Psych Unit 1 Exam: NCLEX Questions
Which of the following structural safety precautions is most important when attempting to prevent a common type of inpatient suicide? Break-away closet bars to prevent hanging Bedroom and dining areas with locked windows to prevent jumping Double-locked doors to prevent escaping from the unit Platform beds to prevent crush injuries
Break-away closet bars to prevent hanging Hangings are the most common method of inpatient suicide. The other options are important safety measures but don't directly address the suicide method of hanging.
First Generation antipsychotics used to treat Tourette's:
haloperidol and pimozide
A client, prescribed which class of antidepressantive medication should be monitored for the development of premature ejaculation? Monoamine oxidase (MAO) inhibitors Tricyclic antidepressants Atypical antipsychotics selective serotonin reuptake inhibitor (SSRI) antidepressants
selective serotonin reuptake inhibitor (SSRI) antidepressants Treatments include antidepressants in the SSRI category. Conversely, pharmacotherapy may cause erectile dysfunction, and medications may need to be evaluated for change or dose reduction. The other options are not used for premature ejaculation.
A nurse, active in local consumer mental health groups and in local and state mental health associations, keeps aware of state and national legislation affecting mental illness treatment. How can this nurse positively affect the climate for effective, mental health treatment? "By becoming active in politics leading to a potential political career." "By educating the public on the effects that stigmatizing has on mental health clients." "Advocating for laws that would make the involuntary long-term commitment process easier and faster for caregivers of mentally ill persons." "Advocating for reduced mental health insurance benefits to discourage abuse of the system by inappropriate psychiatric admissions."
"By educating the public on the effects that stigmatizing has on mental health clients."
A 29-year-old patient has been admitted following a suicide attempt. Which nursing statement illustrates the concept of patient advocacy? "Dr. Raye, I notice you ordered fluoxetine for this patient. During the admission interview, the client stated they will refuse the medication because of adverse effects they experienced previously." "Dr. Raye, during the admissions interview the patient stated that there is a family history of three other suicide attempts in the past." "I'd like you tell me more about your depression and your suicide attempt?" "I will take you on a tour of the unit and orient you to the rules so you can get adjusted here."
"Dr. Raye, I notice you ordered fluoxetine for this patient. During the admission interview, the client stated they will refuse the medication because of adverse effects they experienced previously."
Which statement by a patient who has been taught cognitive reframing indicates that the teaching was successful? "I do not have the ability to handle that job." "I can be successful if I do all the things required to learn the job." "I may be fired from the job but eventually I will find something else to do with my life." "I can never learn all there is to know for the job."
"I can be successful if I do all the things required to learn the job." Cognitive reframing changes the individual's perceptions of stress by reassessing a situation and replacing irrational beliefs with more positive self-statements. The other options are all negative cognitive distortions that would prevent the individual from success.
Consider both Sullivan's term security operations and Freud's term defense mechanisms. Which statement suggests that the client's specialized treatment goal has been successfully met? "I really think I can succeed in school now." "I'm experiencing much less anxiety about school now." "Going back to school is hard and I'll need support." "I know that I'm not the only person who has a difficult time in school."
"I'm experiencing much less anxiety about school now." Both Sullivan and Freud coined terms to mean actions that individuals do that are an attempt to reduce anxiety. The terms to do not refer to activities that increase self-esteem. Security operations and defense mechanisms are not conscious and therefore do not increase self-awareness. These terms do not refer to reducing cognitive distortions.
A 17-year-old patient confides to the nurse that they have been thinking of ways to kill a peer. What response should the nurse give when the patient states, "you have to keep it a secret because its confidential information"? "I will keep it a secret, but you and I need to discuss ways to deal with this situation appropriately without committing a crime." "Yes, I will keep it confidential. We have laws to protect patients' confidentiality." "Issues of this kind have to be shared with the treatment team and your parents." "I will have to share this with the treatment team, but we will not share it with your parents."
"Issues of this kind have to be shared with the treatment team and your parents." Although adolescent patients request confidentiality, issues of sexual abuse, threats of suicide or homicide, or issues that put the patient at risk for harm must be shared with the treatment team and the parents. A threat of this nature must be discussed with the treatment team and the parents. Confidentiality laws do not protect information that would lead to harm to the patient or others.
A client being prepared for discharge tells the nurse, "Dr. Jacobson is putting me on some medication called naltrexone. How will that help me?" Which response is appropriate teaching regarding naltrexone? "It helps your mood so that you don't feel the need to do drugs." "It will keep you from experiencing flashbacks." "It is a sedative that will help you sleep at night so you are more alert and able to make good decisions." "It helps prevent relapse by reducing drug cravings."
"It helps prevent relapse by reducing drug cravings." Naltrexone is used for withdrawal and also to prevent relapse by reducing the craving for the drug. None of the other options do not accurately describe the action of naltrexone.
A patient is presenting with behaviors that indicate anger. When approached, the patient states harshly, "I'm fine! Everything's great." Which response should the nurse provide to the patient? "Okay, but we are all here to help you, so come get one of the staff if you need to talk." "I'm glad everything is good. I am going to give you your schedule for the day and we can discuss how the groups are going." "I don't believe you. You are not being truthful with me." "It looks as though you are saying one thing but feeling another. Can you tell me what may be upsetting you?"
"It looks as though you are saying one thing but feeling another. Can you tell me what may be upsetting you?" This response uses the therapeutic technique of clarifying; it addresses the difference between the patient's verbal and nonverbal communication and encourages sharing of feelings. The other options do not address the patient's obvious distress or are confrontational and judgmental. None of the other options provides this support.
Resilience is characteristic of mental health that allows people to adapt to tragedies, trauma, and loss. Which client behavior demonstrates this characteristic? "My mother made decisions about my husband's funeral when I just couldn't do that." "Losing my job was hard but my skills will help me get another one." "In spite of all the treatment, I know I'll never be really healthy." "My kids, happiness is worth any sacrifice I have to make."
"Losing my job was hard but my skills will help me get another one."
A nurse on the psychiatric unit has a past history of alcoholism and has regular meetings with a mentor. Which statement made to the nurse's mentor would indicate the presence of countertransference? "My patient is being discharged tomorrow. I provided discharge teaching and stressed the importance of calling the help line number should she become suicidal again." "My patient has been abusing alcohol. I told her that the only way to recover was to go 'cold turkey' and to get away from her dysfunctional family and to do it now!" "My patient started drinking after 14 years of sobriety. We are focusing on his treatment plan of attending AA (Alcoholics Anonymous) meetings five times a week after discharge." "My patient, is an elderly woman with depression. She calls me by her daughter's name because she says I remind her of her daughter."
"My patient has been abusing alcohol. I told her that the only way to recover was to go 'cold turkey' and to get away from her dysfunctional family and to do it now!" This statement indicates countertransference; the nurse may be overidentifying with the patient because of a past history of alcoholism. Providing adamant advice to the patient that, besides being nontherapeutic, may be more relevant to personal past experiences than to the patient's. The discharge teaching for a patient being discharged and focusing on the treatment plan for the alcoholic patient are appropriate and show no signs of countertransference. The patient calling the nurse by her daughter's name is transference rather than countertransference.
Consider the nurse-patient relationship on an inpatient psychiatric unit. Which of the following statements made by the nurse reflects an accurate understanding of when the issue of termination should first be discussed? "You are being discharged today, so I'd like to bring up the subject of termination—discussing your time here and summarizing what coping skills you have attained." "I haven't met my new patient yet, but I am working through my feelings of anxiety in dealing with a patient who wanted to kill herself." "Now that we are working on your problem-solving skills and behaviors you'd like to change, I'd like to bring up the issue of termination." "Now that we've discussed your reasons for being here and how often we will meet, I'd like to talk about what we will do at the time of your discharge."
"Now that we've discussed your reasons for being here and how often we will meet, I'd like to talk about what we will do at the time of your discharge." The issue of termination is brought up first in the orientation phase. All the other options describe other phases of the nurse-patient relationship—the termination phase, the preorientation phase, and the working phase.
Which statement made by the nurse would acknowledge that they understand the difference between the ethnicity and culture? "So, ethnicity refers to having the same life goals whereas culture refers to race." "So, ethnicity refers to norms within a culture, and culture refers to shared likes and dislikes." "So, ethnicity refers to shared history and heritage, whereas culture refers to sharing the same beliefs and values." "So, ethnicity refers to race, and culture refers to having the same worldview."
"So, ethnicity refers to shared history and heritage, whereas culture refers to sharing the same beliefs and values."
The mother of a 3-year-old boy just diagnosed with autism spectrum is tearful and states, "The doctor said we need to start therapy right away. I just don't understand how helpful it will be—he's only 3 years old!" What response should the nurse provide to the mother's statement? "You are right, 3 years old is very young to start therapy, but it will make you feel better to be doing something." "Starting him on treatment now gives Taylor a much greater chance for a productive life." "If your child starts therapy now, he will be able to stop therapy sooner." "If you have questions, its best to ask the doctor."
"Starting him on treatment now gives Taylor a much greater chance for a productive life." Early intervention for children with autism can greatly enhance their potential for a full, productive life. 3 years old is not too young to start therapy since the sooner therapy is started, the better the outcome. The patient will most likely not be able to stop therapy as interventions will continue indefinitely. Telling the mother to ask her provider abdicates the nurse's responsibility to provide education to patients and families.
A patient admitted with anxiety asks, "What exactly are stressors?" What is the nurse's best response to the patient's question? "Stressors are events that happen that threaten your current functioning and require you to adapt." "Stressors are complicated neuro stimuli that cause mental illness." "It's best if you ask questions like that of your provider for a complete answer." "Instead of focusing on what stressors are, let's explore your coping skills."
"Stressors are events that happen that threaten your current functioning and require you to adapt." Stressors are psychological or physical stimuli that are incompatible with current functioning and require adaptation. Stressors are not complicated neuro stimuli; telling the patient to address these questions to her provider fails to educate the patient, which is the nurse's responsibility. Exploring coping skills would be a good intervention at a later time but does not address the patient's question and changes the subject.
When considering the duty to warn and protect third parties, which client statement should the nurse report to the treatment team members? "That judge is going to really regret putting me in here." "All politicians need to be shot." "When I'm elected president, I'll make them all pay for doubting me." "The man out there who is laughing at me is going to die."
"That judge is going to really regret putting me in here." The duty to protect is an ethical and legal obligation of health care workers to protect patients from physically harming themselves or others. This duty arises when the patient presents a serious danger to another. While all that statements infer the client's intention to harm, only the correct option is credible since it actually identifies the possible victim.
A patient who recently loss a parent begins crying during a one-to-one session with the nurse. Which of the following responses by the nurse illustrates empathy? "I'm so sorry. My father died 2 years ago, so I know how you are feeling." "You need to focus on yourself right now. You deserve to take time just for you." "That must have been such a hard situation for you to deal with." "I know that you will get over this. It just takes time."
"That must have been such a hard situation for you to deal with." This response reflects understanding of the patient's feelings, which is empathy. Feeling sorry for the client represents sympathy, whereas not addressing the patient's concern belittles the patient's feelings of grief she is expressing by changing the subject. Telling the patient she will get over it does not reflect empathy and is closed-ended.
A 26-year-old patient is brought to the emergency room by a friend. The patient is unable to give any coherent history. Which response should the nurse provide when the patient's friend offers to provide information regarding the patient? "I'm sorry, but I cannot take any information from you as it would violate confidentiality laws." "There is no need for that as I will call his primary care provider to obtain the information we need." "Yes, I will be happy to get any information and history that you can provide." "Yes, however, we will have to get a release signed from the patient for you to be able to talk with me."
"Yes, I will be happy to get any information and history that you can provide." The friend is a secondary source of information that will be helpful since the patient is not able to give any history or information at this time. Confidentiality laws do not prohibit obtaining information from a secondary source. The friend can provide information and/or history immediately and may be able to relate events that happened just before coming to the hospital. A release would not be necessary to take information about the patient from a secondary source, and a psychotic patient would not be competent to sign a release.
A client has been admitted to your inpatient psychiatric unit with suicidal ideation. In a one-to-one session with the nurse, he shares the terrible guilt he feels over sexually abusing his stepdaughter and wanting to die because of it. Which of the following responses you could make reflects a helpful trait in a therapeutic relationship? "It's good that you feel guilty. That means you still have a chance of being helped." "Of course you feel guilty. You did a horrendous thing. You shouldn't even forget what you did." "The biggest question is, will you do it again? You will end up having even worse guilt feelings because you hurt someone again." "You are suffering with guilt over what you did. Let's talk about some goals we could work on that may make you want to keep living."
"You are suffering with guilt over what you did. Let's talk about some goals we could work on that may make you want to keep living." This response demonstrates suspending value judgment, a helpful trait in establishing and maintaining a therapeutic relationship. Although it is difficult, nurses are more effective when they don't use their own value systems to judge patients' thoughts, feelings, or behaviors. The other options are all judgmental responses. Judgment on the part of the nurse will most likely interfere with further explorations of feelings and hinder the therapeutic relationship.
A new nurse has accepted a position as staff nurse on a psychiatric unit. Which statement made by the new nurse requires additional instructions regarding the therapies provided on the unit? "You will participate in unit activities and groups daily." "You will be given a schedule daily of the groups we would like you to attend." "You will attend a psychotherapy group that I lead that will help you care for yourself." "You will see your provider daily in a one-to-one session."
"You will attend a psychotherapy group that I lead that will help you care for yourself." Basic level RNs cannot perform psychotherapy. The other options are all appropriate expectations of a patient's schedule on a psychiatric unit. DIF: Cognitive Level: Analyze (Analysis) REF: pages 14, 15 TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment
Which of the following statements represent a nontherapeutic communication technique? Select all that apply. 1. "Why didn't you attend group this morning?" 2. "From what you have said, you have great difficulty sleeping at night." 3. "What did your boyfriend do that made you leave? Are you angry at him? Did he abuse you in some way?" 4. "If I were you, I would quit the stressful job and find something else." 5. "I'm really proud of you for the way you stood up to your brother when he visited today." 6. "You mentioned that you have never had friends. Tell me more about that." 7. "It sounds like you have been having a very hard time at home lately."
1. "Why didn't you attend group this morning?" 3. "What did your boyfriend do that made you leave? Are you angry at him? Did he abuse you in some way?" 4. "If I were you, I would quit the stressful job and find something else." 5. "I'm really proud of you for the way you stood up to your brother when he visited today."
Based on the current understanding of brain physiology, which neurotransmitter would be the expected target of medication prescribed to manage depression? Select all that apply. 1. Dopamine 2. γ-aminobutyric acid (GABA) 3. Serotonin 4. Norepinephrine 5. Acetylcholine
1. Dopamine 3. Serotonin 4. Norepinephrine Antidepressant medication targets serotonin and norepinephrine. While dopamine is implicated in schizophrenia (increase) and Parkinson's disease (decrease), it is also believed to be a factor in depression. GABA is implicated in anxiety disorders. Acetylcholine is implicated in Alzheimer's disease as well as Huntington's disease and Parkinson's disease.
According to the DSM-V, which statement made by an adult client supports the criteria for generalized anxiety disorder? 1. I've been really anxious for at least 2 years now. 2. My anxiety has to be genetic; my mom was a terrible worrier too. 3. My marriage is in trouble because I'm always so irritable. 4. I've had a good physical and my health care provider says I'm in good health. 5. Its hard falling asleep and even harder staying asleep; I'm restless all night.
1. I've been really anxious for at least 2 years now. 3. My marriage is in trouble because I'm always so irritable. 4. I've had a good physical and my health care provider says I'm in good health. 5. Its hard falling asleep and even harder staying asleep; I'm restless all night.
Which of the following statements are true regarding the differences between a social relationship and a therapeutic relationship? Select all that apply. 1. In a social relationship, both parties' needs are met; in a therapeutic relationship, only the patient's needs are to be considered. 2. A social relationship is instituted for the main purpose of exploring one member's feelings and issues; a therapeutic relationship is instituted for the purpose of friendship. 3. Giving advice is done in social relationships; in therapeutic relationships giving advice is not usually therapeutic. 4. In a social relationship, both parties come up with solutions to problems and solutions may be implemented by both (a friend may lend the other money, etc.); in a therapeutic relationship, solutions are discussed but are only implemented by the patient. 5. In a social relationship, communication is usually deep and evaluated; in a therapeutic relationship, communication remains on a more superficial level, allowing patients to feel comfortable.
1. In a social relationship, both parties' needs are met; in a therapeutic relationship, only the patient's needs are to be considered. 3. Giving advice is done in social relationships; in therapeutic relationships giving advice is not usually therapeutic. 4. In a social relationship, both parties come up with solutions to problems and solutions may be implemented by both (a friend may lend the other money, etc.); in a therapeutic relationship, solutions are discussed but are only implemented by the patient.
An 8-year-old patient is newly diagnosed with attention deficit hyperactivity disorder (ADHD). It is important that the parents be educated to the fact that symptoms will take which form? (Select all that apply). of, inattention, and impulsivity have to be apparent: Select all that apply. 1. Low frustration tolerance 2. Poor school performance 3. Impulsive behaviors 4. Easily intimidated 5. Mood swings
1. Low frustration tolerance 2. Poor school performance 3. Impulsive behaviors 5. Mood swings
Which medication is FDA approved for treatment of obsessive-compulsive disorder in children? Select all that apply. 1. Sertraline 2. Fluoxetine 3. Clomipramine 4. Duloxetine
1. Sertraline 2. Fluoxetine 3. Clomipramine The FDA has approved four medications for use in children with obsessive-compulsive disorder. They are clomipramine (Anafranil), fluoxetine (Prozac), fluvoxamine (Luvox), and sertraline (Zoloft).
A 9-year-old patient has been diagnosed with an intellectual development disorder (IDD). Which assessment findings support this diagnosis? Select all that apply. 1. Unable to explain the phrase, "Raining cats and dogs" 2. Reads below age level 3. Is capable of providing effective oral self care 4. Enjoy interacting with developmentally similar peers 5. Physically lashes out when frustrated
1. Unable to explain the phrase, "Raining cats and dogs" 2. Reads below age level 5. Physically lashes out when frustrated
A 12-year-old male patient diagnosed with Tourette's disorder is visiting his provider. The nurse will prepare medication teaching on which class of medication to help manage the tics associated with this disorder? Select all that apply. 1. Mood stabilizers 2. Antianxiety agents 3. Anticholinesterase inhibitors 4. First-generation antipsychotics 5. Second-generation antipsychotics
2. Antianxiety agents 4. First-generation antipsychotics 5. Second-generation antipsychotics Drugs with Food and Drug Administration (FDA) approval for treating tics are the first-generation antipsychotics haloperidol and pimozide, and the second-generation antipsychotic aripiprazole.Clonidine hydrochloride, an alpha 2-adrenergic agonist, used to treat hypertension, is also prescribed for tics. While less effective and far slower acting than the antipsychotics, it has fewer side effects. The antianxiety drug clonazepam (Klonopin) is used as a supplement to other medications. It may work by reducing anxiety and resultant tics.
What are the foundational concerns regarding the use of restraint and seclusion when providing care to children? Select all that apply. 1. Parents may initiate a lawsuit if injury occurs. 2. Staff have conflicted feelings leading to ineffectiveness. 3. Research suggests both are psychologically and physically harmful. 4. Staff tends to be undertrained in use of restraints in children. 5. The principle of least restrictive intervention is a primary concern.
3. Research suggests both are psychologically and physically harmful. 5. The principle of least restrictive intervention is a primary concern.
A nurse states, "I am so frustrated trying to communicate with clients when they insist on speaking in their language instead of English. I think if people want to live here, they ought to have to speak our language and act like we do!" Which response by a peer best promotes culturally competent care? Select all that apply. 1. "You are right, but all patients do have a right to an interpreter, so you need to comply." 2. "I agree that it is frustrating. We should work with their family members to help convince them to speak English." 3. "They will have to learn to speak English eventually to live and work successfully in this country. Just try to be patient and encourage them to try speaking English." 4. "What you are saying is actually considered cultural imposition, which is imposing our own culture onto someone from a different culture." 5. "When their ability to speak and understand English is very limited, we need to have an interpreter present to make sure they can make their needs and feelings known."
4. "What you are saying is actually considered cultural imposition, which is imposing our own culture onto someone from a different culture." 5. "When their ability to speak and understand English is very limited, we need to have an interpreter present to make sure they can make their needs and feelings known." Cultural imposition is imposing our own cultural norms onto those from another cultural group. By obtaining an interpreter for Mr. Tran, the nurse is promoting culturally competent care, ensuring the patient can communicate his feelings and needs thoroughly to the staff. Patients do have a right to an interpreter, but stating that Mike is right is not promoting culturally competent care and is instead confirming his opinion. Asking family members to convince the patient to speak English is not promoting culturally competent care and also undermines the trust between nurse and patient. Instead of encouraging the patient to speak English, an interpreter should be obtained for the patient.
Which of the following patients meets the criteria for an involuntary admission to a psychiatric mental health unit? A 23-year-old college student who has developed symptoms of anxiety and is missing classes and work A 30-year-old accountant who has developed symptoms of depression A 26-year-old kindergarten teacher who is not in touch with reality and was found wandering in and out of traffic on a busy road A 76-year-old retired librarian who is experiencing memory loss and some confusion at times
A 26-year-old kindergarten teacher who is not in touch with reality and was found wandering in and out of traffic on a busy road Inpatient involuntary admission is reserved for patients who are at risk for self-harm or who cannot adequately protect themselves from harm because of their illness (e.g., a psychotic patient). The other options can all be managed at this point in the community setting and don't meet criteria (risk of harm to self and/or others) for admission.
Which hospitalized patient should the nurse identify as being a candidate for the appropriate use of a release from hospitalization known as against medical advice (AMA)? A 37-year-old patient scheduled for discharge in 24 hours wishes to be discharged immediately A 75-year-old patient with dementia who demands to be allowed to go back to his own home A 21-year-old actively suicidal patient who wants to be discharged to home and do outpatient counseling A 32-year-old female patient who wishes to stay in the hospital but whose husband demands that she be discharged into his care
A 37-year-old patient scheduled for discharge in 24 hours wishes to be discharged immediately AMS discharges are sometimes used when the patient does not agree with the provider, as long as the patient is not a danger to himself or herself or to others. The patient with dementia and the patient who is actively suicidal would pose a safety risk and would be not allowed to be discharged AMA. A patient who wishes to stay in the hospital can make that decision; a family member's opinion doesn't impact an AMA discharge.
Which client behavior illustrates eustress? A college student fails an exam. A bride is planning for her wedding. A man is laid off from his job. An adolescent gets into a fight at school.
A bride is planning for her wedding. Eustress is the result of a positive perception toward a stressor, such as having a baby, planning a wedding, or getting a new job. The other options all describe distress, or a negative energy.
The primary goal and benefit of assertive community treatment (ACT) is demonstrated by which situation? A client and family members attend counseling sessions together at a neighborhood clinic Implementation of a more flexible work schedule for staff Improved reimbursement for services provided in the community A client diagnosed with schizophrenia has avoided being rehospitalization for 16 months.
A client diagnosed with schizophrenia has avoided being rehospitalization for 16 months. A primary goal of ACT is working intensely with the patient in the community to prevent rehospitalization. The other options are not goals of ACT.
Which scenarios describe a HIPAA violation associated with a nurse's behavior? An ED (Emergency Department) nurse gives the intensive care unit nurse a client report from a telephone at the nurse's station. A nurse on the medical-surgical floor calls a patient's primary care provider to obtain a list of current medications. A nurse on the cardiac unit gives report to the nurse on the step-down unit while transporting a client in the staff elevator. A nurse on the psychiatric unit gives discharge information to the counseling office regarding a client's outpatient treatment.
A nurse on the cardiac unit gives report to the nurse on the step-down unit while transporting a client in the staff elevator. Discussing a patient's information in public places where it may be overheard is a violation of a patient's confidentiality. The other options describe appropriate interactions for patient continuity of care and support of the treatment plan by the health care team.
Which of the following patients would be appropriate to refer to a partial hospitalization program (PHP)? A depressed patient with a suicidal plan A patient being discharged from an inpatient alcohol rehabilitation unit A client who has stopped taking his or her antipsychotic medication and is neglecting his or her basic needs Jeff, who has mild depression symptoms and is starting outpatient therapy
A patient being discharged from an inpatient alcohol rehabilitation unit PHP is for patients who may need a "step-down" environment from inpatient status or for those who are being diverted from hospitalization with intensive, short-term care from which they return home each day. This patient would be a good candidate after completing alcohol rehab; PHP could possibly help prevent relapse in the early stages after rehab. This patient can be managed with regular outpatient therapy and does not need intensive short-term therapy such as PHP. Someone who is suicidal would require inpatient hospitalization for safety as would someone who is decompensated and not caring for herself. A patient exhibiting mild depression would be managed with outpatient therapy and would not need intensive short-term therapy such as PHP
The nurse is conducting an admission interview with a client who was raped 2 weeks ago. When asked about the rape, the client becomes very anxious and upset and begins to sob. What should be the nurse's response to the client's reaction? Push gently for more information about the rape because the information needs to be documented. Acknowledge that the topic of the rape is upsetting and reassure the client that it can be discussed at another time when she feels more comfortable. Use silence as a therapeutic tool and wait until the client is done sobbing to continue discussing the rape. Reassure the client that anything she says to you will remain confidential.
Acknowledge that the topic of the rape is upsetting and reassure the client that it can be discussed at another time when she feels more comfortable. The best atmosphere for conducting an assessment is one with minimal anxiety on the patient's part. If a topic causes distress, it is best to abandon the topic at that time. It is important not to pry or push for information that is difficult for the patient to discuss. The use of silence continues to expect the patient to discuss the topic now. Reassurance of confidentiality continues to expect the patient to discuss the topic now.
Which nursing behavior best demonstrates the concept of cultural competence? Acquiring knowledge about different cultures Educating patients about the cultural norms of the United States Adjusting personal practice to meet the patients' cultural preferences, beliefs, and practices Engaging in continuing education classes on culture in the process of becoming culturally competent
Adjusting personal practice to meet the patients' cultural preferences, beliefs, and practices Cultural competence means that nurses adjust and conform to their patients' cultural needs, beliefs, practices, and preferences rather than their own. This option does not describe cultural competence. Although nurses are continually learning regarding culture, it is a career-long process. The goal is not to educate patients about our own culture but rather to adjust to their cultural preferences. Although nurses may take continuing education regarding culture, this does not describe the term cultural competence. The other options do not describe cultural competence.
A client's daughter states, "My mother lives with me since my dad died 6 months ago. For the past couple of months, every time I need to leave the house for work or anything else, Mom becomes extremely anxious and cries that something terrible is going to happen to me. She seems OK except for these times, but it's affecting my ability to go to work." This information supports that the client may be experiencing which anxiety-related disorder? Panic disorder Adult separation anxiety disorder Agoraphobia Social anxiety disorder
Adult separation anxiety disorder People with separation anxiety disorder exhibit developmentally inappropriate levels of concern over being away from a significant other. There may also be fear that something horrible will happen to the other person. Adult separation anxiety disorder may begin in childhood or adulthood. The scenario doesn't describe panic disorder. Agoraphobia is characterized by intense, excessive anxiety or fear about being in places or situations from which escape might be difficult or embarrassing or in which help might not be available. Social anxiety disorder, also called social phobia, is characterized by severe anxiety or fear provoked by exposure to a social or a performance situation that will be evaluated negatively by others.
The nurse is caring for a patient on day 1 post surgical procedure. The patient becomes visibly anxious and short of breath, and states, "I feel so anxious! Something is wrong!" What action should the nurse take initially in response to the patient's actions? Reassure the patient that what they are feeling is normal anxiety and do deep breathing exercises with her. Use the call light to inquire whether the patient has been prescribed prn anxiety medication. Call for staff help and assess the client's vital signs. Reassure the patient that you will stay until the anxiety subsides.
Call for staff help and assess the client's vital signs. In anxiety caused by a medical condition, the individual's symptoms of anxiety are a direct physiological result of a medical condition, such as hyperthyroidism, pulmonary embolism, or cardiac dysrhythmias. In this case, Lana is postoperative and could be experiencing a pulmonary embolism, as evidenced by the shortness of breath and anxiety. She needs immediate evaluation for any serious medical condition. The other options would all be appropriate after it has been determined that no serious medical condition is causing the anxiety.
A 19-year-old college sophomore who has been using cocaine and alcohol heavily for 5 months is admitted for observation after admitting to suicidal ideation with a plan to the college counselor. What would be an appropriate priority outcome for this client's treatment plan while in the hospital? Client will return to a predrug level of functioning within 1 week. Client will be medically stabilized while in the hospital. Client will state within 3 days that they will totally abstain from drugs and alcohol. Client will take a leave of absence from college to alleviate stress.
Client will be medically stabilized while in the hospital. If the patient has been abusing substances heavily, he will begin to experience physical symptoms of withdrawal, which can be dangerous if not treated. The priority outcome is for the patient to withdraw from the substances safely with medical support. Substance use disorder outcome measures include immediate stabilization for individuals experiencing withdrawal such as in this instance, as well as eventual abstinence if individuals are actively using, motivation for treatment and engagement in early abstinence, and pursuit of a recovery lifestyle after discharge. The first option is an unrealistic time frame. It is not likely that the patient will make a total commitment to abstinence within this time frame. Although a leave of absence may be an option, the immediate need is to make sure the patient goes through drug and alcohol withdrawal safely.
Anti-anxiety medication used to treat Tourette's:
Clonazepam Used as a supplement to other medications. It may work by reducing anxiety and resultant tics.
Alpha 2-adrenergic agonist, used to treat hypertension, is also prescribed for Tourette's:
Clonidine hydrochloride While less effective and far slower acting than the antipsychotics, it has fewer side effects.
Which statement is true regarding substance addiction and medical comorbidity? Most substance abusers do not have medical comorbidities. There has been little research done regarding substance addiction disorders and medical comorbidity. Conditions such as hepatitis C, diabetes, and HIV infection are common comorbidities. Comorbid conditions are thought to positively affect those with substance addiction in that these patients seek help for symptoms earlier.
Conditions such as hepatitis C, diabetes, and HIV infection are common comorbidities. The more common co-occurring medical conditions are hepatitis C, diabetes, cardiovascular disease, HIV infection, and pulmonary disorders. The high comorbidity appears to be the result of shared risk factors, high symptom burden, physiological response to licit and illicit drugs, and the complications from the route of administration of substances. Most substance abusers do have medical comorbidities. There is research such as the 2001-2003 National Comorbidity Survey Replication (NCS-R) showing the correlation between medical comorbidities and psychiatric disorders. It is more likely that medical comorbidities negatively affect substance addiction in that they cause added symptoms, stress, and burden.
The nurse feels uncomfortable talking with a young male client about his sexual problem. Which action should the nurse take? Ask another nurse to take over the interview so you don't project your feelings onto the patient. Pause the interview and take time to gather your thoughts and do positive self-talk. Continue the interview using an appropriate professional tone and matter-of-fact approach. Ask Lance whether he would feel more comfortable speaking with a physician about his problem.
Continue the interview using an appropriate professional tone and matter-of-fact approach. Remembering your position as a professional and addressing the topics in a tone and manner appropriate of a professional will increase your comfort, along with the patient's. The response in the first option would be confusing to the patient and does not address your feelings or work to resolve them. Pausing the interview would not be appropriate because self-assessment is best done before patient interaction. Asking the patient whether he would feel more comfortable speaking with a physician projects your feelings of being uncomfortable onto the patient and does not carry out your professional role and responsibility.
A recent Hispanic immigrate comes to the mental health clinic after being referred to by her primary care provider. Josefina came to live in the United States from Brazil 5 years ago. During the initial intake assessment, the client reports headaches and backaches "almost every day" and "can't sleep at night." The client looks away when asked about anxiety or depression and states, "I don't know why I was referred to the mental health clinic." Which assessment information should the nurse further explore to assess for possible somatization? Impaired sleep patterns Denial of anxiety or depression Unexplained physical pain Recent immigration to the United States
Denial of anxiety or depression Somatization is described as experiencing and expressing emotional or psychological distress as physical symptoms. The client's behavior associated with the denial of any mental illness or understanding of the possible connection between the symptom/signs and a mental illness presents a need to explore the possibility of somatization. None of the other options support this possibility as directly.
The nurse is providing teaching to a preoperative patient just before surgery. The patient is becoming more and more anxious and begins to report dizziness and heart pounding. The patient also appears confused and is trembling noticeably. Considering the scenario, what decision should the nurse make? To reinforce the preoperative teaching by restating it slowly. Have the patient read the teaching materials instead of providing verbal instruction. Have a family member read the preoperative materials to the patient. Do not attempt any further teaching at this time.
Do not attempt any further teaching at this time. Patients experiencing severe anxiety, as the symptoms suggest, are unable to learn or solve problems. The other options would not be effective because you are still attempting to teach someone who has a severe level of anxiety.
Which medication is FDA approved for treatment of anxiety in children? Sertraline Fluoxetine Clomipramine Duloxetine
Duloxetine A few drugs are approved specifically for anxiety and obsessive-compulsive disorders in children and adolescents. The FDA approved the selective SNRI duloxetine (Cymbalta) in 2014 for children aged 7 to 17 years for generalized anxiety disorder.
A nurse expresses an exclusive belief in the biological model for mental illness when stating "it's the only one I really believe." What conclusion should be drawn from this statement? The biological model is the oldest and most reliable model for explaining mental illness. The biological model has been proven to be successful in finding the cause of most symptoms of mental illness. The biological model is the most popular theory among leading psychiatrists and therefore the one that should be fully embraced. In believing only in the biological model, other influences on mental health including cultural, environmental, social, and spiritual influences are not taken into account.
In believing only in the biological model, other influences on mental health including cultural, environmental, social, and spiritual influences are not taken into account. In believing only in the biological model to the exclusion of other theories and perspectives, influences such as educational, social, spiritual, cultural, environmental, and economic are not considered, and these have also been proven to play a part in mental health and mental illness. The other options are untrue.
A nurse is providing care to a 28-year-old patient diagnosed with bipolar disorder who was admitted in a manic state. According to Maslow's Hierarchy of Needs theory, the nurse should identify which patient symptom as having priority? Rapid, pressured speech Grandiose thoughts Lack of sleep Hyperactive behavior
Lack of sleep Based on Maslow's theory, physiological needs such as food, water, air, sleep, etc., are the priority and must be taken care of first. The other options are symptoms of mania but not as critical as lack of sleep.
A 49-year-old patient diagnosed with schizophrenia at 22 years old is prescribed risperidone. Which nursing assessment is the priority for this patient? Monitoring blood levels to avoid toxicity Monitoring for abnormal involuntary movements Observing for secondary mania Observing for memory changes
Monitoring for abnormal involuntary movements Risperidone has the highest rate of extrapyramidal side effects (EPSs) of the second-generation antipsychotic medications, thus making it imperative to monitor for EPSs. Risperidone is not monitored with blood levels and does not cause mania or memory changes.
A patient is sitting with arms crossed over his or her chest, his or her left leg is rapidly moving up and down, and there is an angry expression on his or her face. When approached by the nurse, the patient states harshly, "I'm fine! Everything's great." Which statement related to communication should the nurse focus on when working with this patient? Verbal communication is always more accurate than nonverbal communication. Verbal communication is more straightforward, whereas nonverbal communication does not portray what a person is thinking. Nonverbal and verbal communication may be different; nurses must pay attention to the nonverbal communication being presented to get an accurate message. Nonverbal communication is about 10% of all communication, and verbal communication is about 90%.
Nonverbal and verbal communication may be different; nurses must pay attention to the nonverbal communication being presented to get an accurate message. Communication is roughly 10% verbal and 90% nonverbal, so nurses must pay close attention to nonverbal cues to accurately assess what the patient is really feeling. The other options are all untrue of verbal and nonverbal communication and are actually the opposite of what is believed of communication.
Jacob is a college student whose friend recently committed suicide. Jacob rates his stress as low. Melissa was also friend with the person who committed suicide, but she rates her stress as high. The difference in how Jacob and Melissa rate their stress may be explained by which coping mechanism? Projection Denial Perception Repression
Perception Perception, which is influenced by gender, culture, age, and life experience, plays a part in how someone will respond to a stress. The perception of a stressor determines the person's emotional and psychological reactions to it. The other options are all defense mechanisms that do not explain the difference in reactions to a stressor.
You are interviewing Lance, a 31-year-old patient who has been referred to the sexual disorders clinic by his primary care provider. A client describing his problem states, "I can have an orgasm, no problem. It just happens way too soon." This descriptions support what form of sexual dysfunction? Erectile disorder Premature ejaculation Delayed ejaculation Male hypoactive sexual desire disorder
Premature ejaculation In premature ejaculation, a man persistently or recurrently achieves orgasm and ejaculation before he wishes to. Erectile disorder (also called erectile dysfunction and impotence) refers to failure to obtain and maintain an erection sufficient for sexual activity. In delayed ejaculation, a man achieves ejaculation during coitus only with great difficulty. Male hypoactive sexual desire disorder is characterized by a deficiency or absence of sexual fantasies or desire for sexual activity.
The treatment team meets to discuss a client's plan of care. Which of the following factors will be priorities when planning interventions? Readiness to change and support system Current college performance Financial ability Availability of immediate family to come to meetings
Readiness to change and support system The plan will take into account acute safety needs, severity and range of symptoms, motivation or readiness to change, skills and strengths, availability of a support system, and the individual's cultural needs. The other options may be factors but are not the priority factors in planning interventions for the patient as much as the patient's perceived need for change and having others who can lend support outside the hospital.
The nurse is caring for an admitted client with a history of becoming aggressive when angry and has caused physical injury to another client and two staff members. When this client begins to demonstrate signs of anger while in the day room what intervention should the nurse implement to address the safety of the milieu? Alert security to come to the unit for a show of strength Request that the client accompany the nurse to the client's room Inform the client that restraints will be used if the behavior continues Prepare to administer a prn chemical restraint to the client
Request that the client accompany the nurse to the client's room Least restrictive alternative doctrine requires using the least drastic means of achieving a specific goal. By first attempting to remove the client to a safer location, the nurse is respecting the client's right to treatment that is less restrictive than the other options.
Which nursing intervention demonstrates the theory behind operant conditioning? Rewarding the client with a token for avoiding an argument with another client Showing the client how to be assertive without being aggressive Demonstrating deep breathing techniques to a group of clients Explaining to the client the consequences of not following unit rules
Rewarding the client with a token for avoiding an argument with another client Operant conditioning is the basis for behavior modification and uses positive reinforcement to increase desired behaviors. For example, when desired goals are achieved or behaviors are performed, patients might be rewarded with tokens. These tokens can be exchanged for food, small luxuries, or privileges. This reward system is known as a token economy. None of the remaining options demonstrate reward for positive behaviors, climate, and structure, for healing.
A client states, "I will always be alone because nobody could ever love me." The nurse recognizes that the client is expressing what cognitive-behavioral concept? Emotional consequence Schema Actualization Aversion
Schema Schemas are unique assumptions about ourselves, according to Beck's theory. This statement is an example of a negative schema. Emotional consequence is the end result of negative thinking process, as described by Ellis. Actualization is a level of Maslow's Hierarchy of Needs. Aversion is a therapy characterized by punishment.
Which statement provides accurate information regarding transvestic disorder? Most people with this disorder are homosexual. Only men are diagnosed with transvestic disorder. Sexual orientation has no bearing on transvestic disorder. Transvestic behavior develops in middle adulthood.
Sexual orientation has no bearing on transvestic disorder. Unlike in gender dysphorias, in transvestic disorder there are no sexual orientation issues, and people with transvestic disorder do not desire a sex change. Transvestites are usually heterosexual. Although more common in men, women are also diagnosed with transvestic disorder. Transvestic disorder usually develops early in life.
A 52-year-old Chinese American client comes to the emergency room reporting anxiety and states, "I am a failure." During the assessment interview, the client shares that they have recently been reprimanded at work for an error they were responsible for. The nurse should explore which possible trigger for the client's anxiety and feelings of failure? The inability to achieve her personal goals in the workplace Shaming the family by being responsible for the error Feeling personally inadequate regarding dependability Traditional belief that failure may result in a changed fate
Shaming the family by being responsible for the error Eastern tradition, such as in China, sees the family as the basis for one's identity, and family interdependence as the norm. The views expressed in options A and C demonstrate Western tradition where self-reliance, individuality, and autonomy are highly valued. In the Eastern view one is born into an unchangeable fate.
A 43-year-old client being seen in the mental health clinic states, "I have always been a practicing Jew, but in the past few months I am questioning everything. I just don't know if I believe in it anymore." Which of the following nursing diagnoses best describes the client's comment? Ineffective coping Spiritual distress Risk for self-harm Hopelessness
Spiritual distress The client is expressing distress regarding his religion and spiritual well-being. The client could be experiencing ineffective coping, but this does not directly relate to his comment. There is nothing in the client's comment that would lead to the conclusion that the patient is having thoughts of harming himself or experiencing hopelessness.
A student nurse in the emergency department is assigned to care for a client convicted of the sexual abuse of a child. The student is repulsed by the client because of the nature of his crime and doesn't know how to care for the client under these circumstances. What action should the student nurse take? Refuse the assignment because personal feelings will prevent the student from providing good care. Talk with a faculty member or an experienced nurse in the emergency department. Perform the activities of care but not engage in conversation with the client. Suggest to the client that he request a different nurse.
Talk with a faculty member or an experienced nurse in the emergency department. Nurses may experience distress when providing care for someone who engages in what they view as objectionable, or even reprehensible, acts. This is sometimes compounded by knowing someone who was a victim or having been victimized ourselves. Talking with a faculty member, a nurse mentor, or someone at a mental health clinic can be helpful and important and may even result in better personal understanding and coping. Refusing an assignment is not an option. Performing the activities of care but not engaging in conversation does not appropriately or fully care for the patient. Telling the patient how she feels would be unprofessional and inappropriate, and is putting the burden of our own feelings onto the patient.
A client, whose friend recently committed suicide, asks the nurse about some ways to help cope with the stress regarding the event. Which option should the nurse discuss with the client? Isolation for a short time so that the pain isn't reinforced by explaining her feelings over and over Antianxiety medication to help her relax Starting a hobby to keep her mind off the troubling event Talking with friends and attending a loss support group
Talking with friends and attending a loss support group Social supports and support groups are two effective ways to cope with stress and stressful events. Isolation is never a healthy option; talking about feelings usually decreases stress, not increases. There is no evidence to suggest Melissa is anxious. Trying to "keep her mind off" the stressor does not develop coping mechanisms to deal with stress but rather encourages not dealing with the problem.
A 72-year-old patient diagnosed with Parkinson's disease is demonstrating behaviors associated with anxiety and has had several falls lately and is reluctant to take medications as prescribed. When his provider orders lorazepam, 1 mg PO bid, the nurse questions the prescription based primarily on what fact? The client may become addicted faster than younger patients. The client is at risk for falls. The client has a history of nonadherence with medications. The client should be treated with cognitive therapies because of his advanced age.
The client is at risk for falls. An important nursing intervention is to monitor for side effects of the benzodiazepines, including sedation, ataxia, and decreased cognitive function. In a patient who has a history of falls, lorazepam would be contraindicated because it may cause sedation and ataxia leading to more falls. There is no evidence to suggest that elderly patients become addicted faster than younger patients. A history of nonadherence would not lead to you to question this drug order. Medication and other therapies are used congruently with all age levels.
When considering client rights, which client can be legally medicated against his or her wishes? The client has accepted the medication in the past. The client may cause imminent harm to himself or others. The client's primary provider orders the medication. The client's mental illness may relate to cognitive impairment.
The client may cause imminent harm to himself or others. A patient may be medicated against his or her will without a court hearing in an emergency if the patient poses a danger to himself or herself or to others. The other options are not legally valid reasons to give medication against a patient's will.
When preparing to hold an admission interview with a client, the nurse pulls up a chair and sits facing the client with his or her knees almost touching. When the nurse leans in close to speak, the client becomes visibly flustered and gets up and leaves the room. What is the most likely explanation for client's behavior? The nurse violated the client's personal space by physically being too close. The client has issues with sharing personal information. The nurse failed to explain the purpose of the admission interview. The client is responding to the voices by ending the conversation.
The nurse violated the client's personal space by physically being too close. By sitting and leaning in so closely, the nurse has entered into intimate space (0 to 18 inches), rather than social distance. This has likely made the patient may feel uncomfortable with being so close to someone unknown to them. All the other options lack evidence and jump to conclusions regarding the patient's behavior.
A 55-year-old patient recently came to the United States from England on a work visa. The patient was admitted for severe depression following the death of a life partner weeks ago. While discussing the death and its effects the patient shows little emotion. Which of the following explanations is most plausible for this lack of emotion? The patient in denial. The response may reflect cultural norms. The response may reflect personal guilt. The patient may have an antisocial personality.
The response may reflect cultural norms. Showing little emotion while in distress may be a cultural phenomenon. Some cultures, such as the British and German cultures, tend to value highly the concept of self-control and may show little facial emotion in the presence of emotional turmoil. There is no evidence to suggest the patient's lack of emotion is a result of any of the other options.
Which assessment should the nurse perform to evaluate the pharmacokinetic affect of a monoamine oxidase inhibitors (MAOIs) antidepressant medication? The status of the client's appetite The results of the liver function test The level of depression exhibited by the client The client's current sleeping patterns
The results of the liver function test Pharmacokinetics refers to the movement of a drug through the body. Four basic processes of pharmacokinetics which determine the concentration of a drug at its sites of action are easily remembered with the acronym ADME: absorption, distribution, metabolism, and excretion. MAOIs can affect liver function and require monitoring. The other options are related to the medication's pharmacodynamic effects.
A 26-year-old patient who abuses heroin states to you, "I've been using more heroin lately because I've begun to need more to feel the effect I want." What effect does this statement describe? Intoxication Tolerance Withdrawal Addiction
Tolerance Tolerance is described as needing increasing greater amounts of a substance to receive the desired result to become intoxicated or finding that using the same amount over time results in a much-diminished effect. Intoxication is the effect of the drug. Withdrawal is a set of symptoms patients experience when they stop taking the drug. Addiction is loss of behavioral control with craving and inability to abstain, loss of emotional regulation, and loss of the ability to identify problematic behaviors and relationships.
When considering mental illness, recovery is best described to a client by which statement? Working, living, and participating in the community Never having to visit a mental health provider again Being able to understand the nature of the diagnosed illness A period of time when signs and symptoms are being managed
Working, living, and participating in the community Recovery is described as the ability of the individual to work, live, and participate in the community. Never having to visit a mental health provider is unrealistic. While important to recovery understanding of the disorder is not a demonstration of recovery. Remission is a period of time when signs and symptoms are being managed.
Second Generation antipsychotic used to treat Tourette's:
aripiprazole
