Ticket To Test Exam 1

A tornado destroys a client's house. This represents which type of crisis?

adventitious

A client is receiving clozapine. For which life-threatening disorder should the nurse be alert when assessing this client?

agranulocytosis

Which of the following is an accepting body position for therapeutic communication?

Hands at the side of the body

Which would be considered a situational crisis?

Job promotion

3s Which can correctly be identified as a behavioral response to grief?

crying uncontrollably

Which neurological function is governed by the action of serotonin?

mood

A client has been discharged from the hospital with a prescription for lorazepam. Which instruction should the nurse provide to this client?

"Make sure that you don't drink any alcohol when you're taking this medication."

4s Which question asked by the nurse indicates that the nurse is assessing the judgment of the client?

"What would you do if you found $10 on the side of the road?"

The nurse is assessing a client in crisis. The client states, "I don't feel like I can go on anymore." Which of the following is the nurse's best response?

"Are you having thoughts of hurting yourself?"

After teaching a group of nurses about crisis, the group leader determines that the education was successful based on which statement by the group?

"Crisis is a time-limited event."

38s After being presented with the potential benefits of ECT, a client has replied, "I've seen enough movies to know there's no way I'm going to have any shock therapy." What is the most therapeutic response to this client's concerns?

"Don't believe what you see in movies. ECT is safe and effective and you're asleep the whole time."

A client with a diagnosis of depression has been taking citalopram (Celexa) for several weeks but is frustrated by the persistence of his depression. The client has told the nurse that he has just begun supplementing his antidepressant with St. John's wort. How should the nurse respond?

"It's best that you stop taking the St. John's wort until you talk to you doctor."

3s Kübler-Ross defines five stages of psychosocial responses to dying and death. Which statement is characteristic of the bargaining stage?

"Just let me live to see my grandson born."

When a client's family member questions the likelihood of long-term memory loss for a client scheduled for electroconvulsive therapy (ECT), the psychiatric nurse replies ...

"He may not immediately remember some of the events surrounding the treatment but his memory will return in a matter of hours to just weeks."

During a regular home health visit to an elderly client, the nurse observes that the client has feelings of hopelessness and despair. The client says, "I'm old, and my life has no purpose anymore. But promise me you won't tell anyone." How should the nurse respond?

"I'm sorry, but I can't keep that kind of secret."

Which of the following questions is best to ask when assessing the client's judgment?

"If you found yourself downtown without money or a car, how would you get home?"

The nurse is assessing a client who is grieving the loss of a spouse. According to Kubler-Ross's stages of grieving, which statement indicates that the client is in the depression stage?

"My spouse is gone. I am having a really hard time finding a reason to keep going."

A nurse is working with a client on strategies to help disrupt the pattern associated with the escalation of his aggression. Which of the following would the nurse most likely include in the education plan? Select all that apply.

"Try counting to 10 when you begin to have those feelings." "Attempt to do something different, like watch television to help distract you." "Remove yourself from the situation when you start to have the feelings."

A nurse is assessing a client's spirituality. Which question would be most appropriate to ask?

"What gives your life meaning?"

4s A nurse is caring for a client who is hospitalized for a mental disorder. The nurse is legally obligated to breach the client's confidentiality if the client states:

"When I get out of here, I'm going to kill my neighbor."

3s A nurse is speaking to a client who attempted suicide. The client says, "It is my dream to become a doctor, and I failed the entrance exam. I am so mad at myself." Which statement indicates genuine interest by the nurse?

"You must have been really upset."

3s A client suddenly jumps up from the chair and begins yelling and cursing at the nurse. The best response by the nurse would be ...

"You seem angry. Tell me more about how you're feeling."

Which mental health client meets criteria to be involuntarily committed?

A client diagnosed with borderline personality disorder who is threatening to self-harm

Which of the following standardized rating scales is used to identify adverse effects associated with antipsychotic medications?

Abnormal Involuntary Movement Scale AIMS

Which of the following best describes the main differences between anger and violence?

Anger is a normal human emotional response to perceived frustration of desires or needs; violence is a destructive physical or verbal response to anger.

A client is receiving cognitive-behavioral therapy as part of the treatment plan for anger. Which of the following would most likely be included? Select all that apply.

Avoiding stimuli identified to provoke the anger Monitoring one's self for cues related to anger arousal Identifying ways to disrupt the anger response Engaging in relaxation training

A client with persistent depression is considering electroconvulsive therapy (ECT). The nurse has seen ECT be effective in other cases. When the client expresses fear and doubt about undergoing ECT, the nurse tries to talk the client into it, because the nurse truly believes it will help the client. Which two ethical concepts are in conflict?

Beneficence and autonomy

Which of the following integrative therapies rely on natural substances such as herbs, diet, and nutritional supplements?

Biologically based practices

When discussing a client's mental health condition with someone other than the health care team, the nurse must be aware of which of the following?

Breach of confidentiality

A new nursing student correctly identifies which as most essential for guiding psychiatric-mental health nursing actions?

Code of Ethics for Nurses

4s What is accurate regarding documenting in the client record?

Courts consider acts not recorded as acts not done.

During the assessment of a person in crisis, the nurse should do which of the following first?

Determine whether psychiatric symptoms are related to a physical cause.

A nurse on the inpatient unit is talking with a client with a history of violent behavior towards others. It is important for the nurse to minimize her risk during this one-on-one intervention by doing which of the following?

Having the client sit farthest from the door

A mental health nurse is caring for a client with an anxiety and substance use disorder. The family is requesting to see the client's records. The nurse understands that this would be a violation of which law?

Health Insurance Portability and Accountability Act (HIPAA)

Which action by the nurse or client represents the working phase of the therapeutic relationship?

Identifying past ineffective behaviors

A group of nurses is reviewing the various drug classes used to treat psychiatric disorders. The nurses demonstrate understanding when they identify which as examples of antianxiety medications? Select all that apply.

Lorazepam Buspirone

20s A psychiatric-mental health nurse is describing uncomplicated bereavement to a group of nurses working with terminally ill clients. Which information would the nurse most likely include in the discussion?

Most bereaved persons experience uncomplicated bereavement.

Nurses are encouraged to constantly be aware of the nonverbal communication of a client with mental illness primarily for which reason?

Nonverbal communication provides additional client information that is acted out unconsiously

A psychiatric-mental health nurse is engaged in crisis intervention. The nurse would expect to focus on which area? Select all that apply.

Prevention of relapse Stabilization Symptom reduction

The nurse is caring for a client with depression using milieu therapy. Which intervention should the nurse include in this therapy? Select all that apply

Promote growth by role modeling Maintain a therapeutic environment Encourage communication between clients

Client charts are legal documents that can be used in court; therefore, all nursing notes and progress records should above all include which information?

Reflect descriptive, nonjudgmental, and objective statements

A nurse can accurately identify which personal characteristics that contribute to mental health? Select all that apply.

Sense of responsibility for one's own actions Personal self-awareness Relatively worry free Generally happy with life

A hospice nurse is providing emotional care and support for a family who lost a son. The care will be provided based on what knowledge?

Stages of grief reactions may overlap and are individualized

While interacting with a client experiencing aggression, which of the following client assessments would lead the nurse to suspect that an episode of aggression is about to occur? Select all that apply.

Staring in an intimidating fashion Using sarcastic comments Mumbling Pacing

For a plaintiff to receive monetary damages by suing a professional nurse for malpractice, the plaintiff must prove all except which element of nursing negligence?

The act in which the nurse engaged resulted in physical injury to the client.

Breaching a client's confidentiality is acceptable under which circumstance?

The client has discussed the intent to kill someone.

Short-term use of restraints is permitted only in which situation?

The client is imminently aggressive and a danger to the self or others.

a 28-year-old client is being treated with lithium carbonate for bipolar disorder. The nurse emphasizes the signs and symptoms of toxicity based on which factor associated with the client?

The client runs marathons frequently.

A 22-year-old client has voluntarily sought treatment for an eating disorder at a rural residential facility. Despite a promising start, the client has been involved in recent conflicts with staff members and insists that the client wants to leave the facility. Staff members have refused to facilitate the client's transportation from the facility and have stated that they will not return the client's money and identification that were held when the client was admitted. Staff at the treatment facility may be guilty of false imprisonment due to what?

The client voluntarily admitted for treatment.

The nurse is preparing a care plan for a client experiencing grief. What are the expected outcomes of a successful intervention? Select all that apply.

The client will identify the meaning of the loss. The client will develop healthy strategies for coping with loss. The client will recognize the negative effects of the loss on the client's life.

The nurse is planning treatment for a client with aggressive and psychotic behavior. What should be the immediate goals of treatment for this client? Select all that apply.

The client will not harm the self. The client will demonstrate decreased acting out behavior. The client will withhold from harming others or damaging the hospital property.

The nurse is speaking with a client. While listening, the nurse faces the client and leans slightly toward the client. How does the client interpret this gesture?

The nurse is keenly interested in the client's concerns.

The nurse is speaking with a client. The nurse sits with legs crossed and arms folded across the chest while listening to the client. How might the client interpret this posture of the nurse? Choose the best answer.

The nurse may be showing nonacceptance toward the client.

The nurse is documenting a plan of care for a mental health patient. Which of the following would be appropriate for the nurse to include in the documentation?

The nurse should include both objective and subjective data.

Which is the most appropriate overall nursing goal for crisis intervention?

The overall goal of crisis intervention is to help the client return to the pre-crisis level of functioning.

While conducting an interview with a 14-year-old mental health client, the client tells the nurse that the client has a plan to kill students at the client's school because they will not stop picking on the client. The client says, "I have everything I need all set up, including a gun." What would be the nurse's responsibility after hearing this statement?

To break the client's confidentiality because the client has threatened the lives of other people

A nurse is reading a journal article about anticonvulsant agents used in psychiatric-mental health commonly used to treat clients with bipolar disorder. Which medication would the nurse most likely find being discussed in the article? Select all that apply.

Valproate Carbamazepine Lamotrigine

A nurse is faced with an ethical dilemma involving a client. Which question would be most important for the nurse to ask first when engaging in the process of ethical decision making?

What do I know about the situation?

In the process of electroconvulsive therapy, what is electricity used to induce?

a seizure

During an admission assessment, the nurse asks a client the meaning of the proverb, "People in glass houses should not throw stones." Which clinical feature is the nurse assessing?

abstract reasoning

During assessment, a nurse asks a client to explain the meaning of the saying: "A penny saved is a penny earned." The nurse is assessing:

abstract reasoning

A client diagnosed with terminal cancer is making plans to take flying lessons because that has always been the client's personal goal and it will allow the client to visit the client's elderly parents. What stage of death and dying according to Kübler-Ross is best illustrated in this description?

acceptance

Which of the following stages of grieving, according to Kubler-Ross (1969), occurs when the person shows evidence of coming to terms with death?

acceptance

In which ways can anticipatory grief be helpful for the client and family?

acceptance of impending death

Principles that serve as codes of conduct about right and wrong behaviors to guide actions are known as what?

ethics

After receiving word from the oncologist that the client's tumor is malignant, the client says to the nurse, "If you people had the faintest clue what you were doing, I wouldn't be like this." The nurse should recognize that the client may be experiencing which stage of grief?

anger

Seclusion and restraint are nursing interventions to be used for an individual in which situation?

as a last resort

A client who has bipolar disorder stops taking medication because the client says the client likes how the client feels in a manic state. The client is exercising which principle?

autonomy

The client's right to self-determination and independence is guided by which ethical principle?

autonomy

Which ethical principle involves the right of the client to make his or her own decisions?

autonomy

Which sign of escalating behaviors, if displayed by a client, requires immediate intervention?

banging their head against a wall

Which stages of grieving, according to Kubler-Ross (1969), occurs when the person asks God or fate for more time to delay the inevitable loss?

bargaining

3s Which of the following terms is used to describe the process by which a person experiences the grief?

bereavement

Disclosure of client information beyond the interdisciplinary team without consent of the client is a breach of what?

confidentiality

Milieu therapy is a stable and coherent social organization to facilitate an individual's treatment. Which concept would the nurse most likely include as a key concept? Select all that apply.

containment validation structured interaction open communication

When educating a client on a newly prescribed medication, the nurse includes information related to all but which one of the following?

cost of the medication

During a care conference, the nurse therapist receives feedback from a colleague who says that the therapist seems "blind" to a client's manipulative behavior. The nurse therapist's "blind spot" is an example of which processes?

countertransference

A client is yelling, pacing, and becoming violent toward staff members. What technique should be tried first to control the situation initially?

deescalation

The client has been recently diagnosed with cancer. When the nurse tells the client about the diagnosis, the client says, "I have been eating healthy food and working out regularly." According to the Kubler-Ross's stages of grieving, which stage of grief is the client in?

denial

After being laid off from work, a client becomes increasingly withdrawn and fatigued, spends entire days in bed, is unkempt, and is eating and sleeping poorly. The nurse would recognize that the client is in which stage of grieving, according to Kubler-Ross?

depression

According to the decision in Tarasoff vs. Regents of the University of California, which takes precedence when a client admits to wanting to kill another person?

duty to warn

Which of the following is the essential component the nurse must bring to the therapeutic nurse-client relationship?

empathy

What term is used to identify the situation when ethical principles conflict or when there is not one clear course of action in a given situation?

ethical dilemma

A nurse is preparing a continuing education presentation about various psychopharmacologic agents for a group of psychiatric-mental health nurses. The nurse is planning to discuss selective serotonin reuptake inhibitors. Which agents would the nurse include in this group? Select all that apply.

fluoxetine sertraline

A nurse is completing an assessment interview, and is attempting to bring the conversation back to the questions at hand when the client goes off on a tangent. Which assessment interview behavior is the nurse using?

focusing

A client tells the nurse that the client is afraid to quit a stressful job at a day care center because the client doesn't think the client has any marketable skills. Which therapeutic communication technique would be helpful to use in this situation?

voicing doubt

Which personality trait is associated with aggressive behavior?

impulsivitiy

Which is considered a psychosocial factor that can influence mental health?

interpersonal relationships

The nurse is caring for a client with schizophrenia. The client says, "Somebody is trying to kill me." The nurse responds by saying, "Isn't the weather nice? You should sit outside for a while." Which type of communication does this indicate?

introducing an unrelated topic

The nurse is setting goals and beginning to plan interventions for a client who was admitted recently. In what phase of the therapeutic relationship is the nurse functioning?

introductory phase

2s Which is an example of a traumatic crisis?

kidnapping

A client asks if the medication has any possible negative side effects. The nurse considers the client highly suggestible, believes the medication will benefit the client, and, since the client has no history of cardiovascular disease, does not tell the client of the potential for cardiac dysrhythmias. The nurse's actions involve a conflict between veracity and which other ethical principle?

nomalefience

When initiating an assessment, the nurse should use which type of questioning?

open-ended questions

When the mental health nurse asks the client, "Do you recall what month and year this is?" the nurse is assessing which part of the mental status examination?

orientation

Which of the following is a possible side effect of ECT?

short term memory loss

The nurse indicates interest in and acceptance of the client by all of the following except:

sitting behind desk

A nursing student has difficulty with the rigorous workload of courses during the first semester of nursing school and does not pass all required classes. The type of crisis the student is experiencing is which of the following?

situational crisis

A depressed, suicidal client is scheduled for electroconvulsive therapy (ECT), which requires consent. Legally, who should sign the consent for this treatment?

the client

The nurse-client relationship is classified as which type of relationship?

therapeutic

2s A nurse tells a client that the nurse will come back in 10 minutes to reassess the client's pain. When the nurse returns in 10 minutes, which aspect of the therapeutic relationship is the nurse developing?

trust