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 Choices: 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
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 Choices: 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, 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
Question: Which individual diagnosed with a mental illness may need emergency or involuntary hospitalization for mental illness?
Answer Choices: a. The patient who resumes using heroin while still taking methadone. b. The patient who reports hearing angels playing harps during thunderstorms. c. The patient who throws a heavy plate at a waiter at the direction of command hallucinations. d. The patient who does not show up for an outpatient appointment with the mental health nurse.
Answer: C
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
Question: The spouse of a patient who experiences delusions asks the nurse, “Are there any circumstances under which the treatment team is justified in violating the patient’s right to confidentiality?” What is the nurse’s best response?
Answer Choices: a. “We can’t violate that confidence under any circumstances.” b. “We can do that only at the discretion of the psychiatrist.” c. “We are obligated to answer questions asked by law enforcement.” d. “We are not bound if the patient threatens the life of another person.”
Answer: D
Question: A nurse cares for an older adult patient admitted for treatment of depression. The health care provider prescribes an antidepressant medication, but the dose is more than the usual adult dose. The nurse is obligated to take what action?
Answer Choices: a. Implement the order as written but document the concern. b. Hold the medication and then notify the health care provider. c. Consult a drug reference if a pharmacist is not available. d. Give the usual geriatric dosage at the scheduled times.
Answer: B
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 Choices: a. Need for authorization b. Duty to warn and protect c. Patient right to confidentiality d. Patient’s right to self-actualization
Answer: B
Question: After leaving work, a staff nurse realizes that documentation of the administration of a medication to a patient was omitted. This off-duty nurse telephones the unit and tells the nurse, “Please document the administration of the medication I forgot to do. My password is alphal.” What action should the on-duty nurse take?
Answer Choices: a. Suggest the nurse return and document. b. Refer the matter to the charge nurse to resolve. c. Access the record and document the information. d. Report the request to the patient’s health care provider.
Answer: B
Question: A patient diagnosed with mental illness asks a psychiatric technician, “What’s the matter with me?” The technician replies, “Your wing nuts need tightening.” The nurse who overheard the exchange should take action based on what principle?
Answer Choices: a. Violation of the patient’s right to be treated with dignity and respect b. The nurse’s obligation to report caregiver negligence c. Preventing defamation of the patient’s character d. Supervisory liability
Answer: A
Question: Which documentation of a patient’s behavior best demonstrates a nurse’s observations?
Answer Choices: a. Isolates self from others. Frequently fell asleep during group. Vital signs stable. b. Calmer and more cooperative. Participated actively in group. No evidence of psychotic thinking. c. Appeared to hallucinate. Patient frequently increased volume on television, causing conflict with others. d. Wears four layers of clothing. States, “I need protection from dangerous bacteria trying to penetrate my skin.”
Answer: D
Question: A nurse volunteers for a committee that must revise the hospital policies and procedures for suicide precautions. Which resources would provide the best guidance? (Select all that apply.)
Answer Choices: 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, E
Question: In which situations does a nurse have a duty to intervene and report? (Select all that apply.)
Answer Choices: a. A peer is unable to write behavioral outcomes. b. A health care provider consults the Physicians’ Desk Reference. c. A peer tries to provide patient care in an alcohol-impaired state. d. A team member has violated the boundaries of a vulnerable patient. e. A patient refuses a medication prescribed by a licensed health care provider.
Answer: C, D
Question: Which situations qualify as abandonment on the part of a nurse? (Select all that apply.)
Answer Choices: 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, B
Question: A new staff nurse completes orientation to the psychiatric unit. This nurse will expect to ask an advanced practice nurse to perform which action for patients?
Answer Choices: a. Perform mental health assessment interviews. b. Establish therapeutic relationships. c. Prescribe psychotropic medication. d. Individualize nursing care plans.
Answer: C
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 Choices: a. Imbalanced nutrition: Less than body requirements b. Chronic low self-esteem c. Risk for suicide d. Hopelessness
Answer: C
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 Choices: 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
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
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. What is the nurse’s next action?
Answer Choices: a. Continue the current plan without changes. b. Remove this nursing diagnosis from the plan of care. c. Write a new nursing diagnosis that better reflects the problem. d. Revise the outcome target date and interventions.
Answer: D
Question: A patient begins a new program to assist with building social skills. In which part of the plan of care should a nurse record the item “Encourage patient to attend one psychoeducational group daily”?
Answer Choices: a. Assessment b. Analysis c. Planning d. Implementation e. Evaluation
Answer: D
Question: Before assessing a new patient, a nurse is told by another health care worker, “I know that patient. No matter how hard we work, there isn’t much improvement by the time of discharge.” What action will the nurse take to provide appropriate care for this patient?
Answer Choices: a. Document the other worker’s assessment of the patient. b. Assess the patient based on data collected from all sources. c. Validate the worker’s impression by contacting the patient’s significant other. d. Discuss the worker’s impression with the patient during the assessment interview.
Answer: B