MSII Quiz 12

A patient says, I just dont think I can keep going on. I just want it all to end. The nurse assesses that this patient has suicidal ideation. What is the nurses best response?

"Do you have any thoughts of harming yourself?"

A 5-year-old patient was in an accident in which his cousin was killed. The patient starts to wet the bed at night. What question should the nurse ask the mother when she confirms that it has been several years since the patient had any difficulty with bedwetting?

"Do you think this is related to the accident?"

A nurse is assessing a patient with an acute stress disorder. What characteristics of this disorder should the nurse assess? (Select all that apply.)

- Diminished awareness of surroundings - Derealization - Depersonalizationd - Amnesia

A nurse is caring for a newly admitted female client who has depression and refuses to get out of bed, dress, or participate in group therapy. Which of the following is an appropriate nursing response?

"I will assist you in getting out of bed and getting dressed."

A client is admitted to the inpatient unit and is being considered for electroconvulsive therapy (ECT). The client appears calm, but the family is hypervigilant and anxious. The client's mother begins to cry and states, "My child's brain will be destroyed. How can the doctor do this?" The nurse makes which therapeutic response?

"It sounds as though you have some concerns about the ECT procedure. Why don't we sit down together and discuss any concerns you may have?"

A patient admitted with a conversion disorder after an automobile accident insists he is paralyzed, although no physical cause for his paraplegia can be found. What is the best nursing response when the patient asks the nurse to push him to his room?

"OK. I am going that way myself."

A nurse is caring for a client who has paranoid schizophrenia and a new prescription for risperidone. The client asks the nurse what the medicine is supposed to do. Which of the following responses should the nurse make?

"This medication will help to clear your thinking"

A nursing instructor is explaining the difference between illusion and hallucination. Which examples provided by students in the class indicate an illusion? (Select all that apply.)

- A car backfiring being perceived as gunfire - The television news being perceived as someone talking to you - A spot on the wall being perceived as a spider.

Which patient diagnosis and behavior should lead a nurse to conclude the patient is using the defense mechanism of denial?

A patient with emphysema continues to smoke.

What should a nurse suspect a patient diagnosis might be when the patient states, I often feel restless, have a tight sensation in my chest, and have an increased heart rate at times?

Anxiety disorder

A nurse assesses that a 42-year-old patient lives with her parents and is dependent on them for decisions about her life. Which mental health characteristic is this patient lacking?

Autonimous behavior

A nurse is reinforcing discharge teaching with a client who has bipolar disorder and is to begin taking lithium. Which of the following instructions should the nurse include in the teaching?

Avoid dieting

A nurse is caring for a client who begins showing signs of alcohol withdrawal delirium. Which of the following medications should the nurse administer?

Lorazepam

A patient is given anxiolytic medications for a mental disorder. What type of approach is this considered?

Biologic approach

A patient who has a history of episodes of road rage thinks that she is a very good driver and does not understand why she keeps being told she is a poor driver. She is losing her license now, and she tells the nurse that she is feeling very unhappy and abandoned. She feels like she might hurt herself. The nurse realizes that the patient is exhibiting which personality disorder?

Borderline

Since the summer weather began, a patient taking lithium for manic episodes has been walking daily. What important instruction should the nurse provide to this patient?

Maintain hydration

What is the best action for the nurse to implement to effectively listen therapeutically to a patient?

Concentrate on the patient and not think of responses to the patient while he or she is speaking.

A client was admitted to a medical unit with acute blindness. Many tests are performed, and there seems to be no organic reason why this client cannot see. The nurse later learns that the client became blind after witnessing a hit-and-run car crash in which a family of three was killed. The nurse suspects that the client may be experiencing which?

Conversion disorder

While in the dayroom, one of the patients becomes very agitated and begins to threaten to harm the other patients and is directing violence at the other patients and staff. What is the most appropriate nursing implementation?

Decrease the stimuli and use restraints if all other measures fail.

A nurse is caring for a client who has paranoid schizophrenia and is taking quetiapine. The nurse should observe the client for which of the following adverse effects?

Drowsiness

Dystonic reactions, pseudoparkinsonism, akathisia, and tardive dyskinesia are types of which effect?

Extrapyramidal symptoms

How does fear differ from anxiety?

Fear is a response to a specific threat.

A patient is admitted with posttraumatic stress disorder (PTSD) says he had a very stressful experience when in high school and has never really recovered. What is the most appropriate nursing action?

Guide the patient in relaxation techniques to distract him when flashbacks occur.

A nurse is caring for a client who has depression and is discussing ADLs with his family. The nurse identifies that after discharge, the client is able to perform which of the following if independent with ADLs?

Hygiene

A patient is brought in from the emergency department after telling the physician that he is a relative of the president of the United States. He says that he should not be detained because he has important business to attend to that involves national security. He is dressed in a bright coat with plaid pants and gets very angry when you try to question him. What is this patient is experiencing?

Manic episode

A group of nursing students are taking their first major examination. What should the nursing instructor expect the students might experience?

Mild anxiety

What is a common cause of delirium?

Neoplasms

The nurse is assigned to care for a client experiencing disturbed thought processes. The nurse is told that the client believes that the food is being poisoned. Which communication technique should the nurse plan to use to encourage the client to eat?

Open-ended questions and silence

A nurse is assigned to a client who is psychotic. The client is pacing, agitated, and using aggressive gestures and rapid speech. The nurse determines that which of the following is the immediate priority of care?

Provide safety for both the client and other clients on the unit.

A patient who went away to college in September returns in October, thinking that he is a drummer in a popular rock band. What is this most likely a manifestation of?

Schizophrenia

A long-time patient with schizophrenia in the inpatient unit has developed involuntary movements of his tongue. What has this patient developed?

Tardive dyskinesia

When performing a mental status examination, a nurse notes that the patient keeps repeating, I didnt do it. I didnt do it. I didnt do it. This response would be an example of which one of the components of the mental status examination?

Thought content

A nurse is caring for a client who has schizophrenia and begins to talk about fantasy subjects. Which of the following is an appropriate intervention by the nurse?

Encourage the client to focus on reality-based issues

A manic client announces to everyone in the dayroom that a stripper is coming to perform that evening. When the psychiatric nurse's aide firmly states that the client's behavior is not appropriate, the manic client becomes verbally abusive and threatens physical violence to the nurse's aide. Based on the analysis of this situation, the nurse determines that the appropriate action would be to

Escort the manic client to his or her room.

Which nursing diagnosis is appropriate for all patients with an anxiety, a somatoform, or a dissociative disorder?

Ineffective coping

A patient states that he feels angry at work for no reason and often yells at his coworkers. The therapist asks the patient to describe events and then tells the patient to try different strategies to cope with these angry outbursts. What type of approach is this considered?

Interpersonal

A nurse in an acute care mental health facility is caring for a hospitalized client who has agoraphobia. The nurse observes the client making progress when he is able to participate in which of the following activities?

A picnic in a local park