Mental Health Self Assessments
A client is brought to the emergency room after a brutal physical assault. Although oriented and coherent, the client cannot remember the assault or events surrounding it. The priority intervention by the nurse is to provide: Frequent reality orientation Physical comfort and safety Thoughtful questioning for the police report Referral to a community support group
Physical comfort and safety Maslow's hierarchy of needs establishes that the patient needs to feel safe after an assault. It is not an appropriate time in the relationship to begin questioning or referral.
A university student presents to the ED after having a panic attack at school during an exam. Which of the following identifies the type of crisis that the patient is experiencing? situational anticipated life transition psychiatric emergency life stress event
anticipated life transition The student is experiencing an anticipated life transition to college
Which child shows behaviors indicative of mental illness? Age 3 months: cries after feeding until burped; sucks thumb Age 9 months: does not eat vegetables; likes to be rocked Age 3 years: mute; passive toward adults; twirls when walking Age 6 years: developed enuresis after the birth of a sibling Symptoms consistent with pervasive developmental disorder are evident in the key. The behaviors of the other children are within normal ranges.
Age 3 years: mute; passive toward adults; twirls when walking Symptoms consistent with pervasive developmental disorder are evident in the key. The behaviors of the other children are within normal ranges.
The nurse is running a psychoeducational group on anger management . The form of leadership style for this type of group is: lasseiz-faire democratic authoritative universal
authoritative The role of the leader of the group is to impart information. It is not a therapy group but needs all members to listen and learn.
In working with clients with late stage AD, which is a priority intervention? Assist the client to consume fluids and food to prevent electrolyte imbalance Reorient the client to place and time frequently to reduce confusion and fear Encourage the client to participate in own ADLs to promote self esteem Assist with ambulation to prevent injury from falls
Assist the client to consume fluids and food to prevent electrolyte imbalance Need to encourage patient to eat and drink at later stages of illness
A nurse conducts group therapy on the eating disorders unit. Sessions are scheduled immediately after meals. What is the rationale? Provide a forum for journaling about foods eaten. Shift the patients' focus from food to psychotherapy. Promote processing of anxiety associated with eating. Focus on weight control mechanisms and food preparation.
Promote processing of anxiety associated with eating. Eating produces high anxiety for all patients with eating disorders. Anxiety levels must be lowered if the patient is to be successful in attaining therapeutic goals. The distracters are not desirable and do not support the rationale.
The nurse has identified that the patient with mania is not eating or taking fluids due to excessive activity. The most appropriate food item for this patient would be: Cheese and crackers Protein Shake Chicken and baked potato French fries
Protein Shake A milkshake can be carried for patients who are unable to stop moving but also provides nutrition and fluids
A patient discloses several concerns and associated feelings. If the nurse wishes to seek clarification, which comment would be appropriate? "What are the common elements here?" "Tell me again about your experiences." "Am I correct in understanding that..." "Tell me everything from the beginning."
"Am I correct in understanding that..." Allows the patient to validate that they were heard and allows clarification on the part of both speakers.
Which comment(s) by an elderly person best indicate successful completion of developmental tasks? Select all that apply. "I am proud of my children's successes in life." "I should have given to charities more often." "My relationship with my father made life more difficult for me." Correct! "My experiences in the war helped me appreciate the meaning of life." "I often wonder what would have happened if I had chosen a different career."
"I am proud of my children's successes in life." Ability to look back on experiences in life and look to future generations.
Which remark would the nurse expect to hear during the working stage of group therapy? "My problems are very personal and private; how do I know you people will not tell others what you hear in group?" "I have enjoyed this group; hard to believe that only a few weeks ago I couldn't even bring myself to talk here." "One thing everyone seems to have in common is that sometimes it's hard to be truly honest with those you love most." "I don't think I agree with that; it might help you, but it seems like it would upset your family."
"I don't think I agree with that; it might help you, but it seems like it would upset your family." The group has developed trust enough in each other to be able to tell their opinion.
A client has Obsessive - Compulsive Disorder (OCD). Which of the following statements made by the client to the nurse would be the BEST indicator of improvement? "I have more control over my thoughts and behaviors" "I know that my thoughts and behaviors are not normal" "I only do my ritual to reward myself when I have been good" "My friends don't know about my disorder"
"I have more control over my thoughts and behaviors" Having more control over thoughts helps the patient feel more control over behaviors
A client has chronic pain disorder. Which statement by the client indicates to the nurse that the plan of care has been successful? "I realize that my pain can be influenced by stress" "I should avoid most physical activity". "Relaxation techniques only work when I am anxious about my pain". "I should keep myself pain-free by increasing my pain medication as I need it"
"I realize that my pain can be influenced by stress"
A nurse interacts with a newly hospitalized patient. Select the example of offering self. "I've also had traumatic life experiences. Maybe it would help if I told you about them." "Why do you think you had so much difficulty adjusting to this change in your life?" "I hope you will feel better after getting accustomed to how this unit operates." "I'd like to sit with you for a while to help you get comfortable talking to me."
"I'd like to sit with you for a while to help you get comfortable talking to me." The nurse is acknowledging the level of the patient's suffering and offering to be with them during in the painful experience.
A client treated for hypochondriasis has an upsetting phone call with her husband. She subsequently asks for an analgesic. The client states, "My head is killing me , and I know there is a tumor in there somewhere or it wouldn't hurt like this". The nurse's therapeutic response would be: "You have no brain tumor. It is just your anger towards your husband" "I'll get your vital signs and then call your doctor if they are abnormal" "You must try not to rely on the pain pills because they are addictive" "I'll get your medication and then, let's talk about what just happened".
"I'll get your medication and then, let's talk about what just happened". Acknowledging her immediate needs and helping the patient to begin to make connection between her symptoms and emotions.
A history reveals that a patient virtually stopped eating 5 months ago and lost 25% of body weight. The nurse says, "Describe what you think about your present weight and how you look." Which response would be most consistent with anorexia nervosa? "I'm fat and ugly." "What I think about myself is my business." "I'm grossly underweight, but I cover it well." "I'm a few pounds overweight, but I can live with it."
"I'm fat and ugly." Patients with anorexia nervosa do not recognize their thinness. They perceive themselves to be overweight and unattractive. The patient with anorexia will usually express distorted perceptions of the self and persist in trying to lose more weight even though underweight.
A new nurse asks for advice about talking with a client recently diagnosed with dissociative identity disorder (DID). When the new RN asks "should I talk about her childhood abuse?", the nurse replies: "If she brings up the abuse, listen to her and be supportive" "You will need to really push her to get it all out" "Ask her to discuss this only with her therapist" "Remind her that sometimes adults exaggerate their childhood experiences"
"If she brings up the abuse, listen to her and be supportive" It would not be therapeutic to cut the client off from discussing their experiences and feelings, therefore, the objective of this intervention is to let the patient know that it is OK to talk about the abuse.
A patient tells the nurse, "I don't think I'll ever get out of here." Select the nurse's most therapeutic response. "Everyone feels that way sometimes." "Don't talk that way. Of course you will leave here!" "Keep up the good work and you will be discharged." "It sounds like you don't feel like you're making progress."
"It sounds like you don't feel like you're making progress." The nurse reflects by putting into words what the patient is hinting. By making communication more explicit, issues are easier to identify and resolve. The distracters are nontherapeutic techniques of disapproving, minimizing feelings, and false reassurance.
A patient, Mary, has talked constantly throughout the group therapy session. She has repeated the same material several times. Other members were initially attentive then became bored, inattentive, and finally sullen. Which intervention would be most effective for the nurse leader to take? "Most of you have become quiet. I'm wondering if it might be related to concerns you may have about how the group is progressing today." "Mary has been doing most of the talking. I think it would be helpful for everyone to tell Mary how that has affected your experience of the group." "I noticed that as the group went on, most members became quiet, then disinterested, and now seem almost angry. What is going on?" "Mary, you have been doing most of the talking, and others have not had much chance to speak as a result. Could you please yield to others now?"
"Most of you have become quiet. I'm wondering if it might be related to concerns you may have about how the group is progressing today." The focus remains on the group process and not the problem of the patient who is monopolizing the group.
Which comment most clearly shows a speaker views mental illness with stigma? "Some mental illnesses are inherited." "Most people with mental illness are unmotivated." "Severe environmental stress sometimes causes mental illness." "Some mental illnesses are brain disorders resulting from changes in how impulses are transmitted."
"Most people with mental illness are unmotivated." Denotes an individual who believes that mental illnesses are related to personal characteristics
A patient asks, "What are neurotransmitters? The doctor said mine are imbalanced." Select the nurse's best response. "How do you feel about having imbalanced neurotransmitters?" "You must feel relieved to know that your problem has a physical basis." "Neurotransmitters are substances we eat daily that influence memory and mood." "Neurotransmitters are natural chemicals that pass messages between brain cells."
"Neurotransmitters are natural chemicals that pass messages between brain cells." Psychoeducation of patients is an important role of the psychiatric nurse
A student nurse says, "I don't need to interact with my patients. I learn what I need to know by observation." An instructor can best interpret the nursing implications of Sullivan's theory to this student by responding: "Interactions are required in order to help you develop therapeutic communication skills." "Nurses cannot be isolated. We must interact to provide patients with opportunities to practice interpersonal skills." "Observing patient interactions will help you formulate priority nursing diagnoses and appropriate interventions." "It is important to note patients' behavioral changes, because these signify adjustments in personality."
"Nurses cannot be isolated. We must interact to provide patients with opportunities to practice interpersonal skills." Sullivan's theory focused on Interpersonal relationships as the vehicle for healing and resolution of internal conflicts
A patient referred to the eating disorders clinic lost 35 pounds over 3 months. To assess eating patterns, the nurse should ask: "Do you often feel fat?" "Who plans the family meals?" "What do you eat in a typical day?" "What do you think about your present weight?"
"What do you eat in a typical day?" Although all the questions might be appropriate to ask, only the correct response focuses on the patient's eating patterns. The distracters focus on distortions in body image and explore the patient's feelings about weight.
The nurse is sitting with a patient diagnosed as having schizophrenia, disorganized type, who starts to laugh uncontrollably, although nothing funny has occurred. The nurse should say: "Please share the joke with me" "Why are you laughing?" "I don't think I said anything funny" "You are laughing. Tell me what's happening"
"You are laughing. Tell me what's happening" The use of reflecting the patient's behavior helps to promote reality testing. It also conveys to the patient that the nurse wants to understand the behavior.
A recently divorced man with severe depression exhibits poor sleep and impaired concentration, leading him to function poorly at work. Inattention to hygiene and irritability with others aggravate problems at work. Co-workers do not recognize that he is depressed and instead assume his behavioral changes are due to drug abuse. One day he is fired. Work had been his one remaining source of self-worth. The man presents at the emergency room seeking medication to help him sleep. Which of the following responses would be most important for the triage nurse to take at this time? "Have you considered seeking treatment for the depression itself?" "Tell me what you have already been trying to help improve your sleep." "We usually don't prescribe sleep medications in the emergency room." "You said you are depressed; have you thought about harming yourself?"
"You said you are depressed; have you thought about harming yourself?" Approximately two-thirds of depressed people contemplate suicide. Depressed patients who exhibit feelings of worthlessness are at higher risk. Significant losses (divorce and loss of job) and depressed mood are major risk factors for suicide. Suicide should be directly assessed. Seeking further information about his sleep habits and exploring treatment options related to depression are desirable but are not as high a priority at this time as assessing possible risk to self. Advising him that sleep medications are not provided by the emergency room could be seen as further rejection and could lead the patient to terminate the assessment prematurely.
Which best exemplifies the use of the defense mechanism of sublimation? A child who has been told by parents that stealing is wrong reminds a friend not to steal A man who loves sports but is unable to play decides to become an athletic trainer Having chronic asthma with frequent hospitalizations, a young girl admires her nurses. She later chooses nursing as a career. A boy who feels angry and hostile decides to become a therapist to help others
A boy who feels angry and hostile decides to become a therapist to help others Channeling of socially or personally unacceptable drives or urges into positive actions
Which of the following best exemplifies the client's use of the defense mechanism of reaction formation? A client feels rage at being raped at a young age, which later is expressed by joining law enforcement. A client is unhappy about being a father, although others know him to dote on his son A client is drinking 6-8 beers a day while still going to AA as a group leader A client is angry that his call bell is not answered and decides to call the nurse when it is unnecessary.
A client is unhappy about being a father, although others know him to dote on his son Dealing with negative emotions by exaggerating opposite behaviors or emotions
Which situation reflects the defense mechanism of projection? A husband has an affair and then buys his wife a diamond necklace A promiscuous wife accuses her husband of having an affair A wife, failing to become pregnant, works hard at becoming teacher of the year. A man who was sexually assaulted as a child remembers nothing of the event.
A promiscuous wife accuses her husband of having an affair Attributing negative feelings or emotions onto others
The nurse is caring for a patient who is from Laos. The family is very involved in his care and believes that spirits are responsible for his delusions and auditory hallucinations. The nurse's intervention would include: Acknowledgement of the importance of his cultural background Attempt to distance the patient from his family for the sake of his treatment Education of the family to the importance of treatment Referral of the patient to community social services
Acknowledgement of the importance of his cultural background Culture has an impact on all aspects of the nursing process from assessment to intervention. It is important to acknowledge the beliefs of the family and patient.
A new staff nurse completes orientation to a psychiatric unit. This nurse may expect which of the following to be expected in his/her scope of practice? Conduct mental health assessments Establish therapeutic relationships Create holistic nursing care plans All of the above
All of the above
Nonverbal communication is an essential component of therapeutic communication with a patient. An appropriate use of nonverbal techniques would include the following: Leaning forward while the patient is talking Maintaining eye contact Using silence All of the above
All of the above All of the responses are examples of nonverbal communication.
An 18-year-old referred to the mental health center often cooks gourmet meals but eats only tiny portions. The patient wears layers of loose clothing saying, "I like the style." The patient's weight dropped from 130 to 95 pounds. She has amenorrhea. Which diagnosis is most likely? Eating disorder not otherwise specified Anorexia nervosa Bulimia nervosa Binge eating
Anorexia nervosa Overcontrol of eating behaviors, extreme weight loss, amenorrhea, preoccupation with food, and wearing several layers of loose clothing to appear larger are part of the clinical picture of an individual with anorexia nervosa. The bulimic individual usually is near normal weight. The binge eater is often overweight. The patient with eating disorder not otherwise specified may be obese.
What classification of drugs shares similar features with alcohol overdose and alcohol withdrawal? Anxiolytics Amphetamines Cocaine PCP
Anxiolytics Anxiolytics or benzodiazepines are CNS depressants, similar to alcohol
On discharge, a client diagnosed with dementia is prescribed donepezil hydrochloride (Aricept). Which of the following would the nurse include in the teaching plan for the client's family? Aricept is a sedative/hypnotic used for short term insomnia Aricept is an Alzheimer's treatment used for mild to moderate dementia Aricept is an antipsychotic used for clients diagnosed with dementia Aricept is an Antianxiety agent used to help with the anxiety of early stage dementia
Aricept is an Alzheimer's treatment used for mild to moderate dementia
A patient is being treated on an inpatient unit for an acute episode of mania. Which of the following nursing actions would be of primary importance early in the acute phase of treatment? Assess for nutritional intake and sleep pattern Engage the family in education about the illness Ensure safety of other patients on the unit Reorient the patient
Assess for nutritional intake and sleep pattern Patients who are acutely manic have difficulty attending to eating, so it is vital to assure that the patient is able to get nutrition and times with decreased stimulation
Which belief will best support a nurse's efforts to provide patient advocacy during a multidisciplinary patient care planning session? All mental illnesses are culturally determined. Schizophrenia and bipolar disorder are cross-cultural disorders. Symptoms of mental disorders are unchanged from culture to culture. Assessment findings in mental disorders reflect a person's cultural patterns.
Assessment findings in mental disorders reflect a person's cultural patterns. Culture can influence how symptoms are manifested and what belief system influences the understanding of the symptoms and illness.
Which nursing intervention has highest priority for a patient with bulimia nervosa? Assist the patient to identify triggers to binge eating. Provide remedial consequences for weight loss. Assess for signs of impulsive eating. Explore needs for health teaching.
Assist the patient to identify triggers to binge eating. most patients with bulimia nervosa, certain situations trigger the urge to binge. Purging then follows bingeing. Often the triggers are anxiety-producing situations. Identification of triggers makes it possible to break the binge/purge cycle. Because binge eating and purging directly affect physical status, the need to promote physical safety assumes highest priority.
A windstorm severely damaged a client's farm. The client recalls very little about the storm and repeatedly says, "I can't believe the farm is destroyed". When the nurse is providing care, which of the following goals should take priority? The client will: Report decreased depression by day 2 Express anger about his loss by day 2 Apply for job retraining by day 2 Attend a support group for disaster survivors by day 2
Attend a support group for disaster survivors by day 2
A patient says, "I never know the answers," and "My opinion doesn't count." The nurse correctly assesses that this patient had difficulty resolving which psychosocial crisis? Initiative versus guilt Trust versus mistrust Autonomy versus shame and doubt Generativity versus self-absorption
Autonomy versus shame and doubt According to Erickson's developmental theory, autonomy allows the individual to maintain their own individual identity, in the company of others. The failure of autonomy is the experience of shame and doubt.
An alcohol-dependent patient admitted yesterday believes that the window blinds are snakes trying to get into the room. The patient is anxious, agitated, and diaphoretic. The nurse can anticipate the health care provider will prescribe a: Benzodiazepine, such as Ativan or Librium Antipsychotic, such as Zyprexa or haldol Monoamine oxidase inhibitor Narcotic analgesic, such as codeine
Benzodiazepine, such as Ativan or Librium Benzodiazepines are used to treat the acute stages of detoxification. They help to decrease anxiety, reduce distortions in environmental stimuli.
A student in the Mood Disorders Clinic states that everything he does is wrong and that nothing he tries ever works. Although he has never failed an exam, he believes he will fail the next one. Based on evidence-based research, which of the following interventions would best address a presentation of this type? Psychoanalytic therapy Desensitization therapy Cognitive-behavioral therapy Alternative and complementary therapies
Cognitive-behavioral therapy Cognitive-behavioral therapy attempts to alter the patient's dysfunctional beliefs by identifying automatic and/or distorted thinking and then questioning it. This is then followed by rewording or reframing the thought in a more realistic manner. The patient is also taught the connection between thoughts and mood. Research shows that cognitive-behavioral therapy involves the formation of new connections between nerve cells in the brain and is at least as effective as medication. Evidence does not support similar effectiveness for the other psychotherapeutic modalities mentioned.
A young female member in a therapy group relates to an older female patient as one might to a mother, accusing her of trying to control her whenever the older member offers observations or suggestions to her. Which therapeutic factor of a group is represented by this behavior? Instillation of hope Existential resolution Development of socializing techniques Corrective recapitulation of the primary family
Corrective recapitulation of the primary family Redoing of the issues that arise in the family of origin; the therapist can use this reaction to help the patient "redo" the dynamics of this relationship.
A patient's nursing care plan includes assessment for auditory hallucinations. Indicators that suggest the patient may be hallucinating include: Aloofness, increased distractibility, and suspicion Elevated mood, hype talkativeness, and distractibility Performing rituals and avoiding open places Darting eyes, distracted, and mumbling to self
Darting eyes, distracted, and mumbling to self All symptoms that the patient is responding to voices that others can not hear.
During an assessment interview, the client tells the nurse, "I can't stop worrying about my makeup. I can't go anywhere nor do anything unless my makeup is fresh and perfect. I wash my face and put on fresh makeup at least once and sometimes twice an hour". The nurse's priority should be to adjust the client's plan of care so that the client will be: Required to spend daytime hours out of own room Given advance notice of approaching time for all group therapy sessions Asked to keep a diary of feelings experienced if unable to groom self at will Allowed to use own cosmetics and grooming products
Given advance notice of approaching time for all group therapy sessions Given time to adapt her behaviors and use more positive coping strategies
The patient describes a sense of detachment from his body when he cut himself. This is an example of which defense mechanism? Dissociation Suppression Denial Projection
Dissociation Split from conscious awareness, memory, or feelings
An 80 year old client admitted to the ED is experiencing fever, urinary frequency, and dysuria. The client is combative and seeing things that others do not see. Which nursing diagnosis reflects this client's problem? Disturbed sensory perception R/T infection AEB visual hallucinations Risk for violence: self directed R/T disorientation Self care deficit R/T decreased perceived need AEB disheveled appearance Social isolation R/T decreased self esteem
Disturbed sensory perception R/T infection AEB visual hallucinations Client is showing signs of urinary tract infection which can precipitate
A nurse is working with a patient on an acute inpatient unit. Which of the following would be a barrier to communication? I'm not sure I follow you. Could you tell me again? Don't worry; it will all work out. Perhaps talking about it would help You might speak of this problem in group today and get some help from others.
Don't worry; it will all work out. This response gives false hope or can be heard as being dismissive of the patient's feelings.
The school nurse learns that since the death of their youngest son, Mr. and Mrs. Jones have been missing work enough to face disciplinary action. The surviving children, aged 8 and 10 years, are having to make their own dinners as best they can. The school nurse notices that the children are wearing dirty clothes and sometimes are inadequately clothed. Which nursing diagnosis would be a priority in this situation? Caregiver role strain Interrupted family processes Compromised resilience Dysfunctional family processes
Dysfunctional family processes The parental unit is unable to deal with the stress of the loss and care for their remaining children. The nurses role would be to help the family identify constructive ways of dealing with the loss.
A client is diagnosed with depersonalization disorder. Which of the following is the nurse most likely to find in the assessment? Two or more personalities Feelings like "being in a dream" Indifference to the symptoms Amnesia about the event.
Feelings like "being in a dream" The patient feels as though they are in a dream like state; unable to connect with their physical body
A hospitalized, alcohol-dependent patient believes that spiders are spinning entrapping webs in the room. The patient is fearful, agitated, and diaphoretic. Which nursing intervention is indicated? Check the patient every 15 minutes One-on-one supervision Keep the room dimly lit Force fluids
Force Fluids Dehydration may be a cause of delirium i.e. auditory/visual hallucinations
A patient has disorganized thinking associated with schizophrenia. Neuroimaging would most likely show dysfunction in which part of the brain? Hippocampus Frontal lobe Cerebellum Brainstem
Frontal lobe dysfunction in the frontal lobe is responsible for disturbances in thought and executive functioning
Operant conditioning is part of the treatment plan to encourage speech in a child who is nearly mute. Which technique applies? Encourage the child to observe others talking. Include the child in small group activities. Give the child a small treat for speaking. Teach the child relaxation techniques.
Give the child a small treat for speaking. Operant conditioning is a behavioral technique that rewards acceptable behavior.
A patient admitted for injuries suffered while intoxicated has been hospitalized for 48 hours. The patient is now shaky, irritable, anxious, diaphoretic, and reports nightmares. The pulse rate is 130 beats/min. The patient shouts, "Bugs are crawling on my bed. I've got to get out of here". Select the most accurate assessment of the situation. The patient: Is attempting to gain attention from staff May have sustained a head injury before admission Has symptoms of alcohol-withdrawal delirium Is having an acute psychosis
Has symptoms of alcohol-withdrawal delirium
Which of the following are part of the CAGE questionnaire screening tool? Select all that apply. Have you ever felt that you should cut down on your drinking? Have people annoyed you by criticizing your drinking? Have you ever felt guilty about your drinking? Have you ever had a drink in the morning to steady your nerves? Have you ever attempted suicide while intoxicated?
Have you ever felt that you should cut down on your drinking? Have you ever felt that you should cut down on your drinking? Have people annoyed you by criticizing your drinking? Have you ever felt guilty about your drinking? Have you ever had a drink in the morning to steady your nerves? but all part of alcohol abuse assessment
A newly admitted patient with schizophrenia approaches the unit nurse and says, "The voices are bothering me. They are yelling at me and telling me stuff. They are really bad". Which response by the nurse would be the most appropriate? Do you hear these voices very often? Do you have a plan for getting away from the voices? I'll stay with you. Tell me what you are hearing. Try to ignore them and play cards with the others
I'll stay with you. Tell me what you are hearing. The nurse uses empathy and assures the patient that they are safe.
A client presents to the emergency department with an acute decrease in cognitive ability. The nurse's assessment should include which of the following? Select all that apply. Slow progression of symptoms Impaired attention and concentration Diminished appetite Symptoms diminish as the day progresses Oriented to time and place with no wandering
Impaired attention and concentration Oriented to time and place with no wandering Client is exhibiting symptoms of delirium with acute onset
Which medication to maintain abstinence would most likely be prescribed for patients with either alcoholism or opioid addiction? Bromocriptine (Parlodel) Methodone (dolophine) Disulfiram (Antabuse) Naltrexone (ReVia)
Naltrexone (ReVia) Naltrexone is used to prevent cravings for substances and can be used for both Alcohol and opioid addiction
When the nurse is planning relapse prevention strategies for clients diagnosed with substance dependence, which of the following should be the initial nursing approach? Address previously successful coping skills Encourage rehearsing stressful situations that may lead to relapse Keep the interventions simple Provide community resources such as AA
Keep the interventions simple When the patient is beginning to detox and admitting that they have a problem with chemical dependency, it is important to be clear and direct until they are able to be cognitively aware.
A patient would benefit from therapy in which peers as well as staff have a voice in determining patient privileges and psychoeducational topics. Which approach would be best? Milieu therapy Cognitive therapy Short-term dynamic therapy Systematic desensitization
Milieu therapy Milieu therapy is a model of therapy that focuses on forming a community among individuals with psychiatric disorders and the staff involved in their care. This form of therapy empowers patients and models appropriate behaviors
A patient with schizophrenia has received typical antipsychotics (e.g. haldol) for a year. His hallucinations are less intrusive, but he remains apathetic, has poverty of thoughts, cannot work, and is socially isolated. To address these symptoms, the nurse might consult with the prescribing health care provider to suggest a change to an atypical antipsychotic such as: Ativan Olanzapine (Zyprexa) Diphenhydramine (Benadryl) Chlorpromazine (Thorazine)
Olanzapine (Zyprexa) The atypical antipsychotics are thought to help with the negative symptoms of schizophrenia (avolition, apathy, poverty of thoughts, etc)
A client with Bipolar II disorder is being seen in an outpatient setting. The nurse practitioner would want to be aware of what differences between Bipolar I and II disorders? Select all that apply: Bipolar I disorder is genetic and Bipolar II is situational Patients with Bipolar I disorder often present with mania being the primary concern whereas Bipolar II presents with treatment resistant depression. The use of antiepileptic medication is common. Antidepressants as monotherapy are contraindicated.
Patients with Bipolar I disorder often present with mania being the primary concern whereas Bipolar II presents with treatment resistant depression. The use of antiepileptic medication is common. Antidepressants as monotherapy are contraindicated.
Parents of a child with ADHD tell the nurse, "We try to teach our child how to behave, but it doesn't help. We feel as though we are terrible parents." Select the nurse's most helpful response. Refer the parents for pastoral counseling. Discuss how traumatic life events precipitate ADHD. Explain the correlation between ADHD and parental conflict. Provide information about the relationship between ADHD and biochemical abnormalities.
Provide information about the relationship between ADHD and biochemical abnormalities. Abnormalities in dopamine receptors and transporters are implicated in ADHD. Parents who understand the possible biochemical causation may be less likely to blame their parenting methods for the child's behavior. The other options have no relevance to ADHD.
A man with severe depression is admitted to the partial hospitalization program for mood disorders after exhibiting unintentional weight loss and refusal to go to work. He does not bathe or shave, sleeps poorly, and repeatedly states: "I'm useless, I'm no good to anyone." Which intervention would be best to include in the patient's initial care plan? Involve patient in activities akin to those at his work to restore comfort. Reinforce his interest in resuming work attendance when it returns. Provide patient with nutrient-dense finger foods and weigh daily. Provide activities that involve concentration and fine motor skills.
Provide patient with nutrient-dense finger foods and weigh daily. In this patient's initial treatment, it is important to focus on basic physiological functioning and safety concerns such as ensuring adequate nutrition. Therefore, interventions focused on basic functioning should be stressed in his initial care plan. Providing finger foods enables easier intake, and nutrient-dense foods require that the patient ingest less food while still maintaining his weight. Severely depressed persons have impaired cognition and would have difficulty with tasks involving concentration or fine motor skills. It is important to choose activities for which the patient would have a high likelihood of success (or a positive experience) in order to reduce failure and reinforcement of negative self-image. Reinforcing an interest in work is desirable but unrealistic for his initial care plan.
A child with ADHD will begin medication therapy. The nurse should prepare a plan to teach the family about which classification of medications? Monoamine oxidase inhibitors Antipsychotic medications Anxiolytic medications Psychostimulant drugs
Psychostimulant drugs Psychostimulant drugs, such as methylphenidate and pemoline (Cylert), increase blood flow to the brain and have proved helpful in reducing hyperactivity in persons with attention deficit hyperactivity disorder. The other medication categories listed are not indicated.
Which of the following interventions is appropriate for the nurse to use on clients with either delirium or dementia? For safety, use physical restraints with an aggressive client Approach quietly and touch the client before speaking Speak in a loud, firm voice to the client Reorient the client to the nurse with each contact
Reorient the client to the nurse with each contact
A client is admitted to the emergency department after a car accident, but does not remember anything about it. The client is using what defense mechanism? Undoing Rationalization Suppression Repression
Repression Unconscious blocking of unpleasant feelings or events
An 11-year-old has Asperger's disorder. Which assessment finding supports this diagnosis? Mutism Tics and twitching Severe developmental delays Restricted and repetitive patterns of behavior
Restricted and repetitive patterns of behavior Most children with Asperger's syndrome manifest restricted and repetitive patterns of behavior as their major symptoms. Idiosyncratic interests may also occur. Verbal skills are rarely impaired. Tics and twitching are more often a part of the clinical picture of Tourette's syndrome. Severe developmental delays are part of the clinical picture of autism rather than Asperger's syndrome.
What is the priority nursing diagnosis for a patient experiencing cocaine intoxication? Risk for altered cardiac perfusion Chronic low self esteem Ineffective denial Dysfunctional grieving
Risk for altered cardiac perfusion First it is the first priority according to Maslow's hierarchy of needs and also the diagnosis pertains directly to the side effects of cocaine use.
A client with Dissociative Identity Disorder (DID) is admitted after an overdose of alcohol and benzodiazepines, claiming that another alter "did it". The nurse formulates which of the following as the priority nursing diagnosis? Post trauma response Risk for self-directed violence Disturbed personal identity Anxiety
Risk for self-directed violence
The patient with new onset Mania is started on Lithium Carbonate. What medication would also be used until the Lithium reaches therapeutic levels? Ativan Cogentin Risperdal Antihypertensive agents
Risperdal An atypical antipsychotic can provide mood stabilizing, antipsychotic properties.
When a patient presents with disorganized thinking and flight of ideas, he is moving quickly and displaying psycho-motor agitation the nurse should: Reorient the patient Set limits and be consistent in approach Listen and be supportive Move away and ignore the patient
Set limits and be consistent in approach Setting limits help the patient with boundaries and safety concerns, being consistent is also important to maintaining safety
When assessing an apparently anxious client, the nurse ensures that questions related to the client's anxiety are: Abstract and nonthreatening Avoided until the anxiety disappears Avoided until the client brings up the subject Specific and direct
Specific and direct Being concrete and specific offer limits to the patient's anxiety
A patient has recently been under significant stress and worked long hours. At home, the patient watches television and eats until going to bed. The patient is too tired to exercise and has gained 25 pounds in 1 month. A desired outcome for the patient is to recognize anxiety that precedes binge eating and reduce it. Which intervention addresses the outcome? Teach stress-reduction techniques such as relaxation and imagery. Encourage the patient to design and implement an exercise program. Explore ways in which the patient may feel more in control of the environment. Encourage the patient to attend a support group such as Overeaters Anonymous.
Teach stress-reduction techniques such as relaxation and imagery. Teaching alternative stress-reduction techniques that may be substituted for overeating most directly addresses the goal of replacing binge eating with a constructive anxiety-releasing activity. The other options offer interventions that relate to other outcomes.
A parent with schizophrenia and 10-year-old child live in a homeless shelter. The child has adapted to shelter life and formed a relationship with a supportive volunteer. The child says, "My three best friends and I got an A on our school science project." Which assessment applies? The child displays resilience. Risk factors for substance abuse are evident. The child is at risk for posttraumatic stress disorder. The child uses intellectualization to deal with problems.
The child displays resilience. Resiliency enables a child to handle the stresses of a difficult childhood. Resilient children can adapt to changes in the environment, take advantage of nurturing relationships with adults other than parents, distance themselves from emotional chaos occurring within the family, and learn and use problem-solving skills. The other options are not supported by data given in the scenario.
A client with Generalized Anxiety Disorder (GAD) states, "I now know that the best thing for me to do is just to try to forget my worries". How should the nurse evaluate this statement? The client is developing insight The client's coping skills are improving The client needs to be encouraged to verbalize feelings The nurse - client relationship should be terminated
The client needs to be encouraged to verbalize feelings The client with GAD internalizes anxiety; she should be encouraged to express emotions
During the first interview with a parent whose child died in a car accident, the nurse feels sorry for the patient and reaches out to take the parent's hand. Select the correct analysis of the nurse's behavior. The parent will perceive the gesture as intrusive and overstepping boundaries. It shows empathy and compassion. It will encourage the parent to continue to express feelings. The action is inappropriate. "No touch" rules are important in all psychiatric interactions. The gesture is premature. The patient's cultural and individual interpretation of touch is unknown.
The gesture is premature. The patient's cultural and individual interpretation of touch is unknown. Touch has various cultural and individual interpretations. Nurses should refrain from using touch until an assessment can be made regarding the way in which the patient will perceive touch. The other options present prematurely drawn conclusions.
There are physiological, psychological, and perceptual changes that occur as anxiety increases. Which of the following illustrates a change in perception? The patient experiences chest pain resembling a heart attack A patient denies that he has experienced changes in his job situation and doesn't talk about it with others An individual has experienced a loss in his family and can't function at work A man uses passive-aggressive behaviors to deal with loss of sense of control in his marriage.
The patient experiences chest pain resembling a heart attack The chest pain is viewed as a heart attack leading the patient to perceive that the stress is overwhelming.
When a patient first began using alcohol, two drinks produced relaxation and drowsiness. After 1 year, four drinks are needed to achieve the same response. Why has this change occurred? The alcohol is less potent Tolerance has developed Hypomagnesemia has occurred Antagonistic effects are evident
Tolerance has developed Tolerance develops and the same amount of alcohol does not generate the same response. More alcohol is needed.
In the development of anxiety, stressors can be real or perceived. True False
True Stress can take many forms, either originating from a real event or perceived solely by the person
A woman presents to an ED after having been the victim of a violent rape. The nurse immediately moves to establish a therapeutic relationship with the patient. True False
True The development of a therapeutic relationship will help the patient feel safe and validated. It will also help with assessment and planning care.
A young man presents to the university health services complaining of symptoms of depression with anxiety. He reveals that his family has disowned him because he has decided to go to school in another town. The nurse's assessment would be that the family is most likely enmeshed and reacting to the patient's independence. True False
True The enmeshed family responds strongly to the perceived independent of its members.
The client is experiencing a Panic Attack. Which of the following actions by the nurse would be appropriate? Select all that apply. Speak loudly and firmly Restrict the patient's physical activity Use simple short sentences Remain calm and serene Teach cognitive restructuring skills
Use simple short sentences Remain calm and serene Demonstrating calming behaviors can help the client begin to control their own anxiety, offering small simple sentences takes into account the patient's limited perceptual field.
A client is admitted to an acute care facility with delirium caused by a serious urinary tract infection. Which of the following assessment data should the nurse expect to find? Select all that apply. Disorientation to time, place, person Ability to perform most self-care activities Normal and stable vital signs Wandering attention Perceptual disturbances Change in level of consciousness
Wandering attention Perceptual disturbances Change in level of consciousness
The wife of a patient with schizophrenia is worried about her 17 year old daughter. She asks the nurse what symptoms mark the prodromal stage of schizophrenia. The nurse should respond by listing the behaviors as: Withdrawal, poor concentration, erratic sleep patterns, and possibility of auditory hallucinations Auditory hallucinations, ideas of reference, thought insertion, and broadcasting Stereotyped behavior, echopraxia, echolalia, waxy flexibility, and thought blocking Looseness of association, concrete thinking, echolalia, paranoid delusions
Withdrawal, poor concentration, erratic sleep patterns, and possibility of auditory hallucinations This list of symptoms describe some of the preliminary symptoms of schizophrenia that occur before the first psychotic episode. The other distracters list actual positive symptoms of the disorder.
A nurse is assisting a patient with moderate stage AD at mealtime. Which statement should the nurse use? Would you like beans or potatoes? Why aren't you eating your dinner, honey? Your food will get cold. Eat your dinner now. If you don't eat, you will get dehydrated.
Would you like beans or potatoes? Giving the patient choices allows for independence but sets clear boundaries from which to choose
A client who is delirious yells out to the nurse: You are an idiot. Get me your supervisor" Which is the best nursing response in this situation? You need to calm down and listen to what I am saying You're very upset, I'll call my supervisor You're going through a difficult time. I'll stay with you. Why do you feel that my calling my supervisor will help anything?
You're going through a difficult time. I'll stay with you.
A nursing diagnosis for a patient with bulimia nervosa is Ineffective coping related to feelings of loneliness and isolation, as evidenced by use of overeating and self-induced vomiting to comfort self. Select the best outcome related to this diagnosis. Within 2 weeks, the patient will: appropriately express angry feelings. verbalize two positive things about self. verbalize the importance of eating a balanced diet. identify two alternative methods of coping with loneliness and isolation.
identify two alternative methods of coping with loneliness and isolation. The outcome of identifying alternative coping strategies is most directly related to the diagnosis of ineffective coping. This outcome is measurable. The distracters relate to other nursing diagnoses.
A nurse works with an adolescent who is moody and withdrawn because the teen's parents are divorcing. Establishing a therapeutic alliance is a priority because: focusing on the strengths of an individual increases the individual's self-esteem. the adolescent should express feelings and not keep them internalized. acceptance and trust convey feelings of security to the adolescent. therapeutic activities provide an outlet for tension.
acceptance and trust convey feelings of security to the adolescent. Trust is frequently an issue because the child or adolescent may never have had a trusting relationship with an adult. In this patient's situation, the trust she once had in her parents has been shattered, robbing her of feelings of security. Only the key relates to the therapeutic alliance.
A 15-year-old is referred to the mental health clinic by juvenile court after an arrest for vandalism and running away from home six times. The teen has been physically abusive to the mother and defiant to the father. The adolescent's problem is most consistent with criteria for: attention-deficit hyperactivity disorder. adolescent depression. conduct disorder. autistic disorder.
conduct disorder. Conduct disorders are manifested by a persistent pattern of behavior in which the rights of others and age-appropriate societal norms are violated. The patient's clinical manifestations do not coincide with criteria of the other disorders.
The nurse therapist assessing a family system perceives the family to be poorly differentiated and determines that family members have little sense of individuality. A desirable outcome is that members will: distinguish who is at fault for the family's dysfunction. develop their own values and beliefs instead of simply adopting those of others. become comfortable adhering to family norms and rules. integrate more effectively with other social systems.
develop their own values and beliefs instead of simply adopting those of others. Individuals within an enmeshed family system must be helped to develop individual identities in order to move out and interact with the outer social world.
A nurse influenced by Peplau's interpersonal theory works with an anxious, withdrawn patient. Interventions should focus on: rewarding desired behaviors. changing the patient's self-concept. administering medications to relieve anxiety. enhancing the patient's interactions with others.
enhancing the patient's interactions with others. Peplau focused on the curative features of the nurse - patient relationship as the healing intervention as the nurse helps the patient move to lower levels of anxiety.
A cognitive strategy the nurse could use to help a dependent patient would be: avoidance training. filling the patient's pill minder. interpreting the patient's dream content. examining the patient's fears related to being independent.
examining the patient's fears related to being independent. Cognitive therapy focuses on the patient's thinking behind their actions. The other selections represent other theories of psychopathology and treatment.
When assessing a 2-year-old with suspected autistic disorder, a nurse would expect: hyperactivity and attention deficits. failure to develop interpersonal skills. a history of disobedience and destructive acts. high levels of anxiety when separated from the parent.
failure to develop interpersonal skills. Autistic disorder involves distortions in development of social skills and language that include perception, motor movement, attention, and reality testing. Caretakers nearly always mention the child's failure to develop interpersonal skills. The distracters are more relevant to ADHD, separation anxiety, and conduct disorder.
A patient with anorexia nervosa is treated as an outpatient. Select the desired outcome related to the nursing diagnosis Imbalanced nutrition: less than body requirements. Within 1 week, the patient will: gain 1 to 2 pounds. exercise 1 hour daily. take a laxative every 3 days. weigh self accurately using balanced scales.
gain 1 to 2 pounds. The correct response is the only option that can be accomplished within 1 week when the patient is an outpatient. The focus would not be on the patient weighing self. The other answers are not desirable outcomes.
A depressed patient who is scheduled to receive electroconvulsive therapy this morning asks the nurse, "How is this treatment supposed to help me?" The best reply would be: "Electroconvulsive therapy seems to ____________." increase the activity of brain chemicals involved in mood interfere with one's memory of why he's feeling depressed serve as a punishment so you can stop punishing yourself open your mind to learning and trying new ways of coping
increase the activity of brain chemicals involved in mood ECT seems to alter neurotransmitter activity, consistent with the biochemical theory of the cause of depression. The other options distort information from other etiological theories and are not supported by research on the mechanism of action of electroconvulsive therapy.
The therapeutic action of neurotransmitter inhibitors that block reuptake cause: decreased concentration of the neurotransmitter in the central nervous system. increased concentration of neurotransmitter in the synaptic gap. destruction of receptor sites. limbic system stimulation.
increased concentration of neurotransmitter in the synaptic gap. There is more serotonin or other neurotransmitters in the synaptic cleft which allows for passage of messages between neurons.
An elderly patient complains bitterly and repetitively about numerous somatic concerns, but he has been examined thoroughly by several different health care providers, and physical examinations suggest that he is in good health. The nurse should suspect that the patient's somatic complaints most likely are: indications of a hidden physical illness. a maladaptive way of coping with stress. indications that he is feeling depressed. typical responses to the aches of growing older.
indications that he is feeling depressed. Elderly persons may have difficulty expressing emotions such as sadness or grief and may express them somatically instead. Somatic complaints may be stress related but are not a coping mechanism per se. No data is offered to support the presence of an undiagnosed medical illness or injury. Although aging processes can produce increasing aches and pains, this patient's presentation of bitter, repetitive somatic complaints and negative physical examinations suggests that a different phenomenon is at work.
A patient says, "My marriage is great. My spouse and I usually agree on everything." The nurse observes the patient's foot moving continuously and fingers twirling a shirt button. What assessment can the nurse make? The patient's communication is: clear. mixed. explicit. inadequate.
mixed. The patient's verbal and nonverbal communication are not congruent. It may indicate ambivalence within the patient.
A nurse uses Maslow's hierarchy of needs to plan care for a patient with mental illness. Which problem will receive priority? The patient: refuses to eat or bathe. reports feelings of alienation from family. is reluctant to participate in unit social activities. is unaware of medication action and side effects.
refuses to eat or bathe. The priority at the base of Maslow's hierarchy of needs is physiological. If the patient is not eating, this problem would take first priority.
Information given to a depressed patient and family when the patient begins selective serotonin reuptake inhibitor (SSRI) antidepressant therapy should include the directive to: avoid exposure to bright sunlight. report increased suicidal thoughts. restrict sodium intake to 1 gm daily. maintain a tyramine-free diet.
report increased suicidal thoughts. Some evidence indicates that suicidal ideation may worsen at the beginning of SSRI antidepressant therapy, so close monitoring is necessary, and the patient and family should be directed to report immediately any intensification in suicidal ideation, intent, or plans. SSRI medications do not increase photosensitivity or require dietary tyramine or sodium restrictions.
A patient in a group therapy session listens for a time and then remarks, "I used to think I was the only one who felt afraid. I guess I'm not as alone as I thought." This is an example of: ventilation. altruism. universality. group cohesiveness.
universality. Universality is the awareness that others have the same feelings or experiences.
