Mental Health Exam 1

a client is hospitalized with a tentative diagnosis of pancreatic cancer. on admission the client asked the nurse "do you think i have anything serious, like cancer?" what is the nurses best reply? what makes you think you have cancer? I don't know if you do, let's talk about it? why don't you discuss this with your primary healthcare provider? you don't need to worry now, we won't know the answer for a few days

I don't know if you do, lets talk about it

A severely depressed, sullen patient has been taking Fluoxetine, an SSRI anti-depressant, for one week. During a follow up visit, the patient smiles euphorically, is giddy with high energy and states: "I feel so much better now". How would the nurse evaluate this behavioral/mood change? The medication has potentiated the effects of Serotonin syndrome The patient may have decided to carry out a plan for self-harm or suicide The medication dosage should be decreased and then tapered upwards for therapeutic levels The patient's behavioral change is normal and one that is expected with taking an antidepressant

The patient may have decided to carry out a plan for self-harm or suicide

A patient who has been severely depressed for two weeks stated to the nurse that she feels like "ending it all" as there is no hope anymore. Which of the following would be the best response by the nurse back to the patient? What is it that makes you think about harming yourself? How long have you thought about harming yourself? What specifically have you thought about doing to harm yourself? Have you tried to harm yourself in the past?

What specifically have you thought about doing to harm yourself?

which situation is an accurate instance of false imprisonment a nurse applies restraints to a conscious client to feed them a nurse applies restraints to an aggressive client after obtaining a signed consent form a nurse applies restraints to a unconscious client who is in danger of sustaining a fall a nurse applies restraints to a client after obtaining an order from the MD

a nurse applies restraints to a conscious client to feed them

There are many legal issues so a nurse must have sufficient psychiatric knowledge when working with mental health patients. How does the State of Wisconsin best define a chapter 51 or Emergency Detention? an involuntary admission of a person who is deemed incompetent of caring for themselves or making medical decisions until a guardian can be appointed a 96-hour hold that only law enforcement or medical doctors can initiate for the involuntary admission to a mental health unit an involuntary admission for an acute mental illness when the individual demonstrates dangerous behaviors such as a massive overdose of prescription medications utilization by law enforcement for involuntary admissions when the guardian gives a statement that the person suffers from a brain injury and is refusing to take medications

an involuntary admission for an acute mental illness when the individual demonstrates dangerous behaviors such as a massive overdose of prescription medications

What is the best approach with therapeutic communication by the nurse for the patient who is severely depressed with psychomotor slowing? fill in the gaps (words in the sentence) for the patient avoid asking the patient for preferences including likes and dislikes as it takes too long Wait for a family member to arrive as they may be able to help the patient communicate more effectively. be prepared to wait for the patient to respond verbally to allow time to 'process' what was just said by the nurse

be prepared to wait for the patient to respond verbally to allow time to 'process' what was just said by the nurse

a nurse is assessing a client for the use of defense mechanisms. in the presence of which defense mechanism does the client express emotional conflicts through motor, sensory or somatic disabilities? projection conversion dissociation compenstation

conversion

What is the nurses specific responsibility when the rights of a client on a mental health unit are restricted by the use of seclusion informing the clients family monitoring pharmacologic interventions completing a denial of rights form and forwarding it to the administrative officer documenting borsht the clients behavior and the reason that specific rights were denied

documenting borsht the clients behavior and the reason that specific rights were denied

which ethical principle is violated when the nurse forgets to give a painkiller to a client as promised? justice fidelity veracity nonmaleficence

fidelity involves being loyal by keeping promises

a person with a history of alcoholism says "I've been drinking since last friday to celebrate my sons graduation from college" what defense mechanism does the nurse identify denial projection identification rationalization

rationalization

a female client terminally ill with cancer says to the nurse "my husband is avoiding me. he doesn't love me anymore because of this awful tumor" what is the nurses more appropriate response? what makes you think he doesn't love you avoidance is a defense, he needs you help to cope do you think he's having difficulty dealing with your illness you seem very upset, tell me how your husband is avoiding you

you seem very upset, tell me how your husband is avoiding you

To help establish a therapeutic nurse-client relationship, the mental health nurse uses various communication techniques to convey a willingness to listen and a genuine desire to view the client and his or her needs to a respectful manner. What is the primary underlying principle guiding this process? Caring is the underlying component of nursing that promotes client care understanding of the psychosocial effects of a specific mental illness is vital to client care each client has a right to appropriate care directed toward both the clients strengths and weaknesses the nurse initials and maintains the nurse client relations so as to be therapeutic in its nature

Caring is the underlying component of nursing that promotes client care

a nurse is in the process of developing a therapeutic relationship with a client who has an addiction problem. What client communication permits the nurse to conclude that they are making progress in the working stage of the relationship? select all that apply: describes how others have caused the addiction verbalizes difficulty identifying personal strengths expresses uncertainty about meeting with the nurse acknowledging the effects of the addiction on the family addresses how the addiction has contributed to family distress

verbalizes difficulty identifying personal strengths acknowledging the effects of the addiction on the family addresses how the addiction has contributed to family distress

Certain questions are applicable in determining nursing negligence. Select all that apply was reasonable care provided? was there a breach of nursing duty? was there an act of omission that resulted in harm? except for the nurses action, would the injury have occurred? did the nurse fully understand the actions would result in harm?

was reasonable care provided? was there a breach of nursing duty? was there an act of omission that resulted in harm? except for the nurses action, would the injury have occurred?

one afternoon a male client on the inpatient psychiatric service complain to the nurse that he has been waiting for more than an hour for someone to accompany him to activities. The nurse replies, "we're doing the best we can, there are many other people on the unit who need attention too" the response demonstrated the nurses use of what type of behavior. impulse control defensive behavior reality reinforcement limit setting behavior

defensive behavior

an older adult who lives alone tells a nurse at the community health center, "i really dont need anyone to talk to. the TV is my best friend" who defense mechanism does the nurse identify? denial projection sublimation displacement

denial

a nurse speaking in support of the best interest of a vulnerable client reflects which nursing duty caring veracity advocacy confidentiality

advocacy

what is the term used to identify the displace of anger in a socially inappropriate manner abuse battery aggression defensiveness

aggression

A nurse is attempting to administer anti-anxiety medication to a patient who is on an involuntary commitment in the hospital. The patient refuses and threatens the nurse and then states "I'm going to kill you". Which nursing action is the highest priority at this time? making a decision to not administer this medication collaborating with the healthcare provider to get the patient declared incompetent initiating the MD protocol for forced court-ordered medications teaching the patient about the pros and cons of taking this medication

initiating the MD protocol for forced court-ordered medications

A patient is clearly depressed about a job transfer to Colorado because of the high cost of living and being much farther away from family. The patient does some research and convinces family members that Colorado has great opportunities for skiing and hiking in the mountains. This is an example of what type of defense mechanism? suppression reaction formation rationalization intellectualization

intellectualization

a client recently was diagnosed as having myelocytic leukemia discusses the diagnosis by referring to statistics, facts and figures. the nurse determines that the client is using which defense mechanisms? projection sublimation identification intellectualization

intellectualization

clients addicted to alcohol often uses the defense mechanism of denial. what is the reason that this defense is so often used? it reduces their feelings of guilt it creates the appearance of independence it helps them live up to others expectations it makes them look better in the eyes of others

it reduces their feelings of guilt

A recently hired nurse is caring for several clients on a mental health unit at a local community hospital. The nurse manager is evaluating the nurses performance. What situation indicated that the nurse-client boundaries of the recently hired nurse are appropriate? the nurse shares with the entire treatment team vital information the client disclosed in a private session the nurse is often busy doing other tasks when the client and nurse are scheduled for a counseling session a client enters the therapeutic group late with the nurses permission even though group rules say that this is not allowed a clients overall behavior is significantly more independent and demonstrated higher function on the days that the nurse is not working

the nurse shares with the entire treatment team vital information the client disclosed in a private session

A patient who has just retired from his job of 40 years expresses concerns of loneliness due to the loss of interacting with his co-workers that he enjoyed working with all these years 'both young and old'. Which response by the nurse is the most therapeutic to help this patient overcome feelings of loneliness? Hint: Consider developmental level/stage of life Now you can finally relax and enjoy life after working so hard all of your life Perhaps you could go into work and visit with your old friends Do you know about the local senior citizen facility here in town where you can meet other individuals who have retired? You would benefit from taking a vacation such as a cruise with other retirees your age

Do you know about the local senior citizen facility here in town where you can meet other individuals who have retired?

Litigation resulting from improper restraint use is a common legal issue. A nursing student is listing points related to the use of the restraints. Which fact needs correction? Restraints can be used when less restrictive interventions are not successful Restraints can be used when all other alternatives have been tried and exhausted Restraints can be used only to ensure the physical safety of the resident or other residents Restraints can be used anytime without a written order from the MD

Restraints can be used anytime without a written order from the MD

A nurse has been accused of defaming a patient's character. Which situation would most likely have led to this complaint by the patient? assault: the nurse threatened that the patient would be physical restrained without justification battery as the nurse touch the patient with consent in an non-emergency situation invasion of privacy: the patient overhears the nurse making false and malicious information about them libel: documenting critical and judgmental statements about the patient in the medical record

libel: documenting critical and judgmental statements about the patient in the medical record

a student nurse is listing different scenarios that comply with basic healthcare ethics. Which scenarios mentioned by the student nurse relate to the healthcare ethic of fidelity? Select all that apply: a nurse monitors a client after providing non pharmacological measures to relive anxiety due to hospitalization a nurse notes that the pain relief measures provided to that client have been ineffective. the nurse formulates a different plan of care a nurse ensures that the client understands the risks and benefits of experimental treatment before signing the appropriate consent form a nurse carefully evaluates the advantages and disadvantages of the clients plan of care to ensure that the risks do no outweigh the benefits a nurse is caring for a client who refuses to be touched by people of certain skin color. the nurse continues providing care since the other colleagues refuse to attend to the client

a nurse monitors a client after providing non pharmacological measures to relive anxiety due to hospitalization a nurse notes that the pain relief measures provided to that client have been ineffective. the nurse formulates a different plan of care a nurse is caring for a client who refuses to be touched by people of certain skin color. the nurse continues providing care since the other colleagues refuse to attend to the client

a nurse is teaching a group of parents about child abuse. what definition of assault should the nurse include in the teaching plan assault is a threat to do bodily harm to another person assault is a legal wrong committed by one person against the property of another assault is a legal wrong committed against the public that is punishable by federal law assault is the application fo force to another person without lawful justification

assault is a threat to do bodily harm to another person

A patient notifies a nurse of current suicidal ideation. Which nursing assessment is the highest priority? notifying all staff members and implementing suicide precautions assessing if the patient has a specific plan to commit suicide placing the patient on 1:1 nursing observation assessing for past history of suicide attempts

assessing if the patient has a specific plan to commit suicide

the nurse is caring for a newly admitted male client with the diagnosis of bipolar disorder who has a history of hyperactivity and combativeness. Later in the evening, a commotion is heard and the new client is found beating another client. What is the legal interpretation of this situation? the client should have been placed in restraints on admission a client who is known to have been combative should have been kept sedated a client with bipolar disorder who is in contact with reality does not require supervision because it was know that the client was frequently combative, close observation by the nursing staff was indicated

because it was know that the client was frequently combative, close observation by the nursing staff was indicated

a client requiring surgery because of mitral valve incompetence is admitted to the hospital and stated, "i need a new valved. my neighbor told me that the surgery is usually successful" what is the nurses most therapeutic response? you really dont need to hide your anxieties you sure came to the right place for a valve job im glad to see youre handling the situation well im sure you have a lot of question to ask about your surgery

im sure you have a lot of question to ask about your surgery

a client on the psychiatric unit is noisy, loud and disruptive. the nurse informs the client "unless you're quiet, you'll be isolated and put in restraints if necessary" How can this interaction be described in relation to the law the information given to the client is actually assault the clients behavior is to be expected and should be ignored clients who are hyperactive need to be restrained for their own protection clients who are disruptive and hyperactive cannot be expected to understand instructions

the information given to the client is actually assault

which action of the nurse relations to the QSEN competency of quality improvement the nurse uses data to monitor the outcomes of care the nurse provides compassionate and coordinated care the nurse works to minimize the risk of harm to the client the nurse combines clinal expertise with client preferences

the nurse uses data to monitor the outcomes of care

According to QSEN what is patient centered care understanding that the client is the source of control when providing care functioning effectively within nursing and inter-professional teams to deliver quality care using data to evaluate outcomes of care processes and designing methods to improve health care minimizing the risk of harm to clients and health care workers through improved professional performance

understanding that the client is the source of control when providing care

Your patient was recently started on an antidepressant medication. As the nurse you are aware that this medication could cause anticholinergic side effects. Which complaint from the patient would most likely indicate this side effect is occurring? lightheadedness, sedation and pounding heart dizziness, fatigue and confusion urinary retention, dry mouth and blurred vision bradycardia, insomnia and heart palpitations

urinary retention, dry mouth and blurred vision