Answer Options:
a. Setting limits on a patient’s romantic overtures toward the nurse
b. Suggesting one-on-one supervision for a patient who is suicidal
c. Informing a patient that the spouse will not be in during visiting hours
d. Helping the patient weigh the consequences of their behaviors and decisions
Answer: D. Helping the patient weigh the consequences of their behaviors and decisions
Question: A nurse talks with the caregiver of a combat veteran diagnosed with severe traumatic brain injuries. The caregiver says, “I don’t know how much longer I can do it. My whole life is consumed with taking care of my partner.” Which response best addresses the needs of the caregiver?
Answer Options:
a. “How are you taking care of yourself?”
b. “Let’s review your partner’s diagnostic results.”
c. “I have some web-based programs for you to visit.”
d. “Your partner is lucky to have someone so devoted.”
Answer: A. “How are you taking care of yourself?”
Question: A patient says to the nurse, “My life does not have any happiness in it anymore. I once enjoyed holidays, but now they’re just another day.” How would the nurse document the patient’s statement?
Answer Options:
a. Vegetative
b. Anhedonia
c. Euphoria
d. Anergia
Answer: B. Anhedonia
Question: Individual nurses must always maintain high ethical standards, even in face of conflicting agency directives. Which statement is correct?
Answer Options:
a. The policies do not absolve an individual nurse of the responsibility to practice according to the professional standards established by a health care agency or state.
b. Agency policies are the legal standard by which a professional nurse must act and therefore override other standards of care.
c. In an institution with substandard policies, the nurse has a responsibility to inform the supervisor and leave the premises.
d. Interpretation of policies by the judicial system is rendered on an individual basis and therefore cannot be predicted.
Answer: a. The policies do not absolve an individual nurse of the responsibility to practice according to the professional standards established by a health care agency or state.
Question: A patient says, “I’ve done a lot of cheating and gambling in my relationships.” What nonjudgmental response by the nurse is most appropriate?
Answer Options:
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. “How do you feel about that?”
Question: A patient diagnosed with major depressive disorder was hospitalized for 8 days. Treatment included six electroconvulsive therapy sessions and aggressive dose adjustments of antidepressant medications. The patient owns a small business and was counseled not to make major decisions for a month. Select the correct rationale for this counseling.
Answer Options:
a. Temporary memory impairments and confusion can be associated with electroconvulsive therapy.
b. Antidepressant medications alter catecholamine levels, which impair decision-making abilities.
c. Antidepressant medications may cause confusion related to a limitation of tyramine in the diet.
d. The patient needs time to reorient himself or herself to a pressured work schedule.
Answer: A. Temporary memory impairments and confusion can be associated with electroconvulsive therapy.
Question: How is severe and persistent mental best characterized?
Answer Options:
a. Mental illness within person 2 weeks’ duration.
b. Severe illness present longer than 2 years.
c. Major ongoing mental illness marked by significant functional impairments.
d. Major mental illness that cannot be treated to relieve symptoms.
Answer: b. Severe illness present longer than 2 years.
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.)
Answer Options:
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. Patient’s subjective responses
D. Description of the patient’s behavior during the interview
Question: A woman says, “I feel as if I should not have survived a small plane crash. Three business associates died. I keep thinking of the others who died because they had families and I do not.” The patient is tearful and continues, “I’m alive, but I don’t know why. It just doesn’t make sense to me the situation.” Which type of therapy was used?
Answer Options:
a. Milieu therapy
b. Psychoanalysis
c. Behavior modification
d. Interpersonal therapy
Answer: d. Interpersonal therapy
Question: A patient diagnosed with major depressive disorder is receiving imipramine 200 mg every night at bedtime. Which assessment finding would prompt the nurse to collaborate with the health care provider regarding potentially hazardous side effects of this drug?
Answer Options:
a. Dry mouth
b. Blurred vision
c. Nasal congestion
d. Urinary retention
Answer: D. Urinary retention
Question: A psychiatric nurse is assisting an isolated patient in an emergency shelter to find affordable housing and may be making daily food allowance choices, etc. One day the community shelter reports the patient’s room was left unlocked, stale groceries are seen at a nearby shelter, and suspicious men are seen isolated from the live alone tenants. Select the community psychiatric nurse’s best initial action.
Answer Options:
a. Report the situation to the manager of the shelter.
b. Tell the patient, “You must stop smoking to save money.”
c. Assess the patient’s weight; determine the foods and amounts eaten.
d. Seek hospitalization for the patient while a new plan is being formulated.
Answer: c. Assess the patient’s weight; determine the foods and amounts eaten.
Question: A patient is brought to the emergency department after a motorcycle accident. The patient is responsive, and diagnosed with a broken leg. The patient’s vital signs are temperature (T), 98.6°F; pulse (P), 72 beats/min (bpm); and respirations (R), 16 breaths per minute. After being informed that surgery is required for the broken leg, which vital sign readings would be expected?
Answer Options:
a. T, 98.6°; P, 64; R, 14
b. T, 98.6°; P, 68; R, 12
c. T, 98.6°; P, 62; R, 16
d. T, 98.6°; P, 84; R, 22
Answer: D. T, 98.6°; P, 84; R, 22
Question: Which finding would prompt the nurse to carefully assess an 8-year-old child for development of a psychiatric disorder?
Answer Options:
a. Being raised by a parent with chronic major depressive disorder
b. Moving to three new homes over a 2-year period
c. Not being promoted to the next grade
d. Having an imaginary friend
Answer: a. Being raised by a parent with chronic major depressive disorder
Question: Why is it important for a nurse to possess an appropriate degree of assertiveness? (Select all that apply.)
Answer Options:
a. Reduces interpersonal stress.
b. Builds effective team relationships.
c. Supports development of technical nursing skills.
d. Reduces potential for the increased risk of client injury.
e. Supports the delivery of effective, appropriate nursing care.
Answer: A. Reduces interpersonal stress.
B. Builds effective team relationships.
D. Reduces potential for the increased risk of client injury.
E. Supports the delivery of effective, appropriate nursing care.
Question: What cognitive strategy should a nurse use to assist a very dependent patient achieve independence?
Answer Options:
a. Reveal dream content.
b. Take prescribed medications.
c. Examine thoughts about being autonomous.
d. Role model ways to ask for help from others.
Answer: c. Examine thoughts about being autonomous.
Question: A clinic nurse is assessing a patient who is suspected of having an undiagnosed depressive disorder. Nursing assessment should include collection of information regarding what focus?
Answer Options:
A. Use of other prescribed medications and over-the-counter products
B. Evidence of pseudoparkinsonism or tardive dyskinesia
C. A history of psoriasis and any other skin disorders
D. A current immunization status
Answer: A. Use of other prescribed medications and over-the-counter products
Question: The patient says, “My marriage is just great. My spouse and I usually agree on everything.” The nurse observes the patient’s foot moving continuously as the patient twirls a shirt button. What type of communication is the patient presenting?
Answer Options:
a. Clear
b. Mixed
c. Precise
Answer: B. Mixed
Question: A disheveled patient with severe depression and psychomotor retardation has not bathed for several days. What action should the nurse take?
Answer Options:
a. Avoid forcing the issue.
b. Bringing up the issue at the community meeting.
c. Calmly telling the patient, “You must bathe daily.”
d. Firmly and neutrally assisting the patient with showering.
Answer: D. Firmly and neutrally assisting the patient with showering.
Question: A patient diagnosed with severe and persistent mental illness lives in a homeless shelter. The priority nursing diagnosis for this patient is Powerlessness. Which intervention should be included in the plan of care?
Answer Options:
a. Encourage mutual goal setting.
b. Verbally communicate empathy.
c. Reinforce participation in activities.
d. Demonstrate an accepting attitude.
Answer: a. Encourage mutual goal setting.