Multichoice Flashcards
The client asks the nurse, “I’ve heard the student nurses talk about the nursing process. Why is there so much emphasis on using the nursing process?” The response that explains the need for nurses to understand and use the nursing process is
A. “Do you think you have a better method we might use?”
B. “The nursing process is a systematic problem-solving method encompassing all components necessary to care for clients.”
C. “Using the nursing process is a way of legitimising our profession and placing us on an equal footing with the pure sciences.”
D. “The nursing process is a one-dimensional, linear approach used to guide us as we make clinical judgments.”
B. “The nursing process is a systematic problem-solving method encompassing all components necessary to care for clients.”
A nurse planning care for an adolescent client will consider interventions that address the developmental task of
A. Developing a trusting relationship with older siblings
B. Achieving individuation from the parents
C. Mastering a competitive sport
D. Completing career goals
B. Achieving individuation from the parents
In planning care for a newly admitted client with depression, the highest priority for the nurse is:
A. Completing a physical health assessment
B. Encouraging expressions of feelings
C. Providing a safe environment
D. Meeting the client at an appropriate level
C. Providing a safe environment
A client with depression mentions to the nurse, “My mother says depression is a chemical disorder. What does she mean?” The nurses’ response is based on the theory that depression primarily involves the following neurotransmitters
A. Serotonin and dopamine
B. Cortisol and GABA
C. COMT and glutamate
D. Monoamine and glycine
A. Serotonin and dopamine
A person with depression is struggling to explore and solve a problem. The nurse determines that it would be therapeutic to offer alternatives. Which of the following approaches should the nurse use to achieve this objective?
A. “Have you thought of…?”
B. “You should…”
C. “Why don’t you…?”
D. “I think you need to…”
A. “Have you thought of…?”
Which piece of subjective data obtained during the nurse’s psychiatric assessment of a client experiencing severe anxiety would indicate the possibility of post traumatic stress disorder?
A. “I keep washing my hands over and over.”
B. “My legs feel weak most of the time.”
C. “I am afraid to go out in public.”
D. “I keep reliving the rape.”
D. “I keep reliving the rape.”
When a nurse has assessed a client as experiencing panic-level anxiety, an intervention that should be implemented immediately is to…
A. Teach relaxation techniques
B. Restrain the client
C. Reduce stimuli
D. Have the client walk up and down the corridor with nurse
C. Reduce stimuli
When assessing suicide risk, which nursing comment is most appropriate?
A. “Do you own a gun?”
B. “You say you won’t be around for much longer; tell me what that means.”
C. “Tell me about your lifestyle.”
D. “Have you written any suicide notes?”
B. “You say you won’t be around for much longer; tell me what that means.”
Which of the following risk principles should the nurse apply when assessing someone for risk of suicide?
A. Clients who attempt suicide and fail will not try again
B. The more specific the plan, the greater the risk for suicide
C. Clients who talk about suicide are less likely to attempt it
D. Clients who attempt suicide and fail do not really want to die
B. The more specific the plan, the greater the risk for suicide
Sally, 42 year old female client is admitted with a diagnosis of acute mania. Her husband states that she has not slept, eaten, or drunk for three days. In addition, he says she is very agitated and has been fighting with the neighbours. He also states that she stopped taking her lithium last week. The priority nursing diagnosis for the client would be
A. Risk to self
B. Risk of dehydration
C. Noncompliance with medication
D. Insomnia
A. Risk to self
Which symptom associated with thought flow is the nurse most likely to assess in a person experiencing mania?
A. Slow, halting speech
B. Flight of ideas
C. Thought blocking
D. Neologisms
B. Flight of ideas
Jonathon was taken off his previous medication (Clozapine) because it cause a life-threatening condition associated with Clozapine is
A. Agranulocytosis
B. Myelin absence
C. Retrocollis
D. Neuroleptic Malignant Syndrome
A. Agranulocytosis
Jonathon has been prescribed Risperidone, 2 mg BD. The nurse would assess neuroleptic malignant syndrome (NMS) if the client had a
A. 30mm Hg decrease in blood pressure reading
B. Respiratory rate of 24 respirations per minute
C. Temperature reading of 38 degrees C
D. Pulse rate of 70 beats per minute
C. Temperature reading of 38 degrees C
Client education for someone who has been prescribed lithium should include the following information:
A. They should discontinue it if they develop a fever or get the flu
B. They need to limit the amount of water they drink to 2L/day to reduce the risk of developing oedema
C. Lithium should be taken in the evening as it is sedating
D. They will need regular (3 monthly) blood tests to ensure levels are in the therapeutic range
D. They will need regular (3 monthly) blood tests to ensure levels are in the therapeutic range
Compulsory assessment and treatment can be considered for those who
A. Pose a serious danger to themselves or others
B. Are incapacitated by drug abuse
C. Are involved in criminal or delinquent behaviour
D. Are severely intellectually disabled
A. Pose a serious danger to themselves or others
To diagnose an intellectual disability, professionals look at both the person’s mental abilities (IQ) and his or her
A. Adaptive skills
B. Communication skills
C. Coping skills
D. Fine motor skills
A. Adaptive skills
One of the purposes of the Mental Health (Compulsory Assessment & Treatment) Act (1992) is to ensure
A. That assessment and treatment occur in the least restrictive environment
B. There is less abuse of the mentally ill
C. People have access to legal aid
D. That there is a standard definition of “Mental Disorder”
A. That assessment and treatment occur in the least restrictive environment
Adam has recently been admitted and diagnosed with Schizophrenia. He is very suspicious and finding it hard to trust people and the environment. When planning his care, what potential changes to Adam’s perceptual ability should you be aware of?
A. He will acknowledge that he is not functioning well
B. He will demonstrate limited insight
C. He will not understand what is being said to him
D. He may well misinterpret environmental stimuli
D. He may well misinterpret environmental stimuli
A newly admitted client is very tense and pacing. He is threatening to leave the unit and says, “You can’t keep me here. I have special powers to protect the world from aliens.” Which of the following interventions would be most helpful?
A. Decrease stimuli and offer him prn medication
B. Discuss problem-solving strategies for decreasing anxiety
C. Place the client in restraints
D. Teach him relaxation strategies
A. Decrease stimuli and offer him prn medication
Frequency and intensity ANSWER: A 19 year old woman is admitted and is acutely psychotic with a diagnosis of undifferentiated schizophrenia. She tells the nurse her thoughts cause earthquakes. The nurse assesses the primary symptom associated with the client’s condition as
A. Altered mood states
B. Disturbed thinking
C. Social isolation
D. Poor impulse control
B. Disturbed thinking
A client who on admission believed the CIA wished to kill him. After five days of hospitalisation with psychotropic medication, the client is interacting appropriately with the other clients and staff and states, “I know that thinking was pretty sick.” Based on the client’s statement, what evaluation can the nurse make?
A. The client is telling the staff what they wish to hear to gain discharge
B. The client is experiencing continuing negative responses to stress
C. Recent behaviour and statements are signs of returning mental health
D. Signs of mental disorder are increasing in frequency and intensity
C. Recent behaviour and statements are signs of returning mental health
Jonathon continues to voice delusional ideation. Which of the following interventions should the nurse plan to use to reduce his focus on delusional thinking?
A. Confronting the delusion
B. Focusing on feelings suggested by the delusion
C. Refuting the delusion with logic
D. Exploring reasons the client has the delusion
B. Focusing on feelings suggested by the delusion
Jonathon presents to the emergency department with a broken leg. He comments to the nurse, “God told me he would protect me from harm, but the devil broke my leg anyway”. This statement would be included in a mental status examination in which of the following categories?
A. Thought form
B. Thought content
C. Insight
D. Judgement
B. Thought content
Jonathon is observed muttering to himself and is hyper-vigilant. Which of the following nursing diagnosis is most appropriate for this?
A. Disturbed sleep
B. Disturbed sensory perception
C. Risk of violence
D. Ineffective coping
B. Disturbed sensory perception
The student nurse is learning how to reduce the stigma associated with mental illness. Which of the statements by the student nurse would reflect that learning has taken place?
A. “A 34 year old is being admitted for suicidal threats as a result of cocaine use.”
B. “We’re admitting a cocaine addict who threatened to kill herself.”
C. “We’re admitting an out-of-control, manic client”
D. “They’ve added another psychotic to my caseload
A. “A 34 year old is being admitted for suicidal threats as a result of cocaine use.”
At a neighbourhood meeting where a halfway house is being proposed for the neighbourhood, a member of the community states, “ We don’t want the facility. We don’t want violent people living near us.” The response by the nurse that best addresses the need to reduce stigma would be
A. “In truth clients living with a psychiatric disorder are more likely to be victims of crime.”
B. “We can give you training in how to defend yourselves so you will be more comfortable.”
C. “Clients with psychiatric disorder are so well medicated that they do not display violent behaviours.”
D. “After a few weeks, the neighbourhood will develop tolerance to this proposal.”
A. “In truth clients living with a psychiatric disorder are more likely to be victims of crime.”
What are the 9 principles of recovery
- Is borne of hope
- Is a journey defined by the individual
- Needs a supportive environment to thrive
- Involves individuals redefining who they are in the presence of a psychiatric label
- Is an active and ongoing process
- Is a non-linear journey
- Recovery skills can be learnt
- Involves a person educating themselves about their illness
- Learning to manage both internalised and external stigma and discrimination
Substance dependence is different to substance abuse. Substance dependence includes an acknowledgment of tolerance to the substance the person is using. Tolerance and be described as…
A. The need to increase the amount of substance the person uses, or there is a decrease in the desired effect that the substance gives
B. The family or whanau become more tolerant of the person’s use of the substances and there is a reduction in recurrent interpersonal communication and skills
C. There is a failure to fulfil major roles at work, school or home with repeated absences suspensions or expulsions
D. There is recurrent use in situations which are physically and psychologically harmful to the person
A. The need to increase the amount of substance the person uses, or there is a decrease in the desired effect that the substance gives
