Exam 1

Question 1

On review of the patient’s record, the nurse notes the admission was voluntary. Based on this information, the nurse anticipates which client’s behavior?
A. Fearfulness regarding treatment measures
B. Anger and aggressiveness directed toward others
C. An understanding of the pathology and symptoms of the diagnosis
D. A willingness to participate in the planning of the care and treatment plan

Answer 1

D

Question 2

A patient admitted voluntarily for the treatment of an anxiety disorder demands to be released from the hospital. Which action should the nurse take initially?
A. Contact the client’s HCP.
B. Call the client’s family to arrange for transportations.
C. Attempt to persuade the client to stay for only a few more days.
D. Tell the client that leaving would likely result in an involuntary commitment.

Answer 2

A. AMA release
Step 1. Contact the physician because the pt needs to be seen before they can leave.
Step 2. Talk to patient about options and have conversation about goals. If you leave AMA, insurance may not cover your stay. Never try to persuade a patient!

Question 3

A patient with a diagnosis of major depression who has attempted suicide says to the nurse, “I should have died! I’ve always been a failure. Nothing ever goes right for me.” Which response demonstrates therapeutic communication?

A. “You have everything to live for”
B. “Why do you see yourself as a failure?”
C. “Feeling like this is all part of being depressed”
D. “You’ve been feeling like a failure for a while?”

Answer 3

D. Restating.

Not A, because that is false reassurance
Not B, never ask why.

Question 4

A client experiencing disturbed thought processes believes that his food has been poisoned. Which communication technique should the nurse use to encourage the client to eat?

A. Using open-ended questions and silence
B. Sharing personal preference regarding food choices
C. Documenting reasons why the client does not want to eat
D, Offering opinions about the necessity of adequate nutrition

Answer 4

A

Not B, that would be personal preference
Not C, that is not helping encourage them to eat
Not D, that is opinion

Question 5

A client diagnoses with terminal cancer says to the nurse, “I’m going to die, and I wish my family would stop hoping for a cure! I get so angry when they carry on like this. After all, I’m the one who’s dying.” Which response by the nurse is therapeutic?

A. “Have your shared your feelings with your family?”
B. “I think we should talk more about your anger with your family”
C. “You’re feeling angry that your family continues to hope for you to be cured?”
D. “You are probably very depressed, which is understandable with such a diagnosis”

Answer 5

C

Not A, that is a yes/no question and is telling pt what to do
Not B, your personal opinion does not matter
Not D, assuming/minimizing feelings

Question 6

What type of therapeutic communication is this?

“I see you are crying.”

Answer 6

Making observations

Question 7

What type of therapeutic communication is this?

“You feel like dying?”

Answer 7

Restating. Using the client’s own words brings attention to the words and allows them to expand

Question 8

What type of therapeutic communication is this?

“Would you like to do an activity with me?” “Would you like to walk around the courtyard with me?”

Answer 8

Offering self

Question 9

What type of therapeutic communication is this?

“I am hearing everything you’re saying. Let’s focus on you thinking about hurting yourself.”

Answer 9

Focusing.

Question 10

What type of therapeutic communication is this?
Client: “I don’t do anything with my life, everyone would be better off if I wasn’t here”
Nurse: “Are you saying you feel worthless?”

Answer 10

Translating into feelings. Going from broad to specific emotion.

Question 11

What type of therapeutic communication is this?
Client: “That cop is following me.”
Nurse: “That is Bill from security. He is not a cop.”

Answer 11

Presenting reality. This is good, straightforward correction.

Question 12

List some examples of NON Therapeutic communication:

Answer 12

• offering personal opinions
• giving advice
• false reassurance
• minimizing feelings
• “why” questions
• offering value judgments
• giving approval/disapproval

Question 13

Describe the defense mechanism of Reaction Formation

Answer 13

Unacceptable feelings or behaviors are controlled or kept out of awareness by overcompensating or demonstrating the opposite behavior of what is actually felt. (ATI)

Adaptive use: person trying to quit smoking repeatedly speaks to adolescents about the dangers of nicotine
Maladaptive use: a person who resents having to care for an aging parent becomes overprotective and restricts their freedoms

Question 14

Describe the defense mechanism of Projection

Answer 14

Attributing one’s unacceptable thoughts and feelings onto another who does not have them

E.g. a married client who is attracted to another person accuses their partner of having an affair.

Question 15

Describe the defense mechanism of Dissociation

Answer 15

A disruption in consciousness, memory, identity, or perception of the environment that results in compartmentalization of uncomfortable or unpleasant aspects of oneself.

Adaptive use: a parent blocks out the noise of their children in order to focus while driving in traffic
Maladaptive use: a person forget who they are following a sexual assault

Question 16

Describe the defense mechanism of Regression

Answer 16

someone who regresses developmentally when upset. Think an adult screaming or having a tantrum

Question 17

Define the meaning of beneficence and provide a nursing example

Answer 17

the quality of doing good; can be described as charity.

e.g. a nurse helps a newly admitted client who has a psychotic disorder to feel safe in the environment of the mental health facility

Question 18

Define the meaning of autonomy and provide a nursing example

Answer 18

the client’s right to make their own decisions. However, the client must accept the consequences of those decisions. The client must also respect the decisions of others.

e.g. rather than giving advice to a client who has difficulty making a decision, a nurse helps the client to explore all alternatives and arrive at a choice.

Question 19

Define the meaning of justice and provide a nursing example

Answer 19

fair and equal treatment for all

e.g. during a treatment team meeting, a nurse leads a discussion regarding whether or not two clients who broke the same facility rule were treated equally. Treating all client’s equally.

Question 20

Define the meaning of fidelity and provide a nursing example

Answer 20

loyalty and faithfulness to the client and to one’s duty.

e.g. a client asks a nurse to be present when they talk to their guardian for the first time in a year. The nurse remains with the client during this interaction.

Question 21

Define the meaning of veracity and provide a nursing example

Answer 21

honesty when dealing with a client

E.g. A client states, “you and that other staff member were talking about me, weren’t you?” The nurse truthfully replies, “We were discussing ways to help you relate to the other clients in a more positive way.”

Question 22

What is milieu therapy?

Answer 22

Milieu therapy creates an environment that is supportive, therapeutic, and SAFE!!

Environment designed to promote healing experiences and provide a corrective setting to enhance a client’s coping abilities.

• correcting perceptions of stressors
• changing coping mechanisms
• improving interpersonal relationship skills
• learning effective stress management strategies
• one aspect is regular community meetings, which include both the clients and the nursing staff

Question 23

What is the most effective safety intervention in Milieu therapy?

Answer 23

Monitoring!!!!

e.g. 1:1 staff member to client at all times

Question 24

What are risk factors for depression/mood spectrum disorders?

Answer 24

Being a woman
Stress
Trauma
Neglect/abuse
Postpartum (PPD)
Family hx
Previous hx of depression
Co-morbid medical and mental health disorders (anxiety disorders, psychotic disorders, SUD, eating disorders, personality disorders)
Neurotransmitter deficiencies and imbalances

Question 25

What are some expected findings among clients with major depressive disorder (MDD)?
Be able to identify these

Answer 25

• anergia (lack of energy)
• anxiety
• client appears sad with Blunted Affect
• social isolation
• poor hygiene
• unkempt hair
• malodorous
• dirty clothes
• depressed mood
• difficulty sleeping or excessive sleeping
• indecisiveness
• can’t concentrate
• suicidal ideation (SI)
• inability to feel pleasure (anhedonia)
• increase or decrease in weight (more than 5% total BW over 1 month

Question 26

What are the criteria for diagnosis with MDD?

Answer 26

1. Single episode or recurrent episodes of unipolar depression
2. Significant change in a client’s normal functioning
3. At least 5 of the following occuring daily for at least 2 weeks:
   - depressed mood
   - difficulty sleeping or too much sleeping
   - indecisiveness
   - decreased ability to concentrate
   - suicidal ideation
   - increase or decrease in motor activity
   - inability to feel pleasure
   - increase or decrease in weight (> 5% TBW over 1 month)

Question 27

Nursing interventions for patient undergoing ECT (electroconvulsive therapy):

Answer 27

-make sure physician has informed consent
-client and family education
-CXR, Blood work, ECG, discontinue Benzos!!!
-IV insertion
30 min prior: IM atropine or glycopyrolate
-short acting IV anesthetic via IV bolus
-muscle relaxant (succinylcholine)
-monitor constantly during and after until spontaneous respirations return
-ongoing vitals, ECG, and cardiac monitoring!!!
-patient reorientation, safety, and personal care

Question 28

What are 3 side effects of ECT:

Answer 28

• short term memory loss
• confusion and disorientation immediately following ECT; can last several hours
• retrograde amnesia

Question 29

What is a major red flag for suicide risk?

Answer 29

Suddenly going from sad and depressed to happy and peaceful. Often the decision to commit suicide gives the person a feeling of relief and calm.

Question 30

What are some risk factors for suicide/self-harm?

Answer 30

Females (more likely to attempt)
Adolescent, middle, older adults more likely to complete
Military personnel/veterans
LGBTQ
Comorbid mental illness
Older adults (life changes, untreated mental health problems, etc.).
Family hx, chronical health issues. 
Psychosocial risk factors:  poor relationships, hx of trauma
American indian and alaska native
Access to lethal weapons
inadequate mental health care
unemployment

Question 31

Protective factors for suicide/self-harm

Answer 31

• Feelings of responsibility toward partner/children
• Pregnancy
• Religious/cultural beliefs
• Overall satisfaction with life
• Community/social support
• Stability/ safe housing
• Stress management and coping skills
• Access to treatment and adequate medical care
• Effective coping/problem-solving skills

Question 32

Identify some appropriate Nursing Interventions for clients at risk of suicide/self harm

Answer 32

Suicide Precautions include:

• plastic utensils only; count when bringing in and out of room.
• remove all sharps, as many cords as possible, trash bags, hoodies, etc.
• 1:1 monitoring!!!! If there was a suicide attempt or high risk
• safety planning

Question 33

Identify some expected findings among clients experiencing abuse/neglect:

Answer 33

Avoiding eye contact
Guarded
Looks to spouse/guardian before answering questions
Doesn’t answer questions themselves
Bruises in various stages of healing (yellow bruises and purple)
Unusual pattern of cuts, bruises, burns, fractures.
Atypical injuries for developmental age (Spiral fractures, dislocated shoulders, TBI in children < 1, shaken baby syndrome)
Observed injuries are inconsistent with subjective history given
Victims may be unable to recollect events

Question 34

Identify some expected findings among clients experiencing abuse/neglect:

Answer 34

Avoiding eye contact
Guarded
Looks to spouse/guardian before answering questions
Doesn’t answer questions themselves
Bruises in various stages of healing (yellow bruises and purple)
Unusual pattern of cuts, bruises, burns, fractures.
Atypical injuries for developmental age (Spiral fractures, dislocated shoulders, TBI in children < 1, shaken baby syndrome)
Observed injuries are inconsistent with subjective history given
Victims may be unable to recollect events

Question 35

What are some verbal cues of potential violence from clients

Answer 35

Loud, rapid talking, yelling and shouting
Threats of harm
Abrupt silence
sarcastic remarks
illogical responses
**statements of fear or suspicion**

Question 36

Nursing interventions to manage anger/protect from violence

Answer 36

Be aware of environment (nurse’s position to door and what is in the room)
Availability of other staff members: take another employee in with you
Be aware of clothing/objects that can cause harm (do not wear jewelry, lanyards, etc.).
Use non-threatening communication
Deescalation

Question 37

Deescalation techniques

Answer 37

Respond quickly
Situational awareness and control of the environment
Remain calm and in control
Encourage client to express feelings verbally
Allow client as much personal space as possible
Do not leave the client alone
Maintain eye contact
Sit/Stand at same level as client
Communicate with honesty, sincerity, and nonaggressive stance
Avoid accusatory or threatening statements
Describe options clearly and offer choices
Reassure the client that staff members are present to help prevent the loss of control
Set clear limits for the client