M.H exam 2

Question 1

A new staff nurse completes an orientation to the psychiatric unit. This nurse will expect to ask an advanced practice nurse to perform which action for clients? a. Perform mental health assessment interviews.
b. Prescribe psychotropic medication.
c. Establish therapeutic relationships.
d. Individualize nursing care plans.

Answer 1

ANS: B
Prescriptive privileges are granted to master’s-prepared nurse practitioners who have taken special courses on prescribing medication. The nurse prepared at the basic level performs mental health assessments, establishes relationships, and provides individualized care planning.

Question 2

A newly admitted client diagnosed with major depressive disorder has gained 20 pounds over a few months and has suicidal ideations. The client has taken antidepressant medication for 1 week without remission of symptoms. What is the priority nursing diagnosis? a. Imbalanced nutrition: more than body requirements
b. Chronic low self-esteem
c. Risk for suicide
d. Hopelessness

Answer 2

ANS: C
Risk for suicide is the priority diagnosis when the client has both suicidal ideation and a plan to carry out the suicidal intent. Imbalanced nutrition, hopelessness, and chronic low self-esteem may be applicable nursing diagnoses, but these problems do not affect client safety as urgently as would a suicide attempt.

Question 3

A client diagnosed with major depressive disorder has lost 20 pounds in one month, has chronic low self-esteem, and a plan for suicide. The client has taken antidepressant medication for 1 week. Which nursing intervention has the highest priority? a. Implement suicide precautions.
b. Offer high-calorie snacks and fluids frequently.
c. Assist the client to identify three personal strengths.
d. Observe client for therapeutic effects of antidepressant medication.

Answer 3

ANS: A
Implementing suicide precautions is the only option related to client safety. The other options, related to nutrition, self-esteem, and medication therapy, are important but are not priorities.

Question 4

The desired outcome for a client experiencing insomnia is, “Client will sleep for a minimum of 5 hours nightly within 7 days.” At the end of 7 days, review of sleep data shows the client sleeps an average of 4 hours nightly and takes a 2-hour afternoon nap. How should the nurse document the outcome?
a. As consistently demonstrated.
b. As often demonstrated.
c. As sometimes demonstrated.
d. As never demonstrated.

Answer 4

ANS: D
The correct response to this question involves applying the evaluation step of nursing process. Although the client is sleeping 6 hours daily, the total is not one uninterrupted session at night. Therefore, the outcome must be evaluated as never demonstrated.

Question 5

The desired outcome for a client experiencing insomnia is, “Client will sleep for a minimum of 5 hours nightly within 7 days.” At the end of 7 days, review of sleep data shows the client sleeps an average of 4 hours nightly and takes a 2-hour afternoon nap. What is the nurse’s next action? a. Continue the current plan without changes.
b. Remove this nursing diagnosis from the plan of care.
c. Write a new nursing diagnosis that better reflects the problem.
d. Examine interventions for possible revision of the target date.

Answer 5

ANS: D
The correct response to this question involves applying the evaluation step of nursing process. Sleeping a total of 5 hours at night remains a reasonable outcome. Extending the period for attaining the outcome may be appropriate. Examining interventions might result in planning an activity during the afternoon rather than permitting a nap. Continuing the current plan without changes is inappropriate. Removing this nursing diagnosis from the plan of care would be correct when the outcome was met and the problem resolved. Writing a new nursing diagnosis is inappropriate because no other nursing diagnosis relates to the problem.

Question 6

A client begins a new program to assist with building social skills. In which part of the plan of care should a nurse record the item, “Encourage client to attend one psychoeducational group daily”?
a. Assessment
b. Analysis
c. Implementation
d. Evaluation

Answer 6

ANS: C
Interventions are the nursing prescriptions to achieve the outcomes. Interventions should be specific.

Question 7

Before assessing a new client, a nurse is told by another health care worker, “I know that client. No matter how hard we work, there isn’t much improvement by the time of discharge.” What action is the nurse’s responsibility?
a. To document the other worker’s assessment of the client.
b. To assess the client based on data collected from all sources.
c. To validate the worker’s impression by contacting the client’s significant other.
d. To discuss the worker’s impression with the client during the assessment interview.

Answer 7

ANS: B
Assessment should include data obtained from both the primary and reliable secondary sources. The nurse should evaluate biased assessments by others as objectively as possible.

Question 8

8. A client presents to the emergency department (ED) with mixed psychiatric symptoms. The admission nurse suspects the symptoms may be the result of a medical problem. Lab results show elevated BUN (blood urea nitrogen) and creatinine. What is the nurse’s next best action? a. Report the findings to the health care provider.
   b. Assess the client for a history of renal problems.
   c. Assess the client’s family history for cardiac problems.
   d. Arrange for the client’s hospitalization on the psychiatric unit

Answer 8

ANS: B
Elevated BUN and creatinine suggest renal problems. Renal dysfunction can often imitate psychiatric disorders. The nurse should further assess the client’s history for renal problems and then share the findings with the health care provider.

Question 9

A client states, “I’m not worth anything. I have negative thoughts about myself. I feel anxious and shaky all the time. Sometimes I feel so sad that I want to go to sleep and never wake up.” Which nursing intervention should have the highest priority? a. Self-esteem–building activities
b. Anxiety self-control measures
c. Sleep enhancement activities
d. Suicide precautions

Answer 9

ANS: D
The nurse would place a priority on monitoring and reinforcing suicide self-restraint because it relates directly and immediately to client safety. Client safety is always a priority concern. The nurse should monitor and reinforce all client attempts to control anxiety, improve sleep patterns, and develop self-esteem, while giving priority attention to suicide self-restraint.

Question 10

Nursing behaviors associated with the implementation phase of nursing process are concerned with what action?
a. Participating in mutual identification of client outcomes.
b. Gathering accurate and sufficient client-centered data.
c. Comparing client responses and expected outcomes.
d. Carrying out interventions and coordinating care.

Answer 10

ANS: D
Nursing behaviors relating to implementation include using available resources, performing interventions, finding alternatives when necessary, and coordinating care with other team members.

Question 11

Select the best outcome for a client with the nursing diagnosis: Impaired social interaction related to sociocultural dissonance as evidenced by stating, “Although I’d like to, I don’t participate because I don’t speak the language very well.” Client will engage in what action? a. Show improved use of language.
b. Demonstrate improved social skills.
c. Become more independent in decision making.
d. Select and participate in one group activity per day.

Answer 11

ANS: D
The outcome describes social involvement on the part of the client. Neither cooperation nor independence has been an issue. The client has already expressed a desire to interact with others. Outcomes must be measurable. Two of the distracters are not measurable.

Question 12

Which statement made by a client during an initial assessment interview should serve as the priority focus for the plan of care?
a. “I can always trust my family.”
b. “It seems like I always have bad luck.”
c. “You never know who will turn against you.”
d. “I hear evil voices that tell me to do bad things.”

Answer 12

ANS: D
The statement regarding evil voices tells the nurse that the client is experiencing auditory hallucinations and may create risks for violence. Safety is the nurse’s first concern. The other statements are vague and do not clearly identify the client’s chief symptom.

Question 13

13. Which entry in the medical record best meets the requirement for problem-oriented charting?
    a. “A: Pacing and muttering to self. P: Sensory perceptual alteration related to internal auditory stimulation. I: Given fluphenazine HCL 2.5 mg po at 0900 and went to room to lie down. E: Calmer by 0930. Returned to lounge to watch TV.”
    b. “S: States, ‘I feel like I’m ready to blow up.’ O: Pacing hall, mumbling to self. A: Auditory hallucinations. P: Offer haloperidol 2 mg po. I: Haloperidol 2 mg po given at 0900. E: Returned to lounge at 0930 and quietly watched TV.”
    c. “Agitated behavior. D: Client muttering to self as though answering an unseen person. A: Given haloperidol 2 mg po and went to room to lie down. E: Client calmer. Returned to lounge to watch TV.”
    d. “Pacing hall and muttering to self as though answering an unseen person.
    haloperidol 2 mg po administered at 0900 with calming effect in 30 minutes. Stated, ‘I’m no longer bothered by the voices.’”

Answer 13

ANS: B
Problem-oriented documentation uses the first letter of key words to organize data: S for subjective data, O for objective data, A for assessment, P for plan, I for intervention, and E for evaluation. The distracters offer examples of PIE charting, focus documentation, and narrative documentation.

Question 14

14. A nurse assesses an older adult client brought to the emergency department (ED) by a family member. The client was wandering outside saying, “I can’t find my way home.” The client is confused and unable to answer questions. Select the nurse’s best action.
    a. Record the client’s answers to questions on the nursing assessment form.
    b. Ask an advanced practice nurse to perform the assessment interview.
    c. Call for a mental health advocate to maintain the client’s rights.
    d. Obtain important information from the family member.

Answer 14

ANS: D
When the client (primary source) is unable to provide information, secondary sources should be used, in this case, the family member. Later, more data may be obtained from other information sources familiar with the client. An advanced practice nurse is not needed for this assessment; it is within the scope of practice of the staff nurse. Calling a mental health advocate is unnecessary. See relationship to audience response question.

Question 15

A nurse asks a client, “If you had fever and vomiting for 3 days, what would you do?” Which aspect of the mental status examination is the nurse assessing? a. Behavior
b. Cognition
c. Affect and mood
d. Perceptual disturbances

Answer 15

ANS: B
Assessing cognition involves determining a client’s judgment and decision making. In this case, the nurse would expect a response of “Call my doctor” if the client’s cognition and judgment are intact. If the client responds, “I would stop eating” or “I would just wait and see what happened,” the nurse would conclude that judgment is impaired. The other options refer to other aspects of the examination.

Question 16

An adolescent asks a nurse conducting an assessment interview, “Why should I tell you anything? You’ll just tell my parents whatever you find out.” Which response by the nurse is appropriate?
a. “That isn’t true. What you tell us is private and held in strict confidence. Your parents have no right to know.”
b. “Yes, your parents may find out what you say, but it is important that they know about your problems.”
c. “What you say about feelings is private, but some things, like suicidal thinking, must be reported to the treatment team.”
d. “It sounds as though you are not really ready to work on your problems and make changes.”

Answer 16

ANS: C
Adolescents are very concerned with confidentiality. The client has a right to know that most information will be held in confidence, but that certain material must be reported or shared with the treatment team, such as threats of suicide, homicide, use of illegal drugs, or issues of abuse. The incorrect responses are not true, will not inspire the confidence of the client, or are confrontational.

Question 17

A nurse wants to assess an adult client’s recent memory. Which question would best yield the desired information?
a. “Where did you go to elementary school?”
b. “What did you have for breakfast this morning?”
c. “Can you name the current president of the United States?”
d. “A few minutes ago, I told you my name. Can you remember it?”.

Answer 17

ANS: B
The client’s recall of a meal provides evidence of recent memory. Two incorrect responses are useful to assess immediate and remote memory. The other distracter assesses the client’s fund of knowledge

Question 18

When a nurse assesses an older adult client, answers seem vague or unrelated to the questions. The client also leans forward and frowns, listening intently to the nurse. An appropriate question for the nurse to ask would be
a. “Are you having difficulty hearing when I speak?”
b. “How can I make this assessment interview easier for you?”
c. “I notice you are frowning. Are you feeling annoyed with me?”
d. “You’re having trouble focusing on what I’m saying. What is distracting you?”

Answer 18

ANS: A
The client’s behaviors may indicate difficulty hearing. Identifying any physical need, the client may have at the onset of the interview and making accommodations are important considerations. By asking if the client is annoyed, the nurse is jumping to conclusions. Asking how to make the interview easier for the client may not elicit a concrete answer. Asking about distractions is a way of asking about auditory hallucinations, which is not appropriate because the nurse has observed that the client seems to be listening intently.

Question 19

19. At what point in an assessment interview would a nurse ask, “How does your faith help you in stressful situations?”
    a. childhood growth and development
    b. substance use and abuse
    c. educational background
    d. coping strategies

Answer 19

ANS: D
When discussing coping strategies, the nurse might ask what the client does when upset, what usually relieves stress, and to whom the client goes to talk about problems. The question regarding whether the client’s faith helps deal with stress fits well here. It would be out of place if introduced during exploration of the other topics.

Question 20

When a new client is hospitalized, a nurse takes the client on a tour, explains rules of the unit, and discusses the daily schedule. The nurse is engaged in what nursing action? a. counseling.
b. health teaching.
c. milieu management.
d. psychobiological intervention.

Answer 20

ANS: C
Milieu management provides a therapeutic environment in which the client can feel comfortable and safe while engaging in activities that meet the client’s physical and mental health needs. Counseling refers to activities designed to promote problem solving and enhanced coping and includes interviewing, crisis intervention, stress management, and conflict resolution. Health teaching involves identifying health education needs and giving information about these needs. Psychobiological interventions involve medication administration and monitoring response to medications.

Question 21

21. After formulating the nursing diagnoses for a new client, what is a nurse’s next action?
    a. Designing interventions to include in the plan of care
    b. Determining the goals and outcome criteria
    c. Implementing the nursing plan of care
    d. Completing the spiritual assessment

Answer 21

ANS: B
The third step of the nursing process is planning and outcome identification. Outcomes cannot be determined until the nursing assessment is complete and nursing diagnoses have been formulated.

Question 22

What is the most appropriate label to complete this nursing diagnosis: related to feelings of shyness and poorly developed social skills as evidenced by watching television alone at home every evening.
a. Deficient knowledge
b. Ineffective coping
c. Social isolation
d. Powerlessness

Answer 22

ANS: C
Nursing diagnoses are selected based on the etiological factors and assessment findings, or evidence. In this instance, the evidence shows social isolation that is caused by shyness and poorly developed social skills.

Question 23

What does “QSEN” refers to?
a. Qualitative Standardized Excellence in Nursing.
b. Quality and Safety Education for Nurses.
c. Quantitative Effectiveness in Nursing.
d. Quick Standards Essential for Nurses.

Answer 23

ANS: B
QSEN represents national initiatives centered on client safety and quality. The primary goal of QSEN is to prepare future nurses with the knowledge, skills, and attitudes to increase the quality, care, and safety in the health care setting in which they work.

Question 24

A nurse documents: “Client is mute despite repeated efforts to elicit speech. Makes no eye contact. Inattentive to staff. Gazes off to the side or looks upward rather than at speaker.” Which nursing diagnosis should be considered? a. Defensive coping
b. Decisional conflict
c. Risk for other-directed violence
d. Impaired verbal communication
.

Answer 24

ANS: D
The defining characteristics are more related to the nursing diagnosis of impaired verbal communication than to the other nursing diagnoses

Question 25

A nurse prepares to assess a new client who moved to the United States from Central America 3 years ago. After introductions, what is the nurse’s next comment? a. “How did you get to the United States?” b. “Would you like for a family member to help you talk with me?” c. “An interpreter is available. Would you like for me to make a request for these services?” d. “Are you comfortable conversing in English, or would you prefer to have a translator present?”

Answer 25

ANS: D The nurse should determine whether a translator is needed by first assessing the client for language barriers. Accuracy of the assessment depends on the ability to communicate in a language that is familiar to the client. Family members are not always reliable translators. An interpreter may change the client’s responses; a translator is a better resource.

Question 26

The nurse records this entry in a client’s progress notes: Client escorted to unit by ER nurse at 2130. Client’s clothing was dirty. In interview room, client sat with hands over face, sobbing softly. Did not acknowledge nurse or reply to questions. After several minutes, abruptly arose, ran to window, and pounded. Shouted repeatedly, “Let me out of here.” Verbal intervention unsuccessful. Order for stat dose 2 mg haloperidol PO obtained; medication administered at 2150. By 2215, client stopped shouting and returned to sit wordlessly in chair. Client placed on one-to-one observation. How should this documentation be evaluated? a. Uses unapproved abbreviations b. Contains subjective material c. Excessively wordy d. Meets standards

Answer 26

ANS: D This narrative note describes client appearance, behavior, and conversation. It mentions that less- restrictive measures were attempted before administering medication and documents client response to medication. This note would probably meet standards. A complete nursing assessment would be in order as soon as the client is able to participate. Subjective material is absent from the note. Abbreviations are acceptable.

Question 27

A nurse assessed a client who reluctantly participated in activities, answered questions with minimal responses, and rarely made eye contact. What information should be included when documenting the assessment? (Select all that apply.) a. The client was uncooperative b. The client’s subjective responses c. Only data obtained from the client’s verbal responses d. A description of the client’s behavior during the interview e. Analysis of why the client was unresponsive during the interview

Answer 27

ANS: B, D Both content and process of the interview should be documented. Providing only the client’s verbal responses would create a skewed picture of the client. Writing that the client was uncooperative is subjectively worded. An objective description of client behavior would be preferable. Analysis of the reasons for the client’s behavior would be speculation, which is inappropriate

Question 28

A nurse performing an assessment interview for a client with a substance use disorder decides to use a standardized rating scale. Which scales are appropriate? (Select all that apply.) a. Addiction Severity Index (ASI) b. Brief Drug Abuse Screen Test (B-DAST) c. Abnormal Involuntary Movement Scale (AIMS) d. Cognitive Capacity Screening Examination (CCSE) e. Recovery Attitude and Treatment Evaluator (RAATE)

Answer 28

ANS: A, B, E Standardized scales are useful for obtaining data about substance use disorders. The ASI, B- DAST, and RAATE are scales related to substance abuse. AIMS assesses involuntary movements associated with antipsychotic medications. The CCSE assesses cognitive function.

Question 29

What information is conveyed by nursing diagnoses? (Select all that apply.) a. Medical judgments about the disorder b. Unmet client needs currently present c. Goals and outcomes for the plan of care d. Supporting data that validate the diagnoses e. Probable causes that will be targets for nursing interventions

Answer 29

ANS: B, D, E Nursing diagnoses focus on phenomena of concern to nurses rather than on medical diagnoses.

Question 30

A client is very suspicious and states, “The FBI has me under surveillance.” Which strategies should a nurse use when gathering initial assessment data about this client? (Select all that apply.) a. Tell the client that medication will help this type of thinking. b. Ask the client, “Tell me about the problem as you see it.” c. Seek information about when the problem began. d. Tell the client, “Your ideas are not realistic.” e. Reassure the client, “You are safe here.”

Answer 30

ANS: B, C, E During the assessment interview, the nurse should listen attentively and accept the client’s statements in a nonjudgmental way. Because the client is suspicious and fearful, reassuring safety may be helpful, although trust is unlikely so early in the relationship. Saying that medication will help or telling the client that the ideas are not realistic will undermine development of trust between the nurse and client.

Question 31

A nurse assesses a confused older adult. The nurse experiences sadness and reflects, “This patient is like one of my grandparents … so helpless.” Which response is the nurse demonstrating? a. Transference b. Countertransference c. Catastrophic reaction d. Defensive coping reaction

Answer 31

ANS: B Countertransference is the nurse’s transference or response to a patient that is based on the nurse’s unconscious needs, conflicts, problems, or view of the world. See relationship to audience response question.

Question 32

Which statement shows a nurse has empathy for a patient who made a suicide attempt? a. “You must have been very upset when you tried to hurt yourself.” b. “It makes me sad to see you going through such a difficult experience.” c. “If you tell me what is troubling you, I can help you solve your problems.” d. “Suicide is a drastic solution to a problem that may not be such a serious matter.”

Answer 32

ANS: A Empathy permits the nurse to see an event from the patient’s perspective, understand the patient’s feelings, and communicate this to the patient. The incorrect responses are nurse- centered (focusing on the nurse’s feelings rather than the patient’s), belittling, and sympathetic.

Question 33

A novice nurse tells a mentor, “I want to convey to my patients that I am interested in them and that I want to listen to what they have to say.” Which behaviors will be helpful in meeting the nurse’s goal? (Select all that apply.) a. Sitting behind a desk, facing the patient b. Introducing self to a patient and identifying own role c. Maintaining control of discussions by asking direct questions d. Using facial expressions to convey interest and encouragement e. Assuming an open body posture and sometimes mirror imaging

Answer 33

ANS: B, D, E Trust is fostered when the nurse gives an introduction and identifies his or her role. Facial expressions that convey interest and encouragement support the nurse’s verbal statements to that effect and strengthen the message. An open body posture conveys openness to listening to what the patient has to say. Mirror imaging enhances patient comfort. A desk would place a physical barrier between the nurse and patient. A face-to-face stance should be avoided when possible and a less intense 90- or 120-degree angle used to permit either party to look away without discomfort.

Question 34

A novice psychiatric nurse has been assigned a parent diagnosed with bipolar disorder. This nurse angrily recalls feelings of embarrassment about the parent’s behavior in the community. Select the best ways for this nurse to cope with these feelings. (Select all that apply.) a. Seek ways to use the understanding gained from childhood to help patients cope with their own illnesses. b. Recognize that these feelings are unhealthy. The nurse should try to suppress them when working with patients. c. Recognize that psychiatric nursing is not an appropriate career choice. Explore other nursing specialties. d. The nurse should begin new patient relationships by saying, “My own parent had mental illness, so I accept it without stigma.” e. Recognize that the feelings may add sensitivity to the nurse’s practice, but supervision is important.

Answer 34

ANS: A, E The nurse needs support to explore these feelings. An experienced psychiatric nurse is a resource that may be helpful. The knowledge and experience gained from the nurse’s relationship with a mentally ill parent may contribute sensitivity to compassionate practice. Self-disclosure and suppression are not adaptive coping strategies. The nurse should not give up on this area of practice without first seeking ways to cope with the memories.

Question 35

After several therapeutic encounters with a patient who recently attempted suicide, which occurrence should cause the nurse to consider the possibility of countertransference? a. The patient’s reactions toward the nurse seem realistic and appropriate. b. The patient states, “Talking to you feels like talking to my parents.” c. The nurse feels unusually happy when the patient’s mood begins to lift. d. The nurse develops a trusting relationship with the patient. nship with the patient is desirable.

Answer 35

ANS: C Strong positive or negative reactions toward a patient or over-identification with the patient indicate possible countertransference. Nurses must carefully monitor their own feelings and reactions to detect countertransference and then seek supervision. Realistic and appropriate reactions from a patient toward a nurse are desirable. One incorrect response suggests transference. A trusting relationship with the patient is desirable. See relationship to audience response question.

Question 36

A patient says, “Please don’t share information about me with the other people.” How should the nurse respond? a. “I will not share information with your family or friends without your permission, but I will share information about you with other staff.” b. “A therapeutic relationship is just between the nurse and the patient. It is up to you to tell others what you want them to know.” c. “It depends on what you choose to tell me. I will be glad to disclose at the end of each session what I will report to others.” d. “I cannot tell anyone about you. It will be as though I am talking about my own problems, and we can help each other by keeping it between us.”

Answer 36

ANS: A A patient has the right to know with whom the nurse will share information and that confidentiality will be protected. Although the relationship is primarily between the nurse and patient, other staff needs to know pertinent data. The other incorrect responses promote incomplete disclosure on the part of the patient, require daily renegotiation of an issue that should be resolved as the nurse–patient contract is established, and suggest mutual problem solving. The relationship must be patient centered. See relationship to audience response question.

Question 36

A nurse is talking with a patient, and 5 minutes remain in the session. The patient has been silent most of the session. Another patient comes to the door of the room, interrupts, and says to the nurse, “I really need to talk to you.” What action should nurse take? a. Invite the interrupting patient to join in the session with the current patient. b. Tell the interrupting patient, “I am not available to talk with you at the present time.” c. End the unproductive session with the current patient and spend time with the interrupting patient. d. Tell the interrupting patient, “This session is 5 more minutes; then I will talk with you.”

Answer 36

ANS: D When a specific duration for sessions has been set, the nurse must adhere to the schedule. Leaving the first patient would be equivalent to abandonment and would destroy any trust the patient had in the nurse. Adhering to the contract demonstrates that the nurse can be trusted, and that the patient and the sessions are important. The incorrect responses preserve the nurse–patient relationship with the silent patient but may seem abrupt to the interrupting patient, abandon the silent patient, or fail to observe the contract with the silent patient.

Question 37

Termination of a therapeutic nurse–patient relationship has been successful when the nurse engages in what activity? a. Avoids upsetting the patient by shifting focus to other patients before the discharge. b. Gives the patient a personal telephone number and permission to call after discharge. c. Discusses with the patient changes that happened during the relationship and evaluates outcomes. d. Offers to meet the patient for coffee and conversation three times a week after discharge. .

Answer 37

ANS: C Summarizing and evaluating progress help validate the experience for the patient and the nurse and facilitate closure. Termination must be discussed; avoiding discussion by spending little time with the patient promotes feelings of abandonment. Successful termination requires that the relationship be brought to closure without the possibility of dependency-producing ongoing contact

Question 38

What behaviors will the patient demonstrate as desirable outcomes for the orientation stage of a nurse–patient relationship? a. Self-responsibility and autonomy. b. A greater sense of independence. c. Rapport and trust with the nurse. d. Resolved transference.

Answer 38

ANS: C Development of rapport and trust is necessary before the relationship can progress to the working phase. Behaviors indicating a greater sense of independence, self-responsibility, and resolved transference occur in the working phase.

Question 39

During which phase of the nurse–patient relationship can the nurse anticipate that the patient’s identified issues will be explored and resolved? a. Preorientation b. Orientation c. Working d. Termination ANS: C During the working phase, the nurse strives to assist the patient in making connections among dysfunctional behaviors, thinking, and emotions and offers support while alternative coping behaviors are tried.

Question 40

During which phase of the nurse–patient relationship can the nurse anticipate that the patient’s identified issues will be explored and resolved? a. Preorientation b. Orientation c. Working d. Termination

Answer 40

ANS: C During the working phase, the nurse strives to assist the patient in making connections among dysfunctional behaviors, thinking, and emotions and offers support while alternative coping behaviors are tried.

Question 41

. At what point in the nurse–patient relationship should a nurse plan to first address termination? a. During the orientation phase b. At the end of the working phase c. Near the beginning of the termination phase d. When the patient initially brings up the topic

Answer 41

ANS: A The patient has a right to know the conditions of the nurse–patient relationship. If the relationship is to be time-limited, the patient should be informed of the number of sessions. If it is open-ended, the termination date will not be known at the outset, and the patient should know that the issue will be negotiated at a later date. The nurse is responsible for bringing up the topic of termination early in the relationship, usually during the orientation phase.

Question 42

Why does the nurse introduces the matter of a contract during the first session with a new patient? a. To specify what the nurse will do for the patient. b. To spell out the participation and responsibilities of each party. c. To indicate the feeling tone established between the participants. d. To prevent either party from prematurely ending the relationship.

Answer 42

ANS: B A contract emphasizes that the nurse works with the patient rather than doing something for the patient. “Working with” is a process that suggests each party is expected to participate and share responsibility for outcomes. Contracts do not, however, stipulate roles or feeling tone, and premature termination is forbidden.

Question 43

As a nurse escorts a patient being discharged after treatment for major depression, the patient gives the nurse a necklace with a heart pendant and says, “Thank you for helping mend my broken heart.” Which is the nurse’s best response? a. “Accepting gifts violates the policies and procedures of the facility.” b. “I’m glad you feel so much better now. Thank you for the beautiful necklace.” c. “I’m glad I could help you, but I can’t accept the gift. My reward is seeing you with a renewed sense of hope.” d. “Helping people is what nursing is all about. It’s rewarding to me when patients recognize how hard we work.”

Answer 43

ANS: C Accepting a gift creates a social rather than therapeutic relationship with the patient and blurs the boundaries of the relationship. A caring nurse will acknowledge the patient’s gesture of appreciation, but the gift should not be accepted. See relationship to audience response question.

Question 44

Which remark by a patient indicates passage from orientation to the working phase of a nurse– patient relationship? a. “I don’t have any problems.” b. “It is so difficult for me to talk about problems.” c. “I don’t know how it will help to talk to you about my problems.” d. “I want to find a way to deal with my anger without becoming violent.”

Answer 44

ANS: D Thinking about a more constructive approach to dealing with anger indicates a readiness to make a behavioral change. Behavioral change is associated with the working phase of the relationship. Denial is often seen in the orientation phase. It is common early in the relationship, before rapport and trust are firmly established, for a patient to express difficulty in talking about problems. Stating skepticism about the effectiveness of the nurse–patient relationship is more typically a reaction during the orientation phase.

Question 45

What is the best explanation a nurse can give to the family of a mentally ill patient regarding how a nurse–patient relationship differs from social relationships? a. “The focus is on the patient. Problems are discussed by the nurse and patient, but solutions are implemented by the patient.” b. “The focus shifts from nurse to patient as the relationship develops. Advice is given by both, and solutions are implemented.” c. “The focus of the relationship is socialization. Mutual needs are met, and feelings are shared openly.” d. “The focus is creation of a partnership in which each member is concerned with growth and satisfaction of the other.”

Answer 45

ANS: A Only the correct response describes elements of a therapeutic relationship. The remaining responses describe events that occur in social or intimate relationships

Question 46

What action should a nurse take to demonstrate genuineness with a patient diagnosed with schizophrenia? a. Restate what the patient says. b. Use congruent communication strategies. c. Use self-revelation in patient interactions. d. Consistently interpret the patient’s behaviors.

Answer 46

behaviors. ANS: B Genuineness is a desirable characteristic involving awareness of one’s own feelings as they arise and the ability to communicate them when appropriate. The incorrect options are undesirable in a therapeutic relationship.

Question 47

A nurse caring for a withdrawn, suspicious patient recognizes development of feelings of anger toward the patient. The nurse should take what action? a. Suppress the angry feelings. b. Express the anger openly and directly with the patient. c. Ask the nurse manager to assign the patient to another nurse. d. Discuss the anger with a clinician during a supervisory session. ANS: D The nurse is accountable for the relationship. Objectivity is threatened by strong positive or negative feelings toward a patient. Supervision is necessary to work through countertransference feelings. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Evaluation MSC: Client Needs: Psychosocial Integrity 16. A nurse wants to enhance growth of a patient by showing positive regard. What nursing action most likely achieve this goal? a. Making rounds daily. b. Staying with a tearful patient. c. Administering medication as prescribed. d. Examining personal feelings about a patient. ANS: B Staying with a crying patient offers support and shows positive regard. Administering daily medication and making rounds are tasks that could be part of an assignment and do not necessarily reflect positive regard. Examining feelings regarding a patient addresses the nurse’s ability to be therapeutic. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity 17. When a patient says, “I’ve done a lot of cheating and manipulating in my relationships.”, what nonjudgmental response should the nurse provide? a. “How do you feel about that?” b. “I am glad that you realize this.” c. “That’s not a good way to behave.” d. “Have you outgrown that type of behavior?” ANS: A Asking a patient to reflect on feelings about his or her actions does not imply any judgment about those actions, and it encourages the patient to explore feelings and values. The remaining options offer negative judgments. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity 18. A patient says, “People should be allowed to commit suicide without interference from others.” A nurse replies, “You’re wrong. Nothing is bad enough to justify death.” What is the best analysis of this interchange? a. The patient is correct. b. The nurse is correct. c. Neither person is correct. d. Differing values are reflected in the two statements. ANS: D Values guide beliefs and actions. The individuals stating their positions place different values on life and autonomy. Nurses must be aware of their own values and be sensitive to the values of others. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Evaluation MSC: Client Needs: Psychosocial Integrity 19. Which issues should a nurse address during the first interview with a patient diagnosed with a psychiatric disorder? a. Trust, congruence, attitudes, and boundaries b. Goals, resistance, unconscious motivations, and diversion c. Relationship parameters, the contract, confidentiality, and termination d. Transference, countertransference, intimacy, and developing resources ANS: C Relationship parameters, the contract, confidentiality, and termination are issues that should be considered during the orientation phase of the relationship. The remaining options are issues that are dealt with later. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity 20. An advanced practice nurse observes a novice nurse expressing irritability regarding a patient with a long history of alcoholism and suspects the new nurse is experiencing countertransference. Which comment by the new nurse confirms this suspicion? a. “This patient continues to deny problems resulting from drinking.” b. “My parents were alcoholics and often neglected our family.” c. “The patient cannot identify any goals for improvement.” d. “The patient said I have many traits like her mother.” ANS: B Countertransference occurs when the nurse unconsciously and inappropriately displaces onto the patient feelings and behaviors related to significant figures in the nurse's past. In this instance, the new nurse’s irritability stems from relationships with parents. The distracters indicate transference or accurate analysis of the patient’s behavior. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 21. Which behavior shows that a nurse values autonomy? a. Suggesting one-on-one supervision for a patient who has suicidal thoughts. b. Informing a patient that the spouse will not be in during visiting hours. c. discussing options and helps the patient weigh the consequences. d. Setting limits on a patient’s romantic overtures toward the nurse. ANS: C A high level of valuing is acting on one’s belief. Autonomy is supported when the nurse helps a patient weigh alternatives and their consequences before the patient makes a decision. Autonomy or self-determination is not the issue in any of the other behaviors. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Evaluation MSC: Client Needs: Safe, Effective Care Environment 22. As a nurse discharges a patient, the patient gives the nurse a card of appreciation made in an arts and crafts group. What is the nurse’s best action? a. Recognize the effectiveness of the relationship and patient’s thoughtfulness. Accept the card. b. Inform the patient that accepting gifts violates policies of the facility. Decline the card. c. Acknowledge the patient’s transition through the termination phase but decline the card. d. Accept the card and invite the patient to return to participate in other arts and crafts groups. ANS: A The nurse must consider the meaning, timing, and value of the gift. In this instance, the nurse should accept the patient’s expression of gratitude. See relationship to audience response question. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Evaluation MSC: Client Needs: Safe, Effective Care Environment 23. A patient says, “I’m still on restriction, but I want to attend some off-unit activities. Would you ask the doctor to change my privileges?” What is the nurse’s best response? a. “Why are you asking me when you’re able to speak for yourself?” b. “I will be glad to address it when I see your doctor later today.” c. “That’s a good topic for you to discuss with your doctor.” d. “Do you think you can’t speak to a doctor?” ANS: C Nurses should encourage patients to work at their optimal level of functioning, which in turn promotes autonomy. A nurse does not act for the patient unless it is necessary. Acting for a patient increases feelings of helplessness and dependency. PTS: 1 DIF: Cognitive Level: Apply (Application)

Answer 47

ANS: D The nurse is accountable for the relationship. Objectivity is threatened by strong positive or negative feelings toward a patient. Supervision is necessary to work through countertransference feelings.

Question 48

A nurse wants to enhance growth of a patient by showing positive regard. What nursing action most likely achieve this goal? a. Making rounds daily. b. Staying with a tearful patient. c. Administering medication as prescribed. d. Examining personal feelings about a patient.

Answer 48

ANS: B Staying with a crying patient offers support and shows positive regard. Administering daily medication and making rounds are tasks that could be part of an assignment and do not necessarily reflect positive regard. Examining feelings regarding a patient addresses the nurse’s ability to be therapeutic.

Question 49

1A patient says, “People should be allowed to commit suicide without interference from others.” A nurse replies, “You’re wrong. Nothing is bad enough to justify death.” What is the best analysis of this interchange? a. The patient is correct. b. The nurse is correct. c. Neither person is correct. d. Differing values are reflected in the two statements.

Answer 49

ANS: D Values guide beliefs and actions. The individuals stating their positions place different values on life and autonomy. Nurses must be aware of their own values and be sensitive to the values of others.

Question 50

When a patient says, “I’ve done a lot of cheating and manipulating in my relationships.”, what nonjudgmental response should the nurse provide? a. “How do you feel about that?” b. “I am glad that you realize this.” c. “That’s not a good way to behave.” d. “Have you outgrown that type of behavior?”

Answer 50

ANS: A Asking a patient to reflect on feelings about his or her actions does not imply any judgment about those actions, and it encourages the patient to explore feelings and values. The remaining options offer negative judgments.

Question 51

Which issues should a nurse address during the first interview with a patient diagnosed with a psychiatric disorder? a. Trust, congruence, attitudes, and boundaries b. Goals, resistance, unconscious motivations, and diversion c. Relationship parameters, the contract, confidentiality, and termination d. Transference, countertransference, intimacy, and developing resources

Answer 51

ANS: C Relationship parameters, the contract, confidentiality, and termination are issues that should be considered during the orientation phase of the relationship. The remaining options are issues that are dealt with later.

Question 52

Which issues should a nurse address during the first interview with a patient diagnosed with a psychiatric disorder? a. Trust, congruence, attitudes, and boundaries b. Goals, resistance, unconscious motivations, and diversion c. Relationship parameters, the contract, confidentiality, and termination d. Transference, countertransference, intimacy, and developing resources

Answer 52

ANS: C Relationship parameters, the contract, confidentiality, and termination are issues that should be considered during the orientation phase of the relationship. The remaining options are issues that are dealt with later.

Question 53

An advanced practice nurse observes a novice nurse expressing irritability regarding a patient with a long history of alcoholism and suspects the new nurse is experiencing countertransference. Which comment by the new nurse confirms this suspicion? a. “This patient continues to deny problems resulting from drinking.” b. “My parents were alcoholics and often neglected our family.” c. “The patient cannot identify any goals for improvement.” d. “The patient said I have many traits like her mother.”

Answer 53

ANS: B Countertransference occurs when the nurse unconsciously and inappropriately displaces onto the patient feelings and behaviors related to significant figures in the nurse's past. In this instance, the new nurse’s irritability stems from relationships with parents. The distracters indicate transference or accurate analysis of the patient’s behavior.

Question 54

Which behavior shows that a nurse values autonomy? a. Suggesting one-on-one supervision for a patient who has suicidal thoughts. b. Informing a patient that the spouse will not be in during visiting hours. c. discussing options and helps the patient weigh the consequences. d. Setting limits on a patient’s romantic overtures toward the nurse.

Answer 54

. ANS: C A high level of valuing is acting on one’s belief. Autonomy is supported when the nurse helps a patient weigh alternatives and their consequences before the patient makes a decision. Autonomy or self-determination is not the issue in any of the other behaviors

Question 55

Which behavior shows that a nurse values autonomy? a. Suggesting one-on-one supervision for a patient who has suicidal thoughts. b. Informing a patient that the spouse will not be in during visiting hours. c. discussing options and helps the patient weigh the consequences. d. Setting limits on a patient’s romantic overtures toward the nurse.

Answer 55

ANS: C A high level of valuing is acting on one’s belief. Autonomy is supported when the nurse helps a patient weigh alternatives and their consequences before the patient makes a decision. Autonomy or self-determination is not the issue in any of the other behaviors.

Question 56

As a nurse discharges a patient, the patient gives the nurse a card of appreciation made in an arts and crafts group. What is the nurse’s best action? a. Recognize the effectiveness of the relationship and patient’s thoughtfulness. Accept the card. b. Inform the patient that accepting gifts violates policies of the facility. Decline the card. c. Acknowledge the patient’s transition through the termination phase but decline the card. d. Accept the card and invite the patient to return to participate in other arts and crafts groups.

Answer 56

ANS: A The nurse must consider the meaning, timing, and value of the gift. In this instance, the nurse should accept the patient’s expression of gratitude. See relationship to audience response question.

Question 57

A patient says, “I’m still on restriction, but I want to attend some off-unit activities. Would you ask the doctor to change my privileges?” What is the nurse’s best response? a. “Why are you asking me when you’re able to speak for yourself?” b. “I will be glad to address it when I see your doctor later today.” c. “That’s a good topic for you to discuss with your doctor.” d. “Do you think you can’t speak to a doctor?”

Answer 57

ANS: C Nurses should encourage patients to work at their optimal level of functioning, which in turn promotes autonomy. A nurse does not act for the patient unless it is necessary. Acting for a patient increases feelings of helplessness and dependency.

Question 58

A community mental health nurse has worked with a patient for 3 years but is moving out of the city and terminates the relationship. When a novice nurse begins work with this patient, what is the starting point for the relationship? a. Begin at the orientation phase. b. Resume the working relationship. c. Initially establish a social relationship. d. Return to the emotional catharsis phase.

Answer 58

ANS: A After termination of a long-term relationship, the patient and new nurse usually have to begin at ground zero, the orientation phase, to build a new relationship. If termination is successfully completed, the orientation phase sometimes progresses quickly to the working phase. Other times, even after successful termination, the orientation phase may be prolonged.

Question 59

As a patient diagnosed with a mental illness is being discharged from a facility, a nurse invites the patient to the annual staff picnic. What is the best analysis of this scenario? a. The invitation facilitates dependency on the nurse. b. The nurse’s action blurs the boundaries of the therapeutic relationship. c. The invitation is therapeutic for the patient’s diversional activity deficit. d. The nurse’s action assists the patient’s integration into community living.

Answer 59

ANS: B The invitation creates a social relationship rather than a therapeutic relationship.

Question 60

Which comment best indicates that a patient perceived the nurse was caring? a. “My nurse always asks me which type of juice I want to help me swallow my medication.” b. “My nurse explained my treatment plan to me and asked for my ideas about how to make it better.” c. “My nurse spends time listening to me talk about my problems. That helps me feel like I am not alone.” d. “My nurse told me that if I take all the medicines I’m prescribed, then I will get discharged sooner.”

Answer 60

ANS: C Caring evidences empathetic understanding as well as competency. It helps change pain and suffering into a shared experience, creating a human connection that alleviates feelings of isolation. The distracters give examples of statements that demonstrate advocacy or giving advice.

Question 61

A nurse says, “I am the only one who truly understands this patient. Other staff members are too critical.” The nurse’s statement indicates what nursing concept? a. Boundary blurring. b. Sexual harassment. c. Countertransference d. Empathy

Answer 61

ANS: A When the role of the nurse and the role of the patient shift, boundary blurring may arise. In this situation the nurse is becoming overinvolved with the patient as a probable result of unrecognized countertransference. When boundary issues occur, the need for supervision exists. The situation does not describe sexual harassment. Data are not present to suggest countertransference or empathy.

Question 62

A nurse ends a relationship with a patient. Which actions by the nurse should be included in the termination phase? (Select all that apply.) a. Focus dialogues with the patient on problems that may occur in the future. b. Help the patient express feelings about the relationship with the nurse. c. Help the patient prioritize and modify socially unacceptable behaviors. d. Reinforce expectations regarding the parameters of the relationship. e. Help the patient to identify strengths, limitations, and problems.

Answer 62

ANS: A, B The correct actions are part of the termination phase. The other actions would be used in the working and orientation phases.

Question 63

Which comment best indicates that a patient perceived the nurse was caring? a. “My nurse always asks me which type of juice I want to help me swallow my medication.” b. “My nurse explained my treatment plan to me and asked for my ideas about how to make it better.” c. “My nurse spends time listening to me talk about my problems. That helps me feel like I am not alone.” d. “My nurse told me that if I take all the medicines I’m prescribed, then I will get discharged sooner.”

Answer 63

.” ANS: C Caring evidences empathetic understanding as well as competency. It helps change pain and suffering into a shared experience, creating a human connection that alleviates feelings of isolation. The distracters give examples of statements that demonstrate advocacy or giving advice

Question 64

A client says to the nurse, “I dreamed I was stoned. When I woke up, I felt emotionally drained, as though I hadn’t rested well.” Which response should the nurse use to clarify the client’s comment? a. “It sounds as though you were uncomfortable with the content of your dream.” b. “I understand what you’re saying. Bad dreams leave me feeling tired, too.” c. “So you feel as though you did not get enough quality sleep last night?” d. “Can you give me an example of what you mean by ‘stoned’?”

Answer 64

ANS: D The technique of clarification is therapeutic and helps the nurse examine the meaning of the client’s statement. Asking for a definition of “stoned” directly asks for clarification. Restating that the client is uncomfortable with the dream’s content is parroting, a nontherapeutic technique. The other responses fail to clarify the meaning of the client’s comment.

Question 65

A client diagnosed with schizophrenia tells the nurse, “The Central Intelligence Agency is monitoring us through the fluorescent lights in this room. The CIA is everywhere, so be careful what you say.” Which response by the nurse is most therapeutic? a. “Let’s talk about something other than the CIA.” b. “It sounds like you’re concerned about your privacy.” c. “The CIA is prohibited from operating in health care facilities.” d. “You have lost touch with reality, which is a symptom of your illness.”

Answer 65

” ANS: B It is important not to challenge the client’s beliefs, even if they are unrealistic. Challenging undermines the client’s trust in the nurse. The nurse should try to understand the underlying feelings or thoughts the client’s message conveys. The correct response uses the therapeutic technique of reflection. The other comments are nontherapeutic. Asking to talk about something other than the concern at hand is changing the subject. Saying that the CIA is prohibited from operating in health care facilities gives false reassurance. Stating that the client has lost touch with reality is truthful but uncompassionate.

Question 66

The client says, “My marriage is just great. My spouse and I always agree.” The nurse observes the client’s foot moving continuously as the client twirls a shirt button. What conclusion can the nurse draw about the client’s statement? a. It is clear. b. It may be distorted. c. It is incongruous. d. It is inadequate.

Answer 66

ANS: C The client’s verbal and nonverbal communication in this scenario are incongruous. Incongruous messages involve transmission of conflicting messages by the speaker. The client’s verbal message that all was well in the relationship was modified by the nonverbal behaviors denoting anxiety. Data are not present to support the choice of the verbal message being clear, distorted, or inadequate.

Question 67

A nurse interacts with a newly hospitalized client. Which of the nurse’s comments applies the communication technique of “offering self?” a. “I’ve also had traumatic life experiences. Maybe it would help if I told you about them.” b. “Why do you think you had so much difficulty adjusting to this change in your life?” c. “I hope you will feel better after getting accustomed to how this unit operates.” d. “I’d like to sit with you for a while to help you get comfortable talking to me.”

Answer 67

ANS: D “Offering self” is a technique that should be used in the orientation phase of the nurse–client relationship. Sitting with the client, an example of “offering self,” helps to build trust and convey that the nurse cares about the client. Two incorrect responses are ineffective and nontherapeutic. The other incorrect response is therapeutic but is an example of “offering hope.”

Question 68

Which technique will best communicate to a client that the nurse is interested in listening? a. Restating a feeling or thought the client has expressed. b. Asking a direct question, such as “Did you feel angry?” c. Making a judgment about the client’s problem. d. Saying, “I understand what you’re saying.”

Answer 68

ANS: A Restating allows the client to validate the nurse’s understanding of what has been communicated. Restating is an active listening technique. Judgments should be suspended in a nurse–client relationship. Close-ended questions such as “Did you feel angry?” ask for specific information rather than showing understanding. When the nurse simply states that he or she understands the client’s words, the client has no way of measuring the understanding.

Question 69

6. A client discloses several concerns and associated feelings. If the nurse wants to seek clarification, which comment would be appropriate? a. “What are the common elements here?” b. “Tell me again about your experiences.” c. “Am I correct in my understanding of that?” d. “Tell me everything from the beginning.”

Answer 69

ANS: C Asking, “Am I correct in my understanding of that ?” permits clarification to ensure that both the nurse and client share mutual understanding of the communication. Asking about common elements encourages comparison rather than clarification. The remaining responses are implied questions that suggest the nurse was not listening.

Question 70

A client tells the nurse, “I don’t think I’ll ever get out of here.” What is the nurse’s most therapeutic response? a. “Don’t talk that way. Of course, you will leave here!” b. “Keep up the good work, and you certainly will.” c. “You don’t think you’re making progress?” d. “Everyone feels that way sometimes.”

Answer 70

ANS: C By asking if the client does not believe that progress has been made, the nurse is reflecting or paraphrasing by putting into words what the client is hinting. By making communication more explicit, issues are easier to identify and resolve. The remaining options are nontherapeutic techniques. Telling the client not to “talk that way” is disapproving. Saying that everyone feels that way at times minimizes feelings. Telling the client that good work will always result in success is falsely reassuring.

Question 70

Documentation in a client’s chart states, “Throughout a 5-minute interaction, client fidgeted and tapped left foot, periodically covered face with hands, and looked under chair while stating, ‘I enjoy spending time with you.’” Which analysis is most accurate? a. The client is giving positive feedback about the nurse’s communication techniques. b. The nurse is viewing the client’s behavior through a cultural filter. c. The client’s verbal and nonverbal messages are incongruent. d. The client is demonstrating psychotic behaviors.

Answer 70

ANS: C When a verbal message is not reinforced with nonverbal behavior, the message is confusing and incongruent. It is inaccurate to say that the client is giving positive feedback about the nurse’s communication techniques. The concept of a cultural filter is not relevant to the situation because a cultural filter determines what we will pay attention to and what we will ignore. Data are insufficient to draw the conclusion that the client is demonstrating psychotic behaviors.

Question 71

While talking with a client diagnosed with major depressive disorder, a nurse notices the client is unable to maintain eye contact. The client’s chin lowers to the chest. The client looks at the floor. Which aspect of communication has the nurse assessed? a. Nonverbal communication b. A message filter c. A cultural barrier d. Social skills areassuring.

Answer 71

ANS: A Eye contact and body movements are considered nonverbal communication. There are insufficient data to determine the level of the client’s social skills or an existing cultural barrier.

Question 72

During the first interview with a parent whose child died in a car accident, the nurse feels empathic and reaches out to take the client’s hand. Select the correct analysis of the nurse’s behavior. a. It shows empathy and compassion. It will encourage the client to continue to express feelings. b. The gesture is premature. The client’s cultural and individual interpretation of touch is unknown. c. The client will perceive the gesture as intrusive and overstepping boundaries. d. The action is inappropriate. Psychiatric clients should not be touched.

Answer 72

ANS: B Touch has various cultural and individual interpretations. Nurses should refrain from using touch until an assessment is completed regarding the way in which the client will perceive touch. The incorrect options present prematurely drawn conclusions.

Question 73

During a one-on-one interaction with the nurse, a client frequently looks nervously at the door. What is the best comment by the nurse regarding this nonverbal communication? a. “I notice you keep looking toward the door.” b. “This is our time together. No one is going to interrupt us.” c. “It looks as if you are eager to end our discussion for today.” d. “If you are uncomfortable in this room, we can move someplace else.” .

Answer 73

ANS: A Making observations and encouraging the client to describe perceptions are useful therapeutic communication techniques for this situation. The other responses are assumptions made by the nurse.

Question 74

a client of color says to a Caucasian nurse, “There’s no sense talking about how I feel. You wouldn’t understand because you live in a white world.” What is the nurse’s best action ? a. Explain, “Yes, I do understand. Everyone goes through the same experiences.” b. Say, “Please give an example of something you think I wouldn’t understand.” c. Reassure the client that nurses interact with people from all cultures. d. Change the subject to one that is less emotionally disturbing.

Answer 74

ANS: B Having the client speak in specifics rather than globally will help the nurse understand the client’s perspective. This approach will help the nurse engage the client. Reassurance and changing the subject are not therapeutic techniques.

Question 75

A newly immigrated client had a nursing diagnosis of situational low self-esteem related to poor social skills as evidenced by lack of eye contact. Interventions were applied to increase the client’s self-esteem but after 3 weeks, the client’s eye contact did not improve. What is the most accurate analysis of this scenario? a. The client’s eye contact should have been directly addressed by role playing to increase comfort with eye contact. b. The nurse should not have independently embarked on assessment, diagnosis, and planning for this client. c. The client’s poor eye contact is indicative of anger and hostility that were unaddressed. d. The nurse should have assessed the client’s culture before making this diagnosis and plan.

Answer 75

ANS: D The amount of eye contact a person engages in is often culturally determined. In some cultures, eye contact is considered insolent, whereas in others eye contact is expected.

Question 76

When a specific client and the nurse sit together, the client often holds the nurse’s hand. The client also links arms with the nurse when they walk. The nurse is uncomfortable with this behavior. Which analysis is most accurate? a. The client is accustomed to touch during conversation, as are members of many ethnic subcultures. b. The client understands that touch makes the nurse uncomfortable and controls the relationship based on that factor. c. The client is afraid of being alone. When touching the nurse, the client is reassured and comforted. d. The client is trying to manipulate the nurse using nonverbal techniques.

Answer 76

ANS: A The most likely answer is that the client’s behavior is culturally influenced

Question 76

A ethnic client uses dramatic body language when describing emotional discomfort. Which analysis most likely explains the client’s behavior? a. This is a characteristic of a histrionic personality disorder. b. The client believes dramatic body language is sexually appealing. c. The client wishes to impress upon staff the degree of emotional pain they are experiencing. d. This may be a characteristic of a culture where dramatic body language is the norm.

Answer 76

ANS: D Members of Hispanic American subcultures tend to use high affect and dramatic body language as they communicate. The other options are more remote possibilities.

Question 77

During an interview, a client attempts to shift the focus from self to the nurse by asking personal questions. How should the nurse respond? a. “Why do you keep asking about me?” b. “Nurses direct the interviews with clients.” c. “Do not ask questions about my personal life.” d. “The time we spend together is to discuss your concerns.”

Answer 77

ANS: D When a client tries to focus on the nurse, the nurse should refocus the discussion back onto the client. Telling the client that interview time should be used to discuss client concerns refocuses discussion in a neutral way. Telling clients not to ask about the nurse’s personal life shows indignation. Saying that nurses prefer to direct the interview reflects superiority. “Why” questions are probing and nontherapeutic.

Question 78

Which principle should guide the nurse in determining the extent of silence to use during client interview sessions? a. A nurse is responsible for breaking silences. b. Clients withdraw if silences are prolonged. c. Silence can provide meaningful moments for reflection. d. Silence helps clients know that what they said was understood.

Answer 78

. ANS: C Silence can be helpful to both participants by giving each an opportunity to contemplate what has transpired, weigh alternatives, and formulate ideas.

Question 79

18. A client is having difficulty making a decision. The nurse has mixed feelings about whether to provide advice. Which principle regarding giving advise usually applies? a. It is rarely helpful. b. It tends to foster independence. c. It helps lift the burden of personal decision making. d. It helps the client develop feelings of personal adequacy.

Answer 79

ANS: A Giving advice fosters dependence on the nurse and interferes with a client’s right to make personal decisions. It robs the client of the opportunity to weigh alternatives and develop problem-solving skills. Furthermore, it may contribute to a client’s feelings of personal inadequacy. Giving advice also keeps the nurse in control and feeling powerful.

Question 80

A school age child tells the school nurse, “Other kids call me mean names and will not sit with me at lunch. Nobody likes me.” what is the nurse’s most therapeutic response? a. “Just ignore them and they will leave you alone.” b. “You should make friends with other children.” c. “Call them names if they do that to you.” d. “Tell me more about how you feel.”

Answer 80

ANS: D The correct response uses exploring, a therapeutic technique. The distracters give advice, a nontherapeutic technique.

Question 81

A client diagnosed with acute depression states, “God is punishing me for my past sins.” What is the nurse’s most therapeutic response? a. “You sound very upset about this.” b. “God always forgives us for our sins.” c. “Why do you think you are being punished?” d. “If you feel this way, you should talk to your minister.”

Answer 81

ANS: A The nurse reflects the client’s comment, a therapeutic technique to encourage sharing for perceptions and feelings. The incorrect responses reflect probing, closed-ended comments, and giving advice, all of which are nontherapeutic.

Question 82

A client cries as the nurse explores the client’s feelings about the death of a close friend. The client sobs, “I shouldn’t be crying like this. It happened a long time ago.” Which responses by the nurse facilitate communication? (Select all that apply.) a. “Why do you think you are so upset?” b. “I can see that you feel sad about this situation.” c. “The loss of a close friend is very painful for you.” d. “Crying is a way of expressing the hurt you are experiencing.” e. “Let’s talk about something else because this subject is upsetting you.”

Answer 82

ANS: B, C, D Reflecting (“I can see that you feel sad,” “This is very painful for you”) and giving information (“Crying is a way of expressing hurt”) are therapeutic techniques. “Why” questions often imply criticism or seem intrusive or judgmental. They are difficult to answer. Changing the subject is a barrier to communication.

Question 82

Which benefits are most associated with use of telehealth technologies? (Select all that apply.) a. Cost savings for clients b. Maximize care management c. Access to services for clients in rural areas d. Prompt reimbursement by third-party payers e. Rapid development of trusting relationships with clients

Answer 82

ANS: A, B, C Telehealth has shown that it can maximize health and improve disease management skills and confidence with the disease process. Many rural parents have felt disconnected from services; telehealth technologies can solve those problems. Although telehealth’s improved health outcomes regularly show cost savings for payers, one significant barrier is the current lack of reimbursement for remote client monitoring by third-party payers. Telehealth technologies have not shown rapid development of trusting relationships.

Question 83

Which comments by a nurse demonstrate use of therapeutic communication techniques? (Select all that apply.) a. “Why do you think these events have happened to you?” b. “There are people with problems much worse than yours.” c. “I’m glad you were able to tell me how you felt about your loss.” d. “I noticed your hands trembling when you told me about your accident.” e. “You look very nice today. I’m proud you took more time with your appearance.”

Answer 83

ANS: C, D The correct responses demonstrate use of the therapeutic techniques making an observation and showing empathy. The incorrect responses demonstrate minimizing feelings, probing, and giving approval, which are nontherapeutic techniques.

Question 84

A nurse interacts with clients diagnosed with various mental illnesses. Which statements reflect the use of therapeutic communication? (Select all that apply.) a. “Tell me more about that situation.” b. “Let’s talk about something else.” c. “I notice you are pacing a lot.” d. “I’ll stay with you a while.” e. “Why did you do that?”

Answer 84

ANS: A, C, D The correct responses demonstrate use of the therapeutic techniques making an observation and showing empathy. The incorrect responses demonstrate changing the subject and probing, which are nontherapeutic techniques

Question 85

A client has acute anxiety related to an automobile accident 2 hours ago. The nurse should teach the client about medication from which group? a. Tricyclic antidepressants b. Antipsychotic drugs c. Mood stabilizers d. Benzodiazepines

Answer 85

ANS: D Benzodiazepines provide anxiety relief. Tricyclic antidepressants are used to treat symptoms of depression. Mood stabilizers are used to treat bipolar disorder. Antipsychotic drugs are used to treat psychosis.

Question 86

A nurse plans health teaching for a client diagnosed with generalized anxiety disorder who begins a new prescription for lorazepam. What information should be included? (Select all that apply.) a. Caution in use of machinery b. Foods allowed on a tyramine-free diet c. The importance of caffeine restriction d. Avoidance of alcohol and other sedatives e. Take the medication on an empty stomach

Answer 86

ANS: A, C, D Caffeine is a central nervous system stimulant that acts as an antagonist to the benzodiazepine lorazepam. Daily caffeine intake should be reduced to the amount contained in one cup of coffee. Benzodiazepines are sedatives, thus the importance of exercising caution when driving or using machinery and the importance of not using other central nervous system depressants such as alcohol or sedatives to avoid potentiation. Benzodiazepines do not require a special diet. Food will reduce gastric irritation from the medication

Question 87

Which prescription medication would the nurse expect to be prescribed for a client diagnosed with a somatic symptom disorder? a. Narcotic analgesics for use as needed for acute pain b. Antidepressant medications to treat co-morbid depression c. Long-term use of benzodiazepines to support coping with anxiety d. Conventional antipsychotic medications to correct cognitive distortions

Answer 87

ANS: B Various types of antidepressants may be helpful in somatic disorders not only directly by reducing depressive symptoms and hence somatic responses, but also indirectly by affecting nerve circuits that affect not only mood but also fatigue, pain perception, GI distress, and other somatic symptoms. Clients may benefit from short-term use of antianxiety medication (benzodiazepines) but require careful monitoring because of risks of dependence. Conventional antipsychotic medications would not be used, although selected atypical antipsychotics may be useful. Narcotic analgesics are not indicated.

Question 88

A person is prescribed sertraline 100 mg PO daily. Which change in sleep is likely secondary to this medication? a. More dreams. b. Excessive sleepiness. c. Less slow-wave sleep. d. Less rapid eye movement (REM) sleep.

Answer 88

ANS: D Sertraline is an SSRI antidepressant medication, which suppresses REM sleep. Dreams would decrease because they occur during REM. Benzodiazepines reduce slow-wave sleep. SSRIs have a side effect of insomnia.

Question 89

A client reports, “The medicine prescribed to help me get to sleep worked well for about a month, but I don’t have any more of those pills. Now my insomnia is worse than ever. I had nightmares the last 2 nights.” Which type of medication did the health care provider most likely prescribe? a. Benzodiazepine b. Tricyclic antidepressant c. Conventional antipsychotic d. Central nervous system (CNS) stimulant

Answer 89

ANS: A Benzodiazepines, members of the hypnotic’s family of medications, can worsen existing sleep disturbances when they are discontinued. This class of medications produces tolerance. Once the drug is discontinued, the individual may have rebound insomnia and nightmares. CNS stimulants worsen insomnia while they are in use. Tricyclic antidepressants and atypical antipsychotics may help insomnia but would not be used for initial therapy

Question 89

A hospitalized client diagnosed with alcohol use disorder believes the window blinds are snakes trying to get in the room. The client is anxious, agitated, and diaphoretic. The nurse can anticipate the health care provider will prescribe what medication intervention? a. narcotic analgesic, such as hydromorphone. b. sedative, such as lorazepam or chlordiazepoxide. c. antipsychotic, such as olanzapine or thioridazine. d. monoamine oxidase inhibitor antidepressant, such as phenelzine.

Answer 89

ANS: B Sedation allows for safe withdrawal from alcohol. Benzodiazepines are the drugs of choice in most regions because of their high therapeutic safety index and anticonvulsant properties. The client’s highest needs related to a need for calming.

Question 90

A client experiences a sudden episode of severe anxiety. Of these medications in the client’s medical record, which is most appropriate to give as a prn anxiolytic? a. buspirone b. lorazepam c. amitriptyline d. desipramine

Answer 90

ANS: B Lorazepam is a benzodiazepine used to treat anxiety. It may be given as a prn medication. Buspirone is long acting and is not useful as a prn drug. Amitriptyline and desipramine are tricyclic antidepressants and considered second- or third-line agents

Question 91

Consider these medications: carbamazepine, lamotrigine, gabapentin. Which medication below also belongs to this group? a. Galantamine b. Valproate c. Buspirone d. Tacrine

Answer 91

ANS: B The medications listed in the stem are mood stabilizers, anticonvulsant types. Valproate (Depakote) is also a member of this group. The distracters are drugs for treatment of Alzheimer’s disease and anxiety.

Question 91

A nurse can anticipate anticholinergic side effects are likely when a client is prescribed which medication? a. lithium. b. buspirone. c. imipramine. d. risperidone.

Answer 91

ANS: C Imipramine is a tricyclic antidepressant with strong anticholinergic properties, resulting in dry mouth, blurred vision, constipation, and urinary retention. Lithium therapy is more often associated with fluid-balance problems, including polydipsia, polyuria, and edema. Risperidone therapy is more often associated with movement disorders, orthostatic hypotension, and sedation. Buspirone is associated with anxiety reduction without major side effects

Question 92

19. A new antidepressant is prescribed for an elderly client diagnosed with major depressive disorder, but the dose is more than the usual geriatric dose. What action should the nurse take? a. Consult a reliable drug reference b. Teach the client about possible side effects and adverse effects. c. Withhold the medication and confer with the health care provider. d. Encourage the client to increase oral fluids to reduce drug concentration.

Answer 92

ANS: C The dose of antidepressants for elderly clients is often less than the usual adult dose. The nurse should withhold the medication and consult the health care provider who wrote the order. The nurse’s duty is to practice according to professional standards as well as intervene and protect the client.

Question 92

A client has acute anxiety related to an automobile accident 2 hours ago. The nurse should teach the client about medication from which group? a. Tricyclic antidepressants b. Antipsychotic drugs c. Mood stabilizers d. Benzodiazepines

Answer 92

ANS: D Benzodiazepines provide anxiety relief. Tricyclic antidepressants are used to treat symptoms of depression. Mood stabilizers are used to treat bipolar disorder. Antipsychotic drugs are used to treat psychosis.

Question 92

A client diagnosed with major depressive disorder began taking a tricyclic antidepressant 1 week ago. Today the client says, “I don’t think I can keep taking these pills. They make me so dizzy, especially when I stand up.” The nurse will implement which intervention? a. limit the client’s activities to those that can be performed in a sitting position. b. withhold the drug, force oral fluids, and notify the health care provider. c. teach the client strategies to manage postural hypotension. d. update the client’s mental status examination.

Answer 92

ANS: C Drowsiness, dizziness, and postural hypotension usually subside after the first few weeks of therapy with tricyclic antidepressants. Postural hypotension can be managed by teaching the client to stay well hydrated and rise slowly. Knowing this information may convince the client to continue the medication. Activity is an important aspect of the client’s treatment plan and should not be limited to activities that can be done in a sitting position. Withholding the drug, forcing

Question 93

A nurse provided medication education for a client diagnosed with major depressive disorder who began a new prescription for phenelzine. Which behavior indicates effective learning? The client a. monitors sodium intake and weight daily. b. wears support stockings and elevates the legs when sitting. c. can identify foods with high selenium content that should be avoided. d. confers with a pharmacist when selecting over-the-counter medications.

Answer 93

ANS: D Over-the-counter medicines may contain vasopressor agents or tyramine, a substance that must be avoided when the client takes MAOI antidepressants. Medications for colds, allergies, or congestion or any preparation that contains ephedrine or phenylpropanolamine may precipitate a hypertensive crisis. MAOI antidepressant therapy is unrelated to the need for sodium limitation, support stockings, or leg elevation. MAOIs interact with tyramine-containing foods, not selenium, to produce dangerously high blood pressure.

Question 94

Client experiences a sudden episode of severe anxiety. Of these medications in the client’s medical record, which is most appropriate to give as a prn anxiolytic? a. buspirone b. lorazepam c. amitriptyline d. desipramine

Answer 94

ANS: B Lorazepam is a benzodiazepine used to treat anxiety. It may be given as a prn medication. Buspirone is long acting and is not useful as a prn drug. Amitriptyline and desipramine are tricyclic antidepressants and considered second- or third-line agents

Question 95

Which prescription medication would the nurse expect to be prescribed for a client diagnosed with a somatic symptom disorder? a. Narcotic analgesics for use as needed for acute pain b. Antidepressant medications to treat co-morbid depression c. Long-term use of benzodiazepines to support coping with anxiety d. Conventional antipsychotic medications to correct cognitive distortions

Answer 95

ANS: B Various types of antidepressants may be helpful in somatic disorders not only directly by reducing depressive symptoms and hence somatic responses, but also indirectly by affecting nerve circuits that affect not only mood but also fatigue, pain perception, GI distress, and other somatic symptoms. Clients may benefit from short-term use of antianxiety medication (benzodiazepines) but require careful monitoring because of risks of dependence. Conventional antipsychotic medications would not be used, although selected atypical antipsychotics may be useful. Narcotic analgesics are not indicated.

Question 96

client reports, “The medicine prescribed to help me get to sleep worked well for about a month, but I don’t have any more of those pills. Now my insomnia is worse than ever. I had nightmares the last 2 nights.” Which type of medication did the health care provider most likely prescribe? a. Benzodiazepine b. Tricyclic antidepressant c. Conventional antipsychotic d. Central nervous system (CNS) stimulant

Answer 96

ANS: A Benzodiazepines, members of the hypnotic’s family of medications, can worsen existing sleep disturbances when they are discontinued. This class of medications produces tolerance. Once the drug is discontinued, the individual may have rebound insomnia and nightmares. CNS stimulants worsen insomnia while they are in use. Tricyclic antidepressants and atypical antipsychotics may help insomnia but would not be used for initial therapy.