Answer Options:
a. Diagnostic and Statistical Manual of Mental Disorders (fifth edition) (DSM-5)
b. State’s nurse practice act
c. State and federal regulations that govern hospitals
d. Summary of common practices of several local hospitals
e. American Nurses Association Scope and Standards of Practice
Answer: C. State and federal regulations that govern hospitals
E. American Nurses Association Scope and Standards of Practice
Question: A patient says, “People should be allowed to commit suicide without interference from others.” A nurse replies, “You’re wrong. Nothing is bad enough to justify death.” What is the best analysis of this interchange?
Answer Options:
a. The patient is correct.
b. The nurse is correct.
c. Neither person is totally correct.
d. Differing values are reflected in the two statements.
Answer: D. Differing values are reflected in the two statements.
Question: A patient states, “I’m not worth anything. I have negative thoughts about myself. I feel anxious and shaky all the time. Sometimes I feel so sad that I want to go to sleep and never wake up.” Which nursing intervention should have the highest priority?
Answer Options:
a. Self-esteem–building activities
b. Anxiety self-control measures
c. Sleep enhancement activities
d. Suicide prevention
Answer: D. Suicide prevention
Question: Which situations qualify as abandonment on the part of a nurse? (Select all that apply.)
Answer Options:
a. The nurse allows a patient with acute mania to refuse hospitalization without taking further action.
b. The nurse terminates employment without referring a seriously mentally ill patient for aftercare.
c. The nurse calls police to bring a suicidal patient to the hospital after a suicide attempt.
d. The nurse refers a patient with persistent paranoid schizophrenia to community treatment.
e. The nurse asks another nurse to provide a patient’s care because of concerns about countertransference.
Answer: A. The nurse allows a patient with acute mania to refuse hospitalization without taking further action.
B. The nurse terminates employment without referring a seriously mentally ill patient for aftercare.
Question: A patient diagnosed with borderline personality disorder has a history of self-mutilation and suicide attempts. The patient receives feelings of depression and anger with life. The treatment team suggests the use of a medication. Which type of medication should the nurse expect?
Answer Options:
a. Selective serotonin reuptake inhibitor (SSRI)
b. Monoamine oxidase inhibitor (MAOI)
c. Benzodiazepine
d. Antipsychotic
Answer: A. Selective serotonin reuptake inhibitor (SSRI)
Question: A patient diagnosed with major depressive disorder repeatedly tells staff members, “I have cancer. It’s my punishment for being a bad person.” Diagnostic tests reveal no cancer. Select the priority nursing diagnosis.
Answer Options:
a. Powerlessness
b. Risk for suicide
c. Stress overload
d. Spiritual distress
Answer: B. Risk for suicide
Question: A multidisciplinary health care team meets 12 hours after an adolescent is hospitalized after a suicide attempt. Members of the team report their assessments. What outcome can be expected from this meeting?
Answer Options:
a. A treatment plan will be formulated.
b. The health care provider will order neuroimaging studies.
c. The team will request a court-appointed advocate for the patient.
d. Assessment of the patient’s need for placement outside the home will be undertaken.
Answer: a. A treatment plan will be formulated.
Question: Which statement shows a nurse has empathy for a patient who made a suicide attempt?
Answer Options:
a. “You must have been very upset when you tried to hurt yourself.”
b. “It makes me sad to see you going through such a difficult experience.”
c. “If you tell me what is troubling you, I can help you solve your problems.”
d. “Suicide is a drastic solution to a problem that may not be such a serious matter.”
Answer: A. “You must have been very upset when you tried to hurt yourself.”
Question: After several therapeutic encounters with a patient who recently attempted suicide, which occurrence should cause the nurse to consider the possibility of countertransference?
Answer Options:
a. The patient’s reactions toward the nurse seem realistic and appropriate.
b. The patient states, “Talking to you feels like talking to my parents.”
c. The nurse feels unusually happy when the patient’s mood begins to lift.
d. The nurse develops a trusting relationship with the patient.
Answer: C. The nurse feels unusually happy when the patient’s mood begins to lift.
Question: What is the most challenging nursing intervention for patients diagnosed with personality disorders who use manipulation to get their needs met?
Answer Options:
a. Supporting behavioral change
b. Monitoring suicide attempts
c. Maintaining consistent limits
d. Using aversive therapy
Answer: C. Maintaining consistent limits
Question: A patient admitted to the psychiatric unit following a suicide attempt is confused and unable to answer questions. What is the nurse’s best action to provide effective nursing care?
Answer Options:
a. Document the patient’s mental status. Obtain other assessment data from the family member.
b. Record the patient’s answers to questions on the nursing assessment form.
c. Ask an advanced practice nurse to perform the assessment interview.
d. Call for a mental health advocate to maintain the patient’s rights.
Answer: A. Document the patient’s mental status. Obtain other assessment data from the family member.
Question: A patient diagnosed with major depressive disorder has lost 20 pounds in 1 month. The patient has chronic low self-esteem and a plan for suicide. The patient has taken an antidepressant medication for 1 week. Which nursing intervention is most directly related to this priority: “Patient will refrain from gestures and attempts to harm self”?
Answer Options:
a. Implement suicide prevention interventions.
b. Frequently offer high-calorie snacks and fluids.
c. Assist the patient to identify three personal strengths.
d. Observe patient for therapeutic effects of antidepressant medication.
Answer: A. Implement suicide prevention interventions.
Question: A newly admitted patient diagnosed with major depressive disorder has lost 20 pounds over the past month and has admitted having suicidal ideations. The patient has taken an antidepressant medication for 1 week without remission of symptoms. Select the priority nursing diagnosis.
Answer Options:
a. Imbalanced nutrition: Less than body requirements
b. Chronic low self-esteem
c. Risk for suicide
d. Hopelessness
Answer: C. Risk for suicide
Question: A patient newly diagnosed with pancreatic cancer says, “My father also died of pancreatic cancer. I took care of him during his illness. I can’t go through that.” Select the highest priority nursing diagnosis.
Answer Options:
a. Anticipatory grieving
b. Ineffective coping
c. Ineffective denial
d. Risk for suicide
Answer: d. Risk for suicide