Answer Choices:
a. Design interventions to include in the plan of care.
b. Determine the goals and outcome criteria.
c. Implement the nursing plan of care.
d. Complete the spiritual assessment.
Answer:
b. Determine the goals and outcome criteria.
Question: Which remark by a patient indicates passage from the orientation phase to the working phase of a nurse–patient relationship? a. “I don’t have any problems.” b. “It is so difficult for me to talk about my problems.” c. “I don’t know how talking about things twice a week can help.” d. “I want to find a way to deal with my anger without becoming violent.”
Answer Choices:
a. “I don’t have any problems.”
b. “It is so difficult for me to talk about my problems.”
c. “I don’t know how talking about things twice a week can help.”
d. “I want to find a way to deal with my anger without becoming violent.”
Answer:
D
Question: A nurse must assess several new patients at a community mental health center. Conclusions concerning current functioning should be made on the basis of what factor?
Answer Choices:
a. The degree of conformity of the individual to society’s norms.
b. The degree to which an individual appears logical and rational.
c. A continuum from mentally healthy to mentally unhealthy.
d. The rate of their intellectual and emotional growth.
Answer:
C. A continuum from mentally healthy to mentally unhealthy.
Question: A patient is admitted to the psychiatric hospital. Which assessment finding best indicates that the patient has a mental illness? The patient:
Answer Choices:
a. Describes coping and relaxation strategies used when feeling anxious.
b. Describes mood as consistently sad, discouraged, and hopeless.
c. Can perform tasks attempted within the limits of own abilities.
d. Reports occasional problems with insomnia.
Answer:
B. Describes mood as consistently sad, discouraged, and hopeless.
Question: When a new patient is hospitalized, a nurse takes the patient on a unit tour, explains the rules of the unit, and discusses the daily schedule. The nurse is engaged in what aspect of care?
Answer Choices:
a. Counseling
b. Health teaching
c. Milieu management
d. Psychobiological intervention
Answer:
c. Milieu management
Question: A nurse’s neighbor asks, “Why aren’t people with mental illness kept in state institutions anymore?” What is the nurse’s best response?
Answer Choices:
a. “Many people are still in psychiatric institutions. Inpatient care is needed because many people who are mentally ill are violent.”
b. “Less restrictive settings are now available to care for individuals with mental illness.”
Answer:
b. “Less restrictive settings are now available to care for individuals with mental illness.”
Question: A patient’s nursing diagnosis is Insomnia. The desired outcome is: “Patient will sleep for a minimum of 5 hours nightly by October 31.” On November 1, a review of the sleep data shows the patient sleeps an average of 4 hours nightly and takes a 2-hour afternoon nap. Which evaluation should be documented?
Answer Choices:
a. Consistently demonstrated
b. Often demonstrated
c. Sometimes demonstrated
d. Never demonstrated
Answer:
d. Never demonstrated
Question: A nurse administers a hypnotic medication that potentiates the action of gamma-aminobutyric acid (GABA). Which finding would be expected?
Answer Choices:
a. Reduced anxiety
b. Improved memory
c. More organized thinking
d. Fewer sensory perceptual alterations
Answer:
A. Reduced anxiety
Question: A patient tells the nurse, “I wanted my health care provider to prescribe diazepam for my anxiety disorder, but buspirone was prescribed instead. Why?” The nurse’s reply should be based on the knowledge of which characteristic of buspirone?
Answer Choices:
a. It does not produce blood dyscrasias.
b. It is not known to cause dependence.
c. It can be administered as needed.
d. It is faster acting than diazepam.
Answer:
b. It is not known to cause dependence.
Question: A patient says, “I’ve done a lot of cheating in my relationships.” What nonjudgmental response by the nurse is most appropriate? a. “How do you feel about that?” b. “It’s good that you realize this.” c. “That’s not a good way to behave.” d. “Have you outgrown that type of behavior?”
Answer Choices:
a. “How do you feel about that?”
b. “It’s good that you realize this.”
c. “That’s not a good way to behave.”
d. “Have you outgrown that type of behavior?”
Answer:
A
Question: A nurse says, “When I was in school, I learned to call upset patients by name to get their attention; however, I read a descriptive research study that says that this approach does not work. I plan to stop calling patients by name.” Which statement is the best appraisal of this nurse’s comment?
Answer Choices:
A. One descriptive research study rarely provides enough evidence to change practice.
Answer:
The correct answer is not provided in the excerpt.
Question: A patient experiencing fluctuating levels of consciousness, disturbed orientation, and perceptual alteration begs, “Someone get these bugs off me.” What is the nurse’s best response?
Answer Choices:
A. “There are no bugs on your legs. Your imagination is playing tricks on you.”
B. “Try to relax. The crawling sensation will go away sooner if you can relax.”
C. “Don’t worry. I will have someone stay here and brush off the bugs for you.”
D. “I don’t see any bugs, but I know you are frightened so I will stay with you.”
Answer:
D
Question: A nurse assesses a confused older adult. The nurse experiences sadness and reflects, “The patient is like one of my grandparents, so helpless.” What feelings does the nurse describe? a. Transference b. Countertransference c. Catastrophic reaction d. Defensive coping reaction
Answer Choices:
a. Transference
b. Countertransference
c. Catastrophic reaction
d. Defensive coping reaction
Answer:
B
Question: A nurse assesses a patient suspected to have somatic system disorder. Which findings support the diagnosis? (Select all that apply.)
Answer Choices:
a. Female
b. Reports frequent dizziness
c. Complains of heavy menstrual bleeding
d. First diagnosed with psoriasis at 12 years of age
e. Reports of back pain, painful urination and frequent diarrhea
Answer:
A, B, C, E
Question: A nurse assesses a patient who reluctantly participates in activities, answers questions with minimal responses, and rarely makes eye contact. What information should be included when documenting the assessment? (Select all that apply.) a. Uncooperative patient b. Patient’s subjective responses c. Only data obtained from the patient’s verbal responses d. Description of the patient’s behavior during the interview e. Analysis of why the patient is unresponsive during the interview
Answer Choices:
a. Uncooperative patient
b. Patient’s subjective responses
c. Only data obtained from the patient’s verbal responses
d. Description of the patient’s behavior during the interview
e. Analysis of why the patient is unresponsive during the interview
Answer:
B, D
Question: A patient who has been taking escitalopram for 2 days says, “This medicine isn’t working.” What is the nurse’s best intervention?
Answer Choices:
a. Discontinuing the medication
b. Explaining that it will take a while for the medication to take effect
c. Escalating the use of the medication
d. Calmly assessing the patient for symptom relief
Answer:
B
Question: A patient being treated in an alcohol rehabilitation unit reveals to the nurse, “I feel terrible guilt for sexually abusing my 6-year-old child before I was admitted.” Based on state and federal law, what action is the nurse expected to take?
Answer Choices:
a. Anonymously report the abuse by telephone to the local child abuse hotline.
b. Replying, “I’m glad you feel comfortable talking to me about it.”
c. Respecting the nurse–patient relationship of confidentiality.
d. Filing a written report on the agency letterhead.
Answer:
a. Anonymously report the abuse by telephone to the local child abuse hotline.
Question: Which scenario best demonstrates an example of eustress? a. A child loses a beloved family pet. b. A single male prepares to take a 1-week vacation to a tropical island with a group of close friends. c. A couple receives a bank notice there were insufficient funds in their account for a recent rent payment. d. A married female receives notification that their current employer is experiencing financial problems and some workers will be terminated.
Answer Choices:
a. A child loses a beloved family pet.
b. A single male prepares to take a 1-week vacation to a tropical island with a group of close friends.
c. A couple receives a bank notice there were insufficient funds in their account for a recent rent payment.
d. A married female receives notification that their current employer is experiencing financial problems and some workers will be terminated.
Answer:
B
Question: A nurse at a behavioral health clinic sees an unfamiliar psychiatric diagnosis on a patient’s insurance form. Which reference should the nurse consult to understand the diagnosis?
Answer Choices:
a. A behavioral health reference manual.
b. NANDA International (NANDA-I)
c. Diagnostic and Statistical Manual of Mental Disorders (DSM-5)
d. International Statistical Classification of Diseases and Related Health Problems (ICD)
Answer:
C. Diagnostic and Statistical Manual of Mental Disorders (DSM-5)
Question: During the first interview with a parent whose child died in a car accident, the nurse feels empathic and reaches out to take the patient’s hand. Select the correct analysis of the nurse’s behavior. a. It shows empathy and compassion. It will encourage the patient to continue to express feelings. b. The gesture is premature. The patient’s cultural and individual interpretation of touch is unknown. c. The patient will perceive the gesture as intrusive and overstepping boundaries. d. The action is inappropriate. Patients in a psychiatric setting should not be touched.
Answer Choices:
a. It shows empathy and compassion. It will encourage the patient to continue to express feelings.
b. The gesture is premature. The patient’s cultural and individual interpretation of touch is unknown.
c. The patient will perceive the gesture as intrusive and overstepping boundaries.
d. The action is inappropriate. Patients in a psychiatric setting should not be touched.
Answer:
B
Question: A patient hurriedly tells the community mental health nurse, “Everything’s a disaster! I can’t concentrate. My disability check didn’t come. My roommate moved out, and I can’t afford the rent. My therapist is moving away. I feel like I’m coming apart.” What should be the immediate focus of nursing care?
Answer Choices:
a. Assisting with the clarification of personal values
b. Helping the patient cope with feelings of abandonment
c. Assisting with the management of anxiety that may lead to psychological disequilibrium
d. Facilitating the clarification of the patient’s misperceptions of the environment
Answer:
c. Assisting with the management of anxiety that may lead to psychological disequilibrium
Question: A nurse supports parental praise of a child who is behaving in a helpful way. When the individual behaves with politeness and helpfulness in adulthood, which ego ideal will most likely result?
Answer Choices:
a. Curiosity
b. Awareness
c. Autonomy
d. Initiative
Answer:
C. Autonomy