Psychiatric Nursing Content Post Test (7/10 Correct)

**A client admitted to a psychiatric facility is refusing all medications. The nurse notes the client appears to be responding to auditory hallucinations. What actions by the nurse would be appropriate? Select All That Apply 1. Assign staff to stay with client. 2. Place client into a seclusion room. 3. Ask client to explain auditory sounds. 4. Frequently reorient client to reality. 5. Turn up radio to mask hallucinations.

1 and 4. CORRECT. Auditory hallucinations, also called "paracusia", are extremely frightening. The client's intense fear may result in striking out at staff, visitor or other clients, and can even cause the client to do self-harm. Nurses must focus on safety by remaining with the client at all times in a quiet room. Reinforcing that feeling of being safe while frequently reorienting the client to reality are priority actions that may continue for hours until the client becomes calmer. 2. INCORRECT. Though the idea of a quiet environment with decreased stimuli is important, a frightened client with hallucinations should never be left alone. 3. INCORRECT. Asking a client to explain hallucinations feeds into the delusion. If the client indicates hearing messages or commands being given, the nurse would acknowledge the hallucination may seem real to the client, but is not perceived by anyone else. 5. INCORRECT. The best approach for a hallucinating client is to decrease stimuli and move client to a quiet environment. Chaos or loud noises would not mask hallucinations perceived within the client's mind.

A client is experiencing a panic attack. What priority action should the nurse take? Choose One 1. Instruct client to deep breathe with the nurse. 2. Teach relaxation techniques. 3. Inform client that symptoms will be gone in 20-30 minutes. 4. Hold the client gently for 5 minutes.

1. Correct: The most important action for the nurse to take is to slow down the client's breathing so that they do not end up in respiratory alkalosis from hyperventilation. 2. Incorrect: Now is not the time to teach! They cannot concentrate on anything but the panic they feel. 3. Incorrect: Again teach them this when they are not having a panic attack. Also teach ways to stop the anxiety from escallating. 4. Incorrect: Approach the client in a nonthreatening manner. Give them space. Do not add to the anxiety by getting in their space.

Which signs/symptoms does the nurse expect to see in a client diagnosed with schizophrenia? Select All That Apply 1. Auditory hallucinations 2. Grandiose delusions 3. Religious preaching all the time. 4. Flat affect 5. Abstract reasoning

1., 2., 3., & 4. Correct: Auditory hallucinations are commonly experienced by the client diagnosed with schizophrenia. Delusions of grandiosity like believing they are a famous person or religious figure is a false fixed belief experienced by the client. If the client is in the acute phase of schizophrenia, the person may be overwhelmed by anxiety and is not able to distinguish thoughts from reality. It is thought that delusions may develop to cope with the anxiety. Religiosity is common. The client may carry a bible all of the time and preach to everyone all of the time. The client may have an inappropriate affect, a flat affect, or a blunted affect. 5. Incorrect: This client has concrete thinking which implies over emphasis on specific details and an impairment in the ability to use abstract concepts. For example, during the nursing history you may ask the client what brought them to the hospital and the answer will be "a cab."

The nurse is planning care for a client admitted with a diagnosis of Alzheimer's Disease. What interventions should the nurse include? Select All That Apply 1. Encourage participation in light exercise. 2. Identify doors with pictures. 3. Monitor food intake. 4. Assign unlicensed assistive personnel to bathe client daily. 5. Reminisce about successful and unsuccessful life events. 6. Weigh weekly.

1., 2., 3., & 6. Correct: It is important to keep the client as active as possible by participating in enjoyable things like light exercise, dancing, singing, simple games, and painting. Identify all doors with pictures or easily identifiable labels. Doors to rooms, closets, and bathrooms are especially important for the client to be able to recognize. Monitor food and liquid intake daily. The client can easily forget to eat and drink. This is one reason the client should be weighed weekly as well. 4. Incorrect: Have the client dress in their own clothes whenever possible and perform their own activities of daily living for as long as possible. This helps to maintain self-esteem. 5. Incorrect: Talk about meaningful things. Help the client focus on a successful life events to increase self-esteem. Talking about unsuccessful life events will not increase self-esteem or be helpful to the client.

The nurse is developing the plan of care for a client admitted for the treatment of mania. Which interventions should the nurse include? Select All That Apply 1. Give one cigarette to client at a time. 2. Discuss delusional belief with client. 3. Have finger foods available at mealtime. 4. Give high calorie fluids between meals. 5. Provide soothing music in room during waking hours.

1., 3., & 4. Correct: We need to protect this client from hazards in their environment. They have no control or awareness of these hazards. If they smoke, only give the client one or two cigarettes at a time, or the client will light a whole pack at once. Finger foods should be provided because the cleint is too busy to stop and eat. They are also too busy to drink, so they can become dehydrated. This is why we provide high calorie fluids for them throughout the day. 2. Incorrect: You are not supposed to talk a lot about the client's delusions. Let the client know that you accept their need for the belief, but that you do not believe it. 5. Incorrect: We want to decrease the stimuli in this client's environment, so that means turning off the TV and radio. Any stimulating activity needs to be interrupted.

A client is admitted to a chemical dependency unit for addiction treatment. Which of the client's belongings should the nurse remove from the client's room? Choose One 1. Shampoo and conditioner 2. Mouthwash and hand sanitizer 3. Toothpaste and dental floss 4. Lotion and foot powder

2. Correct: Mouthwash and hand sanitizers have alcohol in them, which the client may drink. 1. Incorrect: There is not alcohol content in shampoo and conditioner, so these items do not have to be removed from the client's room. 3. Incorrect: We do not want the client to come into contact with anything that contains alcohol. Toothpaste and dental floss are safe for the client to have available. 4. Incorrect: There is no alcohol content in these items, so there is no need to remove them from the room.

A primary healthcare provider has prescribed restraints for a violent adult client. Which measures would the nurse provide as proper interventions for this client? Select All That Apply 1. Observe the client in restraints every hour. 2. Ensure that circulation to extremities is not compromised. 3. Assist client with needs related to nutrition and elimination. 4. Provide help with personal hygiene. 5. Renew restraint prescription in 4 hours if needed.

2., 3., 4. & 5. Correct: These are correct interventions for safety when a violent client requires restraints. When applying restraints you do not want the restraint so tight that extremity circulation is diminished. The client must still be provided with proper nutrition, hydration, and allowed to go to the restroom. If the client is restrained, the client will need help with basic care and comfort measures. Prescriptions for restraints used on an adult client must be renewed every 4 hours if needed. 1. Incorrect: The client in restraints should be observed every 15 minutes. Safety of the client is extremely important. Physical needs, such as food and toileting, should also be addressed.

**A client with a history of paranoid personality disorder is admitted to the hospital with extreme weight loss. Family states client has been refusing medications and food due to fears of being poisoned. What initial response by the nurse is most important? Choose One 1. "Tell me about your fears of being poisoned." 2. "No one is trying to poison your food or meds." 3. "You certainly are having scary thoughts." 4. "You are starving yourself needlessly."

3. CORRECT. The client is so fearful of being poisoned that physical harm has occurred secondary to personal starvation. The responsibility of the nurse is to address the client's fears and establish a trusting nurse/client relationship in order to meet the goal of helping the client feel safe enough to begin to eat. 1. INCORRECT. It is important not to focus on the client's perception of being poisoned by asking for information or clarification. Feeding into the delusion will reinforce that false reality for the client. This is an incorrect open-ended statement by the nurse. 2. INCORRECT. Even though the nurse is making an accurate statement, the client's perception of reality will negate anything that is stated by staff. The nurse is trying to refute what the client believes is true, which means the client will also distrust the nurse. Again the focus is on the poisoning instead of client's feelings. 4. INCORRECT. The client's fear and delusion about poisoning is strong enough to over-ride the pain of starvation. Such an ingrained thought would not be easily changed by this statement. Additionally, this comment by the nurse is belittling what the client assumes to be true, thus eliminating any chance for a trusting nurse/client interaction.

An adolescent is admitted to the psychiatric unit following a repeat suicide attempt. What is the nurse's priority action? Choose One 1. Have staff check on client once every hour. 2. Ask client to explain why suicide was a choice. 3. Place client in quiet seclusion with lights off. 4. Assign a staff member to stay with the client.

4. CORRECT. The client is newly admitted following a repeat suicide attempt and therefore safety is the priority issue. The client should not be left alone, even when using the bathroom, until the primary healthcare provider determines the risk of suicide has abated. 1. INCORRECT. A suicidal client is never left unattended immediately after admission. Checking the client just once an hour increases the potential risk for another suicide attempt. 2. INCORRECT. Demanding an explanation of the client is not an appropriate nursing action and is non-therapeutic. Some clients may be unable to provide an answer while others may be unwilling to discuss the situation with the nurse. This does not focus on client safety. 3. INCORRECT. A suicidal client should not be placed in seclusion, and definitely not in a darkened environment. Such actions do not provide a safe environment for the client and may increase the risk for another suicide attempt.

A client has responded positively to a series of electroconvulsive treatments (ECT), but reports concerns about on-going memory loss. What is the most appropriate response by the nurse? Choose One 1. "It's only been a couple weeks so don't worry." 2. "Are you afraid your memory will not return?" 3. "I will ask the psychiatrist to come talk with you." 4. "You seem very concerned about your memory."

4. CORRECT. The nurse/client relationship is collaborative and nonjudgmental with the goal of facilitating the client's emotional growth. Open-ended statements or questions encourage the client to express feelings and continue verbalizing. This comment by the nurse is open-ended and acknowledges the client's concerns. 1. INCORRECT. Although the nurse has indicated the time frame for memory loss would be greater than two weeks, telling the client not to worry denies the client's right to express feelings. 2. INCORRECT. This question is closed-ended because the client can respond with yes or no. Also, the nurse has suggested feelings of fear, instead of letting the client identify a specific emotion. 3. INCORRECT. It is not appropriate for the nurse to transfer care of the client to another individual currently. Instead, first the nurse should address the client's concerns directly and immediately.