Mental Health exam 1 Rasmussen Questions and Complete Solutions Graded AI+

Mental Health exam 1 Rasmussen Questions and Complete Solutions Graded AI+ A fully developed outcome for a client goal would include: - Answer: time sensitive measurable term attainable for client The nurse understands a client could be at risk for serotonin syndrome when taking which of the following medications in addition to over the counter medications or herbal supplements? - Answer: sertraline (SSRI) A 4-year old child grabs toys from siblings, saying, "I want that toy now!" The siblings cry and the child's parent becomes upset with the behavior. Using Freudian theory, a nurse can interpret the child's behavior as a product of impulses originating in the: - Answer: Id Which expected client outcome should a nurse identify as being correctly formulated? - Answer: Client will initiate interaction with one peer during free time within 2 days. A voluntarily hospitalized patient tells the nurse, "Get me the forms for discharge against medical advice so I can leave now." Which is the nurse's best response? - Answer: "I will get them for you, but let's talk about your decision to leave treatment." The client is being admitted to the inpatient psychiatric unit. The nurse conducts a mental status examination. Which of the following items are included in the examination? - Answer: Appearance Mood and Affect Thought Cognition A client with schizophrenia has recently begun a new medication, clozapine (Clozaril). Which signs and symptoms of a potentially fatal side effect with the nurse teach the client about? - Answer: Sore throat, fever, and malaise Which information suggests that caution is necessary in prescribing a benzodiazepine to an anxious client? - Answer: The client has a history of alcohol dependence. A brother calls to speak to his sister who has been admitted to the psychiatric unit. The nurse connects him to the community phone and the sister is summoned. Later the nurse realizes that the brother was not on the client's approved call list. What law has the nurse broken? - Answer: The Health Insurance Portability and Accountability Act The client attempted suicide by overdosing on pain medication. Once the client ingested the medication, she decided that she did not want to die and she sought immediate treatment. Once the client recovered from the physical effects of overdose, the client voluntarily south inpatient mental health treatment. Which statement is true of voluntary admission? - Answer: The client retains the right to request release. A nurse says to a client, "Things will look better tomorrow after a good night's sleep." This is an example of which communication technique? - Answer: The nontherapeutic technique of giving reassurance. (false reassurance) A patient is involuntarily admitted to a psychiatric unit after calling a friend and saying, "I've got a gun and I'm going to shoot myself." Which of the following rights has the patient lost temporarily? - Answer: The right to leave the hospital without medical approval. A depressed client states, "I have a chemical imbalance in my brain. I have no control over my behavior. Medications are my only hope to feel normal again." Which nursing response is appropriate? - Answer: "Medications are one way to address chemical imbalances. Environmental and interpersonal factors can also have an impact on biological factors." During an intake interview, which question would assist the nurse in gathering data about the client's judgment? - Answer: "If you found a stamped, addressed envelope in the street, what would you do?" A nursing instructor asks a student to describe the nursing process when initiating care of a client. The student nurse understands the nursing process order to be correctly identified as: - Answer: Assessment, Nursing diagnosis, Outcomes, Planning, Implementation, Evaluation During an intake assessment, a nurse asks both physiological and psychosocial questions. The client angrily responds, "I'm here for my heart, not my head problems." Which is the nurse's best response? - Answer: Psychological factors, like excessive stress, have been found to affect medical conditions." A mother rescues two of her four children from a house fire. In an emergency department, she cries, "I should have gone back in to get them. I should have died, not them." Which of the following responses by the nurse is an example of reflection? - Answer: "You're feeling guilty because you weren't able to save your children." An entry level registered nurse works with patients in a community setting. Which groups should this nurse expect to lead? - Answer: Symptom management Medication education Self-care A client has been involuntarily admitted to an inpatient behavioral health unit. During this admission, which of the following rights does the client still retain? - Answer: The right to refuse medications The right to informed consent A mother who is notified that her child was killed in a tragic car accident states, "I can't bear to go on with my life." Which nursing statement conveys empathy? - Answer: "It must be horrible to lose a child, and I'll stay with you until your husband arrives." During the implementation phase of the nursing process, a nurse is teaching an adult depressed patient with a cochlear implant about medications. Which modification in the teaching plan would be the most appropriate for this client? - Answer: Speaking directly face-to-face A 22 year old college student is admitted to hospital following a suicide attempt and states, "No one will ever love a loser like me." According to Erikson's theory of personality development, a nurse should recognize a deficit in which developmental stage? - Answer: Intimacy vs Isolation A nursing instructor is teaching about the monoamine category of neurotransmitters. Which student statement indicates that learning about the function of norepinephrine has occurred? - Answer: Norepinephrine functions to regulate mood, cognition, and perception. A nurse is educating a patient about the difference between mental health and mental illness. Which statement by the patient reflects an accurate understanding of mental health? - Answer: Mental health is successful adaptation to stressors in the internal external environment. The nurse understands a client taking which medication could place a client at high risk for life-threatening hypertensive crisis if tyramine is ingested? - Answer: A client taking tranylcypromine (Parnate) A client taking isocarboxazid (Marplan) A client taking phenelzine (Nardil) A client was recently admitted to the inpatient unit after a suicide attempt and has not responded to SSRIs or tricyclic antidepressants. The client asks the nurse, "I heard about MAOIs (monoamine oxidase inhibitors). Why can't they be added to what I am on now? Wouldn't adding one help?" Which is the appropriate nursing response? - Answer: "Combined use can lead to a life-threatening condition called hypertensive crisis." A 29-year-old client living with parents has few interpersonal relationships. The client states, "I have trouble trusting people." Based on Erikson's developmental theory, which should the nurse recognize as true statements about the client? - Answer: The client has not progressed beyond the trust vs. mistrust development stage. Developmental deficits in earlier life stages have impaired the client's adult functioning. A patient discloses several concerns and associated feelings. If the nurse wishes to seek clarification, which comment would be most appropriate? - Answer: "Am I correct in understanding that..." The health care provider prescribes an antidepressant for an elderly client, but nurse notices that the dosage is greater than the usual adult dosage. Which of the following best describes what action the nurse should take? - Answer: Hold the medication until clarification with the health care provider. Which intervention by a psychiatric nurse best utilizes the ethical principle of autonomy? The nurse: - Answer: Explores alternative solutions with a patient, who then makes a choice. Which of the following should the nurse plan to include in the assessment of an older adult client? - Answer: Identify any age related physical needs and necessary accommodations for this client. A patient is about to be released and tells the staff nurse "I'm glad I'm getting out of here; I swear the first thing I'll do is kill my ex-wife and that stupid boyfriend of hers." Which of the following is the staff nurse's legal duty? - Answer: Report the threat to the treatment team and document the statement. A client tells a nurse that he hates his doctor and plans to hurt the doctor, but she did not report this prior to leaving. When the nurse returns to work the next day, she finds that the physician has been brutally beaten by the client and the physician is hospitalized. Which of the following best represents the nurse's failure to act by not reporting the client's intent? - Answer: Negligence A newly admitted patient is hyperactive, restless, and disorganized. The patient goes to the dining room and begins to throw food. Verbal intervention is ineffective. Seclusion is instituted for the primary purpose of: - Answer: Reducing environmental stimuli that negatively affect the patient. A Mexican American patient puts a picture of the Virgin Mary on the bedside table. Under which section of the assessment should the nurse document this behavior? - Answer: Culture Which of the following best represents a potential liability issue for the professional nurse? - Answer: Placing a patient who talks constantly and loudly into a secluded room alone. A researcher tells the nurse that she would like a patient to participate in a study on the effects of a new medication. The nurse's responsibility in regard to this study is: - Answer: To assess whether the patient has the ability and legal right to give informed consent. A nurse is performing a mental health assessment on an adult client. According to Maslow's hierarchy of needs, which client action would demonstrate the highest achievement in terms of mental health? - Answer: Possessing a feeling of self-fulfillment and realizing full potential. A nurse explains to the family of a mentally ill patient how the nurse-patient relationship differs from other interpersonal relationships. Which is the nurse's best explanation? - Answer: "The focus is on the patient. Problems are discussed by the nurse and patient; but solutions are implemented by the patient" A client who is very dirty and has an offensive odor refused to take a shower when he was admitted to the psychiatric inpatient unit of the hospital. He yelled, "No, no, no bath!" when two staff members carried him into the shower and made him wash himself thoroughly before allowing him to leave the shower area. Which of these statements is correct regarding this patient's rights? - Answer: This was a violation of the patients rights because the patient was restrained by force. The nurse is assessing a client who has a diagnosis of schizophrenia and takes a typical antipsychotic agent daily. Which assessment finding should alert the nurse to a potential adverse effect of a typical antipsychotic medications? - Answer: Temperature of 101F Using Erickson's theory of personality development, which of the following task occur with teenagers during puberty? - Answer: Identifying oneself from one's parents. According to Freud, which statement should a nurse associate with predominance of the superego? - Answer: "I don't ever cheat on tests; its wrong" An inpatient psychiatric physician treating clients omits treatment options for those without insurance. Which violation of an ethical principle should a nurse recognize in this situation? - Answer: Justice During a nurse-client interaction, which nursing statement may belittle the client's feelings and concerns? - Answer: "Don't worry. Everything will be alright" A nurse assessed a patient who participated reluctantly, answered questions with minimal responses, and rarely made eye contact. What data should be included when documenting the assessment? - Answer: A description of the patient's behavior during the interview. Which client action should the nurse expect during the working phase of the nurse-client relationship? - Answer: The client gains insight and incorporates alternative behaviors. The nurse is conversing with a client in a locked in-patient psychiatric unit. The client states," Please don't tell anyone about my sexual abuse." Which nursing response clearly outlines the professional nurse's responsibility related to confidentiality? - Answer: "All the healthcare team is focusing on helping you. I will bring information to the team that can assist them in planning your treatment" Within professional scope of practice, which function is exclusive to the advanced nurse practice specialty? - Answer: Using psychotherapy to improve mental health status. A physically healthy, 35-year-old single client lives with parents who provide total financial support. According to Erikson's theory, which developmental task should a nurse assist the client to accomplish? - Answer: Establishing a career, personal relationships, and societal connections. According to Maslow's hierarchy of needs, Which situation on an in patient psychiatric unit would require priority intervention? - Answer: A client exhibits hostile and angry behaviors tward another client. Which of the following client statements are correctly matched with the personality structure as described by Freud that they exemplify? - Answer: I'll return the purse I found. It's never right to steal. -- Superego I need that car. No one will miss it. -- Id Cheating on a test could get me expelled so I wont do it. -- Ego Which senario describes an individual in Erikson's developmental stage of "old age" exhibiting a negative outcome of despair? - Answer: A 70 year old woman angry about where her life has ended up. A client on a psychiatric unit says "It's a waste of time to be here. I cant talk to you or anyone." Which would be an appropriate therapeutic nursing response? - Answer: Are you feeling that no one understands? Which of the following are examples of nontherapeutic communication blocks? - Answer: Why did you refuse your medication this afternoon? I'm so sorry you feel that way. It is a feeling typical of hospitalized clients. You just think that you are not getting better, you'll see. Everything will work out. The client states "I'm not sure that the doctor has prescribed the correct medication for my sadness." Which would be a therapeutic nursing response? - Answer: So you think this medication is not right for you. Who founded psychoanalytic theory? - Answer: Sigmund Freud Id - Answer: Primitive and pleasure seeking. Part of our unconscious Ego - Answer: A sense of self. Mediates between the Id and the world Superego - Answer: Right and wrong. Our conscious Maslow's Hierarchy of Needs - Answer: Most basic and important needs on the lower level and higher levels are the more distinctly human needs. Cannot be on a level higher than a level that you have not completed Erikson's Stages of Development - Answer: Infancy, Early Childhood, Preschooler, School Age, Adolescence, Young Adulthood, Adulthood, Elderly Infancy: Birth to 1 1/2 yr, trust vs mistrust, developing a basic sense of trust, leading to hope and physical comfort Early Childhood: 1 1/2 to 3 yrs Autonomy vs shame/doubt, gaining self-control, independence with environment Preschooler: 3-6 yr Initiative vs Guilt, achieve sense purpose and mastery of skills School age: 6-12 yr Industry vs Inferiority, gain sense of self-confidence/recognition thru learning, competing, performing Adolescence: 12-20 yrs Identity vs role confusion, integrate all the tasks previously mastered into a secure self Young Adulthood: 20 to 30 yrs Intimacy/solidarity vs isolation, forming intense long lasting relationships, committing to another person, cause, institution Adulthood: 30 to 65 yr, generativity vs self-absorption, achieve life goals, obtain certain awareness of future generations Elderly: 65+ yr, integrity vs despair, obtaining a sense self-worth, finding meaning in one's whole life Understand the role of neurotransmitters as related to disorders: Dopamine: - Answer: • Functions: Fine muscle movement, integration of emotions and thoughts, decision making, and the release of sex hormones. • Increases: Schizophrenia and Main • Decreases: Parkinson's Disease and Depression Understand the role of neurotransmitters as related to disorders: Serotonin: - Answer: • Functions: Mood, sleep regulation, hunger, pain perception, aggression/libido, hormonal activity. • Increases: Anxiety states • Decreases: Depression Understand the role of neurotransmitters as related to disorders: Norepinephrine: - Answer: • Functions: Mood, attention/arousal, fight or flight response • Increases: Mania, Anxiety, Schizophrenia • Decreases: Depression Understand the role of neurotransmitters as related to disorders: GABA: - Answer: • Functions: Reduces anxiety/excitation/aggression, plays a role in pain perception, anticonvulsant/muscle relaxer, may impair cognition • Increases: Reduction of anxiety • Decreases: Main, anxiety, schizophrenia Nurse-Client Relationship: Understand what occurs in the Orientation phase: - Answer: Can last a few meetings, or more. This phase includes building rapport, establishing relationship parameters, creating a formal or informal contract, acknowledging confidentiality, evaluating the client's problems, and beginning a plan for the termination phase Nurse-Client Relationship: Understand what occurs in the Working phase: - Answer: A strong working relationship develops over time and allows the client to work through their problems in a safe/therapeutic setting, while also learning new/better coping skills. Defense mechanisms will probably be exhibited during this phase. The nurse's self-awareness is vital Nurse-Client Relationship: Understand what occurs in the Termination phase: - Answer: The final, integral phase. It is discussed during the other phases and may occur when the patient is discharged or the nurse's rotation ends. Tasks include summarizing the outcomes of the working phase, reviewing what occurred, and exchanging memories for validation purposes. Contact after termination, at a personal level, it's acceptable Understand the differences between a Nurse-client: - Answer: Can be defined as a relationship that is primarily initiated for friendship, enjoyment, or communal effort. Mutual needs are met during the time of a social relationship. Communication doesn't have to be therapeutic in a social relationship (there is advice giving and lending money). The content of such communication can remain superficial Understand the differences between a Social relationship: - Answer: The nurse uses all of their communication skills, understanding of human behavior, and personal insight to enhance the client's growth. This type of relationship is client-focused. Focus and boundaries are both kept clear. Advice isn't given, but the nurse aids the client in exploring their options. The relationship is professional and goal-directed in nature Understand boundaries with clients: - Answer: No self-disclosure, no gift giving/receiving (unless for entire team), touch only if provides therapeutic effect (careful not to startle), no romantic association, no favoring, no secrets, no special attention or time Transference: - Answer: Person consciously and inappropriately displaces anger to a different person Counter transference: - Answer: Tendency of a nurse to displace onto the patient feelings related to people of in the past The role of the psych RN- what is considered within the scope of practice? - Answer: "Psychiatric nursing is a specialized area of nursing practice committed to promoting mental health through the assessment, diagnosis, and treatment of behavioral problems, psychiatric disorders, and comorbid conditions. Psychiatric nursing interventions is an art and a science, employing a purposeful use of self and a wide range of nursing, psychosocial, and neurobiological research evidence to produce effective outcomes." Nursing Process: - Answer: Assessment (gather data) Diagnosis (NANDA and prioritize) Outcome (what is expected outcome?) Planning (interventions, EBP, document) Implementation (therapies providing) Evaluation (goals met?)Developing a goal/outcome includes How to develop a plan of care - Answer: • EBP should be used when developing plans of care. • The plan of care should be client-focused and address their needs. • Nurses work with other healthcare team members to develop plans of care. • Assessments are essential to developing a plan of care that suits the client(s). Mental Health: - Answer: State of well-being in which every individual realizes his/her own potential, can cope with normal stresses of life, can work productively, able to make contribution to community without illness. Fundamental to health Mental Illness: - Answer: Wide range of health conditions/disorders that affect your mood, thinking and behavior, real health conditions that have an immense impact on individuals and families Describe the sections of the psychiatric assessment: - Answer: Establish rapport, obtain an understanding of the problem, review physical status/vitals, assess for risk factors, perform an MSE, assess psychosocial status, identify goals for treatment, formulate a plan of care, document data Describe the sections of the MSE: - Answer: Mental status exam or MMSE (mini mental status exam--evaluating current cognitive processes/function (draw a clock at 10, remember these 3 words) Information gathered in the MSE: - Answer: Information gathered includes personal information (demographics), appearance (grooming, hygiene, tattoos), behavior (body movements, eye contact), speech (rate, volume), affect and mood (flat, animated v. sad), thought (disorganized, coherent, suicidal), perceptual disturbances (hallucinations), and cognition (orientation, memory, knowledge) Describe how to assess: attention - Answer: Performance on serial sevens, digit span tests Describe how to assess: abstraction - Answer: Performance on tests involving similarities, proverbs Describe how to assess: insight - Answer: Ability to identify and understand present condition Describe how to assess: judgement - Answer: Ability to assess a practical dilemma What considerations should be evaluated during an interview? - Answer: Empathetic response: Understanding the feelings of someone else "How upsetting this must be for you." Sympathetic responses: We feel the feelings of others "I know exactly how you feel" Describe and give examples of Therapeutic Communication Techniques: - Answer: Silence, Accepting: Indicates the client has been understood, Sequencing: Puts events and actions in perspective, Observations: Brings attention to the client's behaviors, Restating, Reflecting, Summarizing: Combines the important points to enhance understanding. Describe and give examples of Non-Therapeutic Communication Techniques: - Answer: Advising: Assumes the patient can't think for themselves. • Minimizing: Indicates the nurse doesn't understand the client's emotions. • Falsely Reassuring: Underrates the patient's concerns. • Value Judgements: Prevents problem-solving. • "Why:" Implies criticism; raises defensiveness. Define ethnicity: - Answer: Refers to a social group that shares a common and distinctive culture, religion, language, or the like. - Latino, Asian, African American, Native American Define culture: - Answer: Culture is the arts, beliefs, customs, and so on of a group, place, or time. - Lesbian, Christian, Anarchist, Vegan, Japanese, Military Ethics: - Answer: The set of moral principles of conduct governing an individual or group Negligence: - Answer: Act or omission of an act that breaches the duty of due care and results in injury Autonomy: - Answer: Respecting the rights of others to make own decisions, such as the right to refuse medications Justice: - Answer: Duty to distribute resources and care equally, spending time with each patient equally Beneficence: - Answer: The duty to act as to benefit or promote the good of others such as spending extra time with a highly anxious patient Fidelity: - Answer: Maintaining loyalty and commitment to the patient and doing no wrong to the patient Veracity: - Answer: Ones duty to communicate truthfully What rights do all patients have? - Answer: Right to treatment, right to refuse treatment, right to informed consent, right to withdraw, right to privacy What rights are limited to involuntarily admitted clients? - Answer: Freedom from unreasonable restraints, right to informed consent, right to refuse medication Describe Duty to Warn and how it is used in psychiatric nursing: - Answer: Psychotherapists have a duty to warn a client's potential victim(s). Assess and predicting a patient's danger of violence towards others, ID specific individuals being threatened, ID appropriate actions to protect victims Describe HIPPA and how it is used in psychiatric nursing - Answer: Information obtained from the patient or medical records cannot be given to anyone who isn't directly involved in the patient's care, except in situations relating to duty to warn. Describe when it is appropriate to use restraints/seclusion: - Answer: Used when behavior is harmful to self or others, when alternative methods are unsuccessful (verbal, medication), when a decrease in sensory stimuli is needed, or when a patient requests it. Renewal can only be made in increments of 4 hrs, up to 24 hrs. Must be observed every 15 to 30 minutes. The purpose behind seclusion? - Answer: Restraints and seclusion can only be used to ensure the immediate safety of the patient, staff, and others. They should only be used after all other means have failed to control/contain the crisis situation SSRIs: - Answer: Fluoxetine (Prozac), Sertraline (Zoloft), Paroxetine (Paxil) Side effects: increased serotonin nausea, vomiting. Teaching: Don't stop taking suddenly, can take with food/milk Tricyclics: - Answer: Amitriptyline (Elavil) Imipramine (Tofranil) Side Effects: Anticholinergic, sedation, weight gain, dizziness. Teaching: 4-6 weeks to work, it's easy to overdose. MAOIs: - Answer: Phenelzine (Nardil) Tranylcypromine (Parnate) Side Effects: Dry mouth, nausea, drowsiness, muscle jerks, cramps . Teaching: Avoid tyramine-rich foods (aged cheese, cured meat, beer) due to risk of hypertensive crisis. Recognize serotonin syndrome- S/S - Answer: Symptoms can occur with any of these medications and include restlessness, shivering, diarrhea, muscle rigidity, fever, and seizures. The symptoms can be reduced by using muscle relaxers and drugs that block serotonin production. Recognize serotonin syndrome- nursing implications - Answer: Therapeutic measures: Discontinue, meds propranolol, dantrolene, diazepam, anticonvulsants, artificial ventilation, paralysis. Benzodiazepines: - Answer: Examples: diazepam (Valium), clonazepam (Klonopin), and alprazolam (Xanax) Side Effects: Sedative/hypnotic effects Teaching: Don't stop suddenly, notify provider of pregnancy Concerns for client taking benzo? - Answer: Withdrawal and notify provider if pregnant. Anti-psychotics Typical: - Answer: Examples: haloperidol (Haldol), fluphenazine(Prolixin), and chlorpromazine (Thorazine) Side Effects: Extrapyramidal effects, parkinsonism, NMS, anticholinergic effects. Teaching: Stop slowly, sunscreen, move slowly, routine follow-ups Antipsychotics Atypical: - Answer: Examples: clozapine (Clozaril), risperidone (Risperdal), and aripiprazole (Abilify) Side Effects: Seizures, agranulocytosis, drooling, weight gain Teaching: Stop slowly, smoking lowers levels, move slowly