Psych exam 2

Psych exam 2 An older adult takes digoxin and hydrochlorothiazide daily, as well as lorazepam (Ativan) as needed for anxiety. Over 2 days, this adult developed confusion, slurred speech, an unsteady gait, and fluctuating levels of orientation. These findings are most characteristic of: a. delirium. b. dementia. c. amnestic syndrome. d. Alzheimer disease. - a A patient experiencing fluctuating levels of awareness, confusion, and disturbed orientation shouts, "Bugs are crawling on my legs! Get them off!" Which problem is the patient experiencing? a. Aphasia b. Dystonia c. Tactile hallucinations d. Mnemonic disturbance - c A patient experiencing fluctuating levels of consciousness, disturbed orientation, and perceptual alteration begs, "Someone get these bugs off me." What is the nurse's best response? a. "There are no bugs on your legs. Your imagination is playing tricks on you." b. "Try to relax. The crawling sensation will go away sooner if you can relax." c. "Don't worry. I will have someone stay here and brush o the bugs for you." d. "I don't see any bugs, but I know you are frightened so I will stay with you." - d What is the priority nursing diagnosis for a patient experiencing fluctuating levels of consciousness, disturbed orientation, and visual and tactile hallucinations? a. Bathing/hygiene self-care deficit, related to altered cerebral function, as evidenced by confusion and inability to perform personal hygiene tasks b. Risk for injury, related to altered cerebral function, misperception of the environment, and unsteady gait c. Disturbed thought processes, related to medication intoxication, as evidenced by confusion, disorientation, and hallucinations d. Fear, related to sensory perceptual alterations, as evidenced by hiding from imagined ferocious dogs - b What is the priority intervention for a patient diagnosed with delirium who has fluctuating levels of consciousness, disturbed orientation, and perceptual alterations? a. Avoidance of physical contact b. High level of sensory stimulation c. Careful observation and supervision d. Application of wrist and ankle restraints - c Which environmental adjustment should the nurse make for a patient experiencing delirium with perceptual alterations? a. Keep the patient by the nurse's desk while the patient is awake. Provide rest periods in a room with a television on. b. Light the room brightly, day and night. Awaken the patient hourly to assess mental status. c. Maintain soft lighting day and night. Keep a radio on low volume continuously. d. Provide a well-lit room without glare or shadows. Limit noise and stimulation. - d Which description best applies to a hallucination? A patient: a. looks at shadows on a wall and says, "I see scary faces." b. states, "I feel bugs crawling on my legs and biting me." c. becomes anxious when the nurse leaves his or her bedside. d. tries to hit the nurse when vital signs are taken. - b When used for treatment of patients diagnosed with Alzheimer disease, which medication would be expected to antagonize N-methyl-D-aspartate (NMDA) channels rather than cholinesterase? a. donepezil (Aricept) b. rivastigmine (Exelon) c. memantine (Namenda) d. galantamine (Razadyne) - c An older adult was stopped by police for driving through a red light. When asked for a driver's license, the adult hands the police officer a pair of sunglasses. What sign of dementia is evident? a. Aphasia b. Apraxia c. Agnosia d. Memory impairment - c An older adult drove to a nearby store but was unable to remember how to get home or state an address. When police took the person home, the spouse reported frequent wandering into neighbors' homes. Alzheimer disease was subsequently diagnosed. Which stage of Alzheimer disease is evident? a. 1 (mild) b. 2 (moderate) c. 3 (moderate to severe) d. 4 (late) - b Consider these problems: apolipoprotein E (apoE) malfunction, neuritic plaques, neurobrillary tangles, granulovascular degeneration, and brain atrophy. Which condition corresponds to this group? a. Alzheimer disease b. Wernicke encephalopathy c. Central anticholinergic syndrome d. Acquired immunodeciency syndrome (AIDS)-related dementia - a patient diagnosed with stage 1 Alzheimer disease tires easily and prefers to stay home rather than attend social activities. The spouse does the grocery shopping because the patient cannot remember what to buy. Which nursing diagnosis applies at this time? a. Risk for injury b. Impaired memory c. Self-care deficit d. Caregiver role strain - b A patient has progressive memory deficit associated with dementia. Which nursing intervention would best help the individual function in the environment? a. Assist the patient to perform simple tasks by giving step-by-step directions. b. Reduce frustration by performing activities of daily living for the patient. c. Stimulate intellectual function by discussing new topics with the patient. d. Promote the use of the patient's sense of humor by telling jokes. - a Two patients in a residential care facility are diagnosed with dementia. One shouts to the other, "Move along, you're blocking the road." The other patient turns, shakes a fist, and shouts, "I know what you're up to; you're trying to steal my car." What is the nurse's best action? a. Administer one dose of an antipsychotic medication to both patients. b. Reinforce reality. Say to the patients, "Walk along in the hall. This is not a traffic intersection." c. Separate and distract the patients. Take one to the day room and the other to an activities area. d. Step between the two patients and say, "Please quiet down. We do not allow violence here." - c An older adult patient in the intensive care unit has visual and auditory illusions. Which intervention will be most helpful? a. Place large clocks and calendars on the wall. b. Place personally meaningful objects in view. c. Use the patient's glasses and hearing aids. d. Keep the room brightly lit at all times. - c A patient diagnosed with stage 2 Alzheimer disease calls the police saying, "An intruder is in my home." Police investigate and discover the patient misinterpreted a reflection in the mirror as an intruder. This phenomenon can be assessed as: a. hyperorality. b. aphasia. c. apraxia. d. agnosia. - d During morning care, a nursing assistant asks a patient diagnosed with dementia, "How was your night?" The patient replies, "It was lovely. I went out to dinner and a movie with my friend." Which term applies to the patient's response? a. Sundown syndrome b. Confabulation c. Perseveration d. Delirium - b A patient diagnosed with Alzheimer disease wanders at night. Which action should the nurse recommend for a family to use in the home to enhance safety? a. Place throw rugs on tile or wooden oors. b. Place locks at the tops of doors. c. Encourage daytime napping. d. Obtain a bed with side rails. - b Goals and outcomes for an older adult patient experiencing delirium caused by fever and dehydration will focus on: a. returning to premorbid levels of function. b. identifying stressors negatively affecting self. c. demonstrating motor responses to noxious stimuli. d. exerting control over responses to perceptual distortions. - a An older adult diagnosed with moderate-stage dementia forgets where the bathroom is and has episodes of incontinence. Which intervention should the nurse suggest to the patient's family? a. Label the bathroom door. b. Take the older adult to the bathroom hourly. c. Place the older adult in disposable adult diapers. d. Make sure the older adult does not eat nonfood items. - a patient diagnosed with dementia no longer recognizes family members. The family asks how long it will be before their family member recognizes them when they visit. What is the nurse's best reply? a. "Your family member will never again be able to identify you." b. "I think that is a question the health care provider should answer." c. "One never knows. Consciousness fluctuates in persons with dementia." d. "It is disappointing when someone you love no longer recognizes you." - d A patient diagnosed with severe dementia no longer recognizes family members and becomes anxious and agitated when they attempt reorientation. Which alternative could the nurse suggest to the family members? a. Wear large name tags. b. Focus interaction on familiar topics. c. Frequently repeat the reorientation strategies. d. Strategically place large clocks and calendars. - b What is the priority need for a patient diagnosed with late-stage dementia? a. Promotion of self-care activities b. Meaningful verbal communication c. Maintenance of nutrition and hydration d. Prevention of the patient from wandering - c Which intervention is appropriate to use for patients diagnosed with either delirium or dementia? a. Speak in a loud, firm voice. b. Touch the patient before speaking. c. Reintroduce the health care worker at each contact. d. When the patient becomes aggressive, use physical restraint instead of medication. - c A hospitalized patient experiencing delirium misinterprets reality, and a patient diagnosed with dementia wanders about the home. Which outcome is the priority in both scenarios? Each patient will: a. remain safe in the environment. b. participate actively in self-care. c. communicate verbally. d. acknowledge reality. - a A patient diagnosed with Alzheimer disease has a dressing and grooming self-care deficit. Designate the appropriate interventions to include in the patient's plan of care. Select all that apply. a. Provide clothing with elastic and hook-and-loop closures. b. Label clothing with the patient's name and name of the item. c. Administer antianxiety medication before bathing and dressing. d. Provide necessary items, and direct the patient to proceed independently. e. If the patient resists, use distraction and then try again after a short interval. - a, b, e Which assessment findings would the nurse expect in a patient experiencing delirium? Select all that apply. a. Impaired level of consciousness b. Disorientation to place and time c. Wandering attention d. Apathy e. Agnosia - a, b, c nurse should anticipate that which symptoms of Alzheimer disease will become apparent as the disease progresses from moderate to severe to late stage? Select all that apply. a. Agraphia b. Hyperorality c. Fine motor tremors d. Hypermetamorphosis e. Improvement of memory - a, b, d Health maintenance and promotion efforts for patients diagnosed with severe and persistent mental illness should include education about the importance of regular: a. home safety inspections. b. monitoring of self-care abilities. c. screening for cancer, hypertension, and diabetes. d. determination of adequacy of a patient's support system. - c Severe and persistent mental illness is characterized as a: a. mental illness with longer than 2 weeks' duration. b. major ongoing mental illness marked by significant functional impairments. c. mental illness accompanied by physical impairment and severe social problems. d. major mental illness that cannot be treated to prevent deterioration of cognitive and social abilities. - b A 37-year-old is involuntarily committed to outpatient treatment after sexually molesting a 12yo. The patient says, "That girl looked like she was 19 years old." Which defense mechanism is this patient using? a. Denial b. Identification c. Displacement d. Rationalization - d Which nursing diagnosis is likely to apply to a homeless individual diagnosed with severe and persistent mental illness? a. Insomnia b. Substance abuse c. Chronic low self-esteem d. Impaired environmental interpretation syndrome - c A patient diagnosed with schizophrenia tells the community mental health nurse, "I threw away my pills because they interfere with God's voice." The nurse identifies the cause of the patient's ineffective management of the medication regimen as: a. inadequate discharge planning. b. poor therapeutic alliance with clinicians. c. impaired reasoning secondary to schizophrenia. d. dislike of the side effects of antipsychotic medications. - c A patient diagnosed with severe and persistent mental illness lives independently. This patient has command hallucinations and shouts warnings to neighbors. After a short hospitalization, the patient is prohibited from returning to the apartment. The landlord says, "You can't come back here. You cause too much trouble." What problem is the patient experiencing? a. Grief b. Stigma c. Recidivism d. Lack of insurance parity - b A person diagnosed with severe and persistent mental illness enters a shelter for the homeless. Which intervention should be the nurse's initial priority? a. Develop a relationship b. Find supported employment c. Administer prescribed medication d. Teach appropriate health care practices - a A patient diagnosed with severe and persistent mentally illness lives in a homeless shelter. The priority nursing diagnosis for this patient is Powerlessness. Which intervention should be included in the plan of care? a. Encourage mutual goal setting. b. Verbally communicate empathy. c. Reinforce participation in activities. d. Demonstrate an accepting attitude. - a A homeless patient diagnosed with severe and persistent mental illness became suspicious and delusional. The patient was given depot antipsychotic medication and housing was arranged at a local shelter. After 2 weeks, which statement by the patient indicates significant improvement? a. "I am feeling safe and comfortable here. Nobody bothers me." b. "They will not let me drink. They have many rules in the shelter." c. "Those guys are always watching me. I think someone stole my shoes." d. "That shot made my arm sore. I'm not going to take any more of them." - a For patients diagnosed with severe and persistent mental illness, what is the major advantage of case management? A case manager can: a. modify traditional psychotherapy. b. efficiently access and use resources. c. focus on social skills training and self-esteem building. d. bring groups of patients together to discuss common problems. - b The father of a child diagnosed with schizophrenia says, "I lost my job, so we have no health insurance." The mother says, "I must watch this child all the time. Without supervision, our child becomes violent and destroys furniture." The sibling says, "My parents don't pay very much attention to me." These comments signify: a. life-cycle stressors. b. psychobiologic issues. c. family burden of mental illness. d. stigma associated with mental illness. - c The parent of an adult diagnosed with severe and persistent mental illness asks the nurse, "Why are you making a referral to that vocational rehabilitation program? My child won't ever be able to hold a job." Which is the nurse's best reply? a. "We make this referral to continue eligibility for federal funding." b. "Are you concerned that we're trying to make your child too independent?" c. "If you think the program would be detrimental, we can postpone it for a time." d. "Most patients are capable of employment at some level, competitive or supported." - d An adult says, "When I was a child, I took medication because I couldn't follow my teachers' directions. I stopped taking it when I was about 13. I still have trouble getting organized, which causes difficulty doing my job." Which disorder is most likely? a. Stress intolerance disorder b. Generalized anxiety disorder (GAD) c. Borderline personality disorder d. Adult ADHD - d A patient says, "I often make careless mistakes and have trouble staying focused. Sometimes it's hard to listen to what someone is saying. I have problems putting things in the right order and often lose equipment." Which problem should the nurse document? a. Inattention b. Impulsivity c. Hyperactivity d. Social impairment - a A nurse prepares for an initial interview with a patient with suspected adult ADHD. Questions should be focused to elicit information about which problem? a. Headaches b. Inattention c. Sexual impulses d. Trichotillomania - b A nurse prepares a plan of care for a patient diagnosed with adult ADHD. Which intervention should be included? a. Remind the patient of priorities and deadlines. b. Teach work-related skills such as basic computer literacy. c. Establish penalties for failing to organize and prioritize tasks. d. Give encouragement and strategies for managing and organizing. - d The treatment team believes medication will help a patient diagnosed with adult ADHD. Which class of medications does the nurse expect will be prescribed? a. Benzodiazepines b. Psychostimulants c. Antipsychotics d. Anxiolytics - b An adult diagnosed with ADHD says, "I've always been stupid. I never had friends when I was a child. My parents often punished me because I made mistakes. Now, I can't keep a job." The nurse managing care should consider: a. aversive therapy to extinguish negative behaviors. b. cognitive therapy to help address internalized beliefs. c. group therapy to allow comparison of feelings with others. d. vocational counseling to identify needed occupational skills. - b A new staff nurse tells the clinical nurse specialist, "I'm unsure about my role when patients bring up sexual problems." Which information should the clinical nurse specialist provide? All nurses: a. qualify as sexual counselors. Each has knowledge about the biopsychosocial aspects of sexuality throughout the life cycle. b. should be able to screen for sexual dysfunction and give basic information about sexual feelings, behaviors, and myths. c. should defer questions about sex to other health care professionals because of their limited knowledge of sexuality. d. who are interested in sexual dysfunction can provide sex therapy for individuals and couples. - b Which nursing action should occur first when preparing to work with a patient who has a problem of sexual functioning? a. Acquire knowledge of the patient's sexual roles and preferences b. Develop an understanding of human sexual responses c. Assess the patient's sexual functioning d. Clarify the nurse's own personal values - d A patient tells the nurse, "My sexual functioning is normal when my partner wears lace. Without it, I'm not interested in sex." This comment evidences: a. exhibitionism. b. voyeurism. c. pedophilia. d. fetishism. - d A man tells the nurse, "All my life, I have felt and acted like a woman while living in a man's body. For the past year, I have lived and dressed as a woman. I changed jobs to protect my new identity." Which request is the patient likely to make to the health care provider? a. "Can you refer me for psychological testing?" b. "Will you prescribe estrogen therapy?" c. "Will you alter my medical records?" d. "What should I tell my parents?" - b The manager of a health club put a hidden camera in the women's locker room and videotaped women as they showered and dressed. Which sexual dysfunction is evident? a. Frotteurism b. Exhibitionism c. Pedophilia d. Voyeurism - d Before working with patients regarding sexual concerns, a prerequisite for providing nonjudgmental care is: a. sympathy. b. assertiveness training. c. sexual self-awareness. d. effective communication. - c An adult has been feeling significant tension since losing a home through foreclosure. This person goes to a park, feeds the birds, and then impulsively exposes himself to a group of parents and children. Which term applies to this behavior? a. Voyeurism b. Frotteurism c. Exhibitionism d. Sexual masochism - c A nurse cares for a patient diagnosed with paraphilia. The nurse expects the health care provider may prescribe which type of medication to reduce paraphilic behaviors? a. Selective serotonin reuptake inhibitor (SSRI) b. Erectile dysfunction medication c. Atypical antipsychotic medication d. Mood stabilizer - a A patient diagnosed with severe and persistent mental illness who recently moved to a homeless shelter says, "My life is out of control. I'm like a leaf at the mercy of the wind." The nurse formulates the diagnosis Powerlessness. Outcomes will focus on: a. instilling hope. b. controlling anxiety. c. planning social activities. d. developing personal autonomy. - d Which information should a nurse include in health teaching for adults diagnosed with ADHD and their significant others? SATA a. Tendency for genetic transmission b. Prevention strategies related to substance abuse c. Negative reinforcement strategies to help modify behaviors d. Selective serotonin reuptake inhibitors (SSRIs) are usually prescribed for hyperactivity e. Cognitive therapy may help resolve internalized negative beliefs about self - a, b, e An adult patient tells the case manager, "I don't have bipolar disorder anymore, so I don't need medicine. After I was in the hospital last year, you helped me get an apartment and disability checks. Now I'm bored and don't have any friends." Which resources should the nurse suggest for the patient? Select all that apply. a. Psycho-education classes b. Vocational rehabilitation c. Social skills training d. Homeless shelter e. Crisis intervention - a, b, c Which economic factors are most critical to the success of discharge planning for a patient diagnosed with severe and persistent mental illness? SATA a. Access to housing b. Individual psychotherapy c. Income to meet basic needs d. Availability of health insurance e. Ongoing interdisciplinary evaluation - a, c, d Which statements most clearly indicate that the speaker views mental illness with stigma? SATA a. "We are all a little bit crazy." b. "If people with mental illness would go to church, their problems would be solved." c. "Many mental illnesses are genetically transmitted. It's no one's fault that the illness occurs." d. "Anyone can have a mental illness. War or natural disasters can be too stressful for healthy people." e. "People with mental illness are lazy. They get government disability checks instead of working." - a, b, e A 5-year-old child moves and talks constantly, is easily distracted, and does not listen to the parents. The child awakens before the parents every morning. The child attended kindergarten, but the teacher could not handle the behavior. What is this child's most likely problem? a. Tic disorder b. Oppositional defiant disorder (ODD) c. Intellectual development disorder (IDD) d. Attention deficit hyperactivity disorder (ADHD) - d A child diagnosed with ADHD has hyperactivity, distractibility, and impaired play. The health care provider prescribed methylphenidate (Concerta). The desired behavior for which the nurse should monitor is: a. increased expressiveness in communicating with others. b. improved ability to participate in play with other children. c. ability to identify anxiety and implement self-control strategies. d. improved socialization skills with other children and authority figures. - b A 5-year-old child diagnosed with ADHD bounces out of a chair in the waiting room, runs across the room, and begins to slap another child. What is the nurse's best action? a. Call for emergency assistance from another staff member. b. Instruct the parents to take the child home immediately. c. Direct this child to stop, and then comfort the other child. d. Take the child into another room with toys to act out feelings. - d A 16-year-old adolescent diagnosed with conduct disorder (CD) has been in a residential program for three months. Which outcome should occur before discharge? a. The teen and parents create and consent to a behavioral contract with rules, rewards, and consequences. b. The teen completes an application to enter a military academy for continued structure and discipline. c. The teen is temporarily placed with a foster family until the parents complete a parenting skills class. d. The teen has an absence of anger and frustration for 1 week. - a A child diagnosed with ADHD is going to begin medication therapy. The nurse should plan to teach the family about which classification of medications? a. Central nervous system stimulants b. Monoamine oxidase inhibitors (MAOIs) c. Antipsychotic medications d. Anxiolytic medications - a Shortly after an adolescent's parents announce a plan to divorce, the teen stops participating in sports, sits alone at lunch, and avoids former friends. The adolescent says, "If my parents loved me, then they would work out their problems." What nursing diagnosis is most applicable? a. Ineffective coping b. Decisional conflict c. Chronic low self-esteem d. Disturbed personal identity - a Shortly after a 15-year-old's parents announce a plan to divorce, the adolescent stops participating in sports, sits alone at lunch, and avoids former friends. The adolescent says, "All the other kids have families. If my parents loved me, then they would stay together." Which nursing intervention is most appropriate? a. Develop a plan for activities of daily living. b. Communicate disbelief relative to the adolescent's feelings. c. Assist the adolescent to differentiate reality from perceptions. d. Assess and document the adolescent's level of depression daily. - c When group therapy is to be used as a treatment modality, the nurse should suggest placing a 9yo in a group that uses: a. play activities exclusively. b. group discussion exclusively. c. talk focused on a specific issue. d. play then talk about the play activity. - d When assessing a 2-year-old diagnosed with autism spectrum disorder, a nurse expects: a. hyperactivity and attention decits. b. failure to develop interpersonal skills. c. history of disobedience and destructive acts. d. high levels of anxiety when separated from a parent. - b A 4-year-old child cries and screams from the time the parents leave the child at preschool until the child is picked up 4 hours later. The child is calm and relaxed when the parents are present. The parents ask, "What should we do?" What is the nurse's best recommendation? a. "Send a picture of yourself to school to keep with the child." b. "Arrange with the teacher to let the child call home at playtime." c. "Talk with the school about withdrawing the child until maturity increases." d. "Talk with your health care provider about a referral to a mental health professional." - d A 15-year-old adolescent has run away from home six times. After the adolescent was arrested for prostitution, the parents told the court, "We can't manage our teenager." The adolescent is physically abusive to the mother and defiant with the father. The adolescent's problem is most consistent with criteria for: a. attention deficit hyperactivity disorder (ADHD). b. childhood depression. c. conduct disorder (CD). d. autism spectrum disorder (ASD). - c A 15-year-old adolescent is referred to a residential program after an arrest for theft and running away from home. At the program, the adolescent refuses to participate in scheduled activities and pushes a staff member, causing a fall. Which approach by the nursing staff would be most therapeutic? a. Neutrally permit refusals b. Coax to gain compliance c. Offer rewards in advance d. Establish firm limits - d An adolescent was arrested for prostitution and assault on a parent. The adolescent says, "I hate my parents. They focus all their attention on my brother, who's perfect in their eyes." Which type of therapy might promote the greatest change in this adolescent's behavior? a. Bibliotherapy b. Play therapy c. Family therapy d. Art therapy - c An adolescent is arrested for prostitution and assault on a parent. The adolescent says, "I hate my parents. They focus all their attention on my brother, who's perfect in their eyes." Which nursing diagnosis is most applicable? a. Ineffective impulse control, related to seeking parental attention as evidenced by acting out b. Disturbed personal identity, related to acting out as evidenced by prostitution c. Impaired parenting, related to showing preference for one child over another d. Hopelessness, related to feeling unloved by parents - a Which assessment finding would cause the nurse to consider an 8-year-old child to be most at risk for the development of a psychiatric disorder? a. Being raised by a parent with chronic major depressive disorder b. Moving to three new homes over a 2-year period c. Not being promoted to the next grade d. Having an imaginary friend - a Which child shows behaviors indicative of mental illness? a. 4-year-old who stuttered for 3 weeks after the birth of a sibling b. 9-month-old who does not eat vegetables and likes to be rocked c. 3-month-old who cries after feeding until burped and sucks a thumb d. 3-year-old who is mute, passive toward adults, and twirls while walking - d The child most likely to receive propranolol (Inderal) to control aggression, deliberate self-injury, and temper tantrums is one diagnosed with: a. attention deficit hyperactivity disorder (ADHD). b. post-traumatic stress disorder (PTSD). c. autism spectrum disorder (ASD). d. separation anxiety. - c A 12-year-old child has been the neighborhood bully for several years. The parents say, "We can't believe anything our child says." Recently, the child shot a dog with a pellet gun and set fire to a trash bin outside a store. The child's behaviors are most consistent with: a. conduct disorder (CD). b. defiance of authority. c. anxiety over separation from a parent. d. attention deficit hyperactivity disorder (ADHD). - a The parent of a child diagnosed with Tourette's disorder says to the nurse, "I think my child is faking the tics because they come and go." Which response by the nurse is accurate? a. "Perhaps your child was misdiagnosed." b. "Your observation indicates the medication is effective." c. "Tics often change frequency or severity. That does not mean they aren't real." d. "This finding is unexpected. How have you been administering your child's medication?" - c An 11-year-old child, who has been diagnosed with oppositional defiant disorder (ODD), becomes angry over the rules at a residential treatment program and begins shouting at the nurse. Select the best method to defuse the situation. a. Assign the child to a short time-out. b. Administer an antipsychotic medication. c. Place the child in a therapeutic hold. d. Call a staff member to seclude the child. - a When a 5-year-old child is disruptive, the nurse says, "You must take a time-out." The expectation is that the child will: a. go to a quiet room until called for the next meal. b. slowly count to 20 before returning to the group activity. c. sit on the edge of the activity until able to regain self-control. d. sit quietly on the lap of a staff member until able to apologize for the behavior. - c A child blurts out answers to questions before the questions are complete, demonstrates an inability to take turns, and persistently interrupts and intrudes in the conversations of others. Assessment data show these behaviors relate primarily to: a. intelligence. b. impulsivity. c. inattention. d. defiance. - b A parent diagnosed with schizophrenia and her 13-year-old child live in a homeless shelter. The child has formed a trusting relationship with a shelter volunteer. The child says, "My three friends and I got an A on our school science project." The nurse can assess that the child: a. displays resiliency. b. has a difficult temperament. c. is at risk for post-traumatic stress disorder. d. uses intellectualization to deal with problems. - a A parent diagnosed with schizophrenia and 13-year-old child live in a homeless shelter. The child has formed a trusting relationship with a volunteer. The teen says, "I have three good friends at school. We talk and sit together at lunch." What is the nurse's best suggestion to the treatment team? a. Suggest foster home placement. b. Seek assistance from an intimate partner violence program. c. Make referrals for existing and emerging developmental problems. d. Foster healthy characteristics and existing environmental supports. - d Which behavior indicates that the treatment plan for a child diagnosed with autism spectrum disorder was effective? The child: a. plays with one toy for 30 minutes. b. repeats words spoken by a parent. c. holds the parent's hand while walking. d. spins around and claps hands while walking. - c What are the primary distinguishing factors between the behavior of children diagnosed with oppositional defiant disorder (ODD) and those diagnosed with conduct disorder (CD)? (Select all that apply.) The child diagnosed with: a. ODD relives traumatic events by acting them out. b. ODD tests limits and disobeys authority figures. c. ODD has difficulty separating from the parents. d. CD uses stereotypical or repetitive language. e. CD often violates the rights of others. - b, e A nurse prepares the plan of care for a 15-year-old adolescent diagnosed with moderate intellectual developmental disorder (IDD). What are the highest outcomes that are realistic for this person? (Select all that apply.) Within 5 years, the person will: a. live unaided in an apartment. b. complete high school or earn a general equivalency diploma (GED). c. independently perform his or her own personal hygiene. d. obtain employment in a local sheltered workshop. e. correctly use public buses to travel in the community. - c, d, e A patient with a history of daily alcohol abuse was hospitalized at 0200 today. When would the nurse expect withdrawal symptoms to peak? a. Between 0800 and 1000 today (6 to 8 hours after drinking stopped) b. Between 0200 tomorrow and hospital day 2 (24 to 48 hours after drinking stopped) c. About 0200 on hospital day 3 (72 hours after drinking stopped) d. About 0200 on hospital day 4 (96 hours after drinking stopped) - b A woman in the last trimester of pregnancy drinks 8 to 12 ounces of alcohol daily. The nurse plans for the delivery of an infant who is: a. jaundiced. b. dependent on alcohol. c. healthy but underweight. d. microcephalic and cognitively impaired. - d A patient was admitted last night with a hip fracture sustained in a fall while intoxicated. The patient points to the Buck's traction and screams, "Somebody tied me up with ropes." The patient is experiencing: a. an illusion. b. a delusion. c. hallucinations. d. hypnagogic phenomenon. - a A patient was admitted 48 hours ago for injuries sustained while intoxicated. The patient is shaky, irritable, anxious, and diaphoretic. The pulse rate is 130 beats per minute. The patient shouts, "Snakes are crawling on my bed. I've got to get out of here." What is the most accurate assessment of the situation? The patient: a. is attempting to obtain attention by manipulating staff. b. may have sustained a head injury before admission. c. has symptoms of alcohol withdrawal delirium. d. is having a recurrence of an acute psychosis. - c A patient admitted yesterday for injuries sustained in a fall while intoxicated believes snakes are crawling on the bed. The patient is anxious, agitated, and diaphoretic. What is the priority nursing diagnosis? a. Disturbed sensory perception b. Ineffective coping c. Ineffective denial d. Risk for injury - d A patient admitted yesterday for injuries sustained while intoxicated believes the window blinds are snakes trying to get into the room. The patient is anxious, agitated, and diaphoretic. Which medication can the nurse anticipate the health care provider will prescribe? a. Monoamine oxidase inhibitor, such as phenelzine (Nardil) b. Phenothiazine, such as thioridazine (Mellaril) c. Benzodiazepine, such as lorazepam (Ativan) d. Narcotic analgesic, such as morphine - c A hospitalized patient, injured in a fall while intoxicated, believes spiders are spinning entrapping webs in the room. The patient is anxious, agitated, and diaphoretic. Which nursing intervention has priority? a. Check the patient every 15 minutes. b. Rigorously encourage fluid intake. c. Provide one-on-one supervision. d. Keep the room dimly lit. - c A patient with a history of daily alcohol abuse says, "Drinking helps me cope with being a single parent." Which response by the nurse would help the individual conceptualize the drinking more objectively? a. "Sooner or later, alcohol will kill you. Then what will happen to your children?" b. "I hear a lot of defensiveness in your voice. Do you really believe this?" c. "If you were coping so well, why were you hospitalized again?" d. "Tell me what happened the last time you drank." - d A patient asks for information about Alcoholics Anonymous (AA). Which is the nurse's best response? a. "It is a self-help group with the goal of sobriety." b. "It is a form of group therapy led by a psychiatrist." c. "It is a group that learns about drinking from a group leader." d. "It is a network that advocates strong punishment for drunk drivers." - a Police bring a patient to the emergency department after an automobile accident. The patient is ataxic with slurred speech and mild confusion. The blood alcohol level is 0.40 mg %. Considering the relationship between behavior and blood alcohol level, which conclusion can the nurse draw? The patient: a. rarely drinks alcohol. b. has a high tolerance to alcohol. c. has been treated with disulram (Antabuse). d. has recently ingested both alcohol and sedative drugs. - b A patient admitted to an alcoholism rehabilitation program says, "I'm just a social drinker. I usually have a drink or two at brunch, a few cocktails in the afternoon, wine at dinner, and several drinks during the evening." The patient is using which defense mechanism? a. Rationalization b. Introjection c. Projection d. Denial - d A new patient in an alcoholism rehabilitation program says, "I'm just a social drinker. I usually have a drink or two at brunch, a few cocktails in the afternoon, wine at dinner, and a few drinks in the evening." Which response by the nurse will help the patient view the drinking more honestly? a. "I see," and use interested silence. b. "I think you may be drinking more than you report." c. "Being a social drinker involves having a drink or two once or twice a week." d. "You describe drinking steadily throughout the day and evening. Am I correct?" - d During the third week of treatment, the spouse of a patient in an alcoholism rehabilitation program says, "After discharge, I'm sure everything will be just fine." Which remark by the nurse will be most helpful to the spouse? a. "It is good that you're supportive of your spouse's sobriety and want to help maintain it." b. "Although sobriety solves some problems, new ones may emerge as one adjusts to living without alcohol." c. "It will be important for you to structure life to avoid as much stress as possible. You will need to provide social protection." d. "Remember that alcoholism is a disorder of self-destruction. You will need to observe your spouse's behavior carefully." - b The treatment team plans care for a person diagnosed with schizophrenia and cannabis abuse. The person has recently used cannabis daily and is experiencing increased hallucinations and delusions. Which principle applies to care planning? a. Consider each disorder primary and provide simultaneous treatment. b. The person will benefit from treatment in a residential treatment facility. c. Withdraw the person from cannabis, and then treat the schizophrenia. d. Treat the schizophrenia first, and then establish the goals for the treatment of substance abuse. - a When working with a patient beginning treatment for alcohol abuse, what is the nurse's most therapeutic approach? a. Empathetic, supportive b. Strong, confrontational c. Skeptical, guarded d. Cool, distant - a A patient comes to an outpatient appointment obviously intoxicated. The nurse should: a. explore the patient's reasons for drinking today. b. arrange admission to an inpatient psychiatric unit. c. coordinate emergency admission to a detoxication unit. d. tell the patient, "We cannot see you today because you've been drinking." - d When a person first begins drinking alcohol, two drinks produce relaxation and drowsiness. After one year of drinking, four drinks are needed to achieve the same relaxed, drowsy state. Why does this change occur? a. Tolerance develops. b. The alcohol is less potent. c. Antagonistic effects occur. d. Hypomagnesemia develops. - a Which statement most accurately describes substance addiction? a. It is a lack of control over use. Tolerance, craving, and withdrawal symptoms occur when intake is reduced or stopped. b. It occurs when psychoactive drug use interferes with the action of competing neurotransmitters. c. Symptoms occur when two or more drugs that affect the central nervous system (CNS) have additive effects. d. It involves using a combination of substances to weaken or inhibit the effect of another drug. - a A patient who was admitted for a heroin overdose received naloxone (Narcan), which improved the breathing pattern. Two hours later, the patient reports muscle aches, abdominal cramps, and says, "I feel terrible." Which analysis is correct? a. The patient is exhibiting a prodromal symptom of seizures. b. An idiosyncratic reaction to naloxone is occurring. c. Symptoms of opiate withdrawal are present. d. The patient is experiencing a relapse. - c In the emergency department, a patient's vital signs are: BP 66/40 P 140bpm; R 8 bpm and shallow. The patient overdosed on illegally obtained hydromorphone (Dilaudid). Select the priority outcome. a. Within 8 hours, vital signs will stabilize as evidenced by BP greater than 90/60 P less than 100bpm, and respirations at or above 12bpm b. The patient will be able to describe a plan for home care and achieve a drug-free state before being released from the emergency department. c. The patient will attend daily meetings of Narcotics Anonymous within 1 week of beginning treatment. d. The patient will identify two community resources for the treatment of substance abuse by discharge. - a Select the nursing intervention necessary after administering naloxone (Narcan) to a patient experiencing an opiate overdose. a. Monitor the airway and vital signs every 15 minutes. b. Insert a nasogastric tube and test gastric pH. c. Treat hyperpyrexia with cooling measures. d. Insert an indwelling urinary catheter. - a A nurse worked at a hospital for several months, resigned, and then took a position at another hospital. In the new position, the nurse often volunteers to be the medication nurse. After several serious medication errors, an investigation reveals that the nurse was diverting patient narcotics for self-use. What early indicator of the nurse's drug use was evident? a. Accepting responsibility for medication errors. b. Seeking to be assigned as a medication nurse. c. Frequent complaints of physical pain. d. High sociability with peers. - b A nurse with a history of narcotic abuse is found unconscious in the hospital locker room after overdosing. The nurse is transferred to an inpatient substance abuse unit for care. Which attitudes or behaviors by nursing staff may be enabling? a. Conveying understanding that pressures associated with nursing practice underlie substance abuse. b. Pointing out that work problems are the result, but not the cause, of substance abuse. c. Conveying empathy when the nurse discusses fears of disciplinary action by the state board of nursing. d. Providing health teaching about stress management. - a Which treatment approach is most appropriate for a patient with antisocial tendencies who has been treated several times for substance addiction but has relapsed? a. One-week detoxication program b. Long-term outpatient therapy c. Twelve-step self-help program d. Residential program - d Which nursing diagnosis would likely apply both to a patient diagnosed with schizophrenia as well as a patient diagnosed with amphetamine-induced psychosis? a. Powerlessness b. Disturbed thought processes c. Ineffective thermo-regulation d. Impaired oral mucous membrane - b Which is an important nursing intervention when giving care to a patient withdrawing from a CNS stimulant? a. Make physical contact by frequently touching the patient. b. Offer intellectual activities requiring concentration. c. Avoid manipulation by denying the patient's requests. d. Observe for depression and suicidal ideation. - d Which assessment findings best correlate to the withdrawal from central nervous system depressants? a. Dilated pupils, tachycardia, elevated blood pressure, elation b. Labile mood, lack of coordination, fever, drowsiness c. Nausea, vomiting, diaphoresis, anxiety, tremors d. Excessive eating, constipation, headache - c A patient has smoked two packs of cigarettes daily for many years. When the patient does not smoke or tries to cut back, anxiety, craving, poor concentration, and headache result. What does this scenario describe? a. Substance abuse b. Substance addiction c. Substance intoxication d. Recreational use of a social drug - b Which assessment findings will the nurse expect in an individual who has just injected heroin? a. Anxiety, restlessness, paranoid delusions b. Heightened sexuality, insomnia, euphoria c. Muscle aching, dilated pupils, tachycardia d. Drowsiness, constricted pupils, slurred speech - d A newly hospitalized patient has needle tracks on both arms. A friend states that the patient uses heroin daily but has not used in the past 24 hours. The nurse should assess the patient for: a. slurred speech, excessive drowsiness, and bradycardia. b. paranoid delusions, tactile hallucinations, and panic. c. runny nose, yawning, insomnia, and chills. d. anxiety, agitation, and aggression. - c A nurse is called to the home of a neighbor and finds an unconscious person still holding a medication bottle labeled "phentobarbital sodium." What is the nurse's first action? a. Test reflexes b. Check pupils c. Initiate vomiting d. Establish a patent airway - d An adult in the emergency department states, "I feel restless. Everything I look at wavers. Sometimes I'm outside my body looking at myself. I hear colors. I think I'm losing my mind." Vital signs are slightly elevated. The nurse should suspect a: a. cocaine overdose. b. schizophrenic episode. c. phencyclidine (PCP) intoxication. d. D-lysergic acid diethylamide (LSD) ingestion. - d In what signicant ways is the therapeutic environment dierent for a patient who has ingested Dlysergic acid diethylamide (LSD) than for a patient who has ingested phencyclidine (PCP)? a. For LSD ingestion, one person stays with the patient and provides verbal support. For PCP ingestion, a regimen of limited contact with staff members is maintained, and continual visual monitoring is provided. b. For PCP ingestion, the patient is placed on one-on-one intensive supervision. For LSD ingestion, a regimen of limited interaction and minimal verbal stimulation is maintained. c. For LSD ingestion, continual moderate sensory stimulation is provided. For PCP ingestion, continual high-level stimulation is provided. d. For LSD ingestion, the patient is placed in restraints. For PCP ingestion, seizure precautions are implemented. - a When assessing a patient who has ingested unitrazepam (Rohypnol), the nurse would expect: a. acrophobia. b. hypothermia. c. hallucinations. d. anterograde amnesia. - d A patient is admitted in a comatose state after ingesting 30 capsules of phentobarbital sodium. A friend of the patient says, "Often my friend drinks, along with taking more of the drug than is prescribed." What is the effect of the use of alcohol with this drug? a. The drug's metabolism is stimulated. b. The drug's effect is diminished. c. A synergistic effect occurs. d. There is no effect. - c Which medication is the nurse most likely to see prescribed as part of the treatment plan for both a patient in an alcoholism treatment program and a patient in a program for the treatment of opioid addiction? a. methadone (Dolophine) b. bromocriptine (Parlodel) c. disulram (Antabuse) d. naltrexone (Revia) - d Select the most appropriate outcome for a patient completing the fourth alcohol detoxication program in one year. Before discharge, the patient will a. use rationalization in healthy ways. b. state, "I see the need for ongoing treatment." c. identify constructive outlets for expression of anger. d. develop a trusting relationship with one staff member. - b Which question has the highest priority when assessing a newly admitted patient with a history of alcohol abuse? a. "Have you ever had blackouts?" b. "When did you have your last drink?" c. "Has drinking caused you any problems?" d. "When did you decide to seek treatment?" - b A patient in an alcohol treatment program says, "I have been a loser all my life. I'm so ashamed of what I have put my family through. Now, I'm not even sure I can succeed at staying sober." Which nursing diagnosis applies? a. Chronic low self-esteem b. Situational low self-esteem c. Disturbed personal identity d. Ineffective health maintenance - a Which documentation indicates that the treatment plan for a patient in an alcohol treatment program was effective? a. Is abstinent for 10 days and states, "I can maintain sobriety one day at a time." Spoke with employer, who is willing to allow the patient to return to work in three weeks. b. Is abstinent for 15 days and states, "My problems are under control." Plans to seek a new job where co-workers will not know history. c. Attends AA daily; states many of the members are "real" alcoholics and says, "I may be able to help some of them find jobs at my company." d. Is abstinent for 21 days and says, "I know I can't handle more than one or two drinks in a social setting." - a Which assessment findings support a nurse's suspicion that a patient has been using inhalants? a. Pinpoint pupils and respiratory rate of 12 breaths per minute b. Perforated nasal septum and hypertension c. Drowsiness, euphoria, and constipation d. Confusion, mouth ulcers, and ataxia - d A patient undergoing alcohol rehabilitation decides to accept disulram (Antabuse) therapy to avoid impulsively responding to drinking cues. Which information should be included in the discharge teaching for this patient? Select all that apply. a. Avoid aged cheeses. b. Read labels of all liquid medications. c. Wear sunscreen and avoid bright sunlight. d. Maintain an adequate dietary intake of sodium. e. Avoid breathing fumes of paints, stains, and stripping compounds. - b, e A nurse can assist a patient diagnosed with addiction and the patient's family in which aspects of relapse prevention? SATA a. Rehearsing techniques to handle anticipated stressful situations b. Advising the patient to accept residential treatment if relapse occurs c. Assisting the patient to identify life skills needed for effective coping d. Isolating self from significant others and social situations until sobriety is established e. Teaching the patient about the physical changes to expect as the body adapts to functioning without substances - a, c, e While caring for a patient with a methamphetamine overdose, which tasks are the priorities of care? Select all that apply. a. Administration of naloxone (Narcan) b. Vitamin B12 and folate supplements c. Restoring nutritional integrity d. Prevention of seizures e. Reduction of fever - d, e A patient asks a nurse, "What are neurotransmitters? My doctor says mine are out of balance." The best reply would be: a. "You must feel relieved to know that your problem has a physical basis." b. "Neurotransmitters are chemicals that pass messages between brain cells." c. "It is a high-level concept to explain. You should ask the doctor to tell you more." d. "Neurotransmitters are substances we eat daily that influence memory and mood." - b A psychiatric nurse best implements the ethical principle of autonomy when he or she: a. intervenes when a self-mutilating patient attempts to harm self. b. stays with a patient who is demonstrating a high level of anxiety. c. suggests that two patients who are fighting be restricted to the unit. d. explores alternative solutions with a patient, who then makes a choice. - d Which action by a psychiatric nurse best supports a patient's right to be treated with dignity and respect? a. Consistently addressing a patient by title and surname. b. Strongly encouraging a patient to participate in the unit milieu. c. Discussing a patient's condition with another health care provider in the elevator. d. Informing a treatment team that a patient is too drowsy to participate in care planning. - a 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: a. reveals that the nurse values the principle of justice. b. reinforces the autonomy of the two patients. c. violates the civil rights of the two patients. d. represents the intentional tort of battery. - c In a team meeting a nurse says, "I'm 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? a. Beneficence b. Autonomy c. Fidelity d. Justice - d A nurse's neighbor asks, "Why aren't people with mental illness kept in state institutions anymore?" What is the nurse's best response? a. "Many people are still in psychiatric institutions. Inpatient care is needed because many people who are mentally ill are violent." b. "Less restrictive settings are now available to care for individuals with mental illness." c. "Our nation has fewer persons with mental illness; therefore fewer hospital beds are needed." d. "Psychiatric institutions are no longer popular as a consequence of negative stories in the press." - b Which nursing intervention demonstrates false imprisonment? a. A confused and combative patient says, "I'm getting out of here and no one can stop me." The nurse restrains this patient without a health care provider's order and then promptly obtains an order. b. 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." c. An involuntarily hospitalized patient with suicidal ideation runs out of the psychiatric unit. A nurse rushes after the patient and convinces the patient to return to the unit. d. An involuntarily hospitalized patient with suicidal ideation attempts to leave the unit. A nurse calls the security team and uses established protocols to prevent the patient from leaving. - b A patient should be considered for involuntary commitment for psychiatric care when he or she: a. is noncompliant with the treatment regimen. b. sells and distributes illegal drugs. c. threatens to harm self and others. d. fraudulently files for bankruptcy. - c A nurse at the mental health center prepares to administer a scheduled injection of haloperidol decanoate (Haldol) to a pt 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 nurse's best initial action. a. Stop the medication administration procedure and say to the patient, "Tell me more about the side effects you've been having." b. Say to the patient, "Since I've already drawn the medication in the syringe, I'm required to give it, but let's talk to the doctor about skipping next month's dose." c. Proceed with the injection but explain to the patient that other medications are available that may help reduce the unpleasant side effects. d. Notify other staff members to report to the room for a show of force and proceed with the injection, using restraint if necessary. - a Several 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? a. The policies do not absolve an individual nurse of the responsibility to practice according to the professional standards of nursing care. b. Agency policies are the legal standard by which a professional nurse must act and therefore override other standards of care. c. In an institution with substandard policies, the nurse has a responsibility to inform the supervisor and leave the premises. d. Interpretation of policies by the judicial system is rendered on an individual basis and therefore cannot be predicted. - a A 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? a. Health care provider b. Profession c. Hospital d. Patient - d An example of a breach of a patient's right to privacy occurs when a nurse: a. asks a family to share information about a patient's prehospitalization behavior. b. discusses the patient's history with other staff members during care planning. c. documents the patient's daily behaviors during hospitalization. d. releases information to the patient's employer without consent. - d An adolescent hospitalized after a violent physical outburst tells the nurse, "I'm going to kill my father, but you can't tell anyone." Select the nurse's best response. a. "You're right. Federal law requires me to keep that information private." b. "Those kinds of thoughts will make your hospitalization longer." c. "You really should share this thought with your psychiatrist." d. "I am required to share information with the treatment team." - d A voluntarily hospitalized patient tells the nurse, "Get me the forms for discharge against medical advice so I can leave now." What is the nurse's best initial response? a. "I can't give you those forms without your health care provider's knowledge." b. "I will get them for you, but let's talk about your decision to leave treatment." c. "Since you signed your consent for treatment, you may leave if you desire." d. "I'll get the forms for you right now and bring them to your room." - b The 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? a. "Under the law, treatment must be provided. Hospitalization without treatment violates patients' rights." b. "That's a justifiable concern because the right to treatment extends only to the provision of food, shelter, and safety." c. "Much will depend on other patients, because the right to treatment for a psychotic patient takes precedence over the right to treatment of a patient who is stable." d. "All patients in public hospitals have the right to choose both a primary therapist." - a Which individual with a mental illness may need emergency or involuntary hospitalization for mental illness? The individual who: a. resumes using heroin while still taking methadone. b. reports hearing angels playing harps during thunderstorms. c. throws a heavy plate at a waiter at the direction of command hallucinations. d. does not show up for an outpatient appointment with the mental health nurse. - c A 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: a. anonymously report the abuse by telephone to the local child abuse hotline. b. reply, "I'm glad you feel comfortable talking to me about it." c. respect the nurse-patient relationship of confidentiality. d. file a written report on the agency letterhead. - a The spouse of a patient who has delusions asks the nurse, "Are there any circumstances under which the treatment team is justified in violating the patient's right to confidentiality?" The nurse must reply that confidentiality may be breached: a. under no circumstances. b. at the discretion of the psychiatrist. c. when questions are asked by law enforcement. d. if the patient threatens the life of another person. - d A 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: a. implement the order. b. consult a drug reference. c. give the usual geriatric dosage. d. hold the medication and consult the health care provider. - d A 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: a. released information without proper authorization. b. demonstrated the duty to warn and protect. c. violated the patient's confidentiality. d. avoided charges of malpractice. - b After 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: a. fulfill the request. b. refer the matter to the charge nurse to resolve. c. access the record and document the information. d. report the request to the patient's health care provider. - b A patient diagnosed with mental illness asks a psychiatric technician, "What's the matter with me?" The technician replies, "Your wing nuts need tightening." The nurse who overheard the exchange should take action based on: a. violation of the patient's right to be treated with dignity and respect. b. the nurse's obligation to report caregiver negligence. c. preventing defamation of the patient's character. d. supervisory liability. - a Which documentation of a patient's behavior best demonstrates a nurse's observations? a. Isolates self from others. Frequently fell asleep during group. Vital signs stable. b. Calmer and more cooperative. Participated actively in group. No evidence of psychotic thinking. c. Appeared to hallucinate. Patient frequently increased volume on television, causing conflict with others d. Wears four layers of clothing. States, "I need protection from dangerous bacteria trying to penetrate my skin." - d A nurse volunteers for a committee that must revise the hospital policies and procedures for suicide precautions. Which resources would provide the best guidance? Select all that apply. a. Diagnostic and Statistical Manual of Mental Disorders DSM5 b. State's nurse practice act c. State and federal regulations that govern hospitals d. Summary of common practices of several local hospitals e. American Nurses Association Scope and Standards of Practice for Psychiatric-Mental Health Nursing - c, e In which situations does a nurse have a duty to intervene and report? Select all that apply. a. A peer is unable to write behavioral outcomes. b. A health care provider consults th