Exam 1 NCLEX Flashcards
Which understanding is the basis for the nursing actions focused on minimizing mental health promotion of families with chronically mentally ill members?
a. Family members are at an increased risk for mental illness.
b. The mental health care system is not prepared to deal with family crises.
c. Family members are seldom prepared to cope with a chronically ill individual.
d. The chronically mentally ill receive care best when delivered in a formal setting.
A
When families live with a dominant member who has a persistent and severe mental disorder the outcomes are often expressed as family members who are at increased risk for physical and mental illnesses. The remaining options are not necessarily true.
Which nursing activity shows the nurse actively engaged in the primary prevention of mental disorders?
a. Providing a patient, whose depression is well managed, with medication on time
b. Making regular follow-up visits to a new mother at risk for post-partum depression
c. Providing the family of a patient, diagnosed with depression, information on suicide prevention
d. Assisting a patient who has obsessive compulsive tendencies prepare and practice for a job interview
B
Primary prevention helps to reduce the occurrence of mental disorders by staying involved with a patient. Providing medication and information on existing illnesses are examples of secondary prevention which helps to reduce the prevalence of mental disorders. Assisting a mentally ill patient with preparation for a job interview is tertiary prevention since it involves rehabilitation
What is the best explanation to offer when the mother of a chronically ill teenage patient asks, “Under what circumstances would he be considered incompetent?”
a. “When you can provide the court with enough evidence to show that he is not able to care for himself safely.”
b. “It is not likely that someone his age would be determined to be incompetent regardless of his mental condition.”
c. “He would have to engage in behavior that would result in harm to himself or to someone else; like you or his siblings.”
d. “If the illness becomes so severe that his judgment is impaired to the point where the decisions he makes are harmful to himself or to others.”
D
When a person is unable to cognitively process information or to make decisions about his or her own welfare, the person may be determined to be mentally incompetent. Providing self-care is not the only criteria considered. Age is not a factor considered. The decision is often based on the potential for such behavior.
Which psychiatric nursing intervention shows an understanding of integrated care?
a. A chronically abused woman is assessed for anxiety.
b. A manic patient is taken to the gym to use the exercise equipment.
c. The older adult diagnosed with depression is monitored for suicidal ideations.
d. A teenager who refuses to obey the unit’s rules is not allow to play video games.
A
The majority of health disciplines now recognize that mental disorders and physical illnesses are closely linked. The presence of a mental disorder increases the risk for the development of physical illnesses and vice versa. Assessing a chronically abused individual for anxiety call should attention to the psychiatric disorder that could develop from the abuse. The remaining options show interventions that are appropriate for the mental disorder.
Which nursing activities represent the tertiary level of mental health care? Select all that apply.
a. Providing a depression screening at a local college
b. Helping a mental-challenged patient learn to make correct change
c. Reporting an incidence of possible elder abuse to the appropriate legal agency
d. Regularly assessing a patient’s understanding of their prescribed antidepressants
e. Providing a 6-week parenting class to teenage parents through a local high school
B, D
Tertiary prevention reduces the residual effects of the disorder such as depression and mental retardation. There is no quaternary level of prevention. Primary prevention reduces occurrences of mental disorders such as screenings and parenting classes, and secondary prevention reduces the prevalence of disorders as evidenced by assessing knowledge.
Which assessment findings describe risk factors that increase the potential risk for mental illness? Select all that apply.
a. Possesses high tolerance for stress
b. Is very curious about ‘how things work’
c. Admits to being a member of an ethnic gang
d. Only practicing Jew among school classmates
e. Has a younger sibling who is mentally challenged
C, D, E
Risk factors are internal predisposing characteristics and external influences that increase a person’s vulnerability and potential for developing mental disorders. Types of risk factors and examples include the following: having a mentally-challenged family member in the home; belonging to a punitive gang; and being the object of reject or bullying. The remaining options are protective factors.
Which activity shows that a therapeutic alliance has been established between the nurse and patient?
a. The nurse respects the patient’s right to privacy when visitors are spending time with the patient.
b. The patient is eagerly attending all group sessions and working independently on identifying their personal stressors.
c. The patient is freely describing their feelings related to the physical and emotional trauma they experienced as a child with the nurse.
d. The nurse dutifully administers the patient’s medications on time and with appropriate knowledge of the potential side effects.
C
A primary aspect of working with patients in any setting and particularly in the psychiatric setting is the development of a therapeutic alliance with the patient. Such an alliance is established on trust. It is a professional bond between the nurse and the patient that serves as a vehicle for patients to freely discuss their needs and problems in the absence of the nurse’s criticism or judgment. Any nurse has an obligation to respect the patient’s rights and administer care effectively. The patient’s willingness to participate in the plan of care reflects self motivation.
The nurse demonstrates objective patient care when:
a. Being sympathetic to the patient’s recent loss of a spouse
b. Protecting the anxious patient by eliminating stressors in the milieu
c. Responding to the patient by stating, “I know exactly how you feel.”
d. Facilitating the patient’s exploration of various stress reduction techniques
D
The nurse demonstrates objectivity by helping the patient to process and organize thoughts that are directed toward the solving of his or her own problems. With sympathy, the nurse loses objectivity and moves into his or her own personal feelings. Removing all stress does not allow the patient to develop necessary coping skills.
Which nursing intervention would be appropriately addressed during the orientation phase of the nurse–patient relationship?
a. Self reflection by the nurse regarding personal biases and prejudices regarding the patient
b. Patient works at prioritizing personal needs and develops realistic expected outcomes
c. Establishing the contract between the nurse and the patient regarding mutual needs and expectations
d. Patient commits to the reinforcement of positive personal characteristics while working on problems and concerns
C
A contract or agreement is established during the orientation phase of the relationship. The contract defines limits and expectations of both the patient and the nurse. Self Reflection occurs during the pre-orientation phase while the remaining options are addressed during the working phase of the relationship.
The nurse is effectively facilitating the nurse-patient relationship when:
a. Sharing with an angry patient who is verbally abusive that, “Although I can accept that you are angry, I cannot and will not accept your verbal abuse.”
b. Focusing on the patient’s life experience without relating to the similarities of one’s own experiences
c. Objectively providing constructive criticism that is directed to helping the patient identify inappropriate behaviors
d. Refraining from abandoning the patient regardless of the frustration the interaction causes
A
Accepting the patient’s feelings is essential; however, it is not necessary to accept all of the patient’s behaviors. Assist the patient by setting limits on patient behaviors that are self-defeating or that threaten the patient or others in any way. Setting these limits allows for mutual respect in the therapeutic alliance. The remaining options enhance the patient’s clinical experience rather than the nurse-patient relationship.
Which action on the part of a novice mental health nurse will best minimize fear related to effectively working with the psychotic patient?
a. Be knowledgeable about psychotropic medications and their affect on psychosis.
b. Always arrange for staff support when working one-on-one with a psychotic patient.
c. Take advantage of opportunities to attend workshops devoted to the care of the psychotic patient.
d. Recognize that the psychotic patient is not in control of their behaviors due to their altered though processes.
C
Fear breeds avoidance, but knowledge and preparation diminish fear and bring confidence. Being prepared before entering the psychiatric setting includes having knowledge and understanding of mental disorders. The remaining options do not provide confidence but rather means of controlling or avoiding the psychotic patient.
The greatest negative outcome resulting from a nurse’s fear of a mentally ill patient is that the:
a. Nurse will reinforce negative stereotyping of the mentally ill.
b. Patient will experience increased bias against the nursing staff.
c. Public’s fearfulness of the mentally ill will continue to be exaggerated.
d. Therapeutic alliance between the nurse and patient will not develop effectively.
D
Unrealistic preconceived images, stereotyping, and biases have an effect on nurses that, when resulting in fear, will negatively impact the therapeutic effectiveness of the nurse and the care provided. The remaining options do not have the priority that providing quality patient care has.
Which response by the nurse manager to a novice mental health nurse is most effective when the nurse asks, “How do I justify not keeping a patient’s secret?”
a. “Never promise the patient that you will keep a secret for them.”
b. “Always stop the patient from telling you something as a secret.”
c. “Let the patient know that you will not keep a secret that could ultimately cause harm or affect their treatment.”
d. “Keep reminding yourself that you are not the patient’s friend but rather a professional mental health provider.”
C
Nurses and other healthcare professionals do not keep secrets or make promises to patients when the secret may interfere with the patient’s treatment or put them or others at risk for harm. The remaining options offer appropriate nursing actions but do not effectively answer the nurse’s question.
Which interactions are likely outcomes of a well-established therapeutic alliance? Select all that apply.
a. The nurse states, “I’m not here to judge but rather to help.”
b. The patient states, “I really think I can handle this problem now.”
c. The patient asks his abusive father to attend counseling with him.
d. The nurse sets boundaries for a patient who has few social skills.
e. The patient with anger issues voluntarily goes into the seclusion room.
A, B, C, E
The alliance serves as a vehicle that provides patients with an opportunity to freely discuss their needs and problems in the absence of judgment and criticism, to gain insight into their abilities, to practice new coping skills, and to heal emotional wounds. Setting boundaries is not an outcome of such an alliance.
Which nursing interventions are directly related to the principles on which a therapeutic alliance is based? Select all that apply.
a. Graciously declining to, “Come visit when I get discharged.”
b. Establishing the topic to be discussed at each group session
c. Explaining to the patient the purpose of terminating the alliance
d. Sharing how the nurse also has experienced the same problems
e. Providing subjective feedback to the patient’s efforts at therapy
A, B, C
The principles that focus on the development and maintenance of a healthy alliance include: the relationship is therapeutic rather than social; the focus remains on the patient’s needs and problems rather than on the nurse; the relationship is purposeful and goal directed; the relationship is objective rather than subjective in quality; and the relationship is time-limited rather than open-ended. The sharing of experiencing is not patient centered.
The nurse is attempting to minimize the group’s display of resistance during a therapy session. Which patients are at risk for displaying such behavior? Select all that apply
a. The patient who is cognitively impaired
b. The patient who is older and well educated
c. The patient who is aggressive and attention seeking
d. The patient who has attended similar therapy groups in the past
e. The patient who has been diagnosed with paranoid schizophrenia
A, D, E
A patient who redirects the focus away from himself or herself by changing the subject is engaging in resistance behavior. Patients divert the topic for one or more of several reasons: a fear of being judged; avoiding the repetition of material that has been previously discussed; or the inability to stay cognitively focused. The attention-seeking patient may attempt to monopolize the discussion but not necessarily be at risk for resisting the topic. Age and education are not risk factors.
Which nursing action is a reflection of Hildegard Peplau’s theoretic framework regarding psychiatric mental health nursing?
a. Basing patient outcomes on expected instinctual responses
b. Discussing a patient’s feelings regarding parents and siblings
c. Providing the patient with clean clothes and wholesome food
d. Centering professional practice in a state run psychiatric facility
B
Peplau’s pioneering endeavors and contributions were largely influenced by interpersonal psychotherapy. She believed that disorders evolved in the social context of interpersonal interactions. (i.e., what went on between people). Instinctual responses are more related to intrapersonal interactions. Florence Nightingale was instrumental in the holistic approach to nursing care, whereas Linda Richards’ practice was centered on institutional care of the mental ill.
The nurse is attempting to provide a safe environment for a patient at great risk for self-harm. Which intervention shows an understanding of evidence-based practice (EBP)?
a. Using physical restraints only after all other options have been proven ineffective
b. Referring to the facility’s policies manual for guidelines for applying physical restraints
c. Collecting data regarding the short-term effects of using physical restraints on an aggressive patient
d. Requiring constant monitoring of a patient whose inability to self-regulate anger has required the use of physical restraints
B
Health care systems are participating in the shift in nursing practice by encouraging research in their facilities and by implementing interventions that increase nurses’ knowledge about EBP. Nurses are participating to make evidence-based nursing practices available for their use, and they are helping to determine the outcomes that will benefit patients. The remaining options are examples of long-standing practice related to the use of physical restraints
When a patient asks the nurse, “How can jolting me with an electrical shock possibly do me any good?” the answer most reflective of current biologic theory would be:
a. “ECT must sound like a very frightening treatment alternative to you.”
b. “ECT produces a change in brain chemistry that results in improved mood.”
c. “ECT interrupts brain impulses that are causing hallucinations and delusions.”
d. “ECT provides you with external punishment so you can stop punishing yourself.”
B
Current theory regarding use of ECT is that the electrical stimulus causes electrochemical changes within the brain, resulting in increased availability of neurotransmitters at the synapses and improvement of mood. To suggest that the treatment is frightening does not answer the patient’s question. The treatment is not appropriate for hallucinations or delusions. The remaining option is not appropriate or founded in psychiatric therapy.
Which statement made by a patient just prior to being transported for a scheduled ECT treatment would result in cancellation of the treatment?
a. “I’ll be so glad when this treatment is over.”
b. “Will I remember having this treatment?”
c. “Did eating some crackers cause any problems?”
d. “I’m so tired of being depressed; I don’t think I can go on.”
C
Because the patient is to receive general anesthesia and has orders to remain without food or liquids (NPO), the nurse should notify the physician immediately. The introduction of food into the stomach could result in aspiration of stomach contents during treatment. An expression of hopelessness related to depression would be reason to continue with the treatment. The other options offer no contraindication to treatment.
Which statement by a patient who has given informed consent for ECT confirms that the patient understands the side effects of this treatment?
a. “I won’t remember the pain.”
b. “It will take several weeks before I feel good again.”
c. “My short-term memory loss will be only temporary.”
d. “I will be at increased risk for developing epilepsy later.”
C
Temporary impairment of recent memory is an expected side effect that occurs to some degree during the course of ECT. The other options suggest the patient’s understanding of treatment and side effects is flawed.
A novice nurse who will be assessing a patient after electroconvulsive therapy (ECT) asks her mentor, “What sort of memory impairment is present after several ECT treatments?” The best response for the mentor would be:
a. “It’s hard to say. Treatment affects everyone differently.”
b. “Usually the patient has severe difficulty remembering remote events.”
c. “Patients have mild difficulty remembering recent events, like what was eaten for breakfast.”
d. “Both recent and remote memory is affected, producing profound confused, cognitive states.”
C
Most patients experience transient recent memory impairment after electroconvulsive therapy (ECT). The cognitive deficit becomes more pronounced as the number of treatments increases. When the course of treatments is completed, cognitive deficit generally improves to the pretreatment level. The other options are incorrect.
About an hour after the patient has ECT, he complains of having a headache. The nurse should:
a. Notify the physician stat.
b. Administer an as needed (prn) dose of acetaminophen.
c. Take the patient through a progressive relaxation sequence.
d. Advise going to activities to expend energy and relieve tension.
B.
Post-ECT headache is common. Most physicians routinely write an as needed (prn) order for a headache remedy. Notifying the physician is unnecessary, because this is an expected side effect. Options c and d would not be as useful as medication in this instance.
For which patient is the nurse most likely to need to schedule a pre-ECT workup and teaching?
a. Patient A, who is newly diagnosed with dysthymic disorder
b. Patient B, who has melancholic depression that responded well to ECT 2 years ago
c. Patient C, who was unresponsive to a 6-week trial of SSRI antidepressant therapy
d. Patient D, who has depression associated with diagnosis of inoperable brain tumor
B
Indications for ECT include patients with major mood disorders; patients who have responded to ECT in the past; patients who are unresponsive to antidepressants or unable to tolerate their side effects; and patients who are acutely suicidal or in danger of fluid and electrolyte imbalance related to inability to eat due to depression, severe mania, or severe catatonia. Patients with dysthymia are not candidates for ECT. The patient has not run out of medication options when prescribed only an SSRI. Patients with space-occupying lesions of the brain are not candidates for ECT.
What milieu factor would need most attention from the nurse who is caring for a patient who has received six ECT treatments and has two more scheduled?
a. Safety
b. Trust attainment
c. Therapeutic activities
d. Boundary maintenance
A
To feel safe, patients need to know what is expected of them in their role as patients. The patient receiving ECT often has impaired recent memory and may become confused about the milieu and expectations. The nurse will need to reorient and reteach the patient with cognitive deficit. Options b, c, and d will require attention but not to the same extent as safety
A patient asks the nurse manager to help resolve a situation between her and another patient. Which action would best support the patient’s feelings of safety when experimenting with new ways of being?
a. Encouraging the patient to report the incident to the other patient’s physician
b. Intervening on the patient’s behalf and sorting out the incident with the other patient
c. Suggesting that the patient ignore the situation since the other patient was probably not aware of her behavior
d. Offering to be present and help the patient discusses her feelings about the incident with the other patient
D
Offering to be with the patient affords her a safe nonthreatening opportunity to assume responsibility for meeting her own needs assertively by encouraging skills that affect positive communication. Intervening removes the responsibility from the patient. Ignoring supports passive behavior. There is no need to bring in another person. The patient is capable of addressing the problem herself.
A nurse and patient are entering the termination phase in the group experience. An important nursing intervention will be to:
a. Encourage the group to describe goals for change.
b. Inquire whether the group needs more time to accomplish goals.
c. Assist the group to explore alternative coping strategies for problems.
d. Discuss feelings about leaving the group and the support found with the group.
D
Healthy termination is facilitated when the group and nurse express reactions to termination. The nurse serves as a role model by being open and genuine as the feelings about the losses incurred with ending are discussed. On a positive note, accomplishments and growth are acknowledged and the transfer of safety and trust to the group members is accomplished. Describing goals is accomplished in the orientation phase. Accomplishing goals is part of the working phase in a relationship that does not have a strict time limit. Exploring alternative coping strategies would be part of the working stage.
A novice mental health nurse shares that, “I’ll never get used to playing cards or other games with patients. It seems like a poor use of scarce nursing time.” The best response for the nurse’s mentor would be:
a. “Perhaps you’ll want to rethink your transfer to this unit if you’re really uncomfortable.”
b. “Your comments make a point about scarce resources. I’ll ask the treatment team to review our position on activities.”
c. “Activity co-leadership puts us in a position to help patients develop social skills and support them as they take small risks.”
d. “Managed care has cost us activities therapists. Activities are necessary to give patients something to do, so we have to fill in.”
C
Nurses who engage in co-leadership of therapeutic activities recognize that each activity contributes to outcome attainment. During activities, patients practice skills needed in life situations, process emotions, and give and receive validation and feedback. Suggesting a rethink is not supportive of the nurse. The remaining options do not acknowledge the value of activities therapy.
A patient is scheduled to attend an occupational therapy group to work on the identified goal of “recognizing and using more effective coping techniques.” What measure can the nurse use to continue to support the patient’s attainment of this goal after he returns to the unit?
a. Isolating him from more seriously ill patients
b. Praising him for positive behavioral changes
c. Avoiding setting limits that would increase his anxiety level
d. Permitting him to make mistakes prior to intervening on his behalf
B
Recognizing and pointing out positive changes provides encouragement to continue pursuing change. The remaining option would not achieve the nurse’s goal of supporting the patient’s use of effective coping techniques.
Which intervention best reflects the nursing role regarding effective implementation of behavioral therapy goals?
a. Administering the prescribed medications accurately
b. Interacting effectively with members of the health care team
c. Being aware of all the patient related therapeutic modalities
d. Evaluating patient behaviors to reward economic tokens appropriately
D
The primary role of the nurse who is involved in behavioral therapy is to assess and identify the patient’s problem behaviors in collaboration with the multidisciplinary team. A token economy is a system of behavior reinforcements in which patients earn tokens by performing predetermined desired behaviors. The remaining options are generalized responsibilities that are relevant to any therapy format.
To plan care for a patient with a psychiatric disorder, the nurse keeps in mind that the primary nursing role related to therapeutic activities is:
a. Assisting the patient in accomplishing the activity
b. Ensuring that the patient will comply with the rules of the activity
c. Ensuring that the patient can accomplish the activity in a timely manner
d. Providing a support system for the patient if they fail to complete the activity
A
The nurse’s role in therapeutic activities is that of a professional observer and participant who works with the therapist to enhance the patient’s capabilities and functioning within the parameters of the assigned activity. Assuring accomplishment, compliance, or providing failure support are not nursing roles
Which statement best defines the nurse’s initial role as the patient’s source of help in addressing interpersonal problems?
a. “I’ll work with your doctor to help you get better.”
b. “I’ll be working with you to help solve your marital troubles.”
c. “Your medications will help you feel better as soon as they take effect.”
d. “You will be expected to attend the group activities while you are here.”
B
This statement clearly specifies the nurse’s purpose as a helping professional, and establishes the relationship as therapeutic, rather than social. The nurse has independent functions and does not work exclusively with the doctor. Identifying only medication overlooks the contributions of staff and the therapeutic milieu. Giving information is appropriate, but this statement does not define the nurse’s role as resource
Which statement would the nurse use to describe the primary purpose of boundaries?
a. Boundaries define responsibilities and duties to one’s self in relation to others.
b. Boundaries determine objectives of the various working stage of the relationship.
c. Boundaries differentiate the assumed roles of both the nurse and of the patient.
d. Boundaries prevent undesired material from emerging during the interaction.
A
Boundaries are the social, physical, and emotional limits of the interaction. As such, they serve to define the responsibilities and duties of the nurse in relation to the patient. Objectives and roles are determined during the orientation stage. Emergence of undesired material may be a significant issue for the patient.
A patient tells the nurse, “I really like you. You’re the only true friend I have.” The patient’s remarks call for the nurse to revisit the issue of:
a. Trust
b. Safety
c. Boundaries
d. Countertransference
C
The patient’s remarks call for the nurse to remind the patient of the parameters of the nurse-patient relationship. The remark would also give the nurse the opening to go on to discuss the matter of friendship. The patient’s remarks do not suggest the need to deal with trust, safety, or countertransference.
Which assessment findings suggest to the nurse that this patient has characteristics seen in an individual who has reached self-actualization? Select all that apply.
a. Reports to have, “found peace and security in my religious faith”
b. Effectively “changed occupations” when a chronic vision problem worsened
c. Has consistently earned a six-figure salary as an architect for the last 10 years
d. Has been in a supportive, loving relationship with the same individual for 15 years
e. Provides free literacy tutoring help at the local homeless shelter 3 evenings a week
A, B, D, E
Characteristics of self actualization would include: spiritual well-being, open and flexible, relationally fulfilled, and generosity toward others. Salary doesn’t necessarily reflect self-actualization.
Which action will best facilitate the development of trust between a nurse and patient?
a. Responding positively to the patient’s demands
b. Following through with whatever was promised
c. Clarifying with the patient whenever there is doubt
d. Staying available to the patient for the entire shift
B
Being consistent in keeping one’s word implies that the nurse is trustworthy and does what is agreed upon. Being responsive to demands may not be therapeutic. Instead, the patient will need to learn new techniques for meeting needs. Clarification is important but is not the best method for promoting trust. Trust is better served by shorter contacts at agreed-upon intervals
How can the nurse encourage an extremely shy patient to participate therapeutically in a dance activity group?
a. Offer to dance with the patient.
b. Ask the patient if this is the first dance he has attended.
c. Sit with the patient away from the group.
d. Encourage another patient to ask him to dance.
A
If trust has been established, the patient may feel safe enough to dance with the nurse. If trust has not yet been established, the patient will see the nurse’s invitation as demonstrating respect and reaching out to him. Either way, the action will encourage participation. The nurse should not make another patient responsible for this patient’s participation. The remaining options do not encourage participation.
In response to the nurse’s statement, “Tell me about your family,” the patient became silent and displayed nonverbally that he is uncomfortable. Which statement by the nurse reflects sensitivity to the patient?
a. “I’m so sorry. I didn’t realize your family was a problem for you.”
b. “Learning to express negative feelings will assist you in getting well.”
c. “Perhaps you can talk about your feelings to the physician next time you meet.”
d. “That seems to be a difficult subject for you. We can discuss when you are ready.”
D
This response acknowledges the situation, is respectful, and allows the patient to choose when to refocus the therapeutic interaction. Referring to the family as a problem is not sensitively worded. Offering false reassurance implies that feelings are negative. Suggesting postponing the discussion represents avoidance of dealing with the patient’s feelings.
Which statement is an example of an inference?
a. “He is an alcoholic because his wife nags a lot.”
b. “He states he binges after arguing with his wife.”
c. “You say your alcohol intake exceeds a quart a day.”
d. “So you are saying that you were drinking earlier today.”
A
An inference is an interpretation of behavior that is made by finding motive and forming conclusions without having all the necessary information. The nurse interprets the patient’s behavior, decides on a reason, assigns a motive, and forms a conclusion. The remaining options are validations of observations.
The nurse shows the ability to effectively state a nursing diagnosis reflective of the implications of depression on a patient’s life processes when stating in the patient’s plan of care that:
a. Patient outcomes were partially attained. Implementation of present plan to continue.
b. Patient will initiate and support conversation with nurse therapist by (date 3 weeks in future).
c. Oral medication for anxiety should be administered when depression is assessed to be at the moderate level.
d. Impaired verbal communication r/t impoverished thoughts secondary to depression as evidenced by monosyllabic responses.
D
This statement contains the various components of a nursing diagnosis while expressing the existence of an altered life process. The remaining options reflect other steps, such as evaluation and intervention planning.
A depressed patient shares with the nurse that he, “has been thinking about ending it all”. Based on NANDA recommendations, the nurse:
a. Implements suicide precautions for this patient
b. Includes ‘Risk for Self Harm’ to the patient’s care plan
c. Documents regarding the patient’s safety every 15 minutes
d. Reviews the patient’s chart for references to past incidences of hopeless
B
NANDA states that a nurse is able to change any actual diagnosis on the NANDA list to a risk diagnosis if the problem has not occurred yet. The remaining options, although not inappropriate, do not related to NANDA.
When a patient experiencing acute depression asks what the difference is between a medical and a nursing diagnosis, the nurse responds best when stating:
a. Actually they are very similar in that they both are concerned with helping you get better and lead a happier life.
b. Medical diagnoses are focused on why you are depressed whereas nursing diagnoses are concerned about making your life less sad.
c. Nursing diagnoses are more directed at caring for you, unlike medical diagnoses that focus on finding the cause for your problem.
d. The medical diagnosis identifies that you are experiencing depression whereas the nursing diagnosis identifies how the depression is affecting you.
D
The medical diagnosis involves identifying a mental or physical problem that results in the symptoms that negatively affect a patient’s life. Although the nurse is knowledgeable about the disorders and their treatments, the nursing diagnosis focuses mainly on the patient’s responses to the disorder and the effects that the disorder has on the patient. The types of diagnoses have different foci that result in different actions and concerns
A nurse best shows an understanding of the role of evidence-based research in achieving therapeutic patient care outcomes when:
a. Subscribing to and reading a monthly psychiatric research nursing journal
b. Working on a committee to revise current facility policies regarding the use of chemical restraints
c. Registering to attend a psychiatric workshop on newly developed psychotropic medication therapies
d. Asking an experienced staff member to review the interventions being proposed for a newly admitted patient
B
Evidence-based practice is based on evidence and scientific principles that have been developed through research. The more closely clinical practice reflects relevant research, the more likely it is that patients will receive the best available care. The option that infers action directed at implementing the research is the one that shows best understanding. Reliance only on experience is not reflective of quality nursing care
When engaging in outcomes identification, the nurse:
a. Interviews and collects patient-focused data
b. Re-assesses the patient’s physical and emotional status evaluation
c. Reviews the patient’s existing problems and projects the results of the nursing care
d. Considers the patient’s presenting symptoms and identifies nursing-related problems
C
Outcomes are projections of expected influence that nursing interventions will have on the patient. Interviewing and collecting data is involved in the assessment process, re-assessing is involved in the evaluation process, and identifying related nursing problems is involved in determining appropriate nursing diagnoses.
The nurse shows an understanding of the appropriate use of nursing outcomes regarding triggers for a patient diagnosed with chronic alcohol abuse when stating:
a. “Can you work on identifying three situations that cause you to abuse alcohol?”
b. ”I’ll help you to identify three triggers for your drinking during today’s session.”
c. ”I’m pleased you’ve identified three situations that trigger your abuse of alcohol.”
d. “Do you think you will be able to avoid the three triggers that cause you to drink?”
C
Outcomes sometimes referred to as behavioral goals are used to describe and evaluate the effectiveness of nursing interventions. The correct option shows that the patient was successful at accomplishing an outcome inferring the nursing interventions were successful. The remaining options do not indicate an evaluation of success or failure
The expert nurse is confident that the novice nurse understands the principles that guide the planning of patient care interventions when the:
a. Novice nurse asks the patient to identify their primary concerns
b. Patient successfully achieves the agreed upon nursing outcomes
c. Expert nurse requests that the novice nurse observe several care planning sessions
d. Novice nurse includes interventions that are supported by evidence-based practices
A
Working with the patient to determine treatment priorities is a characteristic of good care planning. Although successful achievement of expected outcomes and inclusion of EBP interventions reflect appropriate care planning, such success is influenced by many different factors. Although appropriate, observing care planning sessions does not necessarily affect successful care planning on the part of the novice nurse
A patient expresses a sense of genuineness in the nurse providing care when sharing with family members that:
a. “I believe the nurse can feel what I’m feeling.”
b. “I always know what the nurse expects of me; the explanations are always clear.”
c. “I can tell the nurse is sincere because the face supports what the mouth is saying.”
d. “I may not always like what the nurse has to say but I can always depend on what I’m told.”
C
Genuineness is demonstrated by congruence between verbal and nonverbal behavior. Empathy is seeing things from the patient’s viewpoint. Clearly stating expectations is a characteristic of clarity. Trustworthiness can be described as dependability
A patient indicates that he is about to share information about his illness that is shocking and embarrassing. Which nursing intervention has priority in this situation in facilitating the communication process?
a. Reassuring the patient that talking will be therapeutic
b. Assuring the patient the information will be kept confidential
c. Responding to the patient’s information in an accepting manner
d. Providing the patient with a private place for the discussion to occur
C
Responding to the patient’s information in a nonjudgmental, accepting manner will encourage continued therapeutic communication. The remaining options, although appropriate, will not have the same generalized affect on the communication process as the correct option.
Which statement indicates that a novice nurse understands the purpose of therapeutic communication? “My goal for communication with any patient is to:
a. maintain relationships.”
b. mutually share information.”
c. promote growth and change.”
d. offer advice and make suggestions.”
C
Therapeutic communication is intended to assist the patient to grow and change. The other options are characteristics of social communication.
Which of the following nursing responses is an example of the therapeutic technique of empathizing?
a. “I think you may be finding this very difficult.”
b. “I see you have been crying since your wife left.”
c. “Help me to understand how this is affecting you.”
d. “It sounds as if this is important to you.”
A
In an empathetic response the nurse exhibits warmth and acknowledges the patient’s feelings. Commenting on the patient’s crying is an example of the technique of making observations. Asking for help to understand is an example of seeking clarification. Finding importance is an example of reflection.
The nurse shows an understanding of an essential purpose of therapeutic communication when (select all that apply):
a. Asking the patient, “How did it make you feel when your son died?”
b. Encouraging the patient to assume responsibility for the problems he or she has
c. Attentively listening as the patient describes the reasons he or she is seeking help
d. Providing the patient with feedback regarding how he or she is implementing stress relief techniques
e. Sharing with the patient the details of several extremely stressful personal events and how they were managed
A, C, D
Therapeutic communication has three essential purposes: (1) to allow the patient to express thoughts, feelings, behaviors, and life experiences in a meaningful way to promote healthy growth; (2) to understand the significance of the patient’s problems and the roles that the patient and the significant people in his or her life play in perpetuating those problems; and (3) to assist with the identification and resolution processes of the patient’s health-related behaviors. Encouraging the patient to assume responsibility for his or her problems may not be appropriate in all cases and it is not appropriate for the nurse to share personal information even if it relates to a problem similar to the patient’s.
The nurse is working on the inclusion of therapeutic humor in interactions with a chronically ill schizophrenic patient who was hospitalized after an attempted suicide. Which outcomes are realistic expectations for this patient? Select all that apply.
a. Improved cognition
b. Decreased interest in self-harm
c. Increased ability to experience pleasure
d. Decrease in the expression of fear and anxiety
e. Appropriate expression of emotions through affect
B, C, D, E
In two studies, researchers found that humor-based group activities provided to patients with chronic schizophrenia showed that they had a significant reduction in negative symptoms, self-injury, self-reported anger, anxiety, and depression. Although the results may be preliminary, they suggest that humor-based interventions may be beneficial for patients with chronic mental illness. There is no supporting evidence that cognitive abilities improve with the introduction of therapeutic humor.
The nurse suspects that the patient’s communication is being negatively influenced by personal attitude when he is heard stating:
a. “They think I’m mentally ill but I’m not; I just get a little depressed at times.”
b. “I can’t concentrate on anything besides getting out of here and back to my kids.”
c. “Obviously my therapist can’t understand where I’m coming from because our lives are so different.”
d. “There isn’t anyone here in this hospital I can trust enough to talk to about why I abuse alcohol and drugs.”
C
Attitude determines how one person responds to another. It includes one’s biases, past experiences, and openness. People of different socioeconomic backgrounds may have difficulty surmounting this barrier. The remaining options reflect factors that can negatively influence communication but they are environmental, knowledge, and relationship oriented.
A patient whose history includes physically abusing his spouse and children has been admitted to the unit for alcohol and drug dependency. Which nurse will likely experience difficulty establishing a therapeutic relationship with this patient?
a. The nurse who has experienced physical abuse
b. The novice nurse who has never cared for an abuser
c. The experienced nurse who has ‘seen too many abusers’
d. The nurse who has been in treatment for abusing a spouse
A
The therapeutic use of the self begins with knowing yourself. Knowing yourself is a complex and lifelong learning process. At the core of self-knowledge is the nurse’s ability to correctly identify his or her own negative or unresolved issues including family backgrounds, dynamic cultural and social issues, values, biases, and prejudices. Having been a victim of physical abuse places this nurse in a situation that can be very harmful to the development of an affective nurse-patient relationship. The novice nurse may lack some of the knowledge and experience necessary to be effective but is not a likely to have intruding biases and prejudices. The experienced nurse is more likely to have worked on the ability to provide effective care in spite of such experience with this type of diagnosis whereas, the nurse having been treated for the diagnosis is most likely to show empathy and caring
A novice nurse asks, “What is so wrong about being sympathetic with a patient who has also lost a parent like I did?” The psychiatric nurse manager responds:
a. “There is a fine line between empathy and sympathy that when crossed makes you less able to be therapeutic.”
b. “Rather than discussing the loss of your parent with the patient, you can talk to me about it whenever you need to.”
c. “I’ll provide you with some excellent materials that I’m sure will help you to understand why sympathy is less therapeutic.”
d. “Sympathy indicates that you are sharing your personal feelings and that changes the focus of the communication from the patient to you.”
D
Empathy should not be confused with sympathy. Sympathy is overinvolvement and sharing your own feelings after hearing about another person’s similar experience. It is not objective, and its primary purpose is to decrease one’s own personal distress. Although substituting sympathy for empathy does lessen the ability to be therapeutic, that is not the best explanation for avoiding it. Offering to discuss the nurse’s loss is a kind gesture but does not address the nurse’s question. Providing materials on the subject would be an appropriate reinforcement but does not address the question well.
Which nursing response would indicate an empathetic approach to a patient who is depressed over recent losses in her life?
a. “Losing a job isn’t always a bad thing.”
b. “I lost my parents last year and still feel sad.”
c. “Please tell me more about what you are feeling.”
d. “Let’s not focus on what’s sad but rather what is good about life.”
C
Empathy or empathic understanding is the nurse’s ability to see things from the patient’s viewpoint and to communicate this understanding to the patient. This response focuses on the patient’s feelings and encourages further discussion. Minimizing the loss or suggesting a change in focus sounds judgmental or patronizing and will likely cut off communication. Although self-disclosure can be therapeutic, this focuses on the nurse’s feelings
A patient who has shown good progress with treatment has shown great resistance to being discharged to an outpatient program. Based on an understanding of the underlying pathology of resistance, the nurse:
a. Recognizes that the behavior will cease when discharge has occurred
b. Refers back to the patient’s progress as an indication of the patient’s strengths
c. Assures the patient that outpatient therapy services will continue to be supportive
d. Shares that although scary, discharge to outpatient therapy is a sign of improvement
B
Resistance to change is part of human nature that both the nurse and the patient need to address and manage so that positive growth will occur. The nurse helps patients to overcome resistance by pointing out their progress and strengths
When providing discharge teaching to a patient for whom English is a second language, what technique will the nurse use to assess the patient’s understanding of the information being shared verbally?
a. Continuously evaluating the patient’s nonverbal cues
b. Periodically asking the patient if they have any questions
c. Asking the patient to repeat the information they are given
d. Providing the information in concise, written form
A
Individuals from different cultures or even different generations often misunderstand and misinterpret an unfamiliar language. Being aware of and critically examining cues that result from nonverbal responses is an excellent technique to check their interpretations. Asking if they have questions is an ineffective technique in light of the language barrier. Repeating the information is no guarantee that the patient understands the information. Providing the information in written form reinforces the material but does not ensure understanding especially if the patient has deficiencies related to reading the language
A nurse is discussing unit expectations with a newly admitted patient diagnosed with poor impulse control. The nurse shows an understanding of the use of body language to convey feelings when documenting that the patient is angry and resistant to authority based on which of the following? Select all that apply.
a. Patient’s reluctance to make eye contact
b. Crossed-arm posture the patient assumes
c. Quizzical expression on the patient’s face
d. Sharp rapping of the patient’s fingers against the table
e. Patient’s tendency to lean forward when seated in the chair
B, D
Body language includes facial expressions, reflexes, body posture, hand gestures, eye movement, mannerisms, touch, and other body motions. Body posture and facial expressions, including eye movements, are two of the most important cues to determine how a person is responding to the message. This patient’s crossed-arm posture and sharp finger rapping are indicators of anger. Poor eye contract is recognized as poor self-esteem or guilt cues, whereas a quizzical expression is likely an indication of confusion. Leaning forward in the chair is generally viewed as a positive sign of interest and/or cooperation
When communicating with a psychotic, schizophrenic patient, the nurse avoids the use of slang phrases most importantly because:
a. Such phrases have different meanings for different people.
b. Such phrases will likely trigger anxiety and frustration in the patient.
c. The use of such phrases is not appropriate when communicating therapeutically with a patient.
d. This patient’s altered thought processes will serve to make understanding such phrases very unlikely.
D
Precise verbal communication is important because spoken words often mean different things to different people. Figures of speech, jokes, clichés, colloquialisms, and other terms or special phrases carry a variety of meanings especially to individuals with altered thought processes. A person with schizophrenia interprets concretely and literally whereas psychosis generally brings about loose associations. Although all the options are reasons to avoid the use of slang phrases, the primary reason in this case in to avoid confusing the patient
The nurse is considering the need for both effective means of communication and safety when caring for a patient with impulse control issues and poor social skills. Which nursing intervention is most appropriate to address these needs?
a. Reminding the patient with each interaction what space boundaries are considered safe and desired
b. Asking the patient to describe and set space boundaries that feel safe and facilitate effective communication
c. Clearly setting space boundaries for the patient so both patient and staff feel safe and can communicate more effectively
d. Discussing the need for space boundaries and how they help both the patient and the staff feel safe and aide in communicating effectively
D
Space as a concept of boundaries and safety is important to understand because the nurse and the patient need to respect the distance that each needs. For successful communication to occur, both parties need to feel safe. Some patients have problems with their boundaries and invade other patients’ own safe zones; patients who perceive this as threatening react aggressively to such boundary violations. The nurse may need to help the patient understand the need for appropriate distances in order for everyone to feel safe and to communicate effectively. Reminding the patient of what the boundaries are without first discussing the importance of space boundaries is not an effective technique. Having the patient set the boundaries does not take into consideration the needs of others, whereas staff setting the boundaries without patient involvement ignores the needs of the patient and prevents the patient from understanding of the situation.
During the termination phase of the nurse-patient relationship with a dependent patient, the nurse evaluates the effectiveness of coping techniques learned by:
a. Role playing with the patient in order to practice being assertive
b. Asking the patient to define the difference between being assertive and being aggressive.
c. Discussing how her father effectively used both assertiveness and aggressiveness to control her
d. Asking, “When you used assertiveness to deal with your father during his visit, how did it work?”
D
Evaluation is a task of the termination phase. Asking such a question encourages patients to evaluate actions and look at the outcomes of behaviors. Role playing to practice the technique, defining the relevant terms, and discussing the effects of the father’s behavior would occur during the working phase of the relationship and does not encourage evaluation of the newly learned skills.
A nurse has for the past 4 weeks been working with a psychotic patient who has been mute and very withdrawn. The patient suddenly encroaches on the nurse’s personal space by touching inappropriately. What is the most therapeutic response by the nurse to address this behavior?
a. Ignore it this time because the patient is, at last, responding.
b. Firmly communicate acceptable boundaries to the patient.
c. Gently touch the patient’s head and then observe the reaction.
d. Smile while telling the patient that people don’t like being touched like that.
ANS: B
The therapeutic response is to clearly communicate appropriate boundaries. There are times when patients misinterpret the nurse’s nurturing as an invitation to an intimate relationship. In these instances, boundaries must be firmly, but neutrally, explained. The behavior should not be ignored since doing so may well result in the patient repeating the behavior with others, perhaps with disastrous results. Touch is often misinterpreted by psychotic patients and in this case has no therapeutic value. Nonverbal communication should always be congruent so as to avoid confusing the patient
A patient is struggling to explore and solve a problem. The nurse determines that it would be therapeutic to offer alternatives. Which verbal introduction should the nurse incorporate in order to achieve this objective?
a. “Have you thought of…”
b. “You should…”
c. “Why don’t you…”
d. “I think you need to…”
A
This encourages the patient to consider alternatives without giving advice. The other options are preludes to giving advice, which is not considered therapeutic
A nurse is contemplating the use of self-disclosure. The expected outcome of this strategy is that the patient will:
a. be informed about expected behaviors
b. express previously withheld feelings
c. foster a mutually supportive relationship with the nurse
d. recognize that the nurse can empathize through shared experiences
B
Self-disclosure should serve one or more of the following purposes: to model and educate; to build the therapeutic alliance; to provide concrete reflection that encourages reality testing. The nurse does not use self-disclosure foster a interdependent relationship that in any way gives support to the nurse. Empathy does not rely upon shared experiences.
The nurse is planning approaches to use to begin the establishment of the nurse-patient relationship. Which therapeutic communication techniques will be most useful to achieve this goal? Select all that apply.
a. Attentively listening as the patient describes their obsessive compulsive rituals
b. Asking the anxious patient if they have a plan for controlling their current anxiety
c. Encouraging the depressed patient to “come and talk with me whenever you want”
d. Sitting quietly in the room while the non-communicating patient unpacks their belongings
e. Responding to the patient’s feelings of loss by stating, “I know that must have made you very sad.”
A, C, D, E
Attentive listening, offering self, silence and empathy are all therapeutic communication techniques that are appropriate for use in the orientation stage of the nurse-patient relationship. Encouraging plan formulation is reserved for the working phase of the relationship.
It is believed that an individual’s locus of control has a major role to play in how stress will be handled. Which statement characterizes an internal locus of control?
a. “I’ll need to manage my money better in order to get out of debt.”
b. “The economy has really caused my finances to be in a real mess.”
c. “I don’t think I’ll ever be able to save enough to pay off my bills.”
d. “Having a family makes being able to stay out of debt really difficult.”
A
Individuals who demonstrate an internal locus of control view their capability to have personal success or failure as having to do with their own efforts and their ability to complete a task. An individual with an external locus of control views task completion as having to do with circumstances beyond his or her control. The options involving the economy, never being able to pay off the bills, and having a family exhibit external control locus.
Although stress may result from either a positive or a negative event, the physical effects are similar. Which statement best describes the long term effects of stress?
a. Eustress is likely to result in short term stress.
b. Chronic distress can take a toll on the individual.
c. Stress usually manifests in physical symptoms first.
d. Distress generally results in more effective coping skills.
B
Distress is damaging to an individual whether it is a result of either positive or negative stress. This stressor can become chronic if the conflict is not resolved. Distress can take a toll on an individual’s body as well as on his or her emotional state. Eustress occurs as a result of a positive stress such as from anticipation of a child’s birth but such stress is not necessarily short term and can result in the same symptoms as distress. Distress is less likely to occur if previous stress has brought about good coping skills.
When explaining the fight-or-flight response to stress, the nurse identifies that the role of the pituitary gland is to:
a. Minimize the secretion of cortisol.
b. Facilitate the conservation of energy.
c. Secrete adrenocorticotropic hormone.
d. Encourage fleeing from the stressor.`
C
The pituitary gland secretes adrenocorticotropic hormone, which stimulates the adrenal cortex to release cortisol. Cortisol is involved in helping the entire body to react to the stress by mobilizing the energy reserves so that the body can rapidly respond to the stressors by either fighting or fleeing
The nurse suggests that a patient help manage the stressors that are triggering generalized anxiety by implementing compartmentalization. Which activity provides proof that the patient is employing this healthy defense mechanism?
a. Attends a meditation class 3 times a week right after work
b. Uses chocolate as a reward when keeping stress under control
c. Counts to 10 before responding to a coworker who is a source of stress
d. Shares with the office manager the situations that regularly cause increased stress
A The person who uses compartmentalization learns to leave the stressor in a designated space. An example of this mechanism would be regularly attending a class that serves to separate the stressful work environment from one’s private life. Using food as a reward may not be healthy and as with the remaining options, it is not examples of compartmentalization.
The spouse of a patient exhibiting symptoms of chronic stress asks how they can help their spouse. Which suggestion by the nurse shows an understanding of a family member’s role in the management of stress?
a. Offer to discuss the problem with the person who is most responsible for causing their spouse’s stress.
b. Listen attentively when their spouse talks about the stressors and provide hugs to show your support.
c. Help the spouse limit the amount of time each day they devote to discussing and otherwise dwelling on the stress.
d. Provide the spouse with a variety of options and techniques for dealing with the stressors and the resulting physical symptoms.
B
People need people to prevent isolation to promote their ability to deal with stress. In a study, it was found that individuals who had significant relationships that involved an expression of affection had a reduction in the fight-or-flight response when stressed. Those who regularly received hugs from their romantic partners had a decrease in resting heart rate and a healthy functioning limbic-hypothalamic-pituitary-adrenal axis. Conversely, individuals who lacked such support showed a higher level of stress and an increased possibility of developing an illness. Offering to confront the source of the stress is not supporting the spouse in learning to manage stress. Limiting time to dwell on obsessive thoughts may be therapeutic, but when a spouse implements this technique too often, it suggests a lack of patience and understanding of the problem. The spouse may not be qualified to provide such therapeutic options; that is the role of a mental health professional.
The patient is being introduced to mindfulness-based stress reduction to help manage chronic stress. The patient is first taught to focus on:
a. What is causing the stress
b. Both inhaling and exhaling
c. Relaxing each major muscle group
d. Visualizing their life without the stress
B
It is helpful to teach individuals a generic method of relaxation by first concentrating on the rhythm of breathing. Paying attention to each breath as one takes in a respiration and releases an expiration provides a focus for the meditation. The remaining options are not steps included in mindful mediation.
The patient has been taught to use the stop, divert, and reframe method to deal with stress. Which responses indicate that the patient can affective utilize the technique when preparing to take a written examination? Select all that apply.
a. Is heard declaring that, “It’s only a test; if I fail this one I will just study harder for the next one..
b. Is observed opening a notebook and focusing on a family picture taken during a recent vacation
c. Is heard stating, “Stop thinking that you can’t correctly answer the question. You can and you will.”
d. Is observed asking the test monitor to be allow to sit somewhere “quiet and away from other people
e. Is heard saying, “I will read the question thoroughly, find the key word, and then look at the options I’m given.”
B, C, E
Stop interrupts the negative train of thought. Divert allows focus on something that will rapidly reduce the stress. Reframe reinforces what you can do to reduce the stressor. The remaining options do not address any of the identified steps in this stress management method.
Nursing interventions appropriate to the generalized adaptation syndrome (GAS) exhaustion state include which of the following? Select all that apply.
a. Planning care to best conserve the patient’s energy
b. Assessment for respiratory disorders such as asthma
c. Monitoring of exacerbation of compulsive ritual behaviors
d. Frequent assessment of pain management related to headaches
e. Planned periods to reinforce effective relaxation techniques
A, B, D, E
If the individual’s body does not adapt and the stressor continues to be prominent, then the third stage, called the exhaustion stage, occurs. The exhaustion stage can manifest itself in the form of illnesses such as infections, headaches, hypertension, asthma attacks, chronic fatigue syndrome, depression, anxiety disorders, and many other chronic conditions.
A culturally diverse patient refuses to participate in a group because of the presence of a person who “can put spells on.” The nurse recognizes a priority need to explore this patient’s:
a. Economic status
b. Home environment
c. Health-illness beliefs
d. Educational background
C
Culture influences beliefs about health and illness, including causes of illness. What the nurse might label as delusional might be a culturally determined belief about illness causation. The other assessments do not relate to the situation as directly.
When working with a patient newly emigrated from Asia who has been assessed as having xenophobia, the nurse could anticipate making the assessment that the individual:
a. Resists sharing food with others
b. Would be reluctant to ride an elevator
c. Is unlikely to talk with nonfamily members
d. Fears the consequences of going out of doors
C
Xenophobia is defined as a morbid fear of strangers. The xenophobic individual would not necessarily resist sharing food (fear of germs), riding in elevators (fear of closed spaces), or going out of doors (fear of open spaces).
An Asian-American patient is referred to the mental health clinic. He has many somatic complaints for which no physical basis has been found. The patient tells the nurse that he does not believe this clinic can help him. Based on knowledge of the beliefs common to this culture, what can the nurse hypothesize about the patient?
a. Because of the cultural stigma attached to mental illness, he may be expressing psychological distress via somatic symptoms.
b. Acculturation has occurred because feelings of hopelessness are alien to his native culture.
c. Suicide is not a present danger because suicidal impulses are rarely associated with feelings of helplessness among Asian-American patients.
d. The patient has rejected both family care and traditional healing methods in favor of health care practices of the new culture.
A
The following facts are known about beliefs commonly held by members of this culture: there is a stigma attached to mental illness; mental illness is often described in somatic terms; members of this culture come into treatment late and often have feelings of hopelessness upon entry into the system; families tend to care for their members with mental illness; and traditional healing has usually been tried and failed before the patient attempts to access the mental health system.
A novice nurse has identified impaired verbal communication for an older Asian patient who recently immigrated to the United States based on the patient’s reluctance to maintain eye contact and engage in a conversation with staff. In order to assure that the diagnosis is appropriate, the nurse manage asks:
a. “Have you asked the patient why communication is difficult for them?”
b. “Could you be misdiagnosing common shyness for a communication issue?”
c. “Have you noticed the patient communicating differently with family when they visit?”
d. “Do you think the patient’s cultural traditions have a part to play in their communication behaviors?”
D
Misunderstanding occurs when the nurse fails to take into account culture-specific interaction patterns. Silence, infrequent eye contact, shame, fear, and language barriers all affect a patient’s ability to interact. In light of the patient’s cultural diversity, the other options are less likely to be pertinent.
A patient diagnosed with paranoid schizophrenia is describing religiously-based delusions that other patients find offensive. Which nursing intervention will the nurse implement to provide a therapeutic milieu?
a. Engaging the delusional patient in prayer in order to redirect the problematic behavior
b. Explaining to the delusional patient that such talk is offensive to some of the milieu and will not be allowed
c. Asking for the pastoral counselor to visit the unit and talk with both the delusional patient as well as the rest of the milieu
d. Removing the delusional patient from the milieu when staff is unable to successfully refocus the conversation to a non-religious topic
C
Occasionally, individuals with serious mental disorders experience delusions that are spiritual or religious in nature. Certified pastoral counselors are skilled with regard to counseling patients and consulting with staff about these problems, and they assist the health care team in ways that address the particular concerns of individual patients. Challenging or debating the truth of a person’s delusions is not therapeutic, and spiritual delusions are no exception. Engaging in spiritual or religious practice with individuals on a psychiatric unit is also inappropriate. Removing the patient from the milieu is seldom therapeutic and done only to maximize milieu safety.
A patient confides to the nurse that she feels guilty about the poor relationship she had with her mother-in-law, who is now deceased. The patient tells the nurse that she is sure God will punish her for this and that she needs to confess her sins to someone. Which of the following is the best response by the nurse?
a. “Would you like to speak to the chaplain when he comes later today? In the meantime, we could talk about your relationship with your mother-in-law.”
b. “It sounds as if you need to talk about this. Let’s sit down in a private area. I’d like to know more about your relationship with your mother-in-law.”
c. “We all have trouble with our in-laws occasionally. God doesn’t punish us for that.”
d. “What’s done is done. We need to focus on your positive qualities.”
A
The patient has identified a specific spiritual problem that a chaplain would be equipped to handle, so a referral is appropriate. The nurse, in the meantime, is equipped to discuss relationship issues. Offering to talk about the relationship without addressing the patient’s expressed spiritual needs is not therapeutic. Suggesting that the patient’s relationship issues are not uncommon minimizes the patient’s feelings. Attempting to refocus the patient dismisses the patient’s needs.
The nurse identifies a patient as being in spiritual distress. Which patient statement supports this nursing diagnosis?
a. “I’ve never felt so alone before in my entire life.”
b. “I don’t know if I could get through this without faith in God.”
c. “I’ve always relied on my faith in God but now I feel I’ve been abandoned.”
d. “Why do bad things happen to good people? I’ve always been a good person.”
C
Spiritual distress is a nursing diagnosis that is defined as a disruption in the value and belief systems that pervades the person’s state of being and that transcends the physical and psychosocial self. Feeling abandoned when one has always relied on faith is an indication of spiritual distress. Feeling alone and questioning why something has occurred is not necessarily spirit based, and not an indication of spiritual distress. Questioning one’s ability to manage an emotion without one’s faith is a testimony to the faith, not an expression of despair.
The nurse believes that a patient is exhibiting internal locus of control related to spiritual development. Which patient statement supports this conclusion?
a. “Praying gives me tremendous comfort.”
b. “I pray because my church says that prayer is the way to God”
c. “I will ask that my fellow church members pray for me to get better.”
d. “My mother prayed daily and she was such a good and kind person.”
A
During development, one’s sense of faith, meaning moral values, and judgment moves from an external locus of control to an internal locus of control. An example of such internal control is the expressed feeling of comfort derived from prayer. The remaining options reflect external locus of control since each is an expression of how beliefs about prayer are provided by others; church doctrine and the faith of others.
A patient who has schizoaffective disorder is being treated with lithium carbonate. He repeatedly resists his medication based on his fine hand tremors as proof of drug poisoning. Which nursing intervention addresses both the patient’s need to comply with treatment and patient rights?
a. Informing staff that the patient is exhibiting manipulative behavior
b. Providing the patient with effective education regarding medication side effects
c. Assuring the patient the tremors are a result of the disorder, not of the medication
d. Providing an assessment to determine if the patient is exhibiting paranoia as well
B
Although the patient has a legal right to refuse medication, medication compliance is vital to successful treatment. Patient and family medication education by nurses and a reassuring therapeutic relationship will greatly assist with medication adherence while preserving the patient’s rights. Identifying manipulative behavior or paranoia does not address compliance or patient rights. The assurance about the tremors is not true.
A patient admitted for treatment of symptoms related to paranoid schizophrenia refuses to sign a consent form allowing the nurse to discuss any aspect of his hospitalization with his parents. Which statement by the nurse best respects the patient’s rights while providing effective care?
a. Reminding the parents that, “I can’t discuss your son even though I want to.”
b. Asking the patient to, “please talk with me about why you don’t trust your parents?”
c. Telling the patient that, “Keeping your parents uninvolved in your care is very painful for them.”
d. Telling the parents that, “While I can’t discuss his care with you, you can tell me anything you think I need to know.”
D
This option provides the family the ability to communicate important medical or behavioral history to the treatment facility without the nurse releasing any information about the patient without that patient’s permission. It is inappropriate for the nurse to express such personal feelings about the patient’s wishes. Challenging the patient’s decision in these manners does not fulfill the nurse’s role as advocate.
A patient is being treated in the inpatient unit for paranoid delusions that his wife is unfaithful resulting in threats to “get her for this whenever I get out.” Which intervention to assure his wife’s safety will his primary therapist include in the discharge plan?
a. Sharing the threats he has made with his wife
b. Requiring mandatory day hospital attendance
c. Advising the patient that he needs continued outpatient services
d. Informing the patient of the consequences of harming his wife
A
The Tarasoff ruling established the necessity for a mental health professional treating a patient who threatens to harm another individual to warn the person against whom the threat is made. The remaining options are not directly related to affecting his wife’s safety
Electroconvulsive therapy (ECT) has been prescribed for a patient diagnosed with chronic depression. Which statement by the patient helps assure the nurse that the patient’s right to informed consent has been respected?
a. “ECT treatment will cure my depression.”
b. “ECT is dangerous but I’m almost out of treatments.”
c. “I may not remember things that happened just before the ECT treatment.”
d. “I’m likely to permanently lose memory of things like dates and numbers.”
C
A potential side effect is memory loss that is usually temporary but that can rarely be irreversible. It is not true that ECT either cures depression or that the treatment is considered physically dangerous
Upon voluntary admission, the nurse will ensure that the patient’s rights are preserved. Which interventions are directly related to a patient’s civil right? Select all that apply.
a. Arranging for the patient to vote in city election by absentee ballot
b. Respecting the patient’s right to refuse a dose of a prescribed medication
c. Arranging for the patient to have a private area in which to visit with friends
d. Deferring to a patient’s expressed wish to “not share a room with anyone else”
e. Changing the assignment because a patient “doesn’t like” a particular staff member
A, B, C
When individuals enter a mental health facility, they usually retain their civil rights, unless such rights are clearly restricted via the use of due process to certify that an individual lacks the capacity or competence to have them. These individuals retain the right to vote, refuse medication, and to have visitors. A private room and selecting of staff are not civil rights that all patients are entitled to
Privileged communication is a legal concept that in some states protects the confidentiality of the nurse-patient relationship. Which information is not protected by this statute? Select all that apply.
a. A threat to “kill that man if he even thinks about leaving me”
b. The patient’s admission to having a sexually transmitted disease
c. The fact that a patient knows who was responsible for her brutal rape
d. The discussion about how the patient sold his prescription drugs to friends
e. Suspicion by the nurse that the patient has been physically abused by a spouse
A, B, E
Privileged communication allows certain information given to professionals by patients to remain secret during any litigation. These statutes exclude the mandatory reporting of violence against a child, an older adult, an impaired adult, and (in some instances) a domestic partner; some communicable diseases that affect public safety; and information that will prevent a felony (e.g., murder) from occurring. Only the patient can give the information regarding her rape and the privilege prevents the nurse from sharing information such as illegal selling of drugs to be used against the patient in a court of law.
A patient diagnosed with schizophrenia is hospitalized under an emergency commitment. Which nursing explanation is most effective when the patient asks, “Why am I being kept here?”
a. “The court believed you needed mental health care.”
b. “Your mental condition became unstable and you relapsed.”
c. “You couldn’t stop doing things that could likely have hurt you.”
d. “I’d suggest that you exercise your patient right to speak to a lawyer.”
C
When the effects of the patient’s mental illness result in an immediate risk of self-harm or harm to others, an emergency commitment is appropriate. While it is correct that such a commitment is court ordered and may be a result of a relapse, these options do not appropriately respond to the patient’s question. The patient does have a right to a lawyer, but this option fails to answer the patient’s question as well.
A patient has been hospitalized and is now being mandated outpatient mental health treatment as a condition for discharge. Which intervention best addresses the nurse’s role of patient advocate when this patient resists the recommendation?
a. Helping the patient identify advantages of outpatient versus inpatient therapy
b. Sharing that outpatient therapy is less expensive than inpatient hospitalization
c. Stressing that outpatient therapy can minimize the need for future hospitalization
d. Discussing the patient’s opposition to outpatient treatment with the treatment team
C
The purpose of mandating outpatient mental health treatment is to break the cyclic pattern of patients who, when discharged from an inpatient treatment facility, subsequently require readmission to the acute psychiatric care setting. While the other options reflect the nurse as advocate, they do not best address this patient’s situation.
