NURS 3381 Exam 2025 WITH Complete Questions and Verified Solutions

1 A patient who immigrated to the United States from Honduras was diagnosed with schizophrenia. The patient took an antipsychotic medication for 3 weeks but showed no improvement. Which resource should the treatment team consult for information on more effective medications for this patient? - ANSWER Clinical algorithm 2 Which historical nursing leader helped focus practice to recognize the importance of science in psychiatric nursing? - ANSWER Hildegard Peplau 3 A nurse consistently strives to demonstrate caring behaviors during interactions with patients. Which reaction by a patient indicates this nurse is effective? A patient reports feeling: - ANSWER connected with others 4 An 86-year-old, previously healthy and independent, falls after an episode of vertigo. Which behavior by this patient best demonstrates resilience? The patient: - ANSWER says, Maybe some physical therapy will help me with my balance 5 A patient is admitted to the psychiatric hospital. Which assessment finding best indicates that the patient has a mental illness? The patient: - ANSWER describes mood as consistently sad, discouraged, and hopeless 6 The goal for a patient is to increase resiliency. Which outcome should a nurse add to the plan of care? Within 3 days, the patient will: - ANSWER identify healthy coping behaviors in response to stressful events 7 Which organization actively seeks to reduce the stigma associated with mental illness through public presentations such as In Our Own Voice (IOOV)? - ANSWER National Alliance on Mental Illness (NAMI) 8 A nurse must assess several new patients at a community mental health center. Conclusions concerning current functioning should be made on the basis of: - ANSWER a continuum from mentally healthy to unhealthy 9 A nurse at a behavioral health clinic sees an unfamiliar psychiatric diagnosis on a patients insurance form. Which resource should the nurse consult to discern the criteria used to establish this diagnosis? - ANSWER Diagnostic and Statistical Manual of Mental Disorders (DSM-5) 10A 40-year-old adult living with parents states, Im happy but I dont socialize much. My work is routine. When new things come up, my boss explains them a few times to make sure I understand. At home, my parents make decisions for me, and I go along with them. A nurse should identify interventions to improve this patients: - ANSWER self-concept 11A patient tells a nurse, I have psychiatric problems and am in and out of hospitals all the time. Not one of my friends or relatives has these problems. Select the nurses best response. - ANSWER It sounds like you are concerned that others dont experience the same challenges as you 12A critical care nurse asks a psychiatric nurse about the difference between a diagnosis in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and a nursing diagnosis. Select the psychiatric nurses best response. - ANSWER The DSM-5 diagnosis influences the medical treatment; the nursing diagnosis offers a framework to identify interventions for problems a patient has or may experience. 13The spouse of a patient diagnosed with schizophrenia says, I dont understand why childhood experiences have anything to do with this disabling illness. Select the nurses response that will best help the spouse understand this condition. - ANSWER Although this disorder more likely has a biological rather than psychological origin, the support and involvement of caregivers is very important. 14Which belief by a nurse supports the highest degree of patient advocacy during a multidisciplinary patient care planning session? - ANSWER Some symptoms of mental disorders may reflect a persons cultural patterns 15A patients history shows intense and unstable relationships with others. The patient initially idealizes an individual and then devalues the person when the patients needs are not met. Which aspect of mental health is a problem? - ANSWER Fulfilling relationships 16In the majority culture of the United States, which individual is at greatest risk to be incorrectly labeled mentally ill? - ANSWER Person who attends a charismatic church and describes hearing Gods voice 17A participant at a community education conference asks, What is the most prevalent type of mental disorder in the United States? Select the nurses best response. - ANSWER Anxiety disorders 18A nurse wants to find a description of diagnostic criteria for a person diagnosed with schizophrenia. Which resource should the nurse consult? - ANSWER Diagnostic and Statistical Manual of Mental Disorders (DSM-5) 19A psychiatric nurse best implements the ethical principle of autonomy when he or she: - ANSWER explores alternative solutions with a patient, who then makes a choice 20Which action by a psychiatric nurse best supports a patients right to be treated with dignity and respect? - ANSWER Consistently addressing a patient by title and surname. 21Several nurses are concerned that agency policies related to restraint and seclusion are inadequate. Which statement about the relationship of substandard institutional policies and individual nursing practice should guide nursing practice? - ANSWER The policies do not absolve an individual nurse of the responsibility to practice according to the professional standards of nursing care. 22A newly admitted patient who is acutely psychotic is a private patient of the senior psychiatrist. To whom does the psychiatric nurse who is assigned to this patient owe the duty of care? - ANSWER Patient 23An example of a breach of a patients right to privacy occurs when a nurse: a. asks a family to share information about a patients prehospitalization behavior. - ANSWER releases information to the patients employer without consent. 24An adolescent hospitalized after a violent physical outburst tells the nurse, Im going to kill my father, but you cant tell anyone. Select the nurses best response. - ANSWER I am required to share information with the treatment team 25A voluntarily hospitalized patient tells the nurse, Get me the forms for discharge against medical advice so I can leave now. What is the nurses best initial response? - ANSWER I will get them for you, but lets talk about your decision to leave treatment 26The family of a patient whose insurance will not pay for continuing hospitalization considers transferring the patient to a public psychiatric hospital. The family expresses concern that the patient will never get any treatment. Which reply by the nurse would be most helpful? - ANSWER Under the law, treatment must be provided. Hospitalization without treatment violates patients rights. 27Which individual with a mental illness may need emergency or involuntary hospitalization for mental illness? The individual who: - ANSWER throws a heavy plate at a waiter at the direction of command hallucinations 28A patient being treated in an alcohol rehabilitation unit reveals to the nurse, I feel terrible guilt for sexually abusing my 6-year-old child before I was admitted. Based on state and federal law, the best action for the nurse to take is to: - ANSWER anonymously report the abuse by telephone to the local child abuse hotline. 29The spouse of a patient who has delusions asks the nurse, Are there any circumstances under which the treatment team is justified in violating the patients right to confidentiality? The nurse must reply that - ANSWER if the patient threatens the life of another person. 30A nurse cares for an older adult patient admitted for treatment of depression. The health care provider prescribes an antidepressant medication, but the dose is more than the usual adult dose. The nurse should: - ANSWER hold the medication and consult the health care provider. 31A patient diagnosed with schizophrenia believes evil spirits are being summoned by a local minister and verbally threatens to bomb a local church. The psychiatrist notifies the minister. The psychiatrist has: - ANSWER demonstrated the duty to warn and protect 32After leaving work, a staff nurse realizes that documentation of the administration of a medication to a patient was omitted. This off-duty nurse telephones the unit and tells the nurse, Please document the administration of the medication I forgot to do. My password is alpha1. The nurse should - ANSWER refer the matter to the charge nurse to resolve. 33A patient diagnosed with mental illness asks a psychiatric technician, Whats the matter with me? The technician replies, Your wing nuts need tightening. The nurse who overheard the exchange should take action based on: - ANSWER violation of the patients right to be treated with dignity and respect. 34Which documentation of a patients behavior best demonstrates a nurses observations? - ANSWER Wears four layers of clothing. States, I need protection from dangerous bacteria trying to penetrate my skin. 35A new staff nurse completes orientation to the psychiatric unit. This nurse will expect to ask an advanced practice nurse to perform which action for patients? - ANSWER Prescribe psychotropic medications 36A newly admitted patient with major depressive disorder has lost 20 pounds over the past month and has suicidal ideation. The patient has taken an antidepressant medication for 1 week without remission of symptoms. Select the priority nursing diagnosis. - ANSWER Risk for suicide 37A patient with major depressive disorder has lost 20 pounds in one month has chronic low self-esteem and a plan for suicide. The patient has taken an antidepressant medication for 1 week. Which nursing intervention is most directly related to this outcome: Patient will refrain from gestures and attempts to harm self? - ANSWER Implement suicide precautions. 38A patients nursing diagnosis is Insomnia. The desired outcome is: Patient will sleep for a minimum of 5 hours nightly by October 31. On November 1, a review of the sleep data shows the patient sleeps an average of 4 hours nightly and takes a 2-hour afternoon nap. Which evaluation should be documented? - ANSWER Never demonstrated 39A patients nursing diagnosis is Insomnia. The desired outcome is: Patient will sleep for a minimum of 5 hours nightly by October 31. On November 1, a review of the sleep data shows the patient sleeps an average of 4 hours nightly and takes a 2-hour afternoon nap. What is the nurses next action? - ANSWER Revise the outcome target date and interventions. 40A patient 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 patient to attend one psychoeducational group daily? - ANSWER Implementation 41Before assessing a new patient, a nurse is told by another health care worker, I know that patient. No matter how hard we work, there isn't much improvement by the time of discharge. The nurses responsibility is to: - ANSWER assess the patient based on data collected from all sources. 42A nurse works with a patient to establish outcomes. The nurse believes that one outcome suggested by the patient is not in the patients best interest. What is the nurses best action? - ANSWER Explore with the patient possible consequences of the outcome. 43A patient states, Im 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? - ANSWER Suicide precautions 44Select the best outcome for a patient with this nursing diagnosis: Impaired social interaction, related to sociocultural dissonance as evidenced by stating, Although Id like to, I dont join in because I dont speak the language very well. The patient will: - ANSWER select and participate in one group activity per day. 45Nursing behaviors associated with the implementation phase of the nursing process are concerned with: - ANSWER carrying out interventions and coordinating care. 46Which statement made by a patient during an initial assessment interview should serve as the priority focus for the plan of care? - ANSWER I hear evil voices that tell me to do bad things. 47Which entry in the medical record best meets the requirement for problem-oriented charting? - ANSWER S: States, I feel like Im ready to blow up. O: Pacing hall, mumbling to self. A: Auditory hallucinations. P: Offer haloperidol (Haldol) 2 mg. I: (Haldol) 2 mg at 0900. E: Returned to lounge at 0930 and quietly watched TV. 48A nurse assesses an older adult patient brought to the emergency department by a family member. The patient was wandering outside, saying, I cant find my way home. The patient is confused and unable to answer questions. Select the nurses best action. - ANSWER Document the patients mental status. Obtain other assessment data from the family member 49A nurse asks a patient, If you had fever and vomiting for 3 days, what would you do? Which aspect of the mental status examination is the nurse assessing? - ANSWER Cognition 50An adolescent asks a nurse conducting an assessment interview, Why should I tell you anything? You'll just tell my parents whatever you find out. Select the nurses best reply. - ANSWER What you say about feelings is private, but some things, like suicidal thinking, must be reported to the treatment team. 51A nurse assessing a new patient asks, What is meant by the saying, You cant judge a book by its cover? - ANSWER Abstraction 52When a nurse assesses an older adult patient, the patients answers seem vague or unrelated to the questions. The patient also leans forward and frowns, listening intently to the nurse. An appropriate question for the nurse to ask would be - ANSWER Are you having difficulty hearing when I speak? 53At one point in an assessment interview a nurse asks, How does your faith help you in stressful situations? This question would be asked during the assessment of: - ANSWER coping strategies 54When a new patient is hospitalized, a nurse takes the patient on a tour, explains the rules of the unit, and discusses the daily schedule. The nurse is engaged in: - ANSWER milieu management 55After formulating the nursing diagnoses for a new patient, what is the next action a nurse should take? - ANSWER Determine the goals and outcome criteria. 56Select 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. - ANSWER Social isolation 57The acronym QSEN refers to: - ANSWER Quality and Safety Education for Nurses. 58A nurse documents: Patient is mute, despite repeated efforts to elicit speech. Makes no eye contact. Is inattentive to staff. Gazes off to the side or looks upward rather than at the speaker. Which nursing diagnosis should be considered? - ANSWER Impaired verbal communication 59A patient asks a nurse, What are neurotransmitters? My doctor says mine are out of balance. The best reply would be: - ANSWER Neurotransmitters are chemicals that pass messages between brain cells 60The parent of an adolescent diagnosed with schizophrenia asks a nurse, My childs doctor ordered a positron-emission tomography (PET) scan. What is that? Select the nurses best reply. - ANSWER PET is a special scan that shows blood flow and activity in the brain. 61A patient has dementia. The health care provider wants to make a differential diagnosis between Alzheimer disease and multiple infarctions. Which diagnostic procedure should a nurse expect to prepare the patient for first? - ANSWER Computed tomography (CT) scan 62A patient has delusions and hallucinations. Before beginning treatment with a psychotropic medication, the health care provider wants to rule out the presence of a brain tumor. For which test will a nurse need to prepare the patient? - ANSWER Computed tomography (CT) scan or magnetic resonance imaging (MRI) 63The nurse wants to assess for disturbances in circadian rhythms in a patient admitted for major depressive disorder. Which question best implements this assessment? - ANSWER What are your worst and best times of day? 64A nurse administers a medication that potentiates the action of gamma aminobutyric acid (GABA). Which finding would be expected? - ANSWER Reduced anxiety 65On the basis of current knowledge of neurotransmitter effects, a nurse anticipates that the treatment plan for a patient with memory difficulties may include medications designed to: - ANSWER prevent destruction of acetylcholine 66A patient has disorganized thinking associated with schizophrenia. Neuroimaging would most likely show dysfunction in which part of the brain? - ANSWER Prefrontal cortex 67A nurse should assess a patient taking a medication with anticholinergic properties for inhibited function of the: - ANSWER parasympathetic nervous system 68The therapeutic action of monoamine oxidase inhibitors (MAOIs) blocks neurotransmitter reuptake, causing: - ANSWER increased concentration of neurotransmitters in the synaptic gap. 69A patient taking medication for mental illness develops restlessness and an uncontrollable need to be in motion. A nurse can correctly analyze that these symptoms are related to which drug action? - ANSWER Dopamine-blocking effects 70A patient has anxiety, increased heart rate, and fear. The nurse would suspect the presence of a high concentration of which neurotransmitter? - ANSWER Norepinephrine 71A patient has symptoms of acute anxiety related to the death of a parent in an automobile accident 2 hours earlier. The nurse should anticipate administering a medication from which group? - ANSWER Benzodiazepines 72A patient is hospitalized for major depressive disorder. Of the medications listed, a nurse can expect to provide the patient with teaching about: - ANSWER fluoxetine (Prozac). 73A patient hospitalized with a mood disorder has aggression, agitation, talkativeness, and irritability. A nurse begins the care plan based on the expectation that the health care provider is most likely to prescribe a medication classified as a(n): - ANSWER mood stabilizer 74A drug causes muscarinic-receptor blockade. A nurse will assess the patient for: - ANSWER dry mouth 75A patient begins therapy with a phenothiazine medication. What teaching should a nurse provide related to the drugs strong dopaminergic effect? - ANSWER Report muscle stiffness. 76A nurse can anticipate anticholinergic side effects are likely to occur when a patient is taking: - ANSWER fluphenazine (Prolixin) 77Priority teaching for a patient taking clozapine (Clozaril) should include which instruction? - ANSWER Report sore throat and fever immediately 78A nurse cares for patients taking various medications, including buspirone (BuSpar), haloperidol (Haldol), trazodone (Desyrel), and phenelzine (Nardil). The nurse will order a special diet for the patient taking: - ANSWER phenelzine. 79A nurse caring for a patient taking a serotonin reuptake inhibitor (SSRI) will develop outcome criteria related to: - ANSWER mood improvement 80A patients spouse, who is a chemist, asks a nurse how serotonin reuptake inhibitors (SSRIs) lift depression. 81The nurse should explain that SSRIs: - ANSWER make more serotonin available at the synaptic gap 82A patient has taken many conventional antipsychotic drugs over years. The health care provider, who is concerned about early signs of tardive dyskinesia, prescribes risperidone (Risperdal). A nurse planning care for this patient understands that atypical antipsychotics: - ANSWER produce fewer motor side effects 83The laboratory report for a patient taking clozapine (Clozaril) shows a white blood cell count of 3000 mm3 84and a granulocyte count of 1500 mm3. The nurse should: - ANSWER report the laboratory results to the health care provider 85A nurse administering psychotropic medications should be prepared to intervene when giving a drug that blocks the attachment of norepinephrine to alpha1 receptors because the patient may experience: - ANSWER orthostatic hypotension. 86A patient says to the nurse, I dreamed I was stoned. When I woke up, I felt emotionally drained, as though I hadnt rested well. Which comment would be appropriate if the nurse seeks clarification? - ANSWER Can you give me an example of what you mean by stoned? 87A patient diagnosed with schizophrenia tells the nurse, The CIA is monitoring us through the fluorescent lights in this room. Be careful what you say. Which response by the nurse would be most therapeutic? - ANSWER It sounds like youre concerned about your privacy 88The patient says, My marriage is just great. My spouse and I usually agree on everything. The nurse observes the patients foot moving continuously as the patient twirls a shirt button. What conclusion can the nurse draw? The patients communication is: - ANSWER mixed 89A nurse interacts with a newly hospitalized patient. Select the nurses comment that applies the communication technique of offering self. - ANSWER Id like to sit with you for a while to help you get comfortable talking to me. 90Which technique will best communicate to a patient that the nurse is interested in listening? - ANSWER Restate a feeling or thought the patient has expressed. 91A patient discloses several concerns and associated feelings. If the nurse wants to seek clarification, which comment would be appropriate? - ANSWER Am I correct in understanding that? 92A patient tells the nurse, I dont think I will ever get out of here. Select the nurses most therapeutic response. - ANSWER You dont think youre making progress? 93Documentation in a patients chart shows, Throughout a 5-minute interaction, patient 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? - ANSWER Patients verbal and nonverbal messages are incongruent 94While talking with a patient with severe depression, a nurse notices the patient is unable to maintain eye contact. The patients chin lowers to the chest while the patient looks at the floor. Which aspect of communication has the nurse assessed? - ANSWER Nonverbal communication 95During the first interview with a parent whose child died in a car accident, the nurse feels empathic and reaches out to take the patients hand. Select the correct analysis of the nurses behavior. - ANSWER The gesture is premature. The patients cultural and individual interpretation of touch is unknown. 96A 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 97An African- American patient says to a Caucasian nurse, Theres no sense talking. You wouldnt understand because you live in a white world. The nurses best action would be to: - ANSWER say, Please give an example of something you think I wouldnt understand. 98A Filipino- American patient had this nursing diagnosis: Situational low self-esteem, related to poor social skills as evidenced by lack of eye contact. Interventions were used to raise the patients self-esteem; however, after 3 weeks, the patients eye contact did not improve. What is the most accurate analysis of this scenario? - ANSWER The nurse should have assessed the patients culture before making this diagnosis and plan 99When a female Mexican-American patient and a female nurse sit together, the patient often holds the nurses hand. The patient also links arms with the nurse when they walk. The nurse is uncomfortable with this behavior and thinks the patient is homosexual. Which alternative is a more accurate assessment? - ANSWER The patient is accustomed to touch during conversations, as are members of many Hispanic subcultures. 100 A Puerto RicanAmerican patient uses dramatic body language when describing emotional discomfort. Which analysis most likely explains the patients behavior? The patient: - ANSWER belongs to a culture in which dramatic body language is the norm 101 During an interview, a patient attempts to shift the focus from self to the nurse by asking personal questions. The nurse should respond by saying: - ANSWER The time we spend together is to discuss your concerns. 102 Which principle should guide the nurse in determining the extent of silence to use during patient interview sessions? - ANSWER Silence can provide meaningful moments for reflection 103 A patient is having difficulty making a decision. The nurse has mixed feelings about whether to provide advice. Which principle usually applies? Giving advice: a. is rarely helpful. - ANSWER is rarely helpful 104 The relationship between a nurse and patient as it relates to status and power is best described by which term? - ANSWER Complementary 105 A patient with severe depression states, God is punishing me for my past sins. What is the nurses best response? - ANSWER You sound very upset about this 106 A nurse assesses a confused older adult. The nurse experiences sadness and reflects, The patient is like one of my grandparents . . . so helpless. What feelings does the nurse describe? - ANSWER Countertransference 107 Which statement shows a nurse has empathy for a patient who made a suicide attempt? - ANSWER You must have been very upset when you tried to hurt yourself 108 After several therapeutic encounters with a patient who recently attempted suicide, which occurrence should cause the nurse to consider the possibility of countertransference? - ANSWER The nurse feels unusually happy when the patients mood begins to lift 109 A patient says, Please dont share information about me with the other people. How should the nurse respond? - ANSWER I wont share information with others without your permission, but I will share information about you with other staff members 110 A nurse is talking with a patient, and 5 minutes remain in the session. The patient has been silent for 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 right now. The nurse should: - ANSWER tell the patient who interrupted, This session is 5 more minutes; then, I will talk with you. 111 Termination of a therapeutic nurse-patient relationship with a patient has been successful when the nurse - ANSWER discusses with the patient changes that have happened during the relationship and evaluates the outcomes. 112 What is the desirable outcome for the orientation stage of a nurse patient relationship? The patient will demonstrate behaviors that indicate: - ANSWER rapport and trust with the nurse 113 During which phase of the nurse-patient relationship can the nurse anticipate that identified patient issues will be explored and resolved? - ANSWER Working 114 At what point in the nurse-patient relationship should a nurse plan to first address termination? - ANSWER In the orientation phase 115 A nurse should introduce the matter of a contract during the first session with a new patient because contracts: - ANSWER spell out the participation and responsibilities of each party 116 As a nurse escorts a patient being discharged after treatment for major depressive disorder, the patient gives the nurse a gold necklace with a heart pendant and says, Thank you for helping mend my broken heart. Which is the nurses best response? - ANSWER Im glad I could help you, but I cant accept the gift. My reward is seeing you with a renewed sense of hope. 117 Which remark by a patient indicates passage from the orientation phase to the working phase of a nurse-patient relationship? - ANSWER I want to find a way to deal with my anger without becoming violent. 118 A nurse explains to the family of a patient who is mentally ill how the nurse-patient relationship differs from social relationships. Which is the best explanation? - ANSWER The focus is on the patient. Problems are discussed by the nurse and patient, but solutions are implemented by the patient. 119 A nurse wants to demonstrate genuineness with a patient diagnosed with schizophrenia. The nurse should: - ANSWER use congruent communication strategies. 120 A nurse caring for a withdrawn, suspicious patient recognizes the development of feelings of anger toward the patient. The nurse should: - ANSWER discuss the anger with a clinician during a supervisory session 121 A nurse wants to enhance the growth of a patient by showing positive regard. The action consistent with this wish is: - ANSWER staying with a tearful patient 122 A patient says, Ive done a lot of cheating and manipulating in my relationships. Select a nonjudgmental response by the nurse. - ANSWER How do you feel about that? 123 A patient says, People should be allowed to commit suicide without interference from others. A nurse replies, Youre wrong. Nothing is bad enough to justify death. What is the best analysis of this interchange? - ANSWER Differing values are reflected in the two statements 124 Which issues should a nurse address during the first interview with a patient diagnosed with a psychiatric disorder? - ANSWER Relationship parameters, the contract, confidentiality, and termination 125 During the first interview, a nurse notices that the patient does not make eye contact. The nurse can correctly analyze that: - ANSWER more information is needed to draw a conclusion 126 Which behavior shows that a nurse values autonomy? The nurse: a. sets limits on a patients romantic overtures toward the nurse. - ANSWER discusses available alternatives and helps the patient weigh the consequences 127 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 nurses best action? - ANSWER Recognize the effectiveness of the relationship and patients thoughtfulness. Accept the card 128 A patient says, Im still on restriction, but I want to attend some off unit activities. Would you ask the doctor to change my privileges? What is the nurses best response? - ANSWER Thats a good topic for you to take up with your doctor 129 A community mental health nurse has worked with a patient for 3 years but is moving out of the city and terminates the relationship. A new nurse who begins work with this patient will: - ANSWER begin at the orientation phase. 130 As a patient diagnosed with 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? - ANSWER The nurses action blurs the boundaries of the therapeutic relationship 131 A nurse says, I am the only one who truly understands this patient. Other staff members are too critical. The nurses statement indicates: - ANSWER boundary blurring. 132 A 26-month-old child displays negative behaviors. The parent says, My child refuses toilet training and shouts, No! when given direction. What do you think is wrong? Select the nurses best reply. - ANSWER This is normal for your childs age. The child is striving for independence 133 A 26-month-old child displays negative behavior, refuses toilet training, and often shouts, No! when given directions. Using Freuds stages of psychosexual development, a nurse would assess the childs behavior is based on which stage? - ANSWER Anal 134 A 26-month-old child displays negative behavior, refuses toilet training, and often shouts, No! when given direction. The nurses counseling with the parent should be based on the premise that the child is engaged in which of Eriksons psychosocial crises? - ANSWER Autonomy versus Shame and Doubt 135 A 4- year-old child grabs toys from siblings, saying, I want that toy now! The siblings cry, and the childs parent becomes upset with the behavior. Using the Freudian theory, a nurse can interpret the childs behavior as a product of impulses originating in the: - ANSWER id 136 The parent of a 4-year-old rewards and praises the child for helping a younger sibling, being polite, and using good manners. A nurse supports the use of praise because, according to the Freudian theory, these qualities will likely be internalized and become part of the childs: - ANSWER superego 137 A nurse supports parental praise of a child who is behaving in a helpful way. When the individual behaves with politeness and helpfulness in adulthood, which feeling will most likely result? - ANSWER Self-esteem 138 A patient comments, I never know the right answer and My opinion is not important. Using Eriksons theory, which psychosocial crisis did the patient have difficulty resolving? - ANSWER Autonomy versus Shame and Doubt 139 Which patient statement would lead a nurse to suspect that the developmental task of infancy was not successfully completed? - ANSWER Im afraid to let anyone really get to know me. 140 A nurse assesses that a patient is suspicious and frequently manipulates others. Using the Freudian theory, these traits are related to which psychosexual stage? - ANSWER Oral 141 An adult expresses the wish to be taken care of and often behaves in a helpless fashion. This adult has needs related to which of Freuds stages of psychosexual development? - ANSWER Oral 142 A nurse listens to a group of recent retirees. One says, I volunteer with Meals on Wheels, coach teen sports, and do church visitation. Another laughs and says, Im too busy taking care of myself to volunteer. I dont have time to help others. These comments contrast which developmental tasks? - ANSWER Generativity versus Self Absorption 143 Cognitive therapy was provided for a patient who frequently said, Im stupid. Which statement by the patient indicates the therapy was effective? - ANSWER Sometimes I do stupid things. 144 A student nurse tells the instructor, I dont need to interact with my patients. I learn what I need to know by observation. The instructor can best interpret the nursing implications of Sullivans theory to the student by responding: - ANSWER Nurses cannot be isolated. We must interact to provide patients with opportunities to practice interpersonal skills 145 A psychiatric technician says, Little of what takes place on the behavioral health unit seems to be theory based. A nurse educates the technician by identifying which common use of Sullivans theory? - ANSWER Structure of the therapeutic milieu of most behavioral health units 146 A nurse uses Maslows hierarchy of needs to plan care for a psychotic patient. Which problem will receive priority? The patient: - ANSWER refuses to eat or bathe 147 Operant conditioning will be used to encourage speech in a child who is nearly mute. Which technique would a nurse include in the treatment plan? - ANSWER Give the child a small treat for speaking 148 The parent of a child diagnosed with schizophrenia tearfully asks a nurse, What could I have done differently to prevent this illness? Select the nurses most caring response. - ANSWER Schizophrenia is a biological illness with similarities to diabetes and heart disease. You are not to blame for your childs illness 149 A nurse uses Peplaus interpersonal therapy while working with an anxious, withdrawn patient. Interventions should focus on: - ANSWER improving the patients interactional skills 150 A patient underwent psychotherapy weekly for 3 years. The therapist used free association, dream analysis, and facilitated transference to help the patient understand unconscious processes and foster personality changes. Which type of therapy was used? - ANSWER Psychoanalysis 151 An advanced practice nurse determines a group of patients would benefit from therapy in which peers and interdisciplinary staff all have a voice in determining the level of the patients privileges. The nurse would arrange for: - ANSWER milieu therapy 152 A nurse psychotherapist works with an anxious, dependent patient. The therapeutic strategy most consistent with the framework of psychoanalytic psychotherapy is: a. emphasizing medication compliance. - ANSWER focusing on feelings developed by the patient toward the nurse 153 A person tells a nurse, I was the only survivor in a small plane crash, but three business associates died. I got anxious and depressed and saw a counselor three times a week for a month. We talked about my feelings related to being a survivor, and now Im fine, back to my old self. Which type of therapy was used? - ANSWER Interpersonal therapy 154 A cognitive strategy a nurse could use to assist a very dependent patient would be to help the patient: - ANSWER examine thoughts about being autonomous 155 A single parent is experiencing feelings of inadequacy related to work and family since one teenaged child ran away several weeks ago. The parent seeks the help of a therapist specializing in cognitive therapy. The psychotherapist who uses cognitive therapy will treat the patient by: a. discussing ego states. - ANSWER helping the patient identify and change faulty thinking 156 A nurse wishes to teach alternative coping strategies to a patient experiencing severe anxiety. The nurse will first need to: - ANSWER Lower the patients current anxiety level 157 A patient approaches the nurse and impatiently blurts out, Youve got to help me! Something terrible is happening. My heart is pounding. The nurse responds, Its almost time for visiting hours. Lets get your hair combed. Which approach has the nurse used? - ANSWER Bringing up an irrelevant topic 158 A patient experiencing moderate anxiety says, I feel undone. An appropriate response for the nurse would be: - ANSWER Im not sure I understand. Give me an example 159 A patient with a high level of motor activity runs from chair to chair and cries, Theyre coming! Theyre coming! The patient does not follow instructions or respond to verbal interventions from staff. The initial nursing intervention of highest priority is to: - ANSWER provide for patient safety 160 A patient with a high level of motor activity runs from chair to chair and cries, Theyre coming! Theyre coming! The patient is unable to follow instructions or respond to verbal interventions from staff. Which nursing diagnosis has the highest priority? - ANSWER Risk for injury 161 A supervisor assigns a worker a new project. The worker initially agrees but feels resentful. The next day, when asked about the project, the worker says, Ive been working on other things. When asked 4 hours later, the worker says, Someone else was using the copier, so I couldnt finish it. The workers behavior demonstrates: - ANSWER passive aggression 162 A patient is undergoing diagnostic tests. The patient says, Nothing is wrong with me except a stubborn chest cold. The spouse reports that the patient smokes, coughs daily, has recently lost 15 pounds, and is easily fatigued. Which defense mechanism is the patient using? - ANSWER Denial 163 A patient with a mass in the left upper lobe of the lung is scheduled for a biopsy. The patient has difficulty understanding the nurses comments and asks, What are they going to do? Assessment findings include a tremulous voice, respirations 28 breaths per minute, and pulse rate 110 beats per minute. What is the patients level of anxiety? - ANSWER Moderate 164 A patient who is preparing for surgery has moderate anxiety and is unable to understand preoperative information. Which nursing intervention is appropriate? - ANSWER Describe the procedure again in a calm manner, using simple language. 165 A nurse encourages an anxious patient to talk about feelings and concerns. What is the rationale for this intervention? - ANSWER Concerns stated aloud become less overwhelming and help problem solving to begin 166 Which assessment question would be most appropriate for the nurse to ask a patient who has possible generalized anxiety disorder (GAD)? - ANSWER Do you find it difficult to control your worrying? 167 A patient in the emergency department has no physical injuries but exhibits disorganized behavior and incoherence after minor traffic accident. In which room should the nurse place the patient? - ANSWER Interview room furnished with a desk and two chairs 168 A person has minor physical injuries after an automobile accident. The person is unable to focus and says, I feel like something awful is going to happen. This person has nausea, dizziness, tachycardia, and hyperventilation. What is this persons level of anxiety? - ANSWER Severe 169 Two staff nurses applied for a charge nurse position. After the promotion was announced, the nurse who was not promoted said, The nurse manager had a headache the day I was interviewed. Which defense mechanism is evident? - ANSWER Projection 170 A patient tells a nurse, My new friend is the most perfect person one could imaginekind, considerate, and good looking. I cant find a single flaw. This patient is demonstrating: - ANSWER idealization 171 A patient experiences an episode of severe anxiety. Of these medications in the patients medical record, which is most appropriate to administer as an as-needed (PRN) anxiolytic medication? - ANSWER lorazepam (Ativan) 172 Two staff nurses applied for promotion to nurse manager. Initially, the nurse not promoted had feelings of loss but then became supportive of the new manager by helping make the transition smooth and encouraging others. Which term best describes the nurses response? - ANSWER Altruism 173 A person who feels unattractive repeatedly says, Although Im not beautiful, I am smart. This is an example of: - ANSWER compensation 174 A person who is speaking about a contender for a significant others affection says in a gushy, syrupy voice, What a lovely person. Thats someone I simply adore. The individual is demonstrating: - ANSWER reaction formation 175 An individual experiences sexual dysfunction and blames it on a partner by calling the person unattractive and unromantic. Which defense mechanism is evident? - ANSWER Rationalization 176 A student says, Before taking a test, I feel a heightened sense of awareness and restlessness. The nurse can correctly assess the students experience as: - ANSWER mild anxiety 177 A student says, Before taking a test, I feel a heightened sense of awareness and restlessness. The nursing intervention most suitable for assisting the student is to: - ANSWER explain that the symptoms are the result of mild anxiety, and discuss the helpful aspects 178 If a cruel and abusive person rationalizes this behavior, which comment is most characteristic of this person? - ANSWER That person should not have provoked me. 179 A patient experiencing severe anxiety suddenly begins running and shouting, Im going to explode! The nurse should: - ANSWER assemble several staff members and state, We will help you regain control 180 A person who has been unable to leave home for more than a week because of severe anxiety says, I know it does not make sense, but I just cant bring myself to leave my apartment alone. Which nursing intervention is appropriate? - ANSWER Teach the person to use positive self-talk 181 Which comment by a person experiencing severe anxiety indicates the possibility of obsessive- compulsive disorder? - ANSWER I check where my car keys are eight times 182 Alprazolam (Xanax) is prescribed for a patient experiencing acute anxiety. Health teaching should include instructions to: - ANSWER avoid alcoholic beverages 183 Which statement is mostly likely to be made by a patient diagnosed with agoraphobia? - ANSWER Being afraid to go out seems ridiculous, but I cant go out the door 184 A patient has the nursing diagnosis Anxiety, related to _ , as evidenced by an inability to control compulsive cleaning. Which phrase correctly completes the etiologic portion of the diagnosis? - ANSWER having persistent thoughts about bacteria, germs, and dirt 185 patient performs ritualistic hand washing. What should the nurse do to help the patient develop more effective coping strategies? - ANSWER Encourage the patient to participate in social activities 186 For a patient experiencing panic, which nursing intervention should be implemented first? - ANSWER Provide calm, brief, directive communication 187 Which finding indicates that a patient with moderate-to-severe anxiety has successfully lowered the anxiety level to mild? The patient: - ANSWER can concentrate on what the nurse is saying 188 A patient tells the nurse, I dont go to restaurants because people might laugh at the way I eat, or I could spill food and be laughed at. The nurse assesses this behavior as consistent with: - ANSWER social anxiety disorder (social phobia) 189 A patient checks and rechecks electrical cords related to an obsessive thought that the house may burn down. The nurse and patient explore the likelihood of an actual fire. The patient states that a house fire is not likely. This counseling demonstrates the principles of: - ANSWER cognitive restructuring 190 A patient has a fear of public speaking. The nurse should be aware that social anxiety disorders (social phobias) are often treated with which type of medication? - ANSWER Beta-blockers 191 A patient tells the nurse, I wanted my health care provider to prescribe diazepam (Valium) for my anxiety disorder, but buspirone (BuSpar) was prescribed instead. Why? The nurses reply should be based on the knowledge that buspirone: - ANSWER does not cause dependence 192 In the shift-change report, an off-going nurse criticizes a patient who wears heavy makeup. Which comment by the nurse who receives the report best demonstrates advocacy? - ANSWER Our patients need our help to learn behaviors that will help them get along in society. 193 A nurse assesses a newly admitted patient diagnosed with major depressive disorder. Which statement is an example of attending? - ANSWER Id like to sit with you a while so you may feel more comfortable talking with me. 194 A patient is hospitalized for depression and suicidal ideation after their spouse asks for a divorce. Select the nurses most caring comment. - ANSWER Lets discuss some means of coping other than suicide when you have these feelings. 195 A patient shows the nurse an article from the Internet about a health problem. Which characteristic of the web sites address most alerts the nurse that the site may have biased and prejudiced information? - ANSWER Address ends in .com. 196 A nurse says, When I was in school, I learned to call upset patients by name to get their attention; however, I read a descriptive research study that says that this approach does not work. I plan to stop calling patients by name. Which statement is the best appraisal of this nurses comment? - ANSWER One descriptive research study rarely provides enough evidence to change practice. Two nursing students discuss career plans after graduation. One student wants to enter psychiatric nursing. 197 The other student asks, Why would you want to be a psychiatric nurse? All they do is talk. You will lose your skills. Select the best response by the student interested in psychiatric nursing. - ANSWER Psychiatric nurses use complex communication skills, as well as critical thinking, to solve multidimensional problems. I'm challenged by those situations. 198 Which research evidence would most influence a group of nurses to change their practice? - ANSWER Systematic review of randomized controlled trials A bill introduced in Congress would reduce funding for the care of people diagnosed with mental illnesses. 199 A group of nurses write letters to their elected representatives in opposition to the legislation. Which role have the nurses fulfilled? - ANSWER Advocacy 200 An informal group of patients discuss their perceptions of nursing care. Which comment best indicates a patients perception that his or her nurse is caring? - ANSWER My nurse spends time listening to me talk about my problems. That helps me feel like I'm not alone. 201 Two hospitalized patients fight when they are in the same room. During a team meeting, a nurse asserts that safety is of paramount importance and therefore the treatment plans should call for both patients to be secluded to prevent them from injuring each other. This assertion: - ANSWER violates the civil rights of the two patients. 202 In a team meeting a nurse says, Im concerned whether we are behaving ethically by using restraint to prevent one patient from self mutilation while the care plan for another patient who has also self mutilated calls for one-on-one supervision. Which ethical principle most clearly applies to this situation? - ANSWER Justice 203 Which scenario is an example of a tort? - ANSWER A nurse gives an as-needed dose of an antipsychotic drug to a patient to prevent violence because a unit is short staffed. 204 A nurses neighbor asks, Why aren't people with mental illness kept in state institutions anymore? What is the nurses best response? - ANSWER Less restrictive settings are now available to care for individuals with mental illness. 205 Which nursing intervention demonstrates false imprisonment? - ANSWER A patient has been irritating, seeking the attention of nurses most of the day. Now a nurse escorts the patient down the hall, saying, Stay in your room or you'll be put in seclusion. 206 A patient should be considered for involuntary commitment for psychiatric care when he or she: - ANSWER threatens to harm self and others 207 A nurse at the mental health center prepares to administer a scheduled injection of haloperidol decanoate (Haldol depot) to a patient with schizophrenia. As the nurse swabs the site, the patient shouts, Stop! I don't want to take that medicine anymore. I hate the side effects. Select the nurses best initial action. - ANSWER Stop the medication administration procedure and say to the patient, Tell me more about the side effects you've been having.