Townsend Psychiatric Mental Health Nursing: Chapters 23, 24, 27 Exam Question With Verified Answers

Townsend Psychiatric Mental Health Nursing: Chapters 23, 24, 27 Exam Question With Verified Answers As a last resort, an agitated, physically aggressive client is placed in four-point restraints. The client yells, "I'll sue you for assault and battery!" The unit manager determines that the nurses are protected under which condition? 1) The client is voluntarily committed and poses a danger to others on the unit. 2) The client is voluntarily committed and has a history of being a danger to others. 3) The client is involuntarily committed because of a history of violent behavior. 4) The client is involuntarily committed and is refusing treatment. - answerAs a threat to others, the client can be restrained despite objections and voluntary commitment. A history of being a danger to others does not indicate a current, imminent threat; therefore, the client has the right to the least restrictive treatment alternative and restraints cannot be legally applied. A history of violent behavior does not indicate a current, imminent threat; therefore, the client has the right to the least restrictive treatment alternative and restraints cannot be legally applied. Treatment refusal is a client's right that can be lost if the client poses an imminent danger to self or others or has been deemed incompetent and assigned a guardian. Neither of these situations exists; therefore, the client has the right to the least restrictive treatment alternative and restraints cannot be legally applied. Oliver has been referred by his boss to the employee assistance program because of difficulties that have arisen in his relationships with coworkers. During the nurse's intake assessment, which of the following statements by Oliver are consistent with a diagnosis of paranoid personality disorder? Select all that apply. 1) "I work very hard at my job." 2) "I stay away from my co-workers because they'd love to see me fail." 3) "I would have my boss' job if administration promoted people fairly." 4) "I set a trap in my office so I can tell if my coworkers have opened my file cabinets." 5) "I feel bad for my boss, he's been so stressed this last year." - answerFeedback 1: This is a neutral statement that neither supports nor negates a diagnosis of paranoid personality disorder. Significant statements would be those that convey inappropriate mistrust of others. Feedback 2: This statement is a generalization of mistrust for all his coworkers and an assumption that they intend to harm him in some way. This statement is consistent with paranoid personality disorder. Feedback 3: The sense that the individual would be more successful if not for unfair treatment is a symptom of paranoid personality disorder. Feedback 4: Testing others' honesty because of a pervasive fear that they can't betrusted is symptomatic of paranoid personality disorder. Feedback 5: Typically people with paranoid personality disorders have a hard exterior and are insensitive to the feelings of others, so this statement is not consistent with the disorder. For the past 3 days, a student has skipped classes, cried constantly, and experienced panic attacks. She is now exhibiting difficulty with short-term memory. What crucial information should the nurse initially obtain prior to planning interventions for this student? 1) The student's description of the precipitating stressor 2) The student's usual ability to cope with stress 3) The student's available support system 4) The student's access to community resources - answer1. It is important to assess the precipitating stressor that led to the student's behavioral symptoms. This information will be crucial when planning client care. After the nurse assesses the precipitating stressor, assessing the student's usual ability to cope with stress could be beneficial. After the nurse assesses the precipitating stressor, assessing the student's available support system could be beneficial. After the nurse assesses the precipitating stressor, assessing the student's access to community resources could be beneficial. The nurse is assessing a client for side effects of electroconvulsive therapy (ECT). Which side effects are common and to be expected? 1) Temporary disorientation 2) Enduring memory loss 3) Residual seizure disorder 4) Cardiovascular complications - answerTemporary memory loss and confusion are common side effects of ECT. Permanent, or enduring, memory loss is not considered a common side effect of ECT. Residual seizure disorder is not considered a common side effect of ECT. Cardiovascular complications are not considered common side effects of ECT. In evaluating learning, the nurse asked the client to answer the following statement: "When used in combination with anxiolytic medication, alcohol leads to _____________ effects and caffeine leads to _______________ effects." 1) Increased; increased 2) Increased; decreased 3) Decreased; decreased 4) Decreased; increased - answer2. Anxiolytic medications work through depression of certain CNS functions. Alcohol, which is a CNS depressant, would increase/potentiate their effects. Caffeine, which is a CNS stimulant, would decrease/inhibit their effects. The disorder that is characterized by the presence of multiple motor tics and one or more vocal tics is called ____________. - answerTourette's disorder Tourette's disorder is characterized by motor tics and vocal tics not attributable to a substance or other medical condition. Pharmacotherapy is not recommended except in very severe cases. Psychosocial therapies such as behavior therapy, individual counseling, and family therapy have been identified as beneficial.