B. Falling asleep in the chair and refusing to eat lunch C. Experiencing muscle rigidity and tremors D. Having excessive salivation and drooling

ANS: A TD manifests as abnormal movements of voluntary muscle groups after a prolonged period of dopamine blockade. Movements may affect any muscle group, but muscles of the face, mouth, tongue, and digits are commonly affected. Falling asleep is reflective of the sedative effect of these medications. Muscle rigidity and drooling reflect EPS caused from imbalance between dopamine and acetylcholine.

A mental health technician asks the nurse, How do psychiatrists determine which diagnosis to give a patient? Which of these responses by the nurse would be most accurate? A. Psychiatrists use pre-established criteria from the APAs Diagnostic and Statistical Manual of Mental Disorders (DSM-5). B. Hospital policy dictates how psychiatrists diagnose mental disorders. C. Psychiatrists assess the patient and identify diagnoses based on the patients unhealthy responses and contributing factors. D. The American Medical Association identifies 10 diagnostic labels that psychiatrists can choose from.

ANS: A The DSM-5 is an organized manual describing mental disorders and the criteria that determine whether a given diagnosis is appropriate. It is published by the American Psychiatric Association (APA). It intends to facilitate accurate and reliable medical diagnosis and treatment. Item C describes nursing rather than medical diagnosis

The nurse should recognize which acronym as representing problem-oriented charting? A. SOAPIE B. SOLER C. DAR D. PQRST

ANS: A The assessment, acronym plan, SOAPIE implementation, represents problem-oriented and evaluation, format. charting, This which type of reflects charting the identifies subjective, nursing objective, diagnoses (client problems) on a written plan of care with appropriate nursing interventions described for each.

Without authorization, a nurse administers an extra dose of narcotic tranquilizer to an agitated client. The nurses coworker observes this action but does nothing for fear of repercussion. What is the ethical interpretation of the coworkers lack of involvement? A. Taking no action is still considered an action by the coworker. B. Taking no action releases the coworker from ethical responsibility. C. Taking no action is advised when potential adverse consequences are foreseen. D. Taking no action is acceptable, because the coworker is only a bystander.

ANS: A The coworkers lack of involvement can be interpreted as an action taken. The coworker is experiencing an ethical dilemma in which a decision needs to be made between two unfavorable alternatives. Although the coworker may be struggling with ethical decision making, he or she has witnessed another nurse dispensing medication outside of the scope of practice; therefore, from a legal perspective, this should be reported.

After assertiveness training, a formerly passive client appropriately confronts a peer in group therapy. The group leader states, Im so proud of you for being assertive. You are so good! Which communication technique has the leader employed? A. The nontherapeutic technique of giving approval B. The nontherapeutic technique of interpreting C. The therapeutic technique of presenting reality D. The therapeutic technique of making observations

ANS: A The group leader has employed the nontherapeutic technique of giving approval. Giving approval implies that the nurse has the right to pass judgment on whether the clients ideas or behaviors are good or bad. This creates a conditional acceptance of the client.

A psychiatric nurse working on an inpatient unit receives a call asking if an individual has been a client in the facility. Which nursing response reflects appropriate legal and ethical obligations? A. Refusing to give any information to the caller, citing rules of confidentiality B. Refusing to give any information to the caller by hanging up C. Affirming that the person has been seen at the facility but providing no further information D. Suggesting that the caller speak to the clients therapist

ANS: A The most appropriate action by the nurse is to refuse to give any information to the caller. Admission to the facility would be considered protected health information (PHI) and should not be disclosed by the nurse without prior client consent.

A Native American client is admitted to an emergency department (ED) with an ulcerated toe secondary to uncontrolled diabetes mellitus. The client refuses to talk to a physician unless a shaman is present. Which nursing intervention is most appropriate? A. Assist the client in contacting a shaman of his choice. B. Explain to the client that voodoo medicine will not heal the ulcerated toe. C. Ask the client to explain what the shaman can do that the physician cannot. D. Inform the client that refusing treatment is a clients right.

ANS: A The most appropriate nursing intervention would be to facilitate meeting the clients need to have a shaman present. The nurse should understand that in the Native American culture, religion and health-care practices are often intertwined. The shaman, a medicine man, may confer with physicians regarding the care of a client. Research supports the importance of both health-care systems in the overall wellness of Native American clients.

What is the most essential task for a nurse to accomplish prior to forming a therapeutic relationship with a client? A. To clarify personal attitudes, values, and beliefs B. To obtain thorough assessment data C. To determine the clients length of stay D. To establish personal goals for the interaction

ANS: A The most essential task for a nurse to accomplish prior to forming a therapeutic relationship with a client is to clarify personal attitudes, values, and beliefs. Understanding ones own attitudes, values, and beliefs is called self-awareness.

A nurse is assessing a client diagnosed with schizophrenia for the presence of hallucinations. Which therapeutic communication technique used by the nurse is an example of making observations? A. You appear to be talking to someone I do not see. B. Please describe what you are seeing. C. Why do you continually look in the corner of this room? D. If you hum a tune, the voices may not be so distracting.

ANS: A The nurse is making an observation when stating, You appear to be talking to someone I do not see. Making observations involves verbalizing what is observed or perceived. This encourages the client to recognize specific behaviors and make comparisons with the nurses perceptions.

Which therapeutic communication technique is being used in this nurse client interaction? Client: My father spanked me often. Nurse: Your father was a harsh disciplinarian. A. Restatement B. Offering general leads C. Focusing D. Accepting

ANS: A The nurse is using the therapeutic communication technique of restatement. Restatement involves repeating the main idea of what the client has said. The nurse uses this technique to communicate that the clients statement has been heard and understood.

Which client should the nurse anticipate to be most receptive to psychiatric treatment? A. A Jewish, female journalist B. A Baptist, homeless male C. A Catholic, black male D. A Protestant, Swedish business executive

ANS: A The nurse should anticipate that the client of Jewish culture would place a high importance on preventative health care and would consider mental health as equally important as physical health. Women are also more likely than men to seek treatment for mental health problems.

The following outcome was developed for a client: Client will list five personal strengths by the end of day 1. Which correctly written nursing diagnostic statement most likely generated the development of this outcome? A. Altered self-esteem R/T years of emotional abuse AEB self-deprecating statements B. Self-care deficit R/T altered thought processes C. Disturbed body image R/T major depressive disorder AEB mood rating of 2/10 D. Risk for disturbed self-concept R/T hopelessness AEB suicide attempt

ANS: A The nurse should determine that altered self-esteem and self-deprecating statements would generate the outcome to list personal strengths by the end of day 1. Self-care deficit, disturbed body image, and risk for disturbed self-concept would generate specific outcomes in accordance with specific needs and goals. The self- care deficit and risk for disturbed self-concept nursing diagnoses are incorrectly written.

Which client response should a nurse expect during the working phase of the nurse-client relationship? A. The client gains insight and incorporates alternative behaviors. B. The client and nurse establish rapport and mutually develop treatment goals. C. The client explores feelings related to reentering the community. D. The client explores personal strengths and weaknesses that impact behaviors.

ANS: A The nurse should expect that the client would gain insight and incorporate alternative behaviors during the working phase of the nurseclient relationship. The client may also overcome resistance, problem-solve, and continually evaluate progress toward goals.

In what way should a nurse expect a traditional Asian American client to view mental illness? A. Mental illness relates to uncontrolled behaviors that bring shame to the family. B. Mental illness is a curse from God related to immoral behaviors. C. Mental illness is cured by home remedies based on superstitions. D. Mental illness is cured by hot and cold herbal remedies.

ANS: A The nurse should expect that traditional Asian Americans are most likely to view mental illness as uncontrolled behavior that brings shame to the family. It is often more acceptable for mental distress to be expressed as physical ailments.

One nurse confronts another and says, You are always so talkative in the meetings. I dont know why you cant stay quiet sometimes. Which reply by the other nurse reflects the technique of clouding/fogging? A. Youre right. I do speak up a lot. B. Sounds to me like youre agitated and we need to talk. What are you truly angry about? C. Are you offended that I speak up, or because my thoughts are in opposition to yours? D. I have the right to express my opinion.

ANS: A This response reflects the use of clouding/fogging. When clouding/fogging is used it concurs with the critics argument without becoming defensive and without agreeing to change.

A newly admitted client asks, Why do we need a unit schedule? Im not going to these groups. Im here to get some rest. Which is the most appropriate nursing reply? A. Group therapy provides the opportunity to learn and practice new coping skills. B. Group therapy is mandatory. All clients must attend. C. Group therapy is optional. You can go if you find the topic helpful and interesting. D. Group therapy is an economical way of providing therapy to many clients concurrently.

ANS: A The nurse should explain to the client that the purpose of group therapy is to learn and practice new coping skills. A basic assumption of milieu therapy is that every interaction, including group therapy, is an opportunity for therapeutic intervention.

The following North American Nursing Diagnosis Association (NANDA) nursing diagnostic stem was developed for a client on an inpatient unit: Risk for injury. What assessment data most likely led to the development of this problem statement? A. The client is receiving electroconvulsive therapy (ECT) and is diagnosed with Parkinsonism. B. The client has a history of four suicide attempts in adolescence. C. The client expresses hopelessness and helplessness and isolates self. D. The client has disorganized thought processes and delusional thinking.

ANS: A The nurse should identify that a client receiving ECT and who is diagnosed with Parkinsonism is at risk for injury due to confusion and potential for falls. History of suicide and hopelessness would lead to the development of nursing diagnosis of risk for suicide. Disorganized thoughts and delusional thinking would lead to the development of a nursing diagnosis of altered thought processes.

Which cultural considerations should a nurse identify with Western European Americans? A. They are present-time oriented and perceive the future as Gods will. B. They value youth, and older adults are commonly placed in nursing homes. C. They are at high risk for alcoholism due to a genetic predisposition. D. They are future oriented and practice preventive health care.

ANS: A The nurse should identify that most Western European Americans are present oriented and perceive the future

A new psychiatric nurse states, This clients use of defense mechanisms should be eliminated. Which is a correct evaluation of this nurses statement? A. Defense mechanisms can be self-protective responses to stress and need not be eliminated. B. Defense mechanisms are a maladaptive attempt of the ego to manage anxiety and should always be eliminated. C. Defense mechanisms, used by individuals with weak ego integrity, should be discouraged and not eliminated. D. Defense mechanisms cause disintegration of the ego and should be fostered and encouraged.

ANS: A The nurse should know that defense mechanisms serve the purpose of reducing anxiety during times of stress. A client with no defense mechanisms may have a lower tolerance for stress, predisposing him or her to anxiety disorders. Defense mechanisms should be confronted when they impede the client from developing healthy coping skills.

A client requests information on several medications in order to make an informed choice about management of depression. A nurse should provide this information to facilitate which ethical principle? A. Autonomy B. Beneficence C. Nonmaleficence D. Justice

ANS: A The nurse should provide the information to support the clients autonomy. A client who is capable of making independent choices should be permitted to do so. In instances when clients are incapable of making informed decisions, a legal guardian or representative would be asked to give consent.

During the first interview with a man from Syria who has just lost his son in a car accident, in sympathy for the mans loss, the female nurse reaches out and hugs him. Which is an accurate evaluation of the nurses action? A. The nurses action should be evaluated as unacceptable due to breach of cultural norms. B. The nurses action should be evaluated as empathetic, encouraging expression of feelings. C. The nurses action should be evaluated as the technique of offering self. D. The nurses action should be evaluated as inappropriate due to poor timing.

ANS: A The nurses action should be evaluated as unacceptable due to breach of cultural norms. During communication, Arab Americans stand close together, maintain steady eye contact, and may touch the others hand or shoulder but only between members of the same sex.

A client has made the decision to leave her alcoholic husband. She is feeling very depressed. Which nontherapeutic statement by the nurse conveys sympathy? A. You are feeling very depressed. I felt the same way when I decided to leave my husband. B. I can understand you are feeling depressed. It was a difficult decision. Ill sit with you. C. You seem depressed. It was a difficult decision to make. Would you like to talk about it? D. I know this is a difficult time for you. Would you like a prn medication for anxiety?

ANS: A The nurses statement, You are feeling very depressed. I felt the same when I decided to leave my husband, is a nontherapeutic statement that conveys sympathy. Sympathy implies that the nurse shares what the client is feeling and by this personal expression alleviates the clients distress.

To promote self-reliance, how should a psychiatric nurse best conduct medication administration? A. Encourage clients to request their medications at the appropriate times. B. Refuse to administer medications unless clients request them at the appropriate times. C. Allow the clients to determine appropriate medication times. D. Take medications to the clients bedside at the appropriate times.

ANS: A The psychiatric nurse promoting self-reliance would encourage clients to request their medications at the appropriate times. Nurses are responsible for the management of medication administration on inpatient psychiatric units; however, nurses must work with clients to foster independence and provide experiences that would foster increased self-esteem.

Which example of a therapeutic communication technique would be effective in the planning phase of the nursing process? A. Weve discussed past coping skills. Lets see if these coping skills can be effective now. B. Please tell me in your own words what brought you to the hospital. C. This new approach worked for you. Keep it up. D. I notice that you seem to be responding to voices that I do not hear.

ANS: A This is an example of the therapeutic communication technique of formulating a plan of action. By the use of this technique the nurse can help the client plan in advance to deal with a stressful situation, which may prevent anger and/or anxiety from escalating to an unmanageable level.

A client is trying to explore and solve a problem. Which nursing statement would be an example of verbalizing the implied? A. You seem to be motivated to change your behavior. B. How will these changes affect your family relationships? C. Why dont you make a list of the behaviors you need to change. D. The team recommends that you make only one behavioral change at a time.

ANS: A This is an example of the therapeutic communication technique of verbalizing the implied. Verbalizing the implied puts into words what the client has only implied or said indirectly.

During a nurseclient interaction, which nursing statement may belittle the clients feelings and concerns? A. Dont worry. Everything will be alright. B. You appear uptight. C. I notice you have bitten your nails to the quick. D. You are jumping to conclusions.

ANS: A This nursing statement is an example of the nontherapeutic communication block of belittling feelings. Belittling feelings occurs when the nurse misjudges the degree of the clients discomfort, suggesting a lack of empathy and understanding.

Which nursing response is an example of the nontherapeutic communication block of requesting an explanation? A. Can you tell me why you said that? B. Keep your chin up. Ill explain the procedure to you. C. There is always an explanation for both good and bad behaviors. D. Are you not understanding the explanation I provided?

ANS: A This nursing statement is an example of the nontherapeutic communication block of requesting an explanation. Requesting an explanation is when the client is asked to provide the reason for thoughts, feelings, behaviors, and events. Asking why a client did something or feels a certain way can be very intimidating and implies that the client must defend his or her behavior or feelings.

A student nurse is learning about the appropriate use of touch when communicating with clients diagnosed with psychiatric disorders. Which statement by the instructor best provides information about this aspect of therapeutic communication? A. Touch carries a different meaning for different individuals. B. Touch is often used when deescalating volatile client situations. C. Touch is used to convey interest and warmth. D. Touch is best combined with empathy when dealing with anxious clients.

ANS: A Touch can elicit both negative and positive reactions, depending on the people involved and the circumstances of the interaction.

A Latino American man refuses to acknowledge responsibility for hitting his wife, stating instead, Its the mans job to keep his wife in line. Which cultural belief may be associated with this clients behavior? A. Traditional Latino American families are male dominated with clear male-female role distinctions. B. Religious tenets of Latino American culture support the use of violence within a marriage. C. Latino American families are female dominated and the mother possesses ultimate authority. D. Marriage dynamics are controlled by dominant females in Latin American families

ANS: A Traditional Latino American families are male dominated with clear male female role distinctions and may impact the clients perception about whether or not striking his wife is physical abuse. The nurse should also recognize that cultural beliefs do no exempt one from adhering to state and federal laws with regard to assault and battery.

Which client statement may indicate a transference reaction? A. I need a real nurse. You are young enough to be my daughter and I dont want to tell you about my personal life. B. I deserve more than I am getting here. Do you know who I am and what I do? Let me talk to your supervisor. C. I dont seem to be able to relate to people. I would rather stay in my room and be by myself. D. My mother is the source of my problems. She has always told me what to do and what to say.

ANS: A Transference occurs when a client unconsciously displaces or transfers to the nurse feelings formed toward a person from the past.

How is the DSM-5 useful in the practice of psychiatric nursing? Select all that apply. A. It informs the nurse of accurate and reliable medical diagnosis. B. It represents progress toward a more holistic view of mindbody. C. It provides a framework for interdisciplinary communication. D. It provides a template for nursing care plans. E. It provides a framework for communication with the client.

ANS: A, B, C The DSM-5 is useful in the practice of psychiatric nursing because it facilitates comprehensive evaluation of the client. In addition, it encourages a holistic view and provides a framework for interdisciplinary communication.

Which of the following are cultural aspects of mental illness? Select all that apply. A. Local or cultural norms define pathological behavior. B. The higher the social class the greater the recognition of mental illness behaviors. C. Psychiatrists typically see patients when the family can no longer deny the illness. D. The greater the cultural distance from the mainstream of society, the greater the likelihood that the illness will be treated with sensitivity and compassion

ANS: A, B, C The fewer ties that a group has with mainstream society, the greater the likelihood of a negative response by society to mental illness. Coercive treatments and involuntary hospitalizations are more common in this population.

A 47-year-old mother of two has recently undergone a radical mastectomy. She refuses to see anyone and remains isolated and withdrawn. Which of the following may be relevant nursing diagnoses for this client? Select all that apply. A. Disturbed body image B. Situational low self-esteem C. Ineffective coping D. Altered thought processes E. Altered sensory perception

ANS: A, B, C The mastectomy is likely to disturb the clients body image. She is ineffectively coping by withdrawing. She may be experiencing negative feelings about herself related to her altered body image, which would result in low self-esteem. None of the symptoms presented indicate a problem with either altered thought or altered sensory perception.

A nurse is caring for four clients. Which of the following clients should the nurse identify as likely to experience difficulty in being assertive? Select all that apply. A. A 20-year-old woman who is completing college homework assignments for several peers. B. A 69-year-old widow who is socially isolated C. A 17-year-old boy with conduct disorder D. A 45-year-old successful executive E. A 50-year-old diagnosed with narcissistic personality disorder

ANS: A, B, C The woman who is taking on the work of others in addition to her own may be having difficulty assertively saying no; the widow who is socially isolated may lack the necessary skills to communicate her needs; and the boy with a conduct disorder is likely to demonstrate aggressive behaviors. The business executive and an individual diagnosed with narcissistic personality disorder are the least likely to have difficulty being assertive.

Which of the following individuals are communicating a message? Select all that apply. A. A mother spanking her son for playing with matches B. A teenage boy isolating himself and playing loud music C. A biker sporting an eagle tattoo on his biceps D. A teenage girl writing, No one understands me E. A father checking for new e-mail on a regular basis

ANS: A, B, C, D The nurse should determine that spanking, isolating, getting tattoos, and writing are all ways in which people communicate messages to others. It is estimated that about 70% to 90% of communication is nonverbal.

A nurse is working with a client who has recently been under a great deal of stress. Which nursing recommendations would be most helpful when assisting the client in coping with stress? Select all that apply. A. Enjoy a pet. B. Spend time with a loved one. C. Listen to music. D. Focus on the stressors. E. Journal your feelings.

ANS: A, B, C, E Focusing on the stressors is more likely to increase stress in the clients life. However, pets, music, journaling feelings, and healthy relationships have all been shown to decrease amounts of stress

A nurse is caring for a client who has recently undergone a radical prostatectomy. Which of the following should the nurse recognize as objective symptoms of low self-esteem? Select all that apply. A. Withdrawal from activities B. A decrease in self-care behaviors C. Poor eye contact D. Reports of pain E. Poor posture

ANS: A, B, C, E Withdrawal from activities, a decrease in self-care behaviors, eye contact, and poor posture are all common objective manifestations of low self-esteem. A report of pain should be evaluated as a physical issue before being attributed solely to low self esteem.

A nurse is assessing a client who appears to be experiencing moderate anxiety during questioning. Which symptoms might the client demonstrate? Select all that apply. A. Fidgeting B. Laughing inappropriately C. Palpitations D. Nail biting E. Extremely limited attention span

ANS: A, B, D The nurse should assess that fidgeting, laughing inappropriately, and nail biting are indicative of heightened stress levels. The client would not be diagnosed with mental illness unless there is significant impairment in other concentrating, areas of daily muscle functioning. tension, and Other sleep indicators disturbance.

A nurse is interviewing a distressed client, who relates being fired after 15 years of loyal employment. Which of the following questions would best assist the nurse to determine the clients appraisal of the situation? Select all that apply. A. What resources have you used previously in stressful situations? B. Have you ever experienced a similar stressful situation? C. Who do you think is to blame for this situation? D. Why do you think you were fired from your job? E. What skills do you possess that might lead to gainful employment?

ANS: A, B, E These questions specifically address the clients coping resources and encourage the client to apply learning from past experiences. These questions also encourage the client to consider alternative methods for dealing with stress. Asking who is to blame does not assess coping abilities but, rather, encourages maladaptive behavior. Requesting an explanation is a nontherapeutic block to communication.

A female nurse is caring for a traditional Arab American male client. When planning effective care for this client, the nurse should be aware of which of the following cultural considerations? Select all that apply. A. Limited touch is acceptable only between members of the same sex. B. Conversing individuals of this culture stand far apart and do not make eye contact. C. Devout Muslim men may not shake hands with women. D. The man is the head of the household and women take on a subordinate role. E. In traditional culture, men are responsible for the education of their children.

ANS: A, C, D When planning effective care for this client, the nurse should be aware that limited touch within this culture is acceptable only between members of the same sex, that devout Muslim men may not shake hands with women, and that women are subordinate to the man, who is the head of household. Conversing individuals of this culture stand close together and maintain eye contact. Arab American women are responsible for the education of the children.

Which of the following nursing interventions fall within the standards of psychiatric mental health clinical nursing practice for a nurse generalist? Select all that apply. A. Assist clients to perform activities of daily living. B. Act as a consultant with other clinicians to provide services for clients and effect system change C. Encourage clients to discuss triggers for relapse D. Use prescriptive authority in accordance with state and federal laws E. Educate families about signs and symptoms of alcohol dependence and withdrawal

ANS: A, C, E Assisting clients to perform daily living activities, encouraging clients to discuss triggers, and educating families are nursing interventions that fall within the standards of psychiatric clinical nursing practice for a nurse generalist. Psychiatric mental health advanced practice registered nurses can consult with other clinicians and use prescriptive authority

Which of the following statements should a nurse recognize as true about defense mechanisms? Select all that apply. A. They are employed when there is a threat to biological or psychological integrity. B. They are controlled by the id and deal with primal urges. C. They are used in an effort to relieve mild to moderate anxiety. D. They are protective devices for the superego. E. They are mechanisms that are characteristically self-deceptive.

ANS: A, C, E Defense mechanisms are employed by the ego in the face of threats to biological and psychological integrity, in an effort to relieve mild to moderate anxiety. Because they redirect focus, they are characteristically self- deceptive.

Which should the nurse recognize as a DSM-5 disorder? A. Obesity B. Generalized anxiety disorder C. Hypertension D. Grief

ANS: B The DSM-5 identifies several disorders that are related to anxiety, including generalized anxiety disorder, somatic symptom disorder, and dissociative disorders.

After disturbing the peace, an aggressive, disoriented, unkempt, homeless individual is escorted to an emergency department by police. The client threatens suicide. Which criteria would enable a physician to consider involuntary commitment? Select all that apply. A. Being dangerous to others B. Being homeless C. Being disruptive to the community D. Being gravely disabled and unable to meet basic needs E. Being suicidal

ANS: A, D, E The physician could consider involuntary commitment when a client is being dangerous to others, is gravely disabled, or is suicidal. If the client is determined to be mentally incompetent, consent should be obtained from the legal guardian or court-approved guardian or conservator. A hospital administrator may give permission for involuntary commitment when time does not permit court intervention.

Which phase of the nurseclient relationship begins when the individuals first meet and is characterized by an agreement to continue to meet and work on setting client-centered goals? A. Preinteraction B. Orientation C. Working D. Termination

ANS: B The orientation phase is when the individuals first meet and is characterized by an agreement to continue to meet and work on setting client-centered goals. There are four phases of relationship development: preinteraction, orientation, working, and termination.

Which is an example of an intentional tort? A. A nurse fails to assess a clients obvious symptoms of neuroleptic malignant syndrome. B. A nurse physically places an irritating client in four-point restraints. C. A nurse makes a medication error and does not report the incident. D. A nurse gives patient information to an unauthorized person

ANS: B A tort is a violation of civil law in which an individual has been wronged and can be intentional or unintentional. A nurse who physically places an irritating client in restraints has touched the client without consent and has committed an intentional tort. Examples of unintentional torts are malpractice and negligence actions.

A nurse is conducting education on anxiety and stress management. Which of the following should be identified as the most important initial step in learning how to manage anxiety? A. Diagnostic blood tests B. Awareness of factors creating stress C. Relaxation exercises D. Identifying support systems

ANS: B Although all of the above answers may be useful in the comprehensive management of stress, the initial step is awareness that stress is being experienced and awareness of factors that create stress.

During a psychoeducational group on assertiveness training, a client asks, Why do we need to learn about this stuff? Which is the most appropriate nursing reply? A. Because your doctor requires you to attend this group. B. Being assertive is the ability to stand up for yourself while respecting the rights of others. C. Assertiveness training teaches you how to ask for what you want, when you want it. D. Assertive people place the needs and rights of others before their own.

ANS: B Assertiveness training assists people to maintain their own self-respect and meet their needs while respecting the rights of others.

A client shows a nurse a piece of artwork that took 3 days to create. How will this achievement improve the clients self-esteem? A. By providing a framework for assertive behavior B. By providing an expression of feelings and a sense of competence and pride C. By providing a positive perception of body image D. By providing appropriate boundaries for relationship establishment

ANS: B Creating the artwork provides expression of feelings and a sense of competence and pride. This will most likely have a positive effect on the clients self-esteem.

Which symptom should a nurse identify as typical of the fight-or-flight response? A. Pupil constriction B. Increased heart rate C. Increased salivation D. Increased peristalsis

ANS: B During the fight-or-flight response, the heart rate increases in response to the release of epinephrine. Pupils dilate to enhance vision. Salivation and peristalsis decrease as the body slows unessential functions.

In the situation presented, which nursing intervention constitutes false imprisonment? A. The client is combative and will not redirect, stating, No one can stop me from leaving. The nurse seeks the physicians order after the client is restrained. B. The client has been consistently seeking the attention of the nurses much of the day. The nurse institutes seclusion. C. A psychotic client, admitted in an involuntary status, runs off the psychiatric unit. The nurse runs after the client and the client agrees to return. D. A client hospitalized as an involuntary admission attempts to leave the unit. The nurse calls the security team and they prevent the client from leaving.

ANS: B False imprisonment is the deliberate and unauthorized commitment of a person within fixed limits by the use of verbal or physical means. Seclusion should only be used in an emergency situation to prevent harm after least restrictive means have been unsuccessfully attempted.

A student nurse tells the instructor, Im concerned that when a client asks me for advice I wont have a good solution. Which should be the nursing instructors best response? A. Its scary to feel put on the spot by a client. Nurses dont always have the answer. B. Remember, clients, not nurses, are responsible for their own choices and decisions. C. Just keep the clients best interests in mind and do the best that you can. D. Set a goal to continue to work on this aspect of your practice.

ANS: B Giving advice tells the client what to do or how to behave. It implies that the nurse knows what is best and that the client is incapable of any self-direction. It discourages independent thinking.

A client is assigned the nursing diagnosis of impaired social interaction R/T sociocultural differences AEB client stating, Although Id like to, I dont join in because I dont speak the language so good. Which correctly written outcome addresses this clients problem? A. The client will collaborate with nursing staff to set specific goals by day 3. B. The client will participate in one group activity of choice by day 2. C. The client will express a desire to interact with others. D. The client will become increasingly independent by discharge.

ANS: B In the planning phase of the nursing process, the nurse works with the client to identify expected outcomes for a plan individualized to the client need or to the situation.

A client has a history of excessive drinking, which has led to multiple arrests for driving under the influence (DUI). The client states, I work hard to provide for my family. I dont see why I cant drink to relax. The nurse recognizes the use of which defense mechanism? A. Projection B. Rationalization C. Regression D. Sublimation

ANS: B The nurse should recognize that the client is using rationalization, a common defense mechanism. The client is attempting to make excuses and create logical reasons to justify unacceptable feelings or behaviors.

On the basis of Eriksons theory, how should a nurse encourage a 40-year-old client to improve his or her self-esteem? A. Encourage the client to review life goals and accomplishments. B. Encourage the client to volunteer at a school, reading to underprivileged children. C. Encourage the client to form lasting intimate relationships. D. Encourage the client to seek recognition for task achievement.

ANS: B Making meaningful contributions to others is a way to meet the developmental task of the generativity versus stagnation (30 to 65 years) stage of Eriksons developmental theory. This action would promote a 40-year-old clients self-esteem.

The nurse is preparing to provide medication instruction for a patient. Which of the following understandings about anxiety will be essential to effective instruction? A. Learning is best when anxiety is moderate to severe. B. Learning is enhanced when anxiety is mild. C. Panic level anxiety helps the nurse teach better. D. Severe anxiety is characterized by intense concentration and enhances the attention span.

ANS: B Mild anxiety sharpens the senses, increases the perceptual field, and results in heightened awareness of the environment. Learning is enhanced. As anxiety increases, attention span decreases and learning becomes more difficult.

A nursing instructor is teaching about cultural characteristics. Which statement by the student indicates the need for further instruction? A. All cultures communicate freely within their group. B. All cultures embrace light therapeutic touch. C. All cultures view the importance of timeliness differently. D. All cultures display biological variations.

ANS: B Not all cultures embrace light therapeutic touch. In the Native American culture, if a hand is offered to another it may be accepted with a light touch; however, in the Asian culture, touching during communication has been historically considered unacceptable. This student statement indicates the need for further instruction.

A client who experiences stress on a regular basis asks a nurse what causes these feelings. Which is the most appropriate nursing response? A. Genetics have nothing to do with your temperament. B. How you reacted to past experiences influences how you feel now. C. If youre in good physical health, your stress level will be low. D. Stress can always be avoided if appropriate coping mechanisms are employed.

ANS: B Past experiences are occurrences that result in learned patterns that can influence an individuals current adaptation response. They include previous exposure to the stressor or other stressors in general, learned coping responses, and degree of adaptation to previous stressors.

A nurse instructs a patient taking a drug that inhibits monoamine oxidase (MAO) to avoid certain foods and drugs because of the risk of: A. hypotensive shock. B. hypertensive crisis. C. cardiac dysrhythmia. D. cardiogenic shock

ANS: B Patients taking MAO-inhibiting drugs must be on a tyramine-free diet to prevent hypertensive crisis. In the presence of MAOIs, tyramine is not destroyed by the liver and in high levels produces intense vasoconstriction, resulting in elevated blood pressure.

A school nurse is assessing a distraught female high school student who is overly concerned because her parents cant afford horseback riding lessons. How should the nurse interpret the students reaction to her perceived problem? A. The problem is endangering her well-being. B. The problem is personally relevant to her. C. The problem is based on immaturity. D. The problem is exceeding her capacity to cope.

ANS: B Psychological stressors to self-esteem and self-image are related to how the individual perceives the situation or event. Self-image is of particular importance to adolescents, who feel entitled to have all the advantages that other adolescents experience.

The experience of being physically restrained can be traumatic. Which nursing intervention would best help the client deal with this experience? A. Administering a tranquilizing medication before applying the restraints B. Talking to the client at brief but regular intervals while the client is restrained C. Decreasing stimuli by leaving the client alone most of the time D. Checking on the client infrequently, in order to meet documentation requirements

ANS: B Restraints are never to be used as punishment or for the convenience of the staff. Connecting with the client by maintaining communication during the period of restraint will help the client recognize this intervention as a therapeutic treatment versus a punishment.

A nurse is educating a patient about the difference between mental health and mental illness. Which statement by the patient reflects an accurate understanding of mental health? A. Mental health is the absence of any stressors. B. Mental health is successful adaptation to stressors in the internal and external environment. C. Mental health is incongruence between thoughts, feelings, and behavior D. Mental health is a diagnostic category in the DSM-5.

ANS: B Several definitions of mental health exist, but this definition highlights concepts of successful adaptation to stressors, including thoughts, feelings, and behaviors that are age-appropriate and congruent with cultural and societal norms.

During the implementation phase of the nursing process, a nurse is teaching an adult depressed patient with a cochlear implant about medications. Which modification in the teaching plan would be the most appropriate for this client? A. Using repetition B. Speaking directly face-to-face C. Employing the use of sign language D. Providing large-print materials

ANS: B Speaking face-to-face is an appropriate way to teach individuals with alterations in hearing.

Within the nurses scope of practice, which function is exclusive to the advance practice psychiatric nurse? A. Teaching about the side effects of neuroleptic medications B. Using psychotherapy to improve mental health status C. Using milieu therapy to structure a therapeutic environment D. Providing case management to coordinate continuity of health services

ANS: B The advanced practice psychiatric nurse is authorized to use psychotherapy to improve mental health. This includes individual, couples, group, and family psychotherapy. It is within the scope of practice of a registered psychiatric mental health nurse generalist to provide education, case management, and milieu therapy.

During a hiring interview, which response by a nursing applicant should indicate that the applicant operates from an ethical egoism framework? A. I would want to be treated in a caring manner if I were mentally ill. B. This job will pay the bills, and the workload is light enough for me. C. I will be happy caring for the mentally ill. Working in Med/Surg kills my back. D. It is my duty in life to be a psychiatric nurse. It is the right thing to do.

ANS: B The applicants comment reflects an ethical egoism framework. This framework promotes the idea that decisions are based on what is good for the individual and may not take the needs of others into account.

Which statement is most accurate regarding the assessment of clients diagnosed with psychiatric problems? A. Medical history is of little significance and can be eliminated from the nursing assessment. B. Assessment provides a holistic view of the client, including biopsychosocial aspects. C. Comprehensive assessments can be performed only by advanced practice nurses. D. Psychosocial evaluations are gained by subjective reports rather than objective observations.

ANS: B The assessment of clients diagnosed with psychiatric problems should provide a holistic view of the client. A thorough assessment involves collecting and analyzing data from the client, significant others, and health-care providers that may include the following dimensions: physical, psychological, sociocultural, spiritual, cognitive, developmental, economic, lifestyle, and functional abilities.

A mother rescues two of her four children from a house fire. In an emergency department, she cries, I should have gone back in to get them. I should have died, not them. Which of the following responses by the nurse is an example of reflection? A. The smoke was too thick. You couldnt have gone back in. B. Youre feeling guilty because you werent able to save your children. C. Focus on the fact that you could have lost all four of your children. D. Its best if you try not to think about what happened. Try to move on.

ANS: B The best response by the nurse is, Youre experiencing feelings of guilt because you werent able to save your children. This response utilizes the therapeutic communication technique of reflection, which identifies a clients emotional response and reflects these feelings back to the client so that they may be recognized and accepted.

In response to a students question regarding choosing a psychiatric specialty, a charge nurse states, Mentally ill clients need special care. If I were in that position, Id want a caring nurse also. From which ethical framework is the charge nurse operating? A. Kantianism B. Christian ethics C. Ethical egoism D. Utilitarianism

ANS: B The charge nurse is operating from a Christian ethics framework. A basic principle in Christian ethics is to do unto others as you would have them do unto you. Kantianism states that decisions should be based on moral law and that actions are bound by a sense of moral duty. Utilitarianism holds that decisions should be made with a focus on the end result being happiness. Ethical egoism promotes the idea that what is right is good for the individual.

What is the main goal of the working phase of the nurse client therapeutic relationship? A. Role modeling to improve interaction with others B. Resolution of the clients problems C. Using therapeutic communication to clarify perceptions D. Helping the client access outpatient treatment

ANS: B The goal of the working phase of the nurseclient therapeutic relationship is to resolve client problems by promoting behavioral change.

A client diagnosed with schizophrenia functions well and is bright, spontaneous, and interactive during hospitalization but then decompensates after discharge. What does the milieu provide that may be missing in the home environment? A. Peer pressure B. Structured programming C. Visitor restrictions D. Mandated activities

ANS: B The milieu, or therapeutic community, provides the client with structured programming that may be missing in the home environment. The therapeutic community provides a structured schedule of activities in which interpersonal interaction and communication with others are emphasized. In the milieu, time is also devoted to personal problems and focus groups.

Which situation exemplifies both assault and battery? A. The nurse becomes angry, calls the client offensive names, and withholds treatment. B. The nurse threatens to tie down the client and then does so against the clients wishes. C. The nurse hides the clients clothes and medicates the client to prevent elopement. D. The nurse restrains the client without just cause and communicates this to family.

ANS: B The nurse in this situation has committed both the acts of assault and battery. Assault refers to an action that results in fear and apprehension that the person will be touched without consent. Battery is the touching of another person without consent.

A hungry, homeless client, diagnosed with schizophrenia, refuses to participate in an admission interview. When the nurse postpones the admission interview, verbally assures safety, and provides a warm meal, he or she is promoting which of the following? A. Sympathy B. Trust C. Veracity D. Manipulation

ANS: B The nurse is promoting trust by postponing the admission interview, assuring safety, and providing a warm meal. Trust implies a feeling of confidence that a person is reliable and sincere and has integrity and veracity. Trustworthiness is demonstrated through nursing interventions that convey a sense of warmth and caring to the client.

When working with clients of any culture, which action should a nurse avoid? A. Maintaining eye contact, based on cultural norms B. Assuming that all individuals who share a culture or ethnic group are similar C. Supporting the client in participating in cultural and spiritual rituals D. Using an interpreter to clarify communication

ANS: B The nurse should avoid assuming that all individuals who share a culture or ethnic group are similar. This action constitutes stereotyping and must be avoided. Within each culture, many variations and subcultures exist. Clients should be treated as individuals.

At what point should the nurse determine that a client is at risk for developing a mental disorder? A. When thoughts, feelings, and behaviors are not reflective of the DSM-5 criteria B. When maladaptive responses to stress are coupled with interference in daily functioning C. When the client communicates significant distress D. When the client uses defense mechanisms as ego protection

ANS: B The nurse should determine that the client is at risk for mental disorder when responses to stress are maladaptive and interfere with daily functioning. The DSM-5 indicates that in order to be diagnosed with a mental disorder, there must be significant disturbance in cognition, emotion, regulation, or behavior that reflects a dysfunction in the psychological, biological or developmental processes underlying mental functioning. These disorders are usually associated with significant distress or disability in social, occupational, or other important activities. The clients ability to communicate distress would be considered a positive attribute.

A teenage boy is attracted to a female teacher. Without objective evidence, a school nurse overhears the boy state, I know she wants me. This statement reflects which defense mechanism? A. Displacement B. Projection C. Rationalization D. Sublimation

ANS: B The nurse should determine that the clients statement reflects the defense mechanism of projection. Projection refers to the attribution of ones unacceptable feelings or impulses to another person. When the client passes the blame of the undesirable feelings, anxiety is reduced. Displacement refers to transferring feelings from one target to another. Rationalization refers to making excuses to justify behavior. Sublimation refers to channeling unacceptable drives or impulses into more constructive, acceptable activities.

Which nursing diagnosis should a nurse identify as being correctly formulated? A. Schizophrenia R/T biochemical alterations AEB altered thought B. Self-care deficit: hygiene R/T altered thought as AEB disheveled appearance C. Depressed mood R/T multiple life stressors D. Developmental disability R/T early-onset schizophrenia AEB hallucinations

ANS: B The nurse should determine that the correctly written diagnosis would be Self-care deficit: hygiene R/T altered thought AEB disheveled appearance. The nursing diagnosis should describe the unhealthy response (inference), the contributing factors, and the data that support the inference.

A nurse maintains an uncrossed arm and leg posture. This nonverbal behavior is reflective of which letter of the SOLER acronym for active listening? A. S B. O C. L D. E E. R

ANS: B The nurse should identify that maintaining an uncrossed arm and leg posture is nonverbal behavior that reflects the O in the active-listening acronym SOLER. The acronym SOLER includes sitting squarely facing the client (S), open posture when interacting with the client (O), leaning forward toward the client (L), establishing eye contact (E), and relaxing (R).

Which client should a nurse identify as a potential candidate for involuntarily commitment? A. A client living under a bridge in a cardboard NURSINGTB.COM box B. A client threatening to commit suicide C. A client who never bathes and wears a wool hat in the summer D. A client who eats waste out of a garbage can

ANS: B The nurse should identify the client threatening to commit suicide as eligible for involuntary commitment. The suicidal client who refuses treatments is a danger to self and requires emergency treatment.

According to Maslows hierarchy of needs, which situation on an inpatient psychiatric unit would require priority intervention by a nurse? A. A client rudely complaining about limited visiting hours B. A client exhibiting aggressive behavior toward another client C. A client stating that no one cares D. A client verbalizing feelings of failure

ANS: B The nurse should immediately intervene when a client exhibits aggressive behavior toward another client. Safety and security are considered lower-level needs according to Maslows hierarchy of needs and must be fulfilled before other, higher-level needs can be met. Clients who complain, have feelings of failure, or state that no one cares are struggling with higher-level needs such as the need for love and belonging or the need for self-esteem.

What is the best rationale for including the clients family in therapy within the inpatient milieu? A. To structure a program of social and work-related activities B. To facilitate discharge from the hospital C. To provide a concrete demonstration of caring D. To encourage the family to model positive behaviors

ANS: B The nurse should include the clients family in therapy within the inpatient milieu to facilitate discharge from the hospital. Family members are invited to participate in some therapy groups and to share meals with the client in the communal dining room. Family involvement may also serve to prevent the client from becoming too dependent on the therapeutic environment.

How should a nurse prioritize nursing diagnoses? A. By the established goal of care B. By the life-threatening potential C. By the physicians priority of care D. By the clients preference

ANS: B The nurse should prioritize nursing diagnoses related to life-threatening potential. Safety is always the nurses first priority.

A client diagnosed with paranoid schizophrenia becomes agitated when asked to play a game. The client responds, Do you want to be my girlfriend? Which nursing response is most appropriate? A. You are upset now. It would be best if you go to your room until you feel better. B. Remember, we have a professional relationship. Are you feeling uncomfortable? C. We have discussed this before. I am not allowed to date clients. D. I think you should discuss your fantasies with your therapist.

ANS: B The nurse should promote the clients insight and perception of reality by confirming appropriate roles in the nurseclient relationship and identifying what is troubling the client in this situation.

Which nursing statement about the concept of psychoses is most accurate? A. Individuals experiencing psychoses are aware that their behaviors are maladaptive. B. Individuals experiencing psychoses experience little distress. C. Individuals experiencing psychoses are aware of experiencing psychological problems. D. Individuals experiencing psychoses are based in reality.

ANS: B The nurse should understand that the client with psychoses experiences little distress, because of his or her lack of awareness of reality. The client with psychoses is unaware that his or her behavior is maladaptive or that he or she has a psychological problem.

Which nursing statement about the concept of neuroses is most accurate? A. An individual experiencing neurosis is unaware that he or she is experiencing distress. B. An individual experiencing neurosis feels helpless to change his or her situation. C. An individual experiencing neurosis is aware of psychological causes of his or her behavior. D. An individual experiencing neurosis has a loss of contact with reality.

ANS: B The nurse should understand that the concept of neuroses includes the following characteristics. The client feels helpless to change his or her situation, the client is aware that he or she is experiencing distress, the client is aware the behaviors are maladaptive, the client is unaware of the psychological causes of the distress, and the client experiences no loss of contact with reality.

Which nursing action demonstrates the role of the teacher in a therapeutic milieu? A. The nurse implements a self-affirmation exercise during a one-to-one client interaction. B. The nurse holds a group meeting to present common side effects of psychiatric medications. C. The nurse introduces the concept of fair play while playing cards with a group of clients. D. The nurse models adaptive and effective coping mechanisms with clients on the psychiatric unit.

ANS: B The nurse, in the role of teacher, identifies learning needs and provides information required by the client or family to improve the clients health.

A client diagnosed with post-traumatic stress disorder is admitted to an inpatient psychiatric unit for evaluation and medication stabilization. Which therapeutic communication technique used by the nurse is an example of a broad opening? A. What occurred prior to the rape, and when did you go to the emergency department? B. What would you like to talk about? C. I notice you seem uncomfortable discussing this. D. How can we help you feel safe during your stay here?

ANS: B The nurses statement, What would you like to talk about? is an example of the therapeutic communication technique of giving broad openings. Using a broad opening allows the client to take the initiative in introducing the topic and emphasizes the importance of the clients role in the interaction.

A client diagnosed with schizophrenia is exhibiting nonverbal behaviors indicating that the client is hearing things that others do not. Which nursing diagnosis accurately reflects this clients problem? A. Altered thought processes B. Altered sensory perception C. Anxiety D. Chronic confusion

ANS: B The nursing diagnosis altered sensory perception accurately reflects the clients symptoms of hearing things that others do not. A nursing diagnosis describes a clients condition and facilitates the prescription of interventions. Delusional thinking, confusion, and disorientation are problems associated with the nursing diagnosis of altered thought processes.

A nursing instructor is teaching students about the purpose of using the nursing process in the care of psychiatric patients. Which of the following statements by the student indicates that learning has occurred? A. The nursing process is a method for interviewing the patient in a systematic way. B. The nursing process is used to assist patients to adapt successfully to stressors within the environment. C. The nursing process is used to provide support for the psychiatric diagnosis. D. The nursing process is used primarily to minimize allegations of negligence.

ANS: B The nursing process is a method for nursing care delivery in which the patients unhealthy responses are identified and interventions are planned, which are designed to assist the patient to adapt more successfully in their environment.

What is the priority nursing action during the orientation (introductory) phase of the nurse-client relationship? A. Acknowledge the clients actions and generate alternative behaviors. B. Establish rapport and develop treatment goals. C. Attempt to find alternative placement. D. Explore how thoughts and feelings about this client may adversely impact care.

ANS: B The priority nursing action during the orientation phase of the nurse-client relationship should be to establish rapport and develop treatment goals. Rapport implies feelings on the part of both the nurse and the client based on respect, acceptance, a sense of trust, and a nonjudgmental attitude. It is the essential foundation of the nurseclient relationship.

What is the purpose when a nurse gathers client information? A. It enables the nurse to modify client behaviors related to personality disorders. B. It enables the nurse to make sound clinical judgments and plan appropriate client care. C. It enables the nurse to prescribe the appropriate medications. D. It enables the nurse to assign the appropriate Axis I diagnosis.

ANS: B The purpose of gathering client information is to enable the nurse to make sound clinical nursing judgments and plan appropriate care. The nurse should complete a thorough assessment of the client, including information collected from the client, significant others, and health-care providers (consistent with HIPAA laws and the clients right to confidentiality).

A bright student confides in the school nurse about conflicts related to attending college or working to add needed financial support to the family. Which coping strategy is most appropriate for the nurse to recommend to the student at this time? A. Meditation B. Problem-solving training C. Relaxation D. Journaling

ANS: B The student must assess his or her situation and determine the best course of action. Problem-solving training, by providing structure and objectivity, can assist in decision making.

Which statement reflects a student nurses accurate understanding of the concepts of mental health and mental illness? A. The concepts are rigid and religiously based. B. The concepts are multidimensional and culturally defined. C. The concepts are universal and unchanging. D. The concepts are unidimensional and fixed.

ANS: B The student nurse should understand that mental health and mental illness are multidimensional and culturally defined. It is important for nurses to be aware of cultural norms when evaluating a clients mental state.

A patient hospitalized with a mood disorder has an elevated unstable mood, aggressiveness, agitation, talkativeness, and irritability. A nurse begins care planning based on the expectation that the health care provider is most likely to prescribe a medication classified as a(n): A. anticholinergic. B. mood stabilizer C. psychostimulant D. antidepressant

ANS: B The symptoms describe a manic attack. Mania is effectively treated by the antimanic drug lithium and selected anticonvulsants such as carbamazepine, valproic acid, and lamotrigine. No drugs from the other classifications listed are effective in the treatment of mania.

Group therapy is strongly encouraged, but not mandatory, on an inpatient psychiatric unit. The unit managers policy is that clients can make a choice about whether or not to attend group therapy. Which ethical principle does the unit managers policy preserve? A. Justice B. Autonomy C. Veracity D. Beneficence

ANS: B The unit managers policy regarding voluntary client participation in group therapy preserves the ethical principle of autonomy. The principle of autonomy presumes that individuals are capable of making independent decisions for themselves and that health-care workers must respect these decisions.

After fasting from 10 p.m. the previous evening, a client finds out that the blood test has been canceled. The client swears at the nurse and states, You are incompetent! Which is the nurses best response? A. Do you believe that I was the cause of your blood test being canceled? B. I see that you are upset, but I feel uncomfortable when you swear at me. C. Have you ever thought about ways to express anger appropriately? D. Ill give you some space. Let me know if you need anything.

ANS: B This is an example of the appropriate use of feedback. Feedback should be directed toward behavior that the client has the capacity to modify.

Which nursing statement is a good example of the therapeutic communication technique of offering self? A. I think it would be great if you talked about that problem during our next group session. B. Would you like me to accompany you to your electroconvulsive therapy treatment? C. I notice that you are offering help to other peers in the milieu. D. After discharge, would you like to meet me for lunch to review your outpatient progress?

ANS: B This is an example of the therapeutic communication technique of offering self. Offering self makes the nurse available on an unconditional basis, increasing clients feelings of self-worth. Professional boundaries must be maintained when using the technique of offering self.

Which therapeutic communication technique should the nurse use when communicating with a client who is experiencing auditory hallucinations? A. My sister has the same diagnosis as you and she also hears voices. B. I understand that the voices seem real to you, but I do not hear any voices. C. Why not turn up the radio so that the voices are muted. D. I wouldnt worry about these voices. The medication will make them disappear.

ANS: B This is an example of the therapeutic communication technique of presenting reality. Presenting reality is when the client has a misperception of the environment. The nurse defines reality or indicates his or her perception of the situation for the client.

A client slammed a door on the unit several times. The nurse responds, You seem angry. The client states, Im not angry. What therapeutic communication technique has the nurse employed, and what defense mechanism is the client unconsciously demonstrating? A. Making observations and the defense mechanism of suppression B. Verbalizing the implied and the defense mechanism of denial C. Reflection and the defense mechanism of projection D. Encouraging descriptions of perceptions and the defense mechanism of displacement

ANS: B This is an example of the therapeutic communication technique of verbalizing the implied. The nurse is putting into words what the client has only implied by words or actions. Denial is the refusal of the client to acknowledge the existence of a real situation, the feelings associated with it, or both.

A client continually waits more than an hour before being seen at the mental health clinic. The client approaches the nurse and states, When I have to wait for more than an hour to be seen, I feel like my time is not important. The nurse recognizes this as what type of behavior? A. Aggressive behavior B. Assertive behavior C. Passiveaggressive behavior D. Passive behavior

ANS: B This response is assertive. The client is openly expressing feelings and attempting to correct a stressful situation.

An emergency department nurse, who has worked 10 straight days, is pulled to the psychiatric unit. Which represents a passive aggressive statement by the emergency department nurse? A. Get someone else to work 3 to 11! Ive been working 10 days straight, and I need a break! B. Okay. Ill do it, then purposefully leaves paperwork undone when leaving the unit at 11 p.m. C. I have worked 10 days straight, and I cannot work tonight. I will work for you tomorrow if you need me. D. Yes, Ill do it. Anything to keep peace with the hospital administration is a good thing.

ANS: B This response is passiveaggressive. The staff nurses anger is expressed indirectly.

A teenager gets a C in algebra. The mother angrily states, All you ever do is listen to music and text your friends. The teenager replies, What is it that youre really upset about, mom? Which response pattern is the teenager expressing? A. Clouding and fogging B. Shifting from content to process C. Delaying assertively D. Assuming responsibility for ones own statements

ANS: B This response reflects the use of shifting from content to process. The teenager is changing the focus of the communication from discussing the topic at hand to analyzing what is actually going on in the interaction.

To effectively care for Asian American clients, a nurse should be aware of which cultural norm? A. Obesity and alcoholism are common problems. B. Older people maintain positions of authority within the culture. C. Milk is a staple in the Asian American diet. D. Asian Americans are likely to seek psychiatric help.

ANS: B To effectively care for clients of the Asian American culture, the nurse should be aware that older people in this culture maintain positions of authority. Obesity and alcoholism are low among Asian Americans. Milk is seldom consumed because a majority of Asian Americans are lactose intolerant. In the Asian culture, psychiatric illness is often believed to be out-of-control behavior and would be considered shameful to individuals and families.

The nurse client therapeutic relationship includes which of the following characteristics? Select all that apply. A. Meeting the psychological needs of the nurse and the client B. Ensuring therapeutic termination C. Promoting client insight into problematic behavior D. Collaborating to set appropriate goals E. Meeting both the physical and psychological needs of the client

ANS: B, C, D, E The nurseclient therapeutic relationship should include promoting client insight into problematic behavior, collaboration to set appropriate goals, meeting the physical and psychological needs of the client, and ensuring therapeutic termination. The nurses psychological needs should not be addressed within the nurseclient relationship.

A nurse attends an interdisciplinary team meeting on an inpatient unit. Which of the following individuals are typically included as members of the interdisciplinary treatment team in psychiatry? Select all that apply. A. Respiratory therapist B. Occupational therapist C. Recreational therapist D. Social worker E. Mental health technician

ANS: B, C, D, E The typical interdisciplinary treatment team in a psychiatric inpatient setting consists of a psychiatrist, psychiatric nurse, psychiatric social worker, music therapist, dietician, psychologist, occupational therapist, recreational therapist, art therapist, mental health technician, and chaplain. Other disciplines may be included on the basis of resources available in a particular hospital setting and individual patient needs.

When interviewing a client of a different culture, which of the following questions should a nurse consider asking? Select all that apply. A. Would using perfume products be acceptable? B. Who may be expected to be present during the client interview? C. Should communication patterns be modified to accommodate this client? D. How much eye contact should be made with the client? E. Would hand shaking be acceptable?

ANS: B, C, D, E When interviewing a client from a different culture, the nurse should consider who might be with the client during the interview, modifications of communication patterns, amount of eye contact, and hand-shaking acceptability, since these are cultural variables.

After a comprehensive assessment, correctly written nursing diagnoses developed for psychiatric clients may include which of the following components? Select all that apply. A. Medical judgments related to the psychiatric disorder B. Unmet client needs present at the moment C. Supporting data that validate the diagnosis D. Outcomes that will be targets for nursing interventions E. Statements of client problems of a functional nature

ANS: B, C, E A nursing diagnosis is a statement of a clients functional problem. An actual nursing diagnosis must include related to (R/T) and as evidenced by (AEB) statements. A risk for diagnosis does not contain AEB because there is only a potential for the problem; it does not yet exist.

The nursing staff is discussing the concept of competency. Which information about competency should a nurse recognize as true? A. Competency is determined with a clients compliance with treatment. B. Refusal of medication can initiate an incompetency hearing leading to forced medications. C. A competent client has the ability to make reasonable judgments and decisions. D. Competency is a medical determination made by the clients physician.

ANS: C A competent individuals cognition is not impaired to an extent that would interfere with decision making.

A patient presents in the Emergency Department immediately following a shooting incident in a school where she has been teaching. There is no evidence of physical injury, but she appears very hyperactive and talkative. Which of these symptoms manifested by the patient are common initial biological responses to stress? Select all that apply. A. Constricted pupils B. Watery eyes C. Unusual food cravings D. Increased heart rate E. Increased respirations

ANS: B, D, E Increased lacrimal secretions, increased heart rate, and increased respirations are identified as initial biological responses to stress. Since dilated pupils rather than constricted pupils are related to Fight or Flight syndrome, this symptom should be assessed for other potential causes. Unusual food cravings have not been identified as a typical biological response to stress.

Which is an example of the ego defense mechanism of regression? A. A mother blames the teacher for her childs failure in school. B. A teenager becomes hysterical after seeing a friend killed in a car accident. C. A woman wants to marry a man exactly like her beloved father. D. An adult throws a temper tantrum when he does not get his own way.

ANS: D Regression is the retreating to an earlier level of development and the comfort measures associated with that level of functioning.

Which of the following are accurate descriptors of a therapeutic community? Select all that apply. A. The unit schedule includes unlimited free time for personal reflection. B. Unit responsibilities are assigned according to client capabilities. C. A flexible schedule is determined by client needs. D. The individual is the sole focus of therapy. E. A democratic form of government exists.

ANS: B, E In a therapeutic community the unit responsibilities are assigned according to client capability, and a democratic form of government exists. Therapeutic communities are structured and provide therapeutic interventions that focus on communication and relationship-development skills.

Because of cultural characteristics, in which of the following cultural groups would a nurses assessment of mood and affect be most challenging? Select all that apply. A. Arab Americans B. Native Americans C. Latino Americans D. Western European Americans E. Asian Americans

ANS: B, E The nurse should expect that both Native Americans and Asian Americans might be difficult to assess for mood and affect. In both cultures, expressing emotions is difficult. Native Americans are encouraged to not communicate private thoughts. Asian Americans may have a reserved public demeanor and may be perceived as shy or uninterested.

How does a democratic form of self-government in the milieu contribute to client therapy? A. By setting punishments for clients who violate the community rules B. By dealing with inappropriate behaviors as they occur C. By setting community expectations wherein all clients are treated on an equal basis D. By interacting with professional staff members to learn about therapeutic interventions

ANS: C A democratic form of self-government in the milieu contributes to client therapy by setting the expectation that all clients should be treated on an equal basis. Clients participate in the decision-making and problem-solving aspects that affect treatment setting. The norms, rules, and behavioral limits are established by the staff and clients. All individuals have input.

A father tells his 5-year-old, Son, today instead of picking flowers in the outfield, lets try to catch a ball. The child subsequently pays attention and catches a ball. Which principle of building self-esteem has the father implemented? A. A sense of competence B. Unconditional love C. Realistic goals D. Reality orientation

ANS: C Low self-esteem can be the result of not being able to achieve established goals. The father has set for the child a realistic goal that the child accomplished. This should promote self-esteem.

Which cultural group is correctly matched with the disease process for which this group is most susceptible? A. African Americans are susceptible to lactose intolerance. B. Western European Americans are susceptible to malaria. C. Arab Americans are susceptible to sickle cell disease. D. Jewish Americans are susceptible to thalassemia.

ANS: C A number of genetic diseases are more common in the Arab American population, including sickle cell disease, tuberculosis, malaria, trachoma, typhus, hepatitis, typhoid fever, dysentery, parasitic infestations, thalassemia, and cardiovascular disease.

A nurse is working in a nursing home. How best can this nurse foster self-esteem in the residents of this facility? A. Allowing them to remain in their rooms as much as they desire to maintain privacy B. Administering anti-anxiety medications as ordered C. Providing a sense of mastery over their environment by giving choices when appropriate D. Teaching assertiveness skills and self-esteem principles

ANS: C A sense of having some power and control over ones life enhances self-esteem.

A client diagnosed with major depressive disorder states, Why should I keep trying to get a job? I mess up everything I do. Which correctly written nursing diagnosis best reflects the content and mood themes in this clients statement? A. Hopelessness R/T poor job performance B. Risk for impaired adjustment R/T inadequate social skills AEB isolation C. Altered role performance R/T the fear of failure AEB not seeking employment D. Chronic low self-esteem R/T major depressive disorder AEB self-hatred

ANS: C An actual nursing diagnosis must include related to (R/T) and as evidenced by (AEB) statements. A risk for diagnosis does not contain AEB because there is only a potential for the problem; it doesnt yet exist. The clients statement indicates that role performance is altered because fear of failure prevents seeking employment.

A nursing student finds that she comes down with a sinus infection toward the end of every semester. When this occurs, which stage of stress is the student most likely experiencing? A. Alarm reaction stage B. Stage of resistance C. Stage of exhaustion D. Fight-or-flight stage

ANS: C At the stage of exhaustion, the students exposure to stress has been prolonged and adaptive energy has been depleted. Diseases of adaptation occur more frequently in this stage.

The nurse manager on the psychiatric unit was explaining to the new staff the differences between typical and atypical antipsychotics. The nurse correctly states that atypical antipsychotics: A. Remain in the system longer B. Act more quickly to reduce delusions C. Produce fewer extrapyramidal effects D. Are risk free for neuroleptic malignant syndrome (NMS)

ANS: C Atypical antipsychotics produce less D2blockade; thus movement disorders are less of a problem. No evidence suggests that the medication remains in the system longer nor that it acts more quicklyto reduce delusions. The atypicals are not risk free for NMS.

A client is concerned that information given to the nurse remains confidential. Which is the nurses best response? A. Your information is confidential. It will be kept just between you and me. B. I will share the information with staff members only with your approval. C. If the information impacts your care, I will need to share it with the treatment team. D. You can make the decision whether your physician needs this information or not.

ANS: C Basic to the psychiatric clients hospitalization is his or her right to confidentiality and privacy. When admitted to an inpatient psychiatric facility, a client gives implied consent for information to be shared with health-care workers specifically involved in the clients care.

A patient has symptoms of acute anxiety related to the death of a parent in an automobile accident 2 hours ago. The patient will need teaching about a drug from which group? A. Tricyclic antidepressants B. Antimanic drugs C. Benzodiazepines D. Antipsychotic drugs

ANS: C Benzodiazepines provide anxiety relief. Tricyclic antidepressants are used to treat symptoms of depression. Antimanic drugs are used to treat bipolar disorder. Antipsychotic drugs are used to treat psychosis.

A nurse should assign which nursing diagnosis to a client needing assistance with assertiveness? A. Disturbed personal identity B. Disturbed thought processes C. Defensive coping D. Impaired verbal communication

ANS: C Defensive coping reflects a self-protective pattern that defends against underlying perceived threats to positive self-regard. Clients who are utilizing defensive coping lack assertiveness skills

The nurse interviewed a client who was uncooperative, answered questions with minimal responses, and rarely made eye contact. Which is the most complete documentation of baseline data obtained during the interview? A. Appears uncooperative. Exhibits characteristics of depression. B. Maintains poor eye contact throughout interview process. Unable to answer interview questions due to depression. C. States I dont need to be here when discussing admission status. Maintains minimal eye contact and offers little data related to triggers for admission. D. Unwilling to respond openly during interview.

ANS: C Documentation occurs in the implementation phase of the nursing process. All charting entries to the clients legal record should be objective and based on assessed data. Implications and generalizations should be avoided.

An unemployed college graduate is experiencing severe anxiety over not finding a teaching position and has difficulty with independent problem-solving. During a routine physical examination, the graduate confides in the clinic nurse. Which is the most appropriate nursing intervention? A. Encourage the student to use the alternative coping mechanism of relaxation exercises. B. Complete the problem-solving process for the client. C. Work through the problem-solving process with the client. D. Encourage the client to keep a journal.

ANS: C During times of high anxiety and stress, clients will need more assistance in problem-solving and decision making.

A patient taking fluphenazine (Prolixin) complains of dry mouth and blurred vision. What would the nurse assess as the likely cause of these symptoms? A. Decreased dopamine at receptor sites B. Blockade of histamine C. Cholinergic blockade D. Adrenergic blocking

ANS: C Fluphenazine administration produces blockade of cholinergic receptors giving rise to anticholinergic effects, such as dry mouth, blurred vision, and constipation.

A nurse is preparing to establish a therapeutic relationship with a grieving family from China. Which nursing intervention would be considered most appropriate? A. Touch each member lightly, as this enhances the communication process. B. Direct questions to the young males of the family, as they maintain positions of authority. C. Avoid direct eye contact, as it implies rudeness. D. Remain objective and empathetic, as Asians express feelings freely

ANS: C In the Asian culture, eye contact is often avoided, as it connotes rudeness and lack of respect.

The following clients are seen in the emergency department. The psychiatric unit has one remaining bed. The triage nurse should expect which client to be admitted? A. The client who is experiencing tremors and has a need for medication adjustment B. The client who is experiencing anxiety and a sad mood after separation from spouse C. The client who is a single parent and hears voices stating, Kill your infant son. D. The client who argued with her boyfriend and inflicted a superficial cut on her arm

ANS: C In the assessment phase of the nursing process, the nurse collects comprehensive health data that are pertinent to the clients health or situation. These data are prioritized to meet client needs, with an emphasis on safety.

The nurse would assess for neuroleptic malignant syndrome (NMS) if a patient on haloperidol (Haldol) develops a: A. 30 mm Hg decrease in blood pressure reading B. Respiratory rate of 24 respirations per minute C. Temperature reading of 104° F D. Pulse rate of 70 beats per minute

ANS: C Increased temperature is the cardinal sign of NMS. This BP is not a significant feature of NMS. There are no significant findings to support the options related to respirations or pulse rate.

Northern European Americans value punctuality, hard work, and the acquisition of material possessions and status. A nurse should recognize that these values may contribute to which form of mental disorders? A. Dissociative disorders B. Neurocognitive disorders C. Stress-related disorders D. Schizophrenia spectrum disorders

ANS: C Northern European American values, such as punctuality, hard work, and acquisition of material possessions, may place this group at risk for stress-related disorders when individuals struggle to meet societal demands.

A patient tells a nurse, "My doctor prescribed Paxil [paroxetine] for my depression. I suppose I'll have side effects like I had when I was taking Tofranil [imipramine]." The nurse's reply should be based on the knowledge that paroxetine is a(n): A. tricyclic antidepressant B. MAOI C. selective serotonin reuptake inhibitor D. selective norepinephrine reuptake inhibitor

ANS: C Paroxetine is a selective serotonin reuptake inhibitor and will not produce the same side effects as imipramine, a tricyclic antidepressant. The patient will probably not experience dry mouth, constipation, or orthostatic hypotension.

A husband accuses his wife of infidelity. Which situation would indicate to the nurse the husbands use of the ego defense mechanism of projection? A. The husband cries and stamps his feet, demanding that his wife be true to her marriage vows. B. The husband ignores the wifes continued absence from the home. C. The husband has already admitted to having an affair with a coworker. D. The husband takes out his marital frustrations through employee abuse.

ANS: C Projection is the attribution of feelings or impulses unacceptable to ones self to another person. In this situation, the husband attributes his infidelity to his wife.

A nursing supervisor is scheduling holiday hours. When the supervisor tells the staff nurse that she needs to work Christmas day, the staff nurse calmly states, I worked last Christmas and will not work this Christmas. When the supervisor says But I need you to work, the nurse repeats I worked last Christmas and will not work this Christmas. This is an example of which assertive behavior technique? A. Shifting from content to process B. Standing up for ones basic rights C. Responding as a broken record D. Defusing

ANS: C Responding as a broken record is an assertive behavior technique that consists of persistently repeating in a calm voice what is wanted.

A nursing instructor is teaching about self-concept. Which student statement indicates a need for further instruction? A. Self-concept is the thinking component of the self. B. Self-concept is a system of learned beliefs about self. C. Self-concept is the degree of regard that individuals have for themselves. D. Self-concept is the attitudes and opinions held true about personal existence.

ANS: C Self-esteem, not self-concept, is the degree of regard that individuals have for themselves. This student statement indicates a need for further teaching.

A nurse administering psychotropic medications should be prepared to intervene when giving a drug that blocks the attachment of norepinephrine to alpha-1 receptors because the patient may experience: A. increased psychotic symptoms. B. a hypertensive crisis. C. orthostatic hypotension. D. severe appetite disturbance.

ANS: C Sympathetic mediated vasoconstriction is essential for maintaining normal blood pressure in the upright position. Blockage of alpha-1 receptors leads to vasodilation and orthostatic hypotension. Orthostatic hypotension may cause fainting and falls. Patients should be taught ways of minimizing this phenomenon.

Which client statement indicates that termination of the therapeutic nurse client relationship has been handled successfully? A. I know I can count on you for continued support. B. I am looking forward to discharge, but I am surprised that we will no longer work together. C. Reviewing the changes that have happened during our time together has helped me put things in perspective. D. I dont know how comfortable I will feel when talking to someone else.

ANS: C Termination should begin in the orientation phase to minimize feelings of loss when the nurseclient relationship ends. Bringing a therapeutic conclusion to the relationship occurs when progress has been made toward attainment of mutually set goals.

Which tool would be appropriate for a nurse to use when assessing mental acuity prior to and immediately following electroconvulsive therapy (ECT)? A. CIWA scale B. GGT C. MMSE D. CAPS scale

ANS: C The MMSE, or mini mental status exam, would be the appropriate tool to use to assess the mental acuity of a client prior to and immediately following ECT. The CIWA scale, or clinical institute withdrawal assessment scale, would be used to assess withdrawal from substances such as alcohol. The CAPS refers to the clinician- administered PTSD scale and would be used to assess signs and symptoms of PTSD. The GGT test is used to assess gamma-glutamyl transferase levels, which may be an indication of alcoholism.

A client has experienced the death of a close family member and at the same time becomes unemployed. This situation has resulted in a 6-month score of 110 on the Recent Life Changes Questionnaire. How should the nurse evaluate this client data? A. The client is experiencing severe distress and is at risk for physical and psychological illness. B. A score of 110 on the Miller and Rahe Recent Life Changes Questionnaire indicates no significant threat of stress-related illness. C. Susceptibility to stress-related physical or psychological illness cannot be estimated without knowledge of coping resources and available supports. D. The client may view these losses as challenges and perceive them as opportunities.

ANS: C The Recent Life Changes Questionnaire is an expanded version of the Schedule of Recent Experiences and the Rahe-Holmes Social Readjustment Rating Scale. A 6-month score of 300 or more, or a year-score total of 500 or more, indicates high stress in a clients life. However, positive coping mechanisms and strong social support can limit susceptibility to stress-related illnesses.

An employee uses the defense mechanism of displacement when the boss openly disagrees with suggestions. What behavior would be expected from this employee? A. The employee assertively confronts the boss B. The employee leaves the staff meeting to work out in the gym C. The employee criticizes a coworker D. The employee takes the boss out to lunch

ANS: C The client using the defense mechanism of displacement would criticize a coworker after being confronted by the boss. Displacement refers to transferring feelings from one target to a neutral or less-threatening target.

A 30-year-old client diagnosed with depression has been exclusively cared for and financially subsidized by his mother since age 17. According to Eriksons theory, the nurse recognizes that the client has been unsuccessful in meeting which developmental task? A. Trust B. Initiative C. Intimacy D. Ego integrity

ANS: C The clients relationship with his mother has contributed to failing completion of the developmental task of intimacy in Eriksons stage of intimacy versus isolation (20 to 30 years). This has resulted in behaviors such as withdrawal, social isolation, aloneness, and the inability to form lasting relationships, leading to his diagnosis of depression.

There is one bed available on an inpatient psychiatric unit. For which client should a nurse advocate emergency commitment? A. An individual who is persistently mentally ill and evicted from an apartment B. An individual treated in the emergency department (ED) for generalized anxiety disorder C. An individual who is delusional and has a plan to kill his wife D. An individual who rates mood 4/10 and is participating in a no-harm safety plan

ANS: C The criteria for involuntary emergency commitment include danger to self and/or others. Of the four clients considered, the client who is delusional and has a plan to kill his wife meets this criterion as a danger to others.

Which statement regarding nursing interventions should a nurse identify as accurate? A. Nursing interventions are independent from the treatment teams goals. B. Nursing interventions are directed solely by written physician orders. C. Nursing interventions occur independently but in concert with overall treatment team goals. D. Nursing interventions are standardized by policies and procedures.

ANS: C The nurse should understand that nursing interventions occur independently but in concert with overall treatment goals. Nursing interventions should be developed and implemented in collaboration with other health-care professionals involved in the clients care.

An instructor is correcting a nursing students clinical worksheet. Which instructor statement is the best example of effective feedback? A. Why did you use the clients name on your clinical worksheet? B. You were very careless to refer to your client by name on your clinical worksheet. C. I noticed that you used the clients name in your written process recording. That is a breach of confidentiality. D. It is disappointing that after being told, youre still using client names on your worksheet.

ANS: C The instructors statement, I noticed that you used the clients name in your written process recording, is an example of effective feedback. Feedback is a method of communication to help others consider a modification of behavior. Feedback should be descriptive, specific, and directed toward a behavior that the person has the capacity to modify and should impart information rather than offer advice or criticism.

A nurse on an inpatient psychiatric unit implements care by scheduling client activities, interacting with clients, and maintaining a safe therapeutic environment. These actions reflect which role of the nurse? A. Health teacher B. Case manager C. Milieu manager D. Psychotherapist

ANS: C The milieu manager implements care by scheduling client activities, interacting with clients, and maintaining a safe therapeutic environment. Health teaching involves promoting health and a safe environment. Case management is utilized to organize client care so that outcomes are achieved. Psychotherapy involves conducting individual, couples, group, and family counseling.

A client diagnosed with dependent personality disorder states, Do you think I should move from my parents house and get a job? Which nursing response is most appropriate? A. It would be best to do that in order to increase independence. B. Why would you want to leave a secure home? C. Lets discuss and explore all of your options. D. Im afraid you would feel very guilty leaving your parents.

ANS: C The most appropriate response by the nurse is, Lets discuss and explore all of your options. In this example, the nurse is encouraging the client to formulate ideas and decide independently the appropriate course of action.

A brother calls to speak to his sister who has been admitted to the psychiatric unit. The nurse connects him to the community phone and the sister is summoned. Later the nurse realizes that the brother was not on the clients approved call list. What law has the nurse broken? A. The National Alliance for the Mentally Ill Act B. The Tarasoff Ruling C. The Health Insurance Portability and Accountability Act D. The Good Samaritan Law

ANS: C The nurse has violated the Health Insurance Portability and Accountability Act (HIPAA) by revealing that the client had been admitted to the psychiatric unit. The nurse should not have provided any information without proper consent from the client.

Which therapeutic communication technique is being used in this nurseclient interaction? Client: When I am anxious, the only thing that calms me down is alcohol. Nurse: Other than drinking, what alternatives have you explored to decrease anxiety? A. Reflecting B. Making observations C. Formulating a plan of action D. Giving recognition

ANS: C The nurse is using the therapeutic communication technique of formulating a plan of action to help the client explore alternatives to drinking alcohol. The use of this technique, rather than direct confrontation regarding the clients poor coping choice, may serve to prevent anger or anxiety from escalating.

A nursing instructor is presenting content on the provisions of the Nurse Practice Act as it relates to their state. Which student statement indicates a need for further instruction? A. The Nurse Practice Act provides a list of definitions of important terms, including the definition of nursing. B. The Nurse Practice Act lists education requirements for licensure and reciprocity. C. The Nurse Practice Act contains detailed statements that describe the scope of practice for registered nurses (RNs). D. The Nurse Practice Act lists the general authority and powers of the state board of nursing.

ANS: C The nurse practice act contains broad, not detailed, statements that describe the scope of practice for various levels of nursing (APN, RN, LPN), not just for the RN. This student statement indicates a need for further instruction.

Which data-gathering technique is employed during the assessment phase of the nursing process? A. Asking the client to rate mood after administering an antidepressant B. Asking the client to verbalize understanding of previously explained unit rules C. Asking the client to describe any thoughts of self-harm D. Asking the client if the group on assertiveness skills was helpful

ANS: C The nurse should ask the client to describe any thoughts of self-harm during the assessment phase of the nursing process. Assessment involves collecting and analyzing data about the client that may include the following dimensions: physical, psychological, sociocultural, spiritual, cognitive, developmental, economic, lifestyle, and functional abilities. The other three options are employed during the evaluation phase of the nursing process

What is being assessed when a nurse asks a client to identify name, date, residential address, and situation? A. Mood B. Perception C. Orientation D. Affect

ANS: C The nurse should ask the client to identify name, date, residential address, and situation to assess the clients orientation. Assessment of the clients orientation to reality is part of a mental status evaluation.

During an intake assessment, a nurse asks both physiological and psychosocial questions. The client angrily responds, Im here for my heart, not my head problems. Which is the nurses best response? A. Its just a routine part of our assessment. All clients are asked these same questions. B. Why are you concerned about these types of questions? C. Psychological factors, like excessive stress, have been found to affect medical conditions. D. We can skip these questions, if you like. It isnt imperative that we complete this section.

ANS: C The nurse should attempt to educate the client on the negative effects of excessive stress on medical conditions. It is not appropriate to skip either physiological or psychosocial questions, as this would lead to an inaccurate assessment.

A client has undergone psychological testing. With which member of the interdisciplinary team should a nurse collaborate to review these results? A. The psychiatrist B. The psychiatric social worker C. The clinical psychologist D. The clinical nurse specialist

ANS: C The nurse should consult with the clinical psychologist to review psychological testing results for the client. Clinical psychologists can administer, interpret, and evaluate psychological tests to assist in the diagnostic process.

A Latin American woman refuses to participate in an assertiveness training group. Which cultural belief should a nurse identify as most likely to have influenced this clients decision? A. Future orientation causes the client to devalue assertiveness skills. B. Decreased emotional expression makes it difficult to be assertive. C. Assertiveness techniques may not be aligned with the clients definition of the female role. D. Religious prohibitions prevent the clients participation in assertiveness

ANS: C The nurse should identify that the Latin American womans refusal to participate in an assertiveness training group may be influenced by the Latin American cultural definition of the female role. Latin Americans place a high value on the male-dominated family. The father usually possesses the ultimate authority.

A fourth-grade boy teases and makes jokes about a cute girl in his class. This behavior should be identified by a nurse as indicative of which defense mechanism? A. Displacement B. Projection C. Reaction formation D. Sublimation

ANS: C The nurse should identify that the boy is using reaction formation as a defense mechanism. Reaction formation is the attempt to prevent undesirable thoughts from being expressed by expressing opposite thoughts or behaviors. Displacement refers to transferring feelings from one target to another. Rationalization refers to making excuses to justify behavior. Projection refers to the attribution of unacceptable feelings or behaviors to another person. Sublimation refers to channeling unacceptable drives or impulses into more constructive, acceptable activities.

Which client statement should a nurse identify as a typical response to stress most often experienced in the working phase of the nurse client relationship? A. I cant bear the thought of leaving here and failing. B. I might have a hard time working with you. You remind me of my mother. C. I cant tell my husband how I feel; he wouldnt listen anyway. D. Im not sure that I can count on you to protect my confidentiality.

ANS: C The nurse should identify that the client statement I cant tell my husband how I feel; he wouldnt listen anyway reflects resistance to change, which is a common behavior in the working phase of the nurseclient relationship. The working phase includes overcoming resistant behaviors on the part of the client as the level of anxiety rises in response to discussion of painful issues.

A nurse is performing a mental health assessment on an adult client. According to Maslows hierarchy of needs, which client action would demonstrate the highest achievement in terms of mental health? A. Maintaining a long-term, faithful, intimate relationship B. Achieving a sense of self-confidence C. Possessing a feeling of self-fulfillment and realizing full potential D. Developing a sense of purpose and the ability to direct activities

ANS: C The nurse should identify that the client who possesses a feeling of self-fulfillment and realizes his or her full potential has achieved self-actualization, the highest level on Maslows hierarchy of needs.

A client who will be receiving electroconvulsive therapy (ECT) must provide informed consent. Which situation should cause a nurse to question the validity of the informed consent? A. The client is paranoid. B. The client is 87 years old. C. The client incorrectly reports his or her spouses name, the date, and the time of day. D. The client relies on his or her spouse to interpret the information.

ANS: C The nurse should question the validity of informed consent when the client incorrectly reports the spouses name, date, and time of day. This indicates that this client is disoriented and may not be competent to make informed choices.

A nurse should recognize that clients who have a history of missed or late medical appointments are most likely to come from which cultural group? A. Northern European Americans B. Asian Americans C. Native Americans D. Jewish Americans

ANS: C The nurse should recognize that Native American clients might have a history of missed or late medical appointments. Many Native Americans are not ruled by the clock. The concept of time is casual and focused on the present.

Devastated by a divorce from an abusive husband, a wife completes grief counseling. Which statement by the wife should indicate to a nurse that the client is in the acceptance stage of grief? A. If only we could have tried again, things might have worked out. B. I am so mad that the children and I had to put up with him as long as we did. C. Yes, it was a difficult relationship, but I think I have learned from the experience. D. I still dont have any appetite and continue to lose weight.

ANS: C The nurse should recognize that the client is in the acceptance stage of grief. During this stage of the grief process, the client would be able to focus on the reality of the loss and its meaning in relation to life.

Which situation contradicts the ethical principle of veracity? A. A nurse provides a client with outpatient resources to benefit recovery. B. A nurse refuses to give information to a physician who is not responsible for the clients care. C. A nurse tricks a client into seclusion by asking the client to carry linen to the seclusion room. D. A nurse treats all of the clients equally regardless of illness severity.

ANS: C The nurse who tricks a client into seclusion has violated the ethical principle of veracity. The principle of veracity refers to ones duty to always be truthful and not intentionally deceive or mislead clients.

A client diagnosed with schizophrenia refuses to take medication, citing the right of autonomy. Under which circumstance would a nurse have the right to medicate the client against the clients wishes? A. When the client makes inappropriate sexual innuendos to a staff member B. When the client constantly demands inappropriate attention from the nurse C. When the client physically attacks another client after being confronted in group therapy D. When the client refuses to bathe or perform hygienic activities

ANS: C The nurse would have the right to medicate a client against his or her wishes if the client physically attacks another client. This client poses a significant risk to safety and is incapable of making rational choices. The clients refusal to accept treatment can be challenged because the client is endangering the safety of others

What should be the nurses primary goal during the preinteraction phase of the nurseclient relationship? A. To evaluate goal attainment and ensure therapeutic closure B. To establish trust and formulate a contract for intervention C. To explore self-perceptions D. To promote client change

ANS: C The nurses primary goal of the preinteraction phase should be to explore self-perceptions. The nurse should be aware of how any preconceptions may affect his or her ability to care for individual clients. Another goal of the preinteraction phase is to obtain available client information.

An angry client on an inpatient unit approaches a nurse, stating, Someone took my lunch! People need to respect others, and you need to do something about this now! The nurses response should be guided by which basic assumption of milieu therapy? A. Conflict should be avoided at all costs on inpatient psychiatric units. B. Conflict should be resolved by the nursing staff. C. Every interaction is an opportunity for therapeutic intervention. D. Conflict resolution should be addressed only during group therapy.

ANS: C The nurses response should be guided by the basic assumption that every interaction is an opportunity for therapeutic intervention. The nurse can utilize milieu therapy to effect behavioral change and improve psychological health and functioning.

The nurse is interviewing a newly admitted psychiatric client. Which nursing statement is an example of offering a general lead? A. Do you know why you are here? B. Are you feeling depressed or anxious? C. Yes, I see. Go on. D. Can you chronologically order the events that led to your admission?

ANS: C The nurses statement, Yes, I see. Go on, is an example of the therapeutic communication technique of a general lead. Offering a general lead encourages the client to continue sharing information.

A client has a nursing diagnosis of Insomnia R/T paranoid thinking AEB midnight awakenings, difficulty falling asleep, and daytime napping. Which is a correctly written and appropriate outcome for this clients problem? A. The client will avoid daytime napping and attend all groups. B. The client will exercise, as needed, before bedtime. C. The client will sleep 7 uninterrupted hours by day four of hospitalization. D. The clients sleep habits will improve during hospitalization.

ANS: C The outcome The client will sleep 7 uninterrupted hours by day four of hospitalization is accurately written and an appropriate outcome to address the client problem of insomnia. Outcomes should be measurable, realistic, client-focused goals that include a time frame. Appropriate nursing interventions are guided by client outcomes.

A clients younger daughter is ignoring curfew. The client states, Im afraid she will get pregnant. The nurse responds, Hang in there. Dont you think she has a lot to learn about life? This is an example of which communication block? A. Requesting an explanation B. Belittling the client C. Making stereotyped comments D. Probing

ANS: C This is an example of the nontherapeutic communication block of making stereotyped comments. Cliches and trite expressions are meaningless in a therapeutic nurse client relationship.

The nurse says to a newly admitted client, Tell me more about what led up to your hospitalization. What is the purpose of this therapeutic communication technique? A. To reframe the clients thoughts about mental health treatment B. To put the client at ease C. To explore a subject, idea, experience, or relationship D. To communicate that the nurse is listening to the conversation

ANS: C This is an example of the therapeutic communication technique of exploring. The purpose of exploring is to delve further into the subject, idea, experience, or relationship. This technique is especially helpful with clients who tend to remain on a superficial level of communication.

Which nursing statement is a good example of the therapeutic communication technique of giving recognition? A. You did not attend group today. Can we talk about that? B. Ill sit with you until it is time for your family session. C. I notice you are wearing a new dress and you have washed your hair. D. Im happy that you are now taking your medications. They will really help.

ANS: C This is an example of the therapeutic communication technique of giving recognition. Giving recognition acknowledges and indicates awareness. This technique is more appropriate than complimenting the client, which reflects the nurses judgment.

A nurse has identified the following nursing diagnosis: ineffective communication R/T lack of assertiveness skills AEB inability to state needs. Which statement encourages the client to acknowledge the priority of this problem? A. Are you having thoughts of harming yourself or others? B. With whom are you least assertive? C. On a scale of 1 to 10, rank the importance of being assertive. D. When are you available to attend the assertiveness training class?

ANS: C This nursing statement encourages the client to objectively evaluate the priority of being assertive. It is important in patient-centered care for the client to prioritize his or her goals for treatment.

A client on an inpatient psychiatric unit tells the nurse, I should have died, because I am totally worthless. In order to encourage the client to continue talking about feelings, which should be the nursing initial response? A. How would your family feel if you died? B. You feel worthless now, but that can change with time. C. Youve been feeling sad and alone for some time now? D. It is great that you have come in for help.

ANS: C This nursing statement is an example of the therapeutic communication technique of reflection. When reflection is used, questions and feelings are referred back to the client so that they may be recognized and accepted.

While trying to control aggressive behavior, a client asks an assertiveness training nurse to give an example of an I statement. Which of the following statements is the best example of this assertive communication technique? A. I would like to know why you came home late without calling me. B. I hate it when you think you can just come home late without calling anyone to let them know where you are. C. I feel angry when you come home late without calling. D. I think you dont care about me, because if you did, youd call me if you were planning on coming home late.

ANS: C This response clearly states feelings about a situation without blaming another.

The dean of nursing criticizes a faculty member about views on academic freedom. The faculty member states, Are you upset because I believe in academic freedom or because you dont? The faculty member is using which technique to promote assertive behavior? A. Standing up for ones basic human rights B. Delaying assertively C. Inquiring assertively D. Responding assertively with irony

ANS: C This response reflects the use of inquiring assertively. Inquiring assertively is an attempt to seek additional information about critical statements.

When interviewing a client, which nonverbal behavior should a nurse employ? A. Maintaining indirect eye contact with the client B. Providing space by leaning back away from the client C. Sitting squarely, facing the client D. Maintaining open posture with arms and legs crossed

ANS: C When interviewing a client, the nurse should employ the nonverbal behavior of sitting squarely, facing the client. Facilitative skills for active listening can be identified by the acronym SOLER. SOLER includes sitting squarely facing the client (S), open posture when interacting with a client (O), leaning forward toward the client (L), establishing eye contact (E), and relaxing (R).

As the client and nurse move from the orientation stage to the working stage of the therapeutic relationship, which is the nurses most therapeutic statement? A. I want to assure you that I will maintain your confidentiality. B. A long-term goal for someone your age would be to develop better job skills. C. Which identified problems would you like for us to initially address? D. I think first we need to focus on your relationship issues.

ANS: C When moving on a continuum from the orientation to working phase of the nurse client relationship, the clients identified goals are addressed through mutual therapeutic work to promote client behavioral change.

A home health nurse visits an 18-year-old client who lives with his mother. The client has been assessed as having low self-esteem. The nurse refers the client for individual counseling. During the next home visit, which assessed client behavior clearly indicates treatment success? A. The client wants to buy a dog but has not yet asked his mothers permission. B. The client asks his mother for permission to buy a dog. C. The client tells his mother he plans to buy a dog. D. The client buys a dog and hides it in the garage.

ANS: C When the client tells his mother he plans to buy a dog, he is making decisions and taking on responsibilities. This indicates an increase in self-confidence and therefore self-esteem.

A nurse is evaluating a clients response to stress. What would indicate to the nurse that the client is experiencing a secondary appraisal of the stressful event? A. When the individual judges the event to be benign B. When the individual judges the event to be irrelevant C. When the individual judges the resources and skills needed to deal with the event D. When the individual judges the event to be pleasurable

ANS: C When the individual judges the resources and skills needed to deal with the event, the individual is conducting a secondary appraisal. There are three types of primary appraisals: irrelevant, benign-positive, and stressful.

The nurse is working with a 15-year-old client suffering from low self-esteem. According to Eriksons psychosocial developmental theory, which factor has most probably influenced this clients self-esteem? A. Regret over life choices B. Lack of personal concern for others C. Inconsistent, overly harsh, or absent parental discipline D. Parental labeling of the child as good regardless of their behavior.

ANS: C When there is inconsistent, overly harsh, or absent discipline in the home, it is difficult for a teenager to develop the independent sense of self needed to achieve a positive self-esteem.

A student nurse asks an instructor which resource is best to use when developing nursing outcomes for clients. Which reply by the instructor most accurately answers the students question? A. Use the Nursing Interventions Classification (NIC), as a reference for nursing outcomes. B. Use the NANDA resource to identify appropriate outcomes. C. Use the Nursing Outcomes Classification (NOC), as a reference for nursing outcomes. D. Copy your standard outcomes from a nursing care plan textbook.

ANS: C NOC is a comprehensive, standardized classification of client outcomes developed to evaluate the effects of nursing interventions. NANDA is a resource for identifying approved nursing diagnoses.

A nurse moving out of state speaks to a client about the need to work with a new nurse. The client states, Im not well enough to switch to a different nurse. What does this client response indicate to the nurse? A. The client is using manipulation to receive secondary gain. B. The client is using the defense mechanism of denial. C. The client is having trouble terminating the relationship. D. The client is using splitting as a way to remain dependent on the nurse.

ANS: C Termination should begin in the orientation phase to minimize feelings of loss when the nurse client relationship ends. When a client feels sadness and loss, behaviors to delay termination may become evident.

Which of the following are characteristics of accurately developed client outcomes? Select all that apply. A. Client outcomes are formulated by nurses independent from other team members. B. Client outcomes are not restricted by time frames. C. Client outcomes are specific and measurable. D. Client outcomes are realistically based on client capability. E. Client outcomes are formally approved by the psychiatrist.

ANS: C, D The nurse should identify that client outcomes should be specific, measurable, and realistically based on client capability. Outcomes should be derived from the diagnosis and should include a time estimate for attainment. Outcomes are most effective when formulated cooperatively by the interdisciplinary team members, client, and significant others.

According to Peplau, which nursing action demonstrates the nurses role as a resource person? A. The nurse balances a safe therapeutic environment to increase the clients sense of belonging. B. The nurse holds a group meeting with the clients on the unit to discuss common feelings about mental illness. C. The nurse monitors the administration of medications and watches for signs of cheeking. D. The nurse explains, in language the client can understand, information related to the clients health care.

ANS: D According to Peplau, a resource person provides specific answers to questions usually formulated with relation to a larger problem.

Which is the most appropriate nursing reply when a client asks what the goal and benefit are of assertive skills training? A. It protects the client from others who express aggressive feelings. B. It gives reliable, expert information so that clients may correct faulty behaviors. C. It clarifies misperceptions that have caused clients to distort reality. D. It improves communication skills in order to improve interpersonal relationships.

ANS: D Assertiveness training helps to develop satisfying interpersonal relationships by teaching people how to communicate in a manner to meet their own needs while respecting the rights and needs of others.

A patient has taken many conventional antipsychotic drugs over years. The health care provider, concerned about early signs of tardive dyskinesia, prescribes risperidone (Risperdal). A nurse planning care for this patient understands that atypical antipsychotics: A. are less costly. B. have higher potency. C. are more readily available. D. produce fewer motor side effects.

ANS: D Atypical antipsychotic drugs often exert their action on the limbic system rather than the basal ganglia. The limbic system is not involved in motor disturbances. Atypical antipsychotics are not more readily available. They are not considered to be of higher potency; rather, they have different modes of action. Atypical antipsychotic drugs tend to be more expensive.

A distraught, single, first-time mother cries and asks a nurse, How can I go to work if I cant afford childcare? What is the nurses initial action in assisting the client with the problem-solving process? A. Determine the risks and benefits for each alternative. B. Formulate goals for resolution of the problem. C. Evaluate the outcome of the implemented alternative. D. Assess the facts of the situation.

ANS: D Before any other steps can be taken, accurate information about the situation must be gathered and assessed.

Which is an accurate description of a common law? A. A common law would be invoked to deal with a nurse who, without justification, threatens a client with restraints. B. A common law would be invoked to deal with a nurse who touches a client without the clients consent. C. A common law would be invoked to deal with a hospital employee who steals drugs, hospital equipment, or both. D. A common law would be invoked to deal with a nurses refusal to provide care for a specific client.

ANS: D Common laws apply to a body of principles that evolve from court decisions resolving various controversies. Common law may vary from state to state. Assault (threats) and battery (touch) are governed by civil law. Stealing is governed by criminal law.

Which is the most significant consequence of the excessive use of defense mechanisms? A. The superego will be suppressed. B. Emotions will be experienced intensely. C. Learning and the ability to grow will be enhanced. D. Problem-solving will be limited.

ANS: D Defense mechanisms become maladaptive when they are used by an individual to such a degree that there is interference with the ability to deal with reality, effective interpersonal relations, or occupational performance.

A nursing instructor is asking students about diseases of adaptation and when they are likely to occur. Which student response indicates that learning has occurred? A. When an individual has limited experience dealing with stress B. When an individual inherits maladaptive genes C. When an individual experiences existing conditions that exacerbate stress D. When an individuals physiological and psychological resources have become depleted

ANS: D During the stage of exhaustion of the general adaptation syndrome, the individual loses the capacity to adapt effectively because physiological and psychological resources have become depleted. This is the time when diseases of adaptation may occur.

A patient is hospitalized for severe depression. Of the medications listed below, a nurse can expect to provide the patient with teaching about: A. clozapine (Clozaril) B. chlordiazepoxide (Librium) C. tacrine (Cognex) D. fluoxetine (Prozac)

ANS: D Fluoxetine is an SSRI. It is an antidepressant that blocks the reuptake of serotonin with few anticholinergic and sedating side effects. Clozapine is an antipsychotic. Chlordiazepoxide is an anxiolytic. Tacrine is used to treat Alzheimer's disease.

A nurse can anticipate anticholinergic side effects are likely when a patient is taking: A. lithium (Lithobid). B. isperidone (Risperdal). C. buspirone (BuSpar). D. fluphenazine (Prolixin).

ANS: D Fluphenazine, a first-generation antipsychotic, exerts muscarinic blockade, resulting in dry mouth, blurred vision, constipation, and urinary retention. Lithium therapy is more often associated with fluid balance problems, including polydipsia, polyuria, and edema. Risperidone therapy is more often associated with movement disorders, orthostatic hypotension, and sedation. Buspirone is associated with anxiety reduction without major side effects.

A client who has slept 6 hours the previous night reports this to the assigned psychiatric nurse. What should be the initial nursing action to address this situation? A. Provide warm milk and a backrub. B. Give a sleep medication. C. Hold a relaxation group before bedtime. D. Review the clients normal sleep pattern.

ANS: D In the assessment phase of the nursing process, the nurse collects comprehensive health data that are pertinent to the clients health or situation. In this situation the nurse must initially determine the clients normal sleep patterns in order to evaluate if a true problem exists.

An instructor overhears a student say, That family seems to disagree more than agree. The family seems to be dysfunctional. To further assess the familys situation, which would be an appropriate instructor reply? A. Families who disagree can be a challenge to the treatment team. B. You seem very critical of the family. Do you believe that you are unable to help them? C. Lets bring the family in for an educational session to improve their communication. D. What appears to trigger family disagreements?

ANS: D In the assessment phase of the nursing process, the nurse collects comprehensive health data that are pertinent to the clients health or situation. In this situation, prior to intervening with this family, the nurse needs further information about the cause of family conflicts.

During an intake interview, which question would assist the nurse in gathering data about the clients judgment? A. What brought you to the hospital? Do you know what day and season it is now? B. On a scale of 1 to 10, how would you rate your stress level? C. What does the phrase a rolling stone gathers no moss mean to you? D. If you found a stamped, addressed envelope in the street, what would you do?

ANS: D In the assessment phase of the nursing process, the nurse collects comprehensive health data that are pertinent to the clients health or situation. The nurse presents a situation that requires the client to make a judgment call and can assess appropriate judgment on the basis of the clients action choice.

Which nursing response would be appropriately used in the evaluation phase of the nursing process? A. If I were in your situation, I would not repeat a behavior that has caused problems. B. What do you think needs changing, and what do you want to do differently? C. What exactly will it take to carry out your plan, and what else do you need to do? D. It sounds like youre saying this new approach is working for you.

ANS: D In the evaluation phase of the nursing process, the nurse and the client evaluate progress toward attainment of the expected outcomes.

On the basis of current knowledge of neurotransmitter effects, a nurse could anticipate that the treatment plan for a patient with memory difficulties might include medications designed to: A. inhibit GABA. B. increase dopamine at receptor sites. C. decrease dopamine at receptor sites. D. prevent destruction of acetylcholine.

ANS: D Increased acetylcholine plays a role in learning and memory. Preventing destruction of acetylcholine by acetylcholinesterase would result in higher levels of acetylcholine, with the potential for improved memory. GABA is known to affect anxiety level rather than memory. Increased dopamine would cause symptoms associated with schizophrenia or mania rather than improve memory. Decreasing dopamine at receptor sites is associated with Parkinson's disease rather than improving memory.

Which should the nurse recognize as an example of the defense mechanism of repression? A. A student aware of the need to study for tomorrows test goes to a movie instead. B. A woman whose son was killed in Iraq does not believe the military report. C. A man who is unhappily married goes to school to become a marriage counselor. D. A woman was raped when she was 12 and no longer remembers the incident.

ANS: D Repression is the involuntary blocking of unpleasant feelings and experiences from ones awareness.

Research undertaken by Miller and Rahe in1997 demonstrated a correlation between the effects of life change and illness. This research led to the development of the Recent Life Changes Questionnaire (RLCQ). Which principle most limits the effectiveness of this tool? A. Specific illnesses are not identified. B. The numerical values associated with specific life events are randomly assigned C. Stress is viewed as only a physiological response. D. Personal perception of the event is excluded.

ANS: D Individuals differ in response to life events. The RLCQ uses a scale that does not take these differences into consideration.

A drug causes muscarinic receptor blockade. A nurse will assess the patient for: A. gynecomastia B. pseudoparkinsonism C. orthostatic hypotension D. dry mouth

ANS: D Muscarinic receptor blockade includes atropine-like side effects such as dry mouth, blurred vision, and constipation. Gynecomastia is associated with decreased prolactin levels. Movement defects are associated with dopamine blockade. Orthostatic hypotension is associated with alpha-1 antagonism.

A nurse assesses that a patient demonstrates anxiety, increased heart rate, and fear. The nurse would suspect the presence of a high concentration of which neurotransmitter? A. GABA B. Histamine C. Acetylcholine D. Norepinephrine

ANS: D Norepinephrine is the neurotransmitter associated with sympathetic nervous system stimulation, preparing the individual for "fight or flight." GABA is a mediator of anxiety level. A high concentration of histamine is associated with an inflammatory response. A high concentration of acetylcholine is associated with parasympathetic nervous system stimulation.

When is self-disclosure by the nurse appropriate in a therapeutic nurseclient relationship? A. When it is judged that the information may benefit the nurse and client B. When the nurse has a duty to warn C. When the nurse feels emotionally indebted toward the client D. When it is judged that the information may benefit the client

ANS: D Self-disclosure on the part of the nurse may be appropriate when it is judged that the information may therapeutically benefit the client. It should never be undertaken for the purpose of meeting the nurses needs.

A school nurse is assessing a female high school student who is overly concerned about her appearance. The clients mother states, Thats not something to be stressed about! Which is the most appropriate nursing response? A. Teenagers! They dont know a thing about real stress. B. Stress occurs only when there is a loss. C. When you are in poor physical condition, you cant experience psychological well-being. D. Stress can be psychological. A threat to self-esteem may result in high stress levels.

ANS: D Stress can be physical or psychological in nature. A perceived threat to self-esteem can be as stressful as a physiological change.

A nurse communication states to a client, technique? Things will look better tomorrow after a good nights sleep. This is an example of A. The therapeutic technique of giving advice B. The therapeutic technique of defending C. The nontherapeutic technique of presenting reality D. The nontherapeutic technique of giving false reassurance

ANS: D The nurses statement, Things will look better tomorrow after a good nights sleep, is an example of the nontherapeutic technique of giving false reassurance. Giving false reassurance indicates to the client that there is no cause for anxiety, thereby devaluing the clients feelings.

Which rationale by a nursing instructor best explains why it is challenging to globally classify the Asian American culture? A. Extremes of emotional expression prevent accurate assessment of this culture. B. Suspicion of Western civilization has resulted in minimal cultural research. C. The small size of this subpopulation makes research virtually impossible. D. The Asian American culture includes individuals from many different countries.

ANS: D The Asian American culture includes peoples and descendents from Japan, China, Vietnam, the Philippines, Thailand, Cambodia, Korea, Laos, India, and the Pacific Islands. Within this culture there are vast differences in values, religious practices, languages, and attitudes.

A client is experiencing high stress. The client states, My boss treats me like a doormat and thinks nothing of demanding frequent overtime. Which nursing intervention would be appropriate? A. To incorporate the family support system into the clients plan of care B. To teach thought-reframing techniques C. To encourage the client to seek other employment D. To teach the client how to use I statements

ANS: D The ability to use I statements is essential in assertive communication. The situation presented indicates that the client needs assertiveness training.

A 40-year-old client lives with her parents. She has a high school diploma and works at a low-paying job. Her parents give her a weekly allowance to supplement her income. How should the nurse classify their client- parent boundaries? A. As loose B. As rigid C. As flexible D. As enmeshed

ANS: D The client and her parents are overly dependent. The parents control too many aspects of the clients life. Their boundaries are blurred so that it is hard for the client to differentiate her wants and needs from those of her parents. The client parent boundaries are enmeshed.

A physically and emotionally healthy client has just been fired. During a routine office visit he states to a nurse: nurse characterize Perhaps this the was clients the best appraisal thing to of happen. the job Maybe loss stressor? Ill look into pursuing an art degree. How should the A. Irrelevant B. Harm/loss C. Threatening D. Challenging

ANS: D The client perceives the situation of job loss as a challenge and an opportunity for growth.

A patient has disorganized thinking associated with schizophrenia. A PET scan would most likely show dysfunction in which part of the brain? A. Temporal lobe B. Cerebellum C. Brainstem D. Frontal lobe

ANS: D The frontal lobe is responsible for intellectual functioning. The temporal lobe is responsible for the sensation of hearing. The cerebellum regulates skeletal muscle coordination and equilibrium. The brainstem regulates internal organs.

A geriatric client is confused and wandering in and out of every door. Which scenario reflects the least restrictive alternative for this client? A. The client is placed in seclusion. B. The client is placed in a geriatric chair with tray. C. The client is placed in soft Posey restraints. D. The client is monitored by an ankle bracelet.

ANS: D The least restrictive alternative for this client would be monitoring by an ankle bracelet. The client does not pose a direct dangerous threat to self or others, so neither physical restraints nor seclusion would be justified.

In the role of milieu manager, which activity should the nurse prioritize? A. Setting the schedule for the daily unit activities B. Evaluating clients for medication effectiveness C. Conducting therapeutic group sessions D. Searching newly admitted clients for hazardous objects

ANS: D The milieu manager should search newly admitted clients for hazardous objects. Safety of the client and others is the priority. Nurses are responsible for ensuring that the clients safety and physiological needs are met within the milieu.

An involuntarily committed client is verbally abusive to the staff and repeatedly threatening to sue. The client records the full names and phone numbers of the staff. Which nursing action is most appropriate to decrease the possibility of a lawsuit? A. Verbally redirect the client, and then limit one-on-one interaction. B. Involve the hospitals security division as soon as possible. C. Notify the client that documenting personal staff information is against hospital policy. D. Continue professional attempts to establish a positive working relationship with the client.

ANS: D The most appropriate nursing action is to continue professional attempts to establish a positive working relationship with the client. The involuntarily committed client should be respected and has the right to assert grievances if rights are infringed.

A client on an inpatient unit angrily states to a nurse, Peter is not cleaning up after himself in the community bathroom. You need to address this problem. Which is the appropriate nursing response? A. Ill talk to Peter and present your concerns. B. Why are you overreacting to this issue? C. You should bring this to the attention of your treatment team. D. I can see that you are angry. Lets discuss ways to approach Peter with your concerns.

ANS: D The most appropriate nursing response involves restating the clients feeling and developing a plan with the client to solve the problem. According to Skinner, every interaction in the therapeutic milieu is an opportunity for therapeutic intervention to improve communication and relationship-development skills.

A newly admitted client diagnosed with obsessive-compulsive disorder (OCD) washes hands continually. This behavior prevents unit activity attendance. Which nursing statement best addresses this situation? A. Everyone diagnosed with OCD needs to control their ritualistic behaviors. B. It is important for you to discontinue these ritualistic behaviors. C. Why are you asking for help if you wont participate in unit therapy? D. Lets figure out a way for you to attend unit activities and still wash your hands.

ANS: D The most appropriate statement by the nurse is, Lets figure out a way for you to attend unit activities and still wash your hands. This statement reflects the therapeutic communication technique of formulating a plan of action. The nurse attempts to work with the client to develop a plan without damaging the therapeutic relationship or increasing the clients anxiety.

A mother who has learned that her child was killed in a tragic car accident states, I cant bear to go on with my life. Which nursing statement conveys empathy? A. This situation is very sad, but time is a great healer. B. You are sad, but you must be strong for your other children. C. Once you cry it all out, things will seem so much better. D. It must be horrible to lose a child; Ill stay with you until your husband arrives.

ANS: D The nurses response, It must be horrible to lose a child; Ill stay with you until your husband arrives, conveys empathy to the client. Empathy is the ability to see the situation from the clients point of view. Empathy is considered to be one of the most important characteristics of the therapeutic relationship.

A client who frequently exhibits angry outbursts is diagnosed with antisocial personality disorder. Which appropriate feedback should a nurse provide when this client experiences an angry outburst? A. Why do you continue to alienate your peers by your angry outbursts? B. You accomplish nothing when you lose your temper like that. C. Showing your anger in that manner is very childish and insensitive. D. During group, you raised your voice, yelled at a peer, and slammed the door

ANS: D The nurse is providing appropriate feedback when stating, During group, you raised your voice, yelled at a peer, and slammed the door. Giving appropriate feedback involves helping the client consider a modification of behavior. Feedback should give information to the client about how he or she is perceived by others. Feedback should not be evaluative or be used to give advice.

Which therapeutic communication technique is being used in this nurse client interaction? Client: When I get angry, I get into a fistfight with my wife or I take it out on the kids. Nurse: I notice that you are smiling as you talk about this physical violence. A. Encouraging comparison B. Exploring C. Formulating a plan of action D. Making observations

ANS: D The nurse is using the therapeutic communication technique of making observations when noting that the client smiles when talking about physical violence. The technique of making observations encourages the client to compare personal perceptions with those of the nurse.

An African American youth, growing up in an impoverished neighborhood, presents in the emergency department with bruises to his face, chest, and arms. He appears to be upset, is speaking in a dialect that is difficult for the nurse to understand, and is standing within 6 inches of the nurses personal space. What cultural consideration should a nurse identify as playing a role in this youths behavior? A. African Americans frequently speak in different tongues when they are upset. B. Most African Americans have learned to be aggressive when they have to see a health professional. C. African Americans tend to use dialects and invasion of personal space to intimidate others. D. Some African Americans speak in a dialect that is different from standard English and tend toward smaller personal space than that of the dominant culture.

ANS: D The nurse needs to recognize that a tendency toward smaller personal space and the use of dialects different from Standard English are cultural variables and dont necessarily imply aggressive or disrespectful behavior.

A nurse is assessing a client who is experiencing occasional feelings of sadness because of the recent death of a beloved pet. The clients appetite, sleep patterns, and daily routine have not changed. How should the nurse interpret the clients behaviors? A. The clients behaviors demonstrate mental illness in the form of depression. B. The clients behaviors are extensive, which indicates the presence of mental illness. C. The clients behaviors are not congruent with cultural norms. D. The clients behaviors demonstrate no functional impairment, indicating no mental illness.

ANS: D The nurse should assess that the clients daily functioning is not impaired. The client who experiences feelings of sadness after the loss of a pet is responding within normal expectations. Without significant impairment, the clients distress does not indicate a mental illness.

When under stress, a client routinely uses an excessive amount of alcohol. Finding her drunk, her husband yells at her about the chronic alcohol abuse. Which reaction should the nurse recognize as the use of the defense mechanism of denial? A. Hiding liquor bottles in a closet B. Yelling at their son for slouching in his chair C. Burning dinner on purpose D. Saying to the spouse, I dont drink too much!

ANS: D The nurse should associate the client statement I dont drink too much! with the use of the defense mechanism of denial. The client who refuses to acknowledge the existence of a real situation and the feelings associated with it is using the defense mechanism of denial.

An inpatient psychiatric physician refuses to treat clients without insurance and prematurely discharges those whose insurance benefits have expired. Which violation of an ethical principle should a nurse recognize in this situation? A. Autonomy B. Beneficence C. Nonmaleficence D. Justice

ANS: D The nurse should determine that the ethical principle of justice has been violated by the physicians actions. The principle of justice requires that individuals should be treated equally regardless of race, sex, marital status, medical diagnosis, social standing, economic level, or religious belief.

A nurse working on an inpatient psychiatric unit is assigned to conduct a 45-minute education group. What should the nurse identify as an appropriate group topic? A. Dream analysis B. Creative cooking C. Paint by number D. Stress management

ANS: D The nurse should identify that teaching clients about stress management is an appropriate education group topic. Nurses should be able to perform the role of client teacher in the psychiatric area. Nurses need to be able to assess a clients learning readiness. Other topics for education groups include medical diagnoses, side effects

On which task should a nurse place priority during the working phase of relationship development? A. Establishing a contract for intervention B. Examining feelings about working with a particular client C. Establishing a plan for continuing aftercare D. Promoting the clients insight and perception of reality

ANS: D The nurse should place priority on promoting the clients insight and perception of reality during the working phase of relationship development. Establishing a contract for intervention would occur in the orientation phase. Examining feelings about working with a client should occur in the preinteraction phase. Establishing a plan for aftercare would occur in the termination phase.

Which is the best nursing action when a client demonstrates transference toward a nurse? A. Promoting safety and immediately terminating the relationship with the client B. Encouraging the client to ignore these thoughts and feelings C. Immediately reassigning the client to another staff member D. Helping the client to clarify the meaning of the current nurse-client relationship

ANS: D The nurse should respond to a clients transference by clarifying the meaning of the nurse-client relationship, based on the current situation. Transference occurs when the client unconsciously displaces feelings toward the nurse about a person from the past. The nurse should assist the client in separating the past from the present.

Which statement should a nurse identify as correct regarding a clients right to refuse treatment? A. Clients can refuse pharmacological but not psychological treatment. B. Clients can refuse any treatment at any time. C. Clients can refuse only electroconvulsive therapy (ECT). D. Professionals can override treatment refusal if the client is actively suicidal or homicidal.

ANS: D The nurse should understand that health-care professionals can override treatment refusal when a client is actively suicidal or homicidal. A suicidal or homicidal client who refuses treatment may be a danger to self or others. This situation should be treated as an emergency, and treatment may be performed without informed consent.

When planning care for a Latino American client, the nurse should be aware of which cultural influence that may impact access to health care? A. The root doctor may be the first contact made when illness is encountered. B. The yin and yang practitioner may be the first contact made when illness is encountered. C. The shaman may be the first contact made when illness is encountered. D. The curandero may be the first contact made when illness is encountered.

ANS: D The nurse should understand that some Latino Americans may initially contact a curandero when illness is encountered. The curandero is the folk healer who is believed to have a gift from God for healing the sick. Treatments often include supernatural rituals, prayers, magic, practical advice, and indigenous herbs.

In what way should a nurse expect a school-aged child to gain positive self-esteem, according to Eriksons psychosocial developmental stages? A. Through basic need fulfillment and environmental predictability B. Through exploration and experimentation, resulting in self-confidence in ability to perform C. Through positive reinforcement of creativity and recognition of performance D. Through receiving recognition when learning, competing, and performing successfully

ANS: D The school-aged child develops self-confidence by learning, competing, and performing successfully and receiving recognition from significant others, peers, and acquaintances.

Which expected client outcome should a nurse identify as being correctly formulated? A. Client will feel happier by discharge. B. Client will demonstrate two relaxation techniques. C. Client will verbalize triggers to anger by end of session. D. Client will initiate interaction with one peer during free time within 2 days.

ANS: D The statement Client will initiate interaction with one peer during free time within 2 days is an example of a correctly formulated expected outcome. Outcomes should be measurable, realistic, client-focused goals that include a time frame. Appropriate nursing interventions are guided by client outcomes.

During an assertiveness training group, a client admits to aggressive behaviors. The client asks for suggestions for how to become more assertive and less aggressive. Which is the most appropriate nursing reply? A. Several techniques, including meditation and progressive muscle relaxation, appear helpful. B. Theres not much that can be done about aggressive behavior because of biological responses. C. Certain types of medications have been proven effective in promoting assertive communication. D. There are several techniques, including I statements, role playing, and thought stopping, that can help promote assertive behaviors and decrease aggressive behaviors.

ANS: D These techniques promote assertive behaviors and would help diminish aggressive responses.

Which best describes a nurses use of assertive behavior? A. When a nurse attempts to please others and apologizes for awkwardness in a new role B. When a nurse becomes defensive and angry when peers offer suggestions for improvement C. When a nurse has problems making decisions and has a tendency to procrastinate D. When a nurse is open and direct when asked by the nurse manager to complete assignments

ANS: D This is an assertive response. There is clear expression of needs and feelings.

A client states, You wont believe what my husband said to me during visiting hours. He has no right treating me that way. Which nursing response would best assess the situation that occurred? A. Does your husband treat you like this very often? B. What do you think is your role in this relationship? C. Why do you think he behaved like that? D. Describe what happened during your time with your husband.

ANS: D This is an example of the therapeutic communication technique of exploring. The purpose of using exploring is to delve further into the subject, idea, experience, or relationship. This technique is especially helpful with clients who tend to remain on a superficial level of communication.

Which nursing statement is a good example of the therapeutic communication technique of focusing? A. Describe one of the best things that happened to you this week. B. Im having a difficult time understanding what you mean. C. Your counseling session is in 30 minutes. Ill stay with you until then. D. You mentioned your relationship with your father. Lets discuss that further.

ANS: D This is an example of the therapeutic communication technique of focusing. Focusing takes notice of a single idea or even a single word and works especially well with a client who is moving rapidly from one thought to another.

A client tells the nurse, I feel bad because my mother does not want me to return home after I leave the hospital. Which nursing response is therapeutic? A. Its quite common for clients to feel that way after a lengthy hospitalization. B. Why dont you talk to your mother? You may find out she doesnt feel that way. C. Your mother seems like an understanding person. Ill help you approach her. D. You feel that your mother does not want you to come back home?

ANS: D This is an example of the therapeutic communication technique of restatement. Restatement is the repeating of the main idea that the client has verbalized. This lets the client know whether or not an expressed statement has been understood and gives him or her the chance to continue, or clarify if necessary.

An instructor is teaching about assertive rights. Which student statement indicates a need for further instruction? A. The right to be treated with respect is an assertive right. B. The right to say no without feeling guilty is an assertive right. C. The right to change your mind is an assertive right. D. The right to always put oneself first is an assertive right.

ANS: D This is not an assertive right. An assertive right is to consider others as well as yourself. This student statement indicates a need for further instruction.

A client on an inpatient unit is angry with a peer. During lunch, when the peer is not looking, the client spits into his soup. How would the nurse document this interaction? A. Client is displaying assertive behaviors. B. Client is displaying aggressive behaviors. C. Client is displaying passive behaviors. D. Client is displaying passiveaggressive behaviors.

ANS: D This response is passiveaggressive. The clients anger is expressed indirectly by spitting in the soup when the peer is not looking.

After vying for a nurse management position, nurse A is chosen over nurse B. When nurse manager A calls for staff meetings, nurse B is chronically late or absent. Nurse B is exhibiting which type of behavior? A. Passive B. Assertive C. Aggressive D. Passiveaggressive

ANS: D This response is passiveaggressive. The colleague is expressing anger indirectly by being late or absent from the meetings.

An aggressive nurse manager tells a staff nurse she has no business rallying staff to change the schedule. What would be an example of a technique that the staff nurse could use to stand up for her basic human rights? A. What is the real reason that you dont want the schedule changed? B. Sounds to me like youre threatened by this change. C. Are you upset because you dont want to redo the schedule? D. I have the right to express my opinion about the schedule.

ANS: D This response reflects the use of standing up for ones basic human rights.

A nurse charts Verbalizes understanding of the side effects of Prozac. This is an example of which category of focused charting? A. Data B. Problem C. Action D. Response

ANS: D Verbalizes understanding of the side effects of Prozac is an example of the response category of focused charting. The response is a description of the clients reaction to any part of medical or nursing care.