Answer Options:
a. “A: Pacing and muttering to self. P: Sensory perceptual alteration, related to internal auditory stimulation. I: Given fluphenazine 2.5 mg at 0900 and went to room to lie down. E: Calmer by 0930. Returned to lounge to watch TV.”
b. “S: States, ‘I feel like I’m ready to blow up.’ O: Pacing hall, mumbling to self. A: Auditory hallucinations. P: Offer haloperidol 2 mg. I: haloperidol 2 mg at 0900. E: Returned to lounge at 0930 and quietly watched TV.”
c. “Agitated behavior. D: Patient muttering to self as though answering an unseen person. A: Given haloperidol 2 mg and went to room to lie down. E: Patient calmer. Returned to lounge to watch TV.”
d. “Pacing hall and muttering to self as though answering an unseen person. haloperidol 2 mg administered at 0900 with calming effect in 30 minutes. Stated, ‘I’m no longer bothered by the voices.’”
Answer: B. “S: States, ‘I feel like I’m ready to blow up.’ O: Pacing hall, mumbling to self. A: Auditory hallucinations. P: Offer haloperidol 2 mg. I: haloperidol 2 mg at 0900. E: Returned to lounge at 0930 and quietly watched TV.”
Question: The family of a patient whose insurance will not pay for continuing hospitalization considers transferring the patient to a public psychiatric hospital. The family expresses concern that the patient will “never get any treatment.” Which reply by the nurse would be most helpful?
Answer Options:
a. “Under the law, treatment must be provided. Hospitalization without treatment violates patients’ rights.”
b. “That’s a justifiable concern because the right to treatment extends only to the provision of food, shelter, and safety.”
c. “Much will depend on other patients’ needs because the right to treatment for a psychotic patient takes precedence over the right to treatment of a patient who is stable.”
d. “All patients in public hospitals have the right to choose both a primary therapist and a primary nurse.”
Answer: a. “Under the law, treatment must be provided. Hospitalization without treatment violates patients’ rights.”
Question: An adolescent asks a nurse conducting an assessment interview, “Why should I tell you anything? You’ll just tell my parents whatever you find out.” What is the nurse’s best reply regarding patient confidentiality?
Answer Options:
a. “That is not true. What you tell us is private and held in strict confidence. Your parents have no right to know.”
b. “Yes, your parents may find out what you say, but it is important that they know about your problems.”
c. “What you say about feelings is private, but some things, like suicidal ideation, must be reported to the treatment team.”
d. “It sounds as though you are not really ready to work on your problems and make changes.”
Answer: C. “What you say about feelings is private, but some things, like suicidal ideation, must be reported to the treatment team.”
Question: A patient diagnosed with schizophrenia believes evil spirits are being summoned by a local minister and verbally threatens to bomb a local church. What principle governs the proper action in this situation?
Answer Options:
a. Need for authorization
b. Duty to warn and protect
c. Patient right to confidentiality
d. Patient’s right to self-actualization
Answer: B. Duty to warn and protect
Question: The spouse of a patient who experiences delusions asks the nurse, “Under what circumstances under which the treatment team is justified in violating patient confidentiality?” What is the nurse’s best response?
Answer Options:
a. “We can’t violate that confidence under any circumstances.”
b. “The duty to warn at the discretion of the psychiatrist.”
c. “We can’t do that only at the discretion of the law.”
d. “We are required by law to warn the intended victim if there is a clear and present danger.”
Answer: d. “We are required by law to warn the intended victim if there is a clear and present danger.”
Question: A voluntarily hospitalized patient tells the nurse, “Get me the forms I need to sign so I can leave this place now.” What is the nurse’s best initial response?
Answer Options:
a. “I can’t give you those forms without your health care provider’s knowledge.”
b. “I will get them for you, but let’s talk about your decision to leave treatment.”
c. “Since you signed your consent for treatment, you may leave if you desire.”
d. “I’ll get the forms for you right now and bring them to your room.”
Answer: b. “I will get them for you, but let’s talk about your decision to leave treatment.”
Question: A health care provider writes these new prescriptions for a resident in a skilled care facility: egg custodian diet; restraint as needed; limit fluids to 200 mL daily; 1 dose of milk of magnesia 30 mL orally if no bowel movement occurs for 3 days.” Which prescription should the nurse question?
Answer Options:
a. Restraint
b. Fluid restriction
c. Milk of magnesia
d. Sodium restriction
Answer: a. Restraint
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 Options:
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 reflects that, as a nurse, “People diagnosed with mental illnesses used to go to a state hospital. How has that changed?” Select the nurse’s accurate responses. (Select all that apply.)
Answer Options:
a. “Science has made significant improvements in drugs for mental illnesses, so now many people may live in their communities.”
b. “A better selection of less restrictive settings is now available in communities to care for individuals with mental illness.”
c. “National rates of mental illness have declined significantly. The need for state institutions is actually no longer present.”
d. “Most psychiatric institutions were closed because of serious violations of patients’ rights and unsafe conditions.”
e. “Federal legislation and payment for treatment of mental illness have shifted the focus to community rather than institutional settings.”
Answer: a. “Science has made significant improvements in drugs for mental illnesses, so now many people may live in their communities.”
b. “A better selection of less restrictive settings is now available in communities to care for individuals with mental illness.”
e. “Federal legislation and payment for treatment of mental illness have shifted the focus to community rather than institutional settings.”
Question: A patient diagnosed with borderline personality disorder self-inflicted wrist lacerations after gaining new privileges on the unit. The cause of the self-mutilation is probably related to what trigger?
Answer Options:
a. An inherited disorder that manifests itself as an incapacity to tolerate stress.
b. The use of projective identification and splitting to bring anxiety to manageable levels.
c. A constitutional inability to regulate affect, predisposing to psychic disorganization.
d. The fear of abandonment associated with progress toward autonomy and independence.
Answer: D. The fear of abandonment associated with progress toward autonomy and independence.
Question: A nurse surveys the medical records for violations of patients’ rights. Which finding signals a violation?
Answer Options:
a. No treatment plan is present in record.
b. Patient belongings were searched at admission.
c. Physical restraints were used to prevent harm to self.
d. Patient is placed on one-to-one continuous observation.
Answer: a. No treatment plan is present in record.
Question: The nurse is teaching a patient taking a drug that inhibits the action of monoamine oxidase (MAO) to avoid certain foods and drugs because of what risk?
Answer Options:
a. Hypertensive foods
b. Hypertensive crisis
c. Cardiac dysrhythmia
d. Cardiogenic shock
Answer: B
Multiple Response Question 934
The admission note indicates a patient diagnosed with major depressive disorder has displayed symptomology of both anergia and anhedonia. For which measures should the nurse plan? (Select all that apply.)
Answer Options
a. Channeling excessive energy
b. Reducing guilty ruminations
c. Instilling a sense of hopefulness
d. Assisting with self-care activities
e. Accommodating psychomotor retardation
C, D, E
Multiple Response Question 935
A student nurse caring for a patient diagnosed with major depressive disorder reads in the patient’s medical record, “This patient shows vegetative signs of depression.” Which nursing diagnoses most clearly relate to the vegetative signs? (Select all that apply.)
Answer Options
a. Imbalanced nutrition: less than body requirements
b. Chronic low self-esteem
c. Sexual dysfunction
d. Self-care deficit
e. Powerlessness
f. Insomnia
A, C, D, F
Multiple Response Question 936
A patient diagnosed with major depressive disorder is scheduled to undergo electroconvulsive therapy (ECT). Which preoperative interventions should the nurse implement? (Select all that apply.)
Answer Options
a. Administer pretreatment medication 30 to 45 minutes before anesthesia.
b. Withhold food and fluids for a minimum of 6 hours before treatment.
c. Remove dentures, glasses, contact lenses, and hearing aids.
d. Restrain the patient in bed with padded limb restraints.
e. Assist the patient to prepare an advance directive.
A, B, C
Multiple Response Question 937
A patient diagnosed with major depressive disorder shows vegetative signs of depression. Which nursing actions should be implemented? (Select all that apply.)
Answer Options
a. Offer laxatives, if needed.
b. Monitor food and fluid intake.
c. Provide a quiet sleep environment.
A, B, C
Question: A patient experiencing acute mania has exhausted the staff members by noon. The patient has joked, manipulated, insulted, and been aggressive all morning. Staff members are feeling defensive and fatigued. Which is the best action?
Answer Options:
a. Confer with the health care provider regarding use of seclusion for this patient.
b. Hold a staff meeting to discuss consistency and limit setting approaches.
c. Conduct a meeting with all patients to discuss the behavior.
d. Explain to the patient that the behavior is unacceptable.
Answer: B. Hold a staff meeting to discuss consistency and limit setting approaches.
Question: A nurse directs the intervention team who must take an aggressive patient to seclusion. Other patients were removed from the area. Before approaching the patient, the nurse should ensure that which actions are taken by staff? (Select all that apply.)
Answer Options:
a. Remove jewelry, glasses, and harmful items from the patient and staff members.
b. Appoint a person to clear a path and open, close, or lock doors.
c. Quickly approach the patient and grab the closest extremity.
d. Select the person who will communicate with the patient.
e. Move behind the patient to use the element of surprise.
Answer: a. Remove jewelry, glasses, and harmful items from the patient and staff members.
b. Appoint a person to clear a path and open, close, or lock doors.
d. Select the person who will communicate with the patient.
Question: A nurse at the mental health center prepares to administer a scheduled injection of haloperidol decanoate to a patient diagnosed with schizophrenia. As the nurse swabs the site, the patient shouts, “Stop! I don’t want to take that medicine anymore. I hate the side effects.” Select the nurse’s best initial action.
Answer Options:
a. Stop the medication administration procedure and say to the patient, “Tell me more about the side effects you’ve been having.”
b. Say to the patient, “Since I’ve already drawn the medication in the syringe, I’m required to give it, but let’s talk to the doctor about skipping next month’s dose.”
c. Proceed with the injection but explain to the patient that other medications are available that may help reduce the unpleasant side effects.
d. Notify other staff members to report to the room for a show of force and proceed with the injection, using restraint if necessary.
Answer: a. Stop the medication administration procedure and say to the patient, “Tell me more about the side effects you’ve been having.”
Question: A patient experiencing acute mania has disrobed in the hall three times in 2 hours. What intervention should the nurse implement?
Answer Options:
a. Place the patient in the seclusion room.
b. Ask if the patient finds clothes bothersome.
c. Tell the patient that others feel embarrassed.
d. Arrange for one-on-one supervision.
Answer: D. Arrange for one-on-one supervision.
Question: Which nursing intervention demonstrates false imprisonment?
Answer Options:
a. A confused and combative patient says, “I’m getting out of here and no one can stop me.” The nurse restrains this patient without a health care provider’s order and then promptly obtains an order.
b. A patient has been imitating, seeking the attention of nurses most of the day. Now a nurse escorts the patient down the hall, saying, “Stay in your room or you’ll be put in seclusion.”
c. An involuntarily hospitalized patient with suicidal ideation runs out of the psychiatric unit. A nurse rushes after the patient and convinces the patient to return to the unit.
d. An involuntarily hospitalized patient with suicidal ideation attempts to leave the unit. A nurse calls the security team and uses established protocol to prevent the patient from leaving.
Answer: a. A confused and combative patient says, “I’m getting out of here and no one can stop me.” The nurse restrains this patient without a health care provider’s order and then promptly obtains an order.