Test 1 Study Flashcards
DSM 5TR
Diagnose mental disorders and provide description of illness.
A nurse is using the Clinical Judgment Action Model (CJAM) to guide a client’s care. Which of the following tasks is designed to facilitate the analysis of cues?
- Recognizing patterns
- Linking cues
- Determining what is concerning
- Determining the need for additional information
A nurse on an inpatient mental health unit is using the Clinical Judgment Action Model (CJAM) to guide their care of a client. Which of the following tasks should the nurse complete to generate solutions?
- Determine desired outcomes
- Determine the best solution based on evidence
- Determine what resources are needed, including people, equipment, and medications
A nurse is performing a mental status examination for a newly admitted client. Which of the following questions should the nurse include in the examination?
- “How would you describe your mood today?”
- “What is the date today?”
- “Can you please show me how to use this pen?
A group of nurses is discussing implementation of a plan of care for a client who has a mental illness. Which of the following nursing actions should be included when implementing a plan of care?
- Prioritize establishing a therapeutic relationship
- Focus on client-centered, holistic care rather than the client’s diagnosis
- Accurately document implementation of the plan of care
A nurse is discussing the continuum of care with a client. Which of the following information should the nurse include?
The continuum of care included different clinical settings, such as clinics and hospitals.
what is the purpose of the Family Assessment Device (FAD)
“The FAD is used to help assess family functioning, specifically to determine how the roles of the family work in the family dynamics.”
A nurse is caring for a client who is at risk for isolation. Which of the following is the best outcomes for this client?
The client will attend 3 groups per day by the end of the week
A nurse is caring for a client. Which of the following actions by the nurse demonstrates the evaluating outcomes step of the Clinical Judgment Action MOdel (CJAM)?
Revising the plan of care
A nurse is planning a presentation regarding mental illness for a local health fair. Which of the following should the nurse include as a characteristic of mental illlness?
difficulty maintaining social relationships
A nurse is caring for a client who is newly admitted to the acute psychiatric unit for alcohol use disorder. The client reports growing up in a Amish community. Which of the following actions should the nurse take?
Assess for personal bias related to alcohol use disorder before interacting with the client
A nurse is explaining what a “duty to warn” means to a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding?
“If the client threatens to harm another person, health care providers have a responsibility to inform that person.”
A nurse is caring for a client who reports that they are having a hard time completing their ADLs due to feeling anxious. The client also reports feeling tired, difficulty sleeping, and having a poor appetite. The nurse should anticipate they would fall in which end of the mental health continuum?
The client would fall closer towards the mental illness end or struggling.
A nurse is discussing ethical principles with another nurse. Which of the following should the nurse include as an example of the principle of nonmaleficence?
nurse evaluates the client’s desire for autonomy while considering the personal safety of other clients on the unit
A nurse is providing teaching to a group of newly licensed nurses about stigma. Which of the following client scenarios should the nurse include as an example of self-stigma
a client refuses to pick up their prescription for an antidepressant because they do not want the pharmacist to know that they are on an antidepressant
A newly licensed nurse is reviewing the American Nurses Association’s core professional values of nursing. Which of the following actions by the nurse demonstrates the value of empowerment
The nurse provides resources to the client who wants to create a living will before they have surgery
A nurse is reviewing the medical records of a group of clients. The nurse should identify that which of the following factors places a client at risk for mental illness?
A history of abuse
what is the ID
The id is often an area that is used for instant gratification
A nurse in a newly licensed nurse in a mental health facility are discussing the rules related to therapy. Which of the following intervention should the nurse discuss with the newly licensed nurse?
Ensuring a therapeutic nurse-client relationship with those on the unit
A nurse is explaining to a client who has a mental illness why mental health promotion is important. The nurse should inform the client that mental health promotion has a wide variety of benefits, including which of the following?
“mental health, promotion, promotes, positive mental health, which intern helps prevent you from missing work due to mental illness”
A nurse is planning to teach a client about behavioral therapy which of the following statements are the nurse plan to include?
Behavioral therapy is the type of psychotherapy that helps you modify your maladapter behavioral patterns
A nurse is caring for an adolescent, who has an adverse childhood experience and was admitted to the inpatient unit with behavioral problems. The nurse should anticipate the provider prescribing which of the following types of treatment.
Cognitive therapy
A nurse is caring for an older adult client who has major depressive disorder. The client states, I don’t think I am financially prepared for retirement, yet I am eligible to retire this year. The nurse should identify that the client is in which of the following stages of Erikson stages of development?
Ego integrity vs. despair
A nurse is explaining to a newly hired nurse how mental help promotion can be used for clients. Which of the following examples should the nurse use in the explanation? Select or that apply
Following suicide precautions for a client, assisting the client and using adaptive coping skills, allowing the client to use exercise equipment when becoming anxious in group therapy
A nurse is reinforcing teaching with a client about the purpose of psychoanalytic therapy. Which of the following statements should the nurse include in the teaching?
Psychoanalytic therapy helps. You see yourself as an individual and learn adaptive coping skills.
A nurse is planning care for a group of clients. Which of the following clients would benefit from cognitive behavioral therapy (CBT) ?
A client who has Tourette’s syndrome
Pre-Interaction Phase
The pre-interaction phase provides the nurse an opportunity to recognize the needs of the client. The nurse performs a self-evaluation of their beliefs and behaviors before engaging with the client.
Orientation Phase
The nurse collects data, assesses knowledge, and works with the client to develop mutual goals.
Working Phase
The working phase occurs when the nurse and client have established a mutual level of trust and comfort. This phase is when the client is more accepting of the nurse’s interventions and sees the nurse as a source of aid.
Termination Phase
In the termination phase, also known as the resolution phase, of the nurse-client relationship, the goals established in the orientation phase have been met, and new goals are developed. The client continues to build confidence in achieving goals and experiences an improvement in self-reliance.
Transference
Transference can be described as when a client experiences feelings or emotions from a person or object and displaces those feelings or emotions toward the nurse.
countertransference
countertransference is described as when the nurse experiences feelings or emotions from a person or object and displaces those feelings or emotions toward the client.
congruence
facial expressions match the mood
SOLER
is a type of nonverbal communication used by nurses
Affirmations
empowers the client to support healthy behavior change, such as, “You took your medications last night; you are making positive steps in treatment.”
A nurse is interviewing a client who states they are thinking about smoking cessation by using patches. Which of the following responses should
the nurse use to focus with the client?
…..
“What are some important topics in your life?”
“Smoking increases your chance for developing lung cancer.”
“This might not be the best method for you, but we can discuss some options that others have found to be helpful.”
“On a scale of 0 to 10, how confident are you that you could stop smoking if you tried right now?”
“This might not be the best method for you, but we can discuss some options that others have found to be helpful.”
A nurse is working in a mental health facility in an occupational role. Which of the following activities is a function of the occupational role of the nurse?
Reinforcing client education on risk factors
A nurse is planning a care for a client who is completing a diversion program. which of the following goals is appropriate for a client in this type of program?
The client will achieve integration back into the community afterwards.
A charge nurse is discussing with a staff nurse the establishment of credibility when providing nursing care. Which of the following statements
made by the staff nurse indicates a need for further teaching?
“Being dependable will increase my credibility.”
“Using consistency will help to build credibility.”
“Using sympathy will help to build credibility.”
“Using sympathy will help to build credibility.”
because it involves displaying personal emotions.
heroin withdrawal symptoms
Muscle aches
insomnia
dilated pupils
diarrhea
Super ego
“I shouldn’t get that”
Makes you think about morality
ID
“I want what I want”
Being selfish
Ego
“I can wait for what I want”
Being able to delay and wait what you want
Which scenario best demonstrates empathetic caring?
A nurse provides comfort to a colleague after a medication administration error
Which disorder is an example of culture bound syndrome?
Running amok
A 26 month old refused toilet training and says “NO!” Which psycho crisis is evident?
Autonomy Vs. Shame and Doubt
Which of the following elements should a nurse incorporate into a therapeutic milieu to promote reality and assist with improving client outcomes?
- there should be clocks and calenders
- staff wear name tags
- doors should have labels to indicate function of each room
- client’s rooms should have their names on it
- furniture should be arranged in conversational grouping in the common area
Beneficence
actions guided by compassion
Nonmaleficence
No harm
Justice
caring for all clients equally and with the same level of fairness.
SSRI
Are medications for antidepressants.
Fluoxetine
Duloxetine
Paroxetine
*watch out for serotonin syndrome (toxic levels of serotonin).
Autonomy
right to make decisions about one’s own care
Veracity
Being truthfully and authentic with clients during care
Fidelity
trustworthy in following through with promises.
A nurse tells a client that they will return in 30 min with their medication. The nurse returns 30 min later with the client’s medication. Which of
the following ethical principles is the nurse demonstrating?
Beneficence
Autonomy
Veracity
Justice
Veracity.
Veracity involves being truthful and honoring the verbal commitment made to a client.
A nurse overhears unit staff workers making jokes about a nursing student. This is an example of which of the following?
Incivility
Anger
Sexual harassment
Bullying
Incivility.
Incivility is an act or behavior that shows disrespect and lack of courtesy. Such acts, whether intended or unintended, are considered acts of aggression and can affect the well-being of the individual and negatively impact the work environment.
A nurse is discussing false imprisonment with a group of newly hired staff members. Which of the following information should the nurse include?
A client cannot claim false imprisonment if they were restrained by use of an injectable antipsychotic medication.
Claims of false imprisonment can be made if a nurse verbally threatens to place a client in seclusion.
Claims of false imprisonment are most often made in reference to the use of seclusion or restraints.
A client cannot claim false imprisonment if they are involuntarily admitted without being assessed by a provider.
Claims of false imprisonment are most often made in reference to the use of seclusion or restraints.
A nurse on a mental health unit is caring for a client who becomes agitated. The nurse encourages the client to return to their room to calm down.
Which of the following de-escalation techniques is the nurse using?
Seclusion
Time out
Restraints
Distraction
Time out
A nurse is leading a group session when a client begins cursing and running around the room shouting. Which of the following actions should the nurse take?
Suggest the client go someplace quiet and compose themselves.
Suggesting the client go someplace quiet and compose themselves indicates that the nurse will not tolerate their behavior. This is an example of a less restrictive alternative to restraints and will give the client a chance to change their behavior prior to returning to the group.
A nurse is sitting with a client who is extremely anxious until they fall asleep. The nurse should identify that this is an example of which of the
following ethical principles?
Justice
Autonomy
Nonmaleficence
Beneficence
Beneficence.
Beneficence involves promoting good and doing positive action for others
Which of the following is a U.S. congressional act that requires providers to inform their clients of the cost for treatment and whether their insurance will cover it?
Health Insurance Portability and Accountability Act
Affordable Care Act of 2010
No Surprises Act
Nurse Practice Act
No Surprises Act
Concept of Recovery
Recovery means that patient pursues life goals within the context of their mental illness.
Which non therapeutic communication technique can make a person feel interrogated?
Summarizing
Voicing doubt
Excessive questioning
Excessive questioning
What is the Planning in the nursing process ?
Identify safe, evidence based actions
Individuals who have disruptive behavioral disorders have an increased risk of developing:
depression, substance use disorder, or anxiety
First line of defense for antidepressants
SSRI (an SSRI)
Which antidepressant is used for kids and adolescents
Fluoxetine ( an SSRI)
A nurse is caring for a child who has been prescribed a mood-stabilizing medication to manage violent behaviors. The nurse should identify that
the client most likely has which of the following conditions?
Posttraumatic stress disorder (PTSD)
Intermittent explosive disorder (IED)
A communication disorder
Oppositional defiant disorder (ODD)
Intermittent explosive disorder (IED).
Antipsychotic medication is useful for managing aggressive or violent behavior in some children diagnosed with IED.
Dopamine
Pleasure and reward
Serotonin
emotions, sexual behaviors, sleep, and pain
norepinephrine
excitatory neurotransmitter - for learning, sleep, mood, memory, and attention.
histamine
regulates gastric secretions, allergic response, cardiac stimulation, alertness and wakefulness.
GABA
GABA improves sleep, and minimizes depression
Acetylcholine
regulates sleep-wake cycle and muscle functioning.
. Neuroplasticity
brain’s ability to adapt in response to stress or injury.
Monoamine Oxidase Inhibitor
The enzyme monoamine oxidase is inhibited
from degrading monoamine neurotransmitters
like serotonin and dopamine, increasing the length of time they can function.
Tricyclic Antidepressants (TCA)
Blocks serotonin and norepinephrine
Selective Serotonin Reuptake Inhibitor (SSRI)
Serotonin is selectively blocked from reuptake receptors.
A nurse is caring for a client who is experiencing disruptions in sleep, appetite, and reports having a depressed mood. Which of the following
medications should the nurse anticipate the provider to prescribe?
Benzodiazepine
Dopamine antagonist
Selective serotonin reuptake inhibitor
Mood stabilizer
Selective serotonin reuptake inhibitor.
selective serotonin reuptake inhibitors are used to manage manifestations of depression, such as loss of pleasure in activities and disruptions in sleep and appetite.
A nurse is caring for a client who is experiencing opiate withdrawal. Which of the following findings should the nurse expect to observe?
Decreased heart rate and blood pressure
Respiratory depression and excessive drowsiness
Constipation and pupil constriction
Goose flesh and diarrhea
Goose flesh and diarrhea.
The nurse should identify that in opiate withdrawal, large amounts of norepinephrine are released, causing findings, such as goose flesh, muscle aches, and GI discomfort.
which finding is consistent with neuroleptic malignant syndrome?
Hyperthermia and elevated kinase.
s/sx of lithium toxicity
lithium level over 1.5.
GI discomfort –> Jerking movements –> Respiratory complications
A nurse is caring for a client who is experiencing diaphoresis, palpitations, and a sense of impending doom. Which of the following medications should the nurse anticipate the provider to prescribe?
Benzodiazepine
Dopamine antagonist
Selective serotonin reuptake inhibitor
Mood stabilizer
Benzodiazepine
A nurse is caring for a client who has been taking risperidone and reports experiencing muscle spasms in their neck and difficulty opening their
mouth. Which of the following medications should the nurse anticipate the provider to prescribe for this client?
Benadryl.
Diphenhydramine is an anticholinergic medication that is effective in treating extrapyramidal symptoms (EPS) of acute dystonia, such as muscle spasms in the neck and difficulty opening the mouth.
A nurse is caring for a client who is experiencing alternating periods of elevated and depressed mood. Which of the following medications should
the nurse anticipate the provider to prescribe?
Benzodiazepine
Dopamine antagonist
Selective serotonin reuptake inhibitor
Mood stabilizer
Mood stabilizer
A nurse is educating a newly licensed nurse about opiate withdrawal. Which of the following findings should the nurse instruct the newly licensed nurse to monitor for?
Muscle aches
Respiratory depression
Hallucinations
Increased risk of seizure
Muscle aches
CIWA-Ar scale
provides guidelines for the nurse to follow when rating the severity of manifestations of alcohol withdrawal.
A nurse is educating a client about mental illness treatment and the client asks, “Why do some medications that treat mental illness take a few
weeks to become effective?” Which of the following statements should the nurse make?
“The brain has to establish a new neuronal pathway in response to medications.”
A nurse is educating a newly licensed nurse about manifestations of alcohol withdrawal. Which of the following statements by the newly licensed
nurse indicates an understanding of the teaching?
“An increase in the release of the neurotransmitter glutamate causes an elevated heart rate.”
The nurse should identify that in alcohol withdrawal, large amounts of glutamate release, causing CNS excitation, which leads to an increase in
heart rate and blood pressure.
Glutamate
Glutamate is responsible for affective and cognitive functioning.
High levels of glutamate can serve as a precursor to manifestations of psychosis.
how does the brain play a role in aggressive behavior?
Excessive amygdala reaction and inadequate
regulation of the prefrontal area will increase the
likelihood on aggression in the client.
A nurse is caring for a client who is demonstrating aggressive behavior towards others and is not responding to verbal interventions. Which of the following medications should the nurse anticipate the provider prescribing?
Ziprasidone
Paroxetine
Escitalopram
Lithium
Ziprasidone.
Ziprasidone is an antipsychotic that is commonly prescribed to clients who become aggressive, agitated, or violent. it is given IM..
excess serotonin causes
violent and aggressive behavior.
A nurse is caring for an older adult client who has dementia. Which of the following findings should the nurse expect?
Unable to remember the name of a local restaurant
Misplacing keys
Forgetting appointment date
Inability to manage finances
Inability to manage finances.
The nurse should expect a client who has dementia to be unable to perform calculations such as managing their finances. Clients who have dementia might also exhibit poor judgment and attention span, along with impaired memory and abstract thinking.
CJD or Mad cow disease
a type of dementia. This disease is transmitted from animal to human from a prion typically found in contaminated beef that is consumed by the client.
what is the purpose for music therapy for clients with dementia?
improve appetite and decrease depression
According to the DSM-5-TR, insufficiencies in reasoning, problem solving, and planning are examples of deficits in which of the following areas?
Intellectual functioning.
it includes reasoning, problem solving, planning, abstract thinking, judgment, academic learning, and learning from experience.
Which of the following behaviors is commonly associated with clients who have autism spectrum disorder (ASD)?
Pretends by role playing
Lines up the toys in their bedroom
Washes their hands continuously
Repetitive involuntary movements
Lines up the toys in their bedroom.
Clients who have ASD might participate in repetitive and restrictive activities.
A nurse is providing care to a client who has Down syndrome. The nurse recognizes the client is at increased risk of developing which of the
following conditions?
Cancer
Alzheimer’s disease
ADHD
Bipolar disorder
Alzheimer’s disease.
Estimates suggest that more than 50% of individuals who have Down syndrome will develop Alzheimer’s disease.
cognitive signs that might be indicative of a learning disability.
difficulty reading or memory recall.
possible cause of ASD (autism)
A de novo mutation—a genetic alteration that is present for the first time in one family member, rather than an inherited gene—might account for ASD when there is no indication of a family history of the condition.
Manifestations of conduct disorder
Bullying others.
Law breaking activities.
Threats of suicide.
eustress
A positive stress response that results in development growth or fulfillment.
Toxic stress
result of chronic stress where the body learns that fear or trauma is normal.
Biofeedback relaxation technique.
This relaxation method teaches the client physical and mental exercises to help control their specific automatic physical body functions, such as heart rate, blood pressure, and temperature.
guided imagery
imagines a place that of calmness and relaxation.
displacement
redirects stress to someone else instead of the stressor.
cognitive reframing
technique used to change the way a person thinks about something.
mild level of anxiety
a mild level of anxiety can manifest in hypervigilance and restlessness.
moderate level of anxiety
a moderate level of anxiety may have increased vital signs and a diminished level of concentration
severe level of anxiety
Includes somatic symptoms and unable to problem solve
panic level of anxiety
panic level of anxiety may be unaware of their surroundings or display fight, flight, faint, freeze, or fawn behaviors.
Openness
eager to learn and experience new things.
Extraversion
assertive and outgoing
Conscientiousness
efficient and organized
Agreeableness
forgiving, warm, and not demanding
body’s response to acute stress
Blood pressure, heart rate, respiratory rate, and pupillary response are all affected by the body’s physiological responses to stress.
rationalization
In rationalization, a person uses reason or logic to avoid or explain the stressor and avoid their emotions.
Interpersonal violence
occurs when a once-trusted relationship between a child and adult (or two adults) erodes.
Neuroplasticity
Neuroplasticity is the brain’s ability to adapt and change
Reactive attachment disorder
Reactive attachment disorder can occur when there is an absence of adequate caregiving, including the child going many hours without being held or touched as an infant.
adjustment disorder
s/sx: suicide
hypervigilance
a state of constant alertness to potential threats in their surroundings. The individual has a sense of being in constant danger.
self-esteem
feeling competent, achieving goals, and gaining the respect of others.
Self-actualization
Self-actualization means developing one’s highest potential and living life to the fullest.
Repression defense mechanism
returning to immature behavior such as wetting the bed
Reference delusion
False belief that occurrences or events are about them
Persecutory delusion
Belief that someone is harming one’s self
Somatic delusion
Belief that a body party is no longer functioning
5 Stages of grief
- Denial
- Anger
- Bargaining
- Depression
- Acceptance
Countertransference
Attributing feelings that are positive/negative about someone towards the client
