NCLEX 10000 Foundations in Psychiatric Nursing
In the process of dealing with the intense feelings about being raped, victims commonly verbalize that they were afraid they would be killed during the rape and wish that they had been. The nurse should decide that further counseling is needed if the client makes which statement? a) "I did not fight him, but I guess I did the right thing because I am alive." b) "I get so angry at times that I have to have a couple of drinks before I sleep." c) "Suicide would be an easy escape from all this pain, but I could not do it to myself." d) "I wish they gave the death penalty to all rapists and other sexual predators."
"I get so angry at times that I have to have a couple of drinks before I sleep." Correct Explanation: Use of alcohol reflects unhealthy coping mechanisms. The client's report of needing alcohol to calm down needs to be addressed. Survival is the most important goal during a rape.
The family of an older adult wants their mother to have counseling for depression. During the initial nursing assessment, the client denies the need for counseling. Which comment by the client supports the fact that the client may not need counseling? a) "My primary care provider just put me on an antidepressant, and I will be fine in a week or so." b) "My daughter sent me here. She is mad because I do not have the energy to take care of my grandkids." c) "Since I have gotten over the death of my husband, I have had more energy and been more active than before he died." d) "My son got worried because I made this silly comment about wanting to be with my husband in heaven."
"Since I have gotten over the death of my husband, I have had more energy and been more active than before he died." Correct Explanation: Resolving grief and having increased energy and activity convey good mental health, indicating that counseling is not necessary at this time.
The decision is made to involuntarily admit a client to a psychiatric hospital on an emergency detention. The nurse explains the involuntary hospitalization process to the client. Which of the following statements made by the nurse would not be accurate about the involuntary admission process?
"You cannot have any visitors while you're here involuntarily." Explanation: Clients have a right to see visitors regardless of admission status. Involuntary hospitalization requires a psychiatrist state-of-need. Any client admitted involuntarily has the right to legal counsel. The client's release requires medical approval.
What occurs during the working phase of the nurse-client relationship? a) A nurse assesses a client's needs and develops a care plan. b) A nurse and a client discuss their feelings about terminating the relationship. c) A nurse and a client explore each others' expectations of the relationship. d) A nurse and a client evaluate and modify the goals of the relationship.
A nurse and a client evaluate and modify the goals of the relationship. Correct Explanation: The therapeutic nurse-client relationship consists of three phases: introduction or orientation, working, and termination. During the working phase, the nurse and client evaluate and refine the goals established during the orientation phase. In addition, major therapeutic work takes place and insight is integrated into a plan of action. The orientation phase involves assessing the client, formulating a contract, exploring feelings, and establishing expectations about the relationship. During the termination phase, the nurse prepares the client for separation and explores his feelings about the end of the relationship.
One staff member in a psychiatric unit says to the nurse, "Why are we carrying out suicide precautions for someone who is dying? It's pointless and a waste of time." The nurse should:
Call for a multidisciplinary staff meeting. Explanation: The nurse should call for a multidisciplinary staff meeting because there is a need for staff members to share their feelings of anger, frustration, and grief. Because nurses focus on saving human lives, any feelings of hopelessness regarding a dying client can interfere with the client's care and management.
A client is being discharged from the acute inpatient unit but needs further continuous supervision that is less intense than inpatient hospitalization. The nurse should refer the client to which of the following settings?
Subacute unit. Explanation: When inpatient hospitalization is no longer needed, subacute care is the next least restrictive setting when the client requires 24-hour supervision but less extensive and intensive services. Subacute units provide the client with a bed, meals, medication, groups, and activities. The client has autonomy and independence in choosing which groups to attend and can seek employment and housing and apply to school or training.
When developing the plan of care for a client with acute stress disorder who lost her sister in a boating accident, which intervention should the nurse initiate? a) telling the client to avoid details of the accident b) facilitating progressive review of the accident and its consequences c) helping the client to evaluate her sister's behavior d) postponing discussion of the accident until the client brings it up
facilitating progressive review of the accident and its consequences Correct Explanation: The nurse should facilitate progressive review of the accident and its consequences to help the client integrate feelings and memories and to begin the grieving process.
When developing the plan of care for a client with acute stress disorder who lost her sister in a boating accident, which intervention should the nurse initiate? a) telling the client to avoid details of the accident b) helping the client to evaluate her sister's behavior c) postponing discussion of the accident until the client brings it up d) facilitating progressive review of the accident and its consequences
facilitating progressive review of the accident and its consequences Correct Explanation: The nurse should facilitate progressive review of the accident and its consequences to help the client integrate feelings and memories and to begin the grieving process.
Knowing Maslow's hierarchy of needs can assist a nurse in understanding a client's behavior. Place the stages of Maslow's hierarchy of needs in order from basic to most complex. Use all options.
Physiologic needs Safety and security Love and belonging Self-esteem Self-actualization Correct Explanation: Maslow's hierarchy of needs progresses from the most basic to the most complex needs. Physiologic needs are the most basic human needs. Only after physiologic needs have been met can safety concerns be addressed, followed by love and belonging, which then fosters self-esteem and, finally, self-actualization.
A client who has experienced the loss of her husband through divorce, the loss of her job and apartment, and the development of drug dependency is suffering situational low self-esteem. Which outcome is most appropriate initially?
The client will discuss her feelings related to her losses. Explanation: The most appropriate initial outcome for the client is to discuss thoughts and feelings related to her losses. The nurse should help the client identify and verbalize her feelings so that she can externalize her thoughts and emotions and begin to deal with them.
Which outcome should the nurse include in the initial plan of care for a client who is exhibiting psychomotor retardation, withdrawal, minimal eye contact, and unresponsiveness to the nurse's questions? a) The client will participate in milieu activities. b) The client will initiate interactions with peers. c) The client will interact with the nurse. d) The client will discuss adaptive coping techniques.
The client will interact with the nurse. Correct Explanation: In the initial plan of care, the most appropriate outcome would be that the client will interact with the nurse. First, the client would begin interacting with one individual, the nurse.
A client is irritable and hostile. He becomes agitated and verbally lashes out when his personal needs are not immediately met by the staff. When the client's request for a pass is refused by the primary care provider, he utters a stream of profanities. Which of the following statements best describes the client's behavior? a) The client's anger is not intended personally. b) The client's anger is a reliable sign of serious pathology. c) The client's anger is a sign that his condition is improving. d) The client's anger is an intended attack on the primary care provider's skills
The client's anger is not intended personally. Correct Explanation: Staff members sometimes are the recipients of a client's angry behavior because they are safe targets and are available for attack. The display of anger is rarely intended to be personal.
A client is admitted to an inpatient psychiatric unit. After the assessment and admission procedures have been completed, the nurse states, "I'll try to be available to talk with you when needed and will spend time with you each morning from 10:00 until 10:30 in the corner of the dayroom." What is the rationale for communicating these planned nursing interventions? a) To instill hope in the client b) To provide time for completing nursing responsibilities c) To provide a structured environment for the client d) To attempt to establish a trusting relationship
To attempt to establish a trusting relationship Correct Explanation: Availability, reliability, and consistency are critical factors in establishing trust with a client. Being specific about the time and place of meetings helps establish trust, which is initially the main objective.
A client with antisocial personality disorder smokes in prohibited areas and refuses to follow other unit and facility rules. The client persuades others to do his laundry and other personal chores, splits the staff, and will work only with certain nurses. The care plan for this client should focus primarily on:
consistently enforcing unit rules and facility policy. Explanation: Firmness and consistency regarding rules are the hallmarks of a care plan for a client with a personality disorder.
What is a crucial goal of therapeutic communication when helping the client deal with personal issues and painful feelings? a) conveying client respect and acceptance even if not all of the client's behaviors are tolerated b) mutual sharing of information, spontaneity, emotions, and intimacy c) guaranteeing total confidentiality and anonymity for the client d) communicating empathy through gentle touch
conveying client respect and acceptance even if not all of the client's behaviors are tolerated Correct Explanation: The nurse is required to set limits on inappropriate behavior while conveying respect and acceptance of that person. Doing so conveys to the client that he is worthy without posing any harm or embarrassment to the client
The nurse manager of a psychiatric unit notices that one of the nurses commonly avoids a 75-year-old client's company. Which factor should the nurse manager identify as being the most likely cause of this nurse's discomfort with older clients?
fears and conflicts about aging Explanation: The most common reason for the nurse's discomfort with elderly clients is that she has not examined her own fears and conflicts about aging
A nurse is assessing a client with bipolar disorder. Findings include coarse hand tremors, muscle twitching, and mental confusion. These findings suggest: a) hypomania. b) severe lithium toxicity. c) lithium toxicity. d) manic behaviors.
lithium toxicity. Correct Explanation: Symptoms of lithium toxicity include muscle twitching, mental confusion, incoordination, and coarse hand tremors. Symptoms of severe lithium toxicity include ataxia, giddiness, blurred vision, and severe hypotension. These findings don't indicate hypomania or manic behaviors.
The nurse incorporates the underlying premise of crisis intervention, about providing "the right kind of help at the right time," to achieve which initial goal? a) formulation of more effective support systems b) resolution of underlying emotional problems c) development of insight and personal growth d) regaining emotional security and equilibrium
regaining emotional security and equilibrium Correct Explanation: The initial goal in crisis intervention is helping the client regain emotional security and equilibrium. Resolution of the underlying emotional problems, development of insight and personal growth, and formulation of more effective support systems are goals to address as the crisis subsides.
The purpose of biofeedback is to enable a client to exert control over physiologic processes by: a) translating the signals of body processes into observable forms. b) regulating the body processes through electrical control. c) monitoring the body processes for the therapist to interpret. d) shocking the client when an undesirable response is elicited.
translating the signals of body processes into observable forms. Correct Explanation: Biofeedback translates body processes into observable signs so that the client can develop some control over certain body processes
A client states the following to the nurse: "I am a failure, and I wish I had died." Which of the following statements by the nurse demonstrates a therapeutic response? a) "You feel like a failure; would you like to talk more about the way you feel?" b) "You are depressed right now, so feeling like a failure is a normal manifestation." c) "I am glad to hear you speak about your feelings and I am glad you did not die." d) "I think you have had many successes in your life and you should focus on them."
"You feel like a failure; would you like to talk more about the way you feel?" Correct Explanation: Acknowledging the client's feelings by repeating what the client states is therapeutic. It is also therapeutic for the nurse to offer to discuss the client's feelings further
The client, who is dying from acquired immunodeficiency syndrome (AIDS), is admitted to the inpatient psychiatric unit because he attempted suicide. His close friend recently died from AIDS. The client states to the nurse, "What's the use of living? My time is running out." What is the nurse's best response? a) "Life is precious and worth living." b) "Don't give up. There could be a cure for AIDS tomorrow." c) "Let's talk about making some good use of that time." d) "You're in a lot of pain. What are you feeling?"
"You're in a lot of pain. What are you feeling?" Correct Explanation: The nurse recognizes the client's pain, hopelessness, and sense of loss related to his condition and the loss of his friend and encourages him to express his feelings. Giving the client permission to talk about his feelings of sadness, loss, and hopelessness and listening to him is an important nursing intervention for the dying client.
The stigma related to having a mental illness, especially a chronic illness, persists despite improvements in the management of illnesses and an increase in public education. Which view most perpetuates the stigma? a) Mental illness is hereditary. b) Clients cannot prevent mental illness if they want to do so. c) Clients can recover from mental illness if they have willpower. d) Mental illnesses have biochemical bases.
Clients can recover from mental illness if they have willpower. Correct Explanation: Many still believe that recovery from mental illness is a matter of willpower—for example, "pull yourself up by your bootstraps" or "just get over it." This belief persists despite awareness that mental illness is can be hereditary and has a biochemical basis. Mental illness can be prevented only if there is early intervention. Clients cannot prevent it just by the desire to do so.
A nurse assesses a client with psychotic symptoms and determines that the client likely poses a safety threat and needs vest restraints. The client is adamantly opposed to this. What would be the best nursing action?
Contact the physician and obtain necessary orders. Explanation: If a nurse feels that a client needs to be restrained, the nurse should inform the physician and obtain necessary orders.
When should a nurse introduce information about the end of the nurse-client relationship? a) At least one or two sessions before the last meeting b) When the client can tolerate it c) During the orientation phase d) As the goals of the relationship are reached
During the orientation phase Correct Explanation: Preparation for ending the nurse-client relationship should begin during the orientation phase, when realistic limits of the relationship are established.
Parents tell a nurse that they have not met their goal of home management of their son with schizoaffective disorder. They report that the client poses a threat to their safety. Based on this information, what recommendation should the nurse make? a) Tell the parents that the client's behavior releases them from the duty of care. b) Discuss what the family can do to chemically restrain the client at home. c) Evaluate the client for voluntary admission to a mental health facility. d) Arrange for respite care; family members could be aggravating the client's condition.
Evaluate the client for voluntary admission to a mental health facility. Correct Explanation: A voluntary admission is the preferred approach because it involves having the client recognize existing problems and facilitates the client's involvement in treatment.
The nurse planning care for a group of clients who are chronically mentally ill. Which of the following strategies is likely to be the least beneficial for the client population? a) Teaching independent living skills. b) Helping clients in insight-oriented therapy. c) Assisting clients with living arrangements. d) Linking clients with community resources.
Helping clients in insight-oriented therapy. Correct Explanation: Insight-oriented therapy is less beneficial for this client population. The nurse's role in a psychosocial rehabilitation program involves teaching the client to live independently by using interpersonal skills and community resources.
Which action demonstrates the role of the psychiatric nurse in primary prevention?
Providing sexual education classes for adolescents Explanation: The psychiatric nurse participates in primary, secondary, and tertiary prevention activities. Primary prevention includes education programs that promote mental health and prevent future psychiatric episodes such as sexual education classes for adolescents.
Which of the following indicate that a client who has been raped will have future adjustment problems and the need for additional counseling?
When her parents show shame and suspicion about her part in the rape. Explanation: The potential for problems in adjusting after a rape will be increased when those around the victim treat her as though she is to blame for the rape, especially when she already may feel some guilt and shame about it
Erikson described the psychosocial tasks of the developing person in his theoretical model. He proposed that the primary developmental task of the young adult (ages 18 to 25) is: a) industry versus inferiority. b) intimacy versus isolation. c) generativity versus stagnation. d) trust versus mistrust.
intimacy versus isolation. Correct Explanation: The primary developmental task of the young adult is to develop intimacy with another person while making choices about relationships and career.
The nurse strongly believes that all psychiatric medication is a form of chemical mind control. When the client's wife asks about the efficacy of antidepressant medications, which of the following courses of action would be best for this nurse to take? a) Explain that there are not enough current statistics about the efficacy of the treatment. b) Refer the client's wife to another knowledgeable person for information about the treatment. c) Provide a copy of the package insert for the wife to read. d) Give an honest opinion of the treatment.
Refer the client's wife to another knowledgeable person for information about the treatment. Correct Explanation: When strongly opposed to a type of therapy, the nurse should refer people who ask about the therapy to another knowledgeable person.
When a client is about to lose control, the extra staff who come to help commonly stay at a distance from the client unless asked to move closer by the nurse who is talking to the client. What best explains the primary rationale for staying at a distance initially?
The client is likely to perceive others as being closer than they are and feel threatened. Explanation: The client who is about to lose control is experiencing a high degree of anxiety or agitation, which alters the client's ability to perceive reality. Initially, the client may feel threatened by the presence of others.
The purpose of biofeedback is to enable a client to exert control over physiologic processes by: a) monitoring the body processes for the therapist to interpret. b) regulating the body processes through electrical control. c) shocking the client when an undesirable response is elicited. d) translating the signals of body processes into observable forms.
translating the signals of body processes into observable forms. Correct Explanation: Biofeedback translates body processes into observable signs so that the client can develop some control over certain body processes.
The nurse is admitting a client who is anxious and fearful. Which statement by the nurse will help to build a strong, therapeutic nurse-client relationship? Select all that apply. a) "What makes you think that?" b) "Just take one day at a time and everything will be OK." c) "I know how you feel. I get very anxious too at times." d) "I am here if you would like to talk about anything." e) "I will stay with you until you feel less anxious.
• "I am here if you would like to talk about anything." • "I will stay with you until you feel less anxious." Explanation: For the nurse to build a strong relationship with the client, the nurse uses therapeutic communication techniques. These techniques allow the client to express feelings and concerns and also help improve self-esteem. Allowing the client to talk as the person desires is a good example of offering self. This technique gives the client the opportunity to talk if they wish and begins trust.
The nurse's overall goal in planning to assist the client responding to a loss is to: a) encourage the client to work to resolve lingering family conflicts. b) allow the client to express anger. c) make sure the client progresses through all of the stages of the grief process. d) assist the client to engage in the work associated with the normal grieving process.
assist the client to engage in the work associated with the normal grieving process. Correct Explanation: Individuals progress through the stages of loss at their own pace
According to hospital protocol, after a client is restrained, the staff meet and discuss the restraint situation. In addition to sharing feelings and offering support, what should the nurse identify as the long-term goal for the debriefing? a) deciding when to release the client from restraints b) comparing the perceptions of the various staff members c) providing feedback to each other on how procedures were handled d) improving the staff's use of restraint procedures
improving the staff's use of restraint procedures Correct Explanation: The long-term goal of the debriefing after restraining a client is to improve aggression management procedures so that prevention of aggression improves and the frequency of restraint use decreases.
A nurse is teaching self-esteem to a client. Which statements by the client would indicate understanding of the concept? Select all that apply. a) "Physical discipline does not affect my self-esteem." b) "I do not like to make decisions." c) "Living in a critical environment is not good for me." d) "I need to have healthy boundaries." e) "I need to have consistent limits."
• "Living in a critical environment is not good for me." • "I need to have healthy boundaries." • "I need to have consistent limits." Correct Explanation: Self-esteem is how we value or feel worthwhile about ourselves. A variety of factors can aide a person in developing a healthier self-esteem. Here are a few. A structured lifestyle demonstrates acceptance and caring and provides a sense of security. A critical environment erodes a person's esteem. Inconsistent boundaries lead to feelings of insecurity and lack of concern. Physical discipline can decrease self-esteem. When the client starts to make decisions, this can help increase their self-esteem.
A client has been diagnosed with Avoidant Personality Disorder. He reports loneliness, but has fears about making friends. He also reports anxiety about being rejected by others. In a long-term treatment plan, in what order, from first to last, should the nurse list goals for the client? All options must be used. 1 2 3 4 Help the client make a list of small group activities at the center he would find interesting. Teach the client anxiety management and social skills. Talk with the client about his self-esteem and his fears. Ask the client to join one of his chosen activities with the nurse and two other clients.
Talk with the client about his self-esteem and his fears. Teach the client anxiety management and social skills. Help the client make a list of small group activities at the center he would find interesting. Ask the client to join one of his chosen activities with the nurse and two other clients. Correct Explanation: The client needs a stepwise plan for developing a social life. He needs to first work on his self-esteem and reduce his fears of rejection before talking about how to decrease his anxiety and learning new social skills. Helping him chose interesting activities is important before suggesting an activity for him. Then he will be ready to try a structured activity with the nurse present for support and role modeling
The nurse is interacting with a client who is talking about the previous day. The client says that he or she lost an important account, had a flat tire on the way home, and blamed everyone for the problems last evening. What is the nurse's best assessment of the client's behavior? a) The client is using projection. b) The client is using sublimation. c) The client is using displacement. d) The client is using regression.
The client is using displacement. Explanation: This client is using displacement, a mechanism by which feelings of anger and rejection are discharged in an indirect way that is perceived as safe (in this situation, by displacing anger related to work and car problems onto others). Projecting involves attributing one's own emotions to or blaming them on others. Regression is a retreat to an earlier level of developmental behavior in an attempt to relieve anxiety. Sublimation is the socially acceptable discharge of psychic energy or anger through such behavior as exercise or other productive activity.
On admission to the inpatient psychiatric unit, a client's facial expression indicates severe panic. He repeatedly states, "I know the police are going to shoot me. They found out that I'm the child of the devil." What should the nurse say to initiate a therapeutic relationship with this client? a) "You certainly look stressed. Can you tell me about the upsetting events that have occurred in your life recently?" b) "You're having very frightening thoughts. I'll help you find ways to cope with this scary thinking." c) "Hello, my name is ___. I'm a nurse, and I'll care for you when I'm on duty. Should I call you ___, or do you prefer something else?" d) "Hello, ___. I'm going to be caring for you while I'm on duty. You look very frightened, but I'm sure you'll feel better by tomorrow."
"Hello, my name is ___. I'm a nurse, and I'll care for you when I'm on duty. Should I call you ___, or do you prefer something else?" Explanation: The first task during the introductory, or orientation, phase of the nurse-client relationship is to formulate a contract, which begins with the exchange of names and an explanation of the roles and limits of the relationship. These tasks should precede the exploration of relevant stressors and new coping mechanisms.
An elderly client was prescribed lorazepam 1 mg three times a day to help calm her anxiety after her husband's death. The next day the client calls her daughter asking when she is picking her up to go to the graveside. The client says she has been walking up and down the driveway for the past hour waiting for her daughter. Noting the client's agitation, hyperactivity, and insistence, the daughter calls the nurse to report her mother's behavior. Which finding would the nurse suspect as the cause of the mother's behavior, and what action would she suggest? a) The client is experiencing a medication interaction and should go to the emergency department. b) The client is experiencing mania and may need a sleeping pill. c) The client is experiencing a paradoxical reaction to the lorazepam and should stop the new medication immediately. d) The client is overcome by grief and probably needs an antidepressant.
The client is experiencing a paradoxical reaction to the lorazepam and should stop the new medication immediately. Correct Explanation: Paradoxical responses to benzodiazepines are more common in children and the elderly than other age groups and generally occur at the beginning of treatment.
