Exam 1 Study Guide: Q Flashcards
which diagnosis is written correctly?
- risk for social isolation related to low self-esteem evidence by staying in room during the day
- low self-esteem related to MDD evidenced by childhood abuse
- imbalanced nutrition less than body requirements related to suspiciousness evidenced by 20-lb weight loss
- conduct disorder related to childhood sexual abuse evidence by hostile and aggressive abuse
imbalanced nutrition:
less than body requirements related to suspiciousness evidenced by 20 lbs. weight loss is a correctly written nursing diagnosis
evidence of a nutritional problem is documented and the cause of the problem, suspiciousness, is identified
which indicates to the nurse a client is at risk for developing a mental disorder?
- express thoughts, feelings, and behaviors included among diagnostics mental disorder criteria
- demonstrates impaired daily functioning and maladaptive responses to stress
- communicate significant distress that has not interfered with important activities
- employs various defense mechanism to protect the ego from anxiety
demonstrated impaired daily functioning and maladaptive response to stress
a new nurse states “that clients use of defense mechanisms should be eliminated”.
Which is a correct evaluation of the nurse’s statement?
- defense mechanisms are a self-protective response to stress and do not need to be eliminated
- defense mechanisms are maladaptive attempts of the ego to manage anxiety and should always be eliminated
- defense mechanisms are used by individuals with weak ego integrity and should not be eliminated
- defense mechanisms cause disintegration of the ego and should be fostered and encouraged
defense mechanisms are self-protective response to stress and do not need to be eliminated
a client made a decision to leave her alcoholic husband and reports feeling depressed.
which non-therapeutic statement represents sympathy?
- you are depressed. I felt the same way when I decided to leave my husband
- I can understand you are feeling depressed, it was a difficult decision, i’ll sit with you
- you seem depressed, it was a difficult decision. would you like to talk about it
- i know this is a difficult time, would you like medication
you are depressed. I felt the same way when i decided to leave my husband.
- sharing things about yourself/personal information is sympathy not empathy
a nurse in a long-term care setting enters the room and the client begins berating the nurse stating that “he looks like my ex-husband”,
this behavior is best descried as:
- transference
- conversion
- counter transference
- regression
transference
what is the nurses best action when a client demonstrates transference?
help client clarify meaning of current nurse client relationship
a client who was discharged 2 weeks ago sends a thank you card to a psychiatric nurse. the nurse finds season tickets to a football team in the card.
which of the following must the nurse consider when deciding whether or not to keep the tickets?
- material boundaries
- personal boundaries
- social boundaries
- professional boundaries
professional boundaries
a hungry homeless client with schizophrenia refuses to participate in the admission interview. The nurse postpones the interview, verbally assures safety, and provides the client with a meal.
which of the following does the nurse’s actions demonstrate?
- sympathy
- trust
- veracity
- manipulation
trust
a nurse is interviewing a newly admitted psychiatric client.
which nursing statement is an example of offering a general lead?
- do you know why you are here?
- are you feeling depressed or anxious?
- yes, I see, go on
- can you chronologically order the events that led to your admission?
yes, I see, go on
a nurse is assessing a client with schizophrenia for hallucinations.
which therapeutic communication exemplifies making an observation?
- you appear to be talking to someone i don’t see
- please describe what you are seeing
- why do you continually look in the corner of the room?
if you hum a tune, the voices may not be so distracting
you appear to be talking to someone i don’t see
a client diagnosed with dependent personality disorder states, “do you think i should move out from my parents’ house and get a job?”
which response by the nurse is most appropriate?
- it would be best to do that to increase independence
- why would you want to leave a secure home?
- lets discuss and explore all of your options
- im afraid you would feel very guilty leaving your parents
lets discuss and explore all of your options
a client tells the nurse “i feel bad because my mom doesn’t want me to return home after i leave the hospital.”
which response is an example of therapeutic communication?
- its quite common for patients to feel that way after a lengthy hospitalization
- why don’t you talk to your mom, you may find she doesn’t feel that way
- your mother seems like an understanding person, i’ll help you approach her
- you feel that your mom does not want you to com back home?
you feel that your mom does not want you to come back home?
a client in an inpatient psych unit tells the nurse “i should have died because i am worthless.”
to encourage the client to continue talking about their feelings, which should be the nurse’s initial response?
- how would your family feel if you died?
- you feel worthless now but that can change with time
- you’ve been feeling sad and alone for some time now
- it is great that you have come in for help
you’ve been feeling sad and alone for some time now
a nurse says to newly admitted client “tell me more about what led up to your hospitalization.”
what is the purpose of this therapeutic communication technique?
- explore a subject, idea, experience, or relationship
- reframe clients’ thoughts about mental health treatment
- put the client at ease
- communicate that the nurse is listening to the conversation
explore a subject, idea, experience, or relationship
a nurse is caring for a client who tells the nurse he is feeling stressed and overwhelmed.
which of the following response should the nurse make?
- life is rough isn’t it
- im sorry, i know exactly how you are feeling
- dont worry, you will feel beter in no time
- lets talk more about the stress you’re feeling
let’s talk more about the stress you’re feeling
a nurse tells a client “things will look better tomorrow after a good night’s sleep.”
this is an example of which communication technique?
- giving advice
- defending
- presenting reality
- giving false reassurance
giving false reassurance
a student nurse tells her instructor “im concerned when clients ask for advice, i wont have a good solution.”
what would be the instructor’s best response?
- it’s scary to be put on the spot by a client, nurses don’t always have the answer
- remember clients, not nurses, are responsible for their own choices and decisions
- keep the client’s best interest in mind and do the best you can
- set a goal to continue to work on this aspect of your practice
remember, clients, not nurses are responsible for their own choices and decisions
group therapy is strongly encouraged but not mandatory in an inpatient psych unit. the manager’s policy is that clients can make a choice to attend group therapy?
which ethical principle is this?
- justice
- autonomy
- veracity
- justice
autonomy
a client diagnosed with schizophrenia refuses to take his medication citing the right of autonomy. under which circumstance would a nurse have the right to medicate a client against their will?
- makes inappropriate sexual statements to a staff member
- repeatedly demands constant attention from the nurse
- physically attacks another client during group therapy
- refuse to bathe or attend to personal hygiene
physically attacks another client during group therapy
which regulates the scope of practice for register nurses working in a mental health facility located in nurses state?
Nurse Practice Act
a nurse working in an inpatient treatment center receives a call asking if an individual has been a client there.
which response appropriately reflects legal and ethical obligations of the nurse?
- refuse to give information to caller and cite confidentiality laws
- refuse to give any information and hang up
- affirm only that the person has been seen there
- suggest caller contact the client’s psychiatrist
refuse to give information to caller and cite confidentiality laws
which statement should the nurse identify as correct regarding a client’s right to refuse treatment?
- client can refuse pharmacological but not psychological treatment
- professionals can override treatment refusal if a client is suicidal or homicidal
- client can refuse any type of treatment at any time
- the only treatment client can refuse is electroconvulsive therapy
professionals can override treatment refusal if a client is suicidal or homicidal
which client should the nurse identify as a potential candidate for involuntary commitment?
- client living under bridge in cardboard box
- client verbalizing intent to commit suicide
- homeless client refusing to bathe
- client eating waste out of a trash can
client verbalizing intent to commit suicide
a nurse is providing teaching to assistive personnel about clients with restraints
which statement by the assistive personnel indicates understanding?
- i will put all 4 side rails up if the client is confused
- restraints must be very tight to work properly
- i will tie the restraints to the portion of bed that does not move
- i will tie the restraints with the extremities flexed to ensure safe range of motion
i will tie the restraints to the portion of bed that does not move
a client is taking Ritalin for ADHD.
which of the following would be part of the patient education associated with administration of this medication?
- do not take with foods that contain tyramine
- always use sunblock when spending time outdoors
- report for blood tests once a month
- do not discontinue the medication abruptly
do not discontinue the medication abruptly
patients taking an alpha agonist should not discontinue therapy abruptly. to do so may result in symptoms of nervousness, agitation, headache, tremor, and a rapid rise in blood pressure. dosage should be tapered gradually under the supervision of the physician
what part of the brain is responsible for processing feelings or is also called the emotional brain?
- medulla
- limbic system
- pons
- autonomic nervous system
limbic system
the limbic system is the “emotional brain” and can help in stabilizing emotional behavior
the nurse identifies which symptom as typical of the fight-or-flight response?
- decreased heart rate
- decreased peristalsis
- increased salivation
- pupil constriction
decreased peristalsis
during the fight-or-flight response, the heart rate increases in response to the release of epinephrine. pupils dilate to enhance vision. salivation and peristalsis decrease as the body slows unessential functions
the nurse understands that psychotropic medications improve symptoms of mental disorders b acting on which of the following parts of nervous system?
- interneurons
- neural synapse
- the cerebral cortex
- the cerebellum
neural synapse
psychotropic medications improve symptoms of mental disorders by acting on the neural synapse
which part of the nervous system should the nurse identify as playing a major role during stressful situations?
- sympathetic nervous system
- somatic nervous system
- peripheral nervous system
- the cerebellum
sympathetic nervous system
sympathetic division of the nervous system is dominant in stressful situations
a patient was brought to the emergency room and was having an extreme anxiety attack.
what division in the brain would be dominant and responsible to react in this situation?
- sympathetic nervous system
- thalamus
- hypothalamus
- parasympathetic nervous system
sympathetic nervous system
sympathetic division of the nervous system is dominant in stressful situations
anxiety attack = stressful situation
which of the following regulates the scope of practice for a registered nurse working in a mental health facility located in the nurses’ state?
- american nurses’ association
- american psyciatric association
- nurse practice act
- national council of the state board of nursing
nurse practice act
which statement should then nurse identify as correct regarding a protocol/client’s right to refuse treatment?
- clients can refuse pharmacological but not psychological treatment
- clients can refuse any type of psychiatric treatment at any time
- the only treatment a client can refuse is electroconvulsive therapy (ECT)
- professionals can override treatment refusal if the client is actively suicidal or homicidal
professionals can override treatment refusal if the client is actively suicidal or homicidal
professionals can override treatment refusal if the client is actively suicidal or homicidal under a court ordered denial of rights as a petitioned by the interdisciplinary team lead by the psychiatrist
what are defense mechanisms?
behaviors people use to separate themselves from unpleasant events, actions, or thoughts
self-protective responses to stress and DO NOT NEED TO BE ELIMINATED or else anxiety will progress and may get worse
justify unacceptable feelings/behaviors
rationalization
refusing to acknowledge the existence of a real situation or the feelings associated
denial
preventing unacceptable or undesirable thoughts of behaviors from being expressed by exaggerating opposite thoughts or types of behaviors
reaction formation
transfer the feeling from one target to another that is less threatening
displacement
attributing feelings unacceptable to one’s self to another person
projection
the nurse is interviewing a client with a history of alcoholism. the client states, “i work hard to provide for my family. I don’t see why i can’t drink to relax.”
the nurse recognizes the client is using which defense mechanism?
- rathionalization
- regression
- reaction formation
- undoing
rationalization
the client is using rationalization, a common defense mechanism.
the client is attempting to make excuses and create logical reasons to justify unacceptable feelings or behaviors
due to COVID, the nursing unit director informed the unit manager that they need to eliminate the position or have him/her step down as a staff nurse due to budgeting reasons. the manager’s behavior represents the defense mechanism of displacement when he/she does which of the following actions?
- angrily criticizes a coworker
- confronts the nursing director
- cried at home
- eats lunch with the director
angrily criticizes a coworker
displacement refers to transferring feelings from one target to a neutral or less threatening target
a male student is attracted to the school’s female nurse. the male student tells his friend, “i know she has a crush on me.”
the friend recognizes that the student is using which defense mechanism?
- undoing
- projection
- regression
- rationalization
projection
projection refers to the attribution of one’s unacceptable feelings or impulses to another person. when the client “passes the blame” of the undesirable feelings, anxiety is reduced
a male student nurse teases a female classmate and makes jokes about her.
you identify this as what type of defense mechanism?
- reaction formation
- sublimation
- projection
- displacement
reaction formation
the male student nurse is using the defense mechanism of reaction formation. reaction formation is the attempt to prevent undesirable thoughts from being expressed by expressing opposite thoughts or behaviors
True or False:
a client demonstrating impaired daily functioning and maladaptive responses to stress indicates to the nurse that he/she is at risk for developing mental disorder
True
the nurse should determine that the client is at risk for mental disorder when responses to stress are maladaptive and interfere with daily functioning. there must be significant disturbance in cognition, emotion, regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental function to be diagnosed with a mental disorder
True or False:
a feeling of self-fulfillment and realization of full potential is the highest level of functioning according to maslow’s hierarchy of needs
true
