Test Bank: Working With an Individual Patient Keltner: Psychiatric Nursing, 8th Edition,100% CORRECT - $16.49   Add to cart

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Test Bank: Working With an Individual Patient Keltner: Psychiatric Nursing, 8th Edition,100% CORRECT

Test Bank: Working With an Individual Patient Keltner: Psychiatric Nursing, 8th Edition MULTIPLE CHOICE 1. A patient is hospitalized for severe depression. Knowing that the patient will be discharged after a short stay, what is the nurse’s first priority? a. Maximize the benefits of milieu management. b. Immediately begin to explore acute patient issues. c. Develop a goal-directed, problem-centered relationship. d. Choose a specific theoretical model as the basis for care. ANS: C Therapeutic relationships are planned, patient-centered, and goal-directed. This is of particular importance if progress is to be made when the duration of the relationship will be brief. The other options are not the priority. Exploration of patient issues requires trust development before it can proceed. DIF: Cognitive level: Analyzing TOP: Nursing process: Implementation MSC: Client Needs: Safe, Effective Care Environment 2. A nurse tells a patient, “I know how you feel. My spouse can be very insensitive too. I am also considering divorce.” What behavior is the nurse demonstrating? a. Inappropriate self-disclosing b. Countertransference c. Establishment of trust wiNth thRe pIatieGnt B.C M d. Encouraging the patient to UexpSressNnegTative feOelings ANS: A Brief self-disclosure is used to help the patient clarify specific issues, to feel less vulnerable, or to feel more “normal.” When used appropriately, self-disclosure benefits the patient. When used inappropriately, it benefits the nurse. In this case, the self-disclosure burdens the patient with the nurse’s problems. Empathy focuses on the patient. Countertransference would result in different behaviors. Encouraging expression of negative feelings would be more direct. DIF: Cognitive level: Understanding TOP: Nursing process: Evaluation MSC: Client Needs: Safe, Effective Care Environment 3. A patient diagnosed with schizophrenia says to the nurse, “I feel really close to you. You’re the only true friend I have.” What is the nurse’s most therapeutic response? a. “We are not friends. Our relationship is a professional one.” b. “I feel sure there are other friends in your life. Can you name some?” c. “I am glad you trust me. Trust is important for the work we are doing together.” d. “Our relationship is professional, but let’s explore ways to strengthen personal friendships.” ANS: D The patient’s remarks call for the nurse to remind the patient of the parameters of their relationship and take the opportunity to discuss the issue of friends. Only this option incorporates both desired elements. DIF: Cognitive level: Applying TOP: Nursing process: Implementation MSC: Client Needs: Psychosocial Integrity 4. What statement made by a nursing is most helpful when moving into the working stage of a therapeutic relationship with a patient? a. “I want to be helpful to you as we explore your problems and the way you express feelings.” b. “A good long-term goal for someone your age would be to develop better job-related skills.” c. “Of the problems we have discussed so far, which ones would you most like to work on at this time?” d. “When someone gives you a compliment, I notice that you become very quiet and appear uncomfortable.” ANS: C With this remark, the nurse seeks patient collaboration and offers the opportunity to set priorities for the work toward change that will be undertaken. The distracters relate to the orientation stage. DIF: Cognitive level: Applying TOP: Nursing process: Implementation MSC: Client Needs: Psychosocial Integrity 5. Which goal statement is most appropriate for a newly admitted patient currently in the orientation stage of the nurse-patient relationship? a. By the end of the orientation stage of the therapeutic relationship, the patient will demonstrate greater independence. b. By the end of the orientatNioUnRstSagIeNoGf tTheBCraOpMeutic relationship, the patient will demonstrate increased self-responsibility. c. By the end of the orientation stage of the therapeutic relationship, the patient will demonstrate trust and rapport with two staff members. d. By the end of the orientation stage of the therapeutic relationship, the patient will demonstrate ability to problem-solve one issue. ANS: C Establishing trust is the primary task of the orientation stage of the nurse-patient relationship. The other options are too ambitious for this early stage. DIF: Cognitive level: Applying TOP: Nursing process: Planning MSC: Client Needs: Psychosocial Integrity 6. A patient is withdrawn and avoids talking to the nurse. The nurse should identify which action is the initial intervention for this patient? a. Extend a respectful offer to listen and help. b. Directly ask why the patient does not wish to talk. c. Involve the patient in a group activity to decrease isolation. d. Respect the patient’s desire not to talk by leaving the patient alone. ANS: A Patients might be afraid or unable to approach nurses. Nurses must take the initiative to approach the patient, thus acknowledging the patient’s worthiness and conveying acceptance. “Why” questions usually elicit rationalization. Leaving the patient alone does not foster trust. Decreasing isolation will not build trust in the nurse. DIF: Cognitive level: Applying TOP: Nursing process: Implementation MSC: Client Needs: Psychosocial Integrity 7. A patient has identified the need for better anger management and tells the nurse, “I’m afraid that someday I might explode.” What is the best strategy for reducing this patient’s fear of losing control? a. Talking about these feelings openly and directly b. Discussing feelings in general without reference to the patient c. Avoiding any discussion concerning feelings until the patient feels comfortable d. Reassuring the patient that expressing feelings is the first step to resolving them ANS: A Talking openly about feelings conveys the message that feelings are natural and can be handled. Once feelings can be discussed, the focus can shift to learning to cope more effectively with them. The other options are either avoidant or nontherapeutic. DIF: Cognitive level: Applying TOP: Nursing process: Implementation MSC: Client Needs: Psychosocial Integrity 8. Which statement is most therapeutic when working with a patient believed to be experiencing emotional pain? a. “I hear how painful this is for you. I would like to help you deal with it.” b. “I’m so sorry this has hapNpUenRedStIoNyGouT. BYo.uCdOonM’t deserve it.” c. “What would you like me to do to help you through this pain?” d. “I don’t think this is as serious as you believe it is.” ANS: A This remark uses empathy to acknowledge the patient’s feelings and then offers help. Using empathy tells the patient that his or her feelings are understood. Offering help implies hope for a positive resolution. Empathy, rather than sympathy, is a useful tool. Asking what to do for the patient implies helplessness on the part of the nurse. Minimizing the problem is demeaning to the patient. DIF: Cognitive level: Applying TOP: Nursing process: Implementation MSC: Client Needs: Psychosocial Integrity 9. A nurse and patient agree on problems to be addressed during a brief hospital stay. Which interpretation of this action is correct? a. The relationship is moving into the working stage. b. The nurse should reinforce messages about termination. c. The nurse needs to direct the patient to begin journaling. d. Management of emotions must be ensured before work can continue. ANS: A Problems are defined and priorities for work are set as the nurse and patient collaborate during the orientation stage. This sets the stage for transition into the working stage. Management of emotions can occur during the working stage. DIF: Cognitive level: Understanding TOP: Nursing process: Assessment MSC: Client Needs: Psychosocial Integrity 10. A patient with a history of self-mutilation says to the nurse, “I want to stop hurting myself.” What is the initial step of the problem-solving process to be taken toward resolution of a patient’s identified problem? a. Deciding on a plan of action b. Determining necessary changes c. Considering alternative behaviors d. Describing the problem or situation ANS: D The nurse learns how well the patient understands the problem by asking for a detailed, in-depth description of situations, thoughts, feelings, and behaviors relevant to the identified problem. This step must be completed before moving through the problem-solving process. The other actions are premature. DIF: Cognitive level: Understanding TOP: Nursing process: Implementation MSC: Client Needs: Psychosocial Integrity 11. A patient says, “I went out drinking only one time last week. At least I’m trying to change.” The nurse responds, “I appreciate your effort, but you agreed to abstain from alcohol completely.” The nurse’s response demonstrates the ability to manage what potential patient centered problem? a. Cognitive restructuring b. Manipulation c. Hostility d. Denial ANS: B NURSINGTB.COM The correct comment prevents the nurse from being manipulated by the patient. The nurse should address what happened, along with the expectations. The remaining options do not attempt to address the patient’s manipulation of the situation. DIF: Cognitive level: Understanding TOP: Nursing process: Implementation MSC: Client Needs: Psychosocial Integrity 12. A nurse and patient who developed a therapeutic relationship enter into the final phase of their relationship as the patient prepares for discharge. What is an important nursing intervention for this stage of the relationship? a. Providing structure and intensive support b. Informing the patient of the progress made c. Encouraging the patient to describe goals for change d. Discussing feelings about termination with the patient ANS: A Healthy closure is facilitated when the patient discusses his or her reactions to termination and the feelings that she or he might be experiencing. The nurse serves as a role model during termination. Providing structure is related more to the orientation and working stages. Informing the patient of progress is paternalistic. The process of termination is facilitated by collaborative work. Describing goals takes place with passage from the orientation to the working stage. DIF: Cognitive level: Applying TOP: Nursing process: Implementation MSC: Client Needs: Psychosocial Integrity 13. Which statement by a patient would the nurse interpret as willingness to collaborate in the nurse-patient relationship? a. “I know you are here to help me, and will do whatever you tell me to do.” b. “I didn’t want to deal with this at first, but I’m glad you made me face it.” c. “I realize that I have some issues that I need help resolving.” d. “I will do anything to get out of this hospital.” ANS: C Collaboration takes place when patients recognize problems and the need for assistance. The other responses suggest coercion or simple compliance. They fail to demonstrate the element of self-reflection on the part of the patient. DIF: Cognitive level: Analyzing TOP: Nursing process: Assessment MSC: Client Needs: Psychosocial Integrity 14. A novice nurse says, “I have more important things to do than play games with patients. These activities are not a worthwhile use of my time.” What is the nurse manager’s most helpful response? NURSINGTB.COM a. “Games are part of the therapeutic milieu.” b. “Patients need a break from intensive individual therapy.” c. “Informal activities help patients develop social skills and take risks.” d. “Please review material on the psychotherapeutic management model.” ANS: C Nurses who engage in therapeutic activities with patients recognize that each encounter with patients is part of an overall therapeutic picture. Patients discuss real problems and solutions and practice skills needed in real-life situations. These encounters offer opportunities for assessment, for patients to process feelings, and for validation and feedback, as well as for tension relief. The correct answer is the most global response. The distracters do not educate the new nurse about the purpose of informal activities. DIF: Cognitive level: Analyzing TOP: Nursing process: Implementation MSC: Client Needs: Psychosocial Integrity 15. An inpatient says, “Last time I was here, a primary nurse talked with me every day. This time, different nurses work with me. How can I make progress?” Which nursing response best addresses the patient’s concern? a. “Your comments are interesting. With your permission I will share them with the treatment team.” b. “We are using a new system because of managed-care requirements. We are hopeful it will be effective.” c. “Shift reports, care plans, and progress notes help different nurses work with all patients toward their individual goals.” d. “It sounds like you are feeling dissatisfied with your care. After you are discharged, you will receive a form to provide feedback.” ANS: C This reply explains how many nurses are able to share responsibility and accountability for the care of patients. Good communication enables the nurses to be “on the same page” when it comes to working toward the achievement of patient-centered goals that are appropriate for each stage of the nurse-patient relationship. The other options fail to provide the information the patient needs to understand the current practices. DIF: Cognitive level: Applying TOP: Nursing process: Implementation MSC: Client Needs: Psychosocial Integrity 16. Which nursing intervention will initially be most helpful for trust building with a suspicious patient? a. Enforcing rules b. Keeping appointments and promises c. Agreeing not to document the patient’s disclosures d. Openly challenging unclear statements by the patient ANS: B Consistency and honesty regarding intentions are behaviors that promote patient trust. Enforcing rules is important but not necessarily related to trust building. The other options are nontherapeutic. DIF: Cognitive level: ApplyinNg R I GTOBP:.CNursMing process: Implementation MSC: Client Needs: Psychosocial Integrity 17. A patient shouts at a nurse who just entered the room, “You’re an incompetent fool. Leave me alone.” The nurse’s response should be based on which rationale? a. The anger was created by a situation or significant person, not the nurse. b. The reaction probably results from transference and countertransference. c. The patient is probably reacting to fear of loss of emotional control. d. The patient has a right to openly express negative feelings. ANS: A Anger toward the nurse is often displaced anger that has arisen from some situation or significant person in the patient’s life. Nurses feel the brunt of the anger because they are “handy” and might be considered by the patient to be a safe object for the displacement. Knowing that the nurse is not the true object of the anger allows the nurse to plan a therapeutic strategy for helping the individual manage the emotion. None of the other options provides an accurate basis for planning intervention. DIF: Cognitive level: Understanding TOP: Nursing process: Implementation MSC: Client Needs: Psychosocial Integrity 18. Which patient behavior would require the most immediate limit-setting by the nurse? a. The patient makes self-deprecating remarks. b. At a goal-setting meeting, the patient interrupts others to express delusions. c. A patient shouts at a roommate, “You are perverted! You watched me undress.” d. During dinner, a patient manipulates an older adult patient to obtain a second dessert. ANS: C Behaviors that require the most immediate limit-setting are verbal and physical aggression, self-destructive behavior, fire setting, alcohol or drug use, manipulation, inappropriate sexual behaviors, and attempts to leave the hospital without consent. In this case the verbal aggression toward the roommate requires immediate intervention to prevent further escalation. The other options don’t meet the criteria for potential risk for harm. DIF: Cognitive level: Analyzing TOP: Nursing process: Assessment MSC: Client Needs: Psychosocial Integrity 19. A patient playing pool with another patient throws down the pool cue and begins swearing. What action should the nurse implement initially to address this situation? a. Asking other patients to leave the room b. Calling for assistance to restrain the patient c. Suggesting a time-out in the patient’s room d. Restating rules of the milieu related to swearing ANS: C Suggesting a time-out in the patient’s room is often an effective initial strategy, because it permits the patient to go to an area with fewer stimuli. It also removes the patient from other patients who are at risk for injury if the patient’s behavior escalates. Restating the rules of the milieu does not help the patient diffuse the anger. Removing other patients is unnecessary unless the patient’s behavior escalates. DIF: Cognitive level: ApplyinNg R I GTOBP:.CNursMing process: Implementation MSC: Client Needs: Safe, Effective Care Environment 20. A newly admitted patient tells the nurse, “The voices are bothering me.” What should be the nurse’s initial intervention? a. Ignoring the patient’s reference to voices b. Distracting the patient from the hallucinations c. Telling the patient that the voices do not exist d. Seeking a description of the voices to identify themes ANS: D Early assessment of hallucinations is based on the content of the messages. Content often reveals the dynamics of the patient’s symptoms and typically revolves around a theme such as powerlessness, hate, guilt, or loneliness. Ignoring the reference is nontherapeutic and thwarts assessment. Distraction is a possible strategy after the nurse understands the content of the hallucinations. Saying that the voices do not exist negates the patient’s experience. Saying you do not hear them is preferable. DIF: Cognitive level: Applying TOP: Nursing process: Implementation MSC: Client Needs: Psychosocial Integrity 21. What fact about a particular patient will have the greatest impact on nurse-patient collaboration? a. Involuntary admission b. Advance age c. Hallucinations d. Terminal diagnosis ANS: C Patients have a right to make decisions about their care. Collaboration generally produces more effective and enduring change than coercion or simple compliance. However, situations arise during which full collaboration is not possible, such as when patients have an obvious disturbance in their thought processes (e.g., severe hallucinations or delusions). None of the other options are generally considered significant barriers to achieving collaboration with the patient. DIF: Cognitive level: Understanding TOP: Nursing process: Assessment MSC: Client Needs: Psychosocial Integrity 22. A nurse considers interventions for a diabetic patient who needs to change eating habits and lose weight. The nurse will base strategies on which principle? a. The nurse’s primary responsibility is to encourage the change. b. Patient-initiated change is more successful than imposed change. c. For successful change, both the benefit and the risk to the patient must be high. d. Patients value advice from nurses because of the trusting dimensions of the relationship. ANS: B The answer indicates that the patient is invested in the change process. Nurses have multiple responsibilities in the change process, including education and reinforcement. Nurses should avoid giving advice. DIF: Cognitive level: UnderstNandRing I GTOBP:.CNursMing process: Planning MSC: Client Needs: Psychosocial Integrity 23. A psychotic patient tells the nurse, “Get away from me or I’ll hit you. You’re sucking the thoughts out of my head.” To best de-escalate the situation, what intervention should the nurse implement? a. Directing the patient to a chair b. Deny taking the patient’s thoughts c. Increasing the distance between nurse and patient d. Telling the patient, “You will be restrained if you hit me” ANS: C The nurse should do as the patient requests when the request is reasonable. Patients perceiving alterations in reality often need increased personal space to feel less anxious. Denials, touching, and threatening are likely to promote escalation of violent behavior. DIF: Cognitive level: Applying TOP: Nursing process: Implementation MSC: Client Needs: Safe, Effective Care Environment 24. The nurse caring for a hyperactive patient should identify what assessment as being the priority? a. Physical safety b. Emotional trauma c. Manipulative behaviors d. Feelings about the relationship ANS: A Hyperactive patients are at high risk for injury and physical exhaustion, both of which compromise physical safety. Safety needs take priority over emotional needs. DIF: Cognitive level: Applying TOP: Nursing process: Assessment MSC: Client Needs: Safe, Effective Care Environment 25. Assessment findings by the multidisciplinary team after a patient-intake interview are used primarily for what purpose? a. Confirm ongoing discharge planning. b. Expand and confirm the initial assessment. c. Verify the appropriateness of nursing diagnoses. d. Analyze the patient’s feelings about hospitalization. ANS: B As members of the multidisciplinary team interact with the patient, their impressions might support or differ slightly from the initial assessment. The findings are synthesized and used in planning ongoing treatment. The other options have less relevance or are not applicable. DIF: Cognitive level: Understanding TOP: Nursing process: Assessment MSC: Client Needs: Psychosocial Integrity 26. Objective data obtained from family in an initial assessment of a patient are of particular value when which situation exists? a. The patient is too ill to participate. b. The patient’s admission is involuntary. c. Family members have adNmittRed tIhe pGatieBn.t. C M d. The patient has been transferred from a subacute setting. ANS: A Some patients are too ill to participate in or complete the assessment interview. When this is the case, the interviewer uses objective data obtained from patient observation and the reports of family or others present at the time of admission. The other options do not reflect situations in which objective data have maximal value. DIF: Cognitive level: Understanding TOP: Nursing process: Assessment MSC: Client Needs: Psychosocial Integrity 27. As the nurse plans care for a newly admitted patient, identification of dysfunctional behaviors will provide the focus for which component of the nursing process? a. Evaluation b. Nursing diagnosis c. Nursing interventions d. Outcome identification ANS: C The nurse recognizes that dysfunctional behaviors are behaviors that would benefit the patient to change. These dysfunctional behaviors are written as defining characteristics in the nursing diagnosis. Nursing interventions are formulated that address changing dysfunctional behaviors to more adaptive behaviors. The focus of evaluation is patient progress; the focus of nursing diagnosis is patient problems; the focus of outcome identification is adaptive behaviors. DIF: Cognitive level: Understanding TOP: Nursing process: Planning MSC: Client Needs: Psychosocial Integrity 28. A patient tells the nurse, “I was raped a month ago. Since then I’ve felt anxious and have been unable to talk normally to my husband. I’ve had frequent thoughts about cutting my wrists.” What is the priority nursing concern regarding this patient? a. The risk for self-directed violence b. The development of rape traumatic syndrome c. The damage that could result in poor self-esteem d. The demonstration of signs and symptoms of acute anxiety ANS: A The risk for self-injury is of highest priority, because patient safety is involved. None of the other options demonstrate that degree of safety risk. DIF: Cognitive level: Analyzing TOP: Nursing process: Assessment MSC: Client Needs: Physiologic Integrity 29. When the nurse formulates nursing diagnoses, it is necessary to be specific in describing dysfunctional behaviors so as to demonstrate what desired outcome? a. The selection of appropriate desirable behaviors b. The analysis concerning the patient’s feeling at the time of assessment. c. The exploration of the context that precipitated the exacerbation of the illness. d. The determination of how the illness relates to the patient’s total life experience. ANS: A A goal or outcome specifies Nan aRdapItiveGbehBav.iCor toMreplace one that is dysfunctional. The more specific the description of the dysfunctional behavior in the nursing diagnosis, the easier it is to specify an appropriate adaptive behavior. The other options are not relevant reasons for describing dysfunctional behaviors in nursing diagnoses. DIF: Cognitive level: Understanding TOP: Nursing process: Outcome Identification MSC: Client Needs: Psychosocial Integrity 30. What activity would be involved in achieving an appropriate short-term goal for a patient diagnosed with situational low self-esteem? a. Writing a list of strengths, abilities, and talents b. Role-playing with others to improve social skills c. Replacing a negative self-image with a positive one d. Responding with positive self-esteem in all encounters ANS: A A short-term goal is one that can be attained in 4 to 6 days. Identification of strengths, abilities, and talents is attainable within this time frame. The other options are long-term goals. DIF: Cognitive level: Analyzing TOP: Nursing process: Planning MSC: Client Needs: Psychosocial Integrity 31. What is a realistic time frame for achievement of short-term goals for a patient who is newly admitted to the hospital? a. 1 to 2 days. b. 4 to 6 days. c. 1 to 2 weeks. d. 2 to 4 weeks. ANS: B Short-term goals are those achievable in 4 to 6 days for hospitalized patients and somewhat longer for patients in other settings. A period of 1 to 2 days allows too little time. The other options suggest longer times than necessary. DIF: Cognitive level: Understanding TOP: Nursing process: Planning MSC: Client Needs: Safe, Effective Care Environment 32. A patient with suicidal ideation is hospitalized. What is the priority intervention? a. Negotiating a no-harm contract b. Facilitating attendance at groups c. Administering a psychotropic drug d. Determining the precipitating situation ANS: A Preservation of patient safety is of higher priority than any of the other interventions. DIF: Cognitive level: Analyzing TOP: Nursing process: Planning MSC: Client Needs: Safe, Effective Care Environment 33. A patient hospitalized for 6 days has made little progress toward outcomes written at the time of admission. The nurse decides that the lack of progress toward goals indicates a need for what intervention? a. A reassessment b. Delayed discharge NURSINGTB.COM c. Incorrect nursing diagnoses d. Inaccurate nursing interventions ANS: A When the evaluation is made that goals are not being attained, reassessment should take place. Nursing diagnoses might need to be reformulated, more realistic outcomes identified, or nursing interventions changed, but none of these measures can be determined to be appropriate until the reassessment has been completed. DIF: Cognitive level: Applying TOP: Nursing process: Evaluation MSC: Client Needs: Psychosocial Integrity 34. The nurse writing a discharge summary for a patient should include achievements as well as what additional information? a. Care plan updates b. A list of patient strengths c. Effective nursing interventions d. Outcomes that still need to be addressed ANS: D Information included in discharge summaries includes outcomes attained, outcomes still to be attained, discharge instructions, medication instructions, and follow-up appointments. The other items are not part of a discharge summary. DIF: Cognitive level: Understanding TOP: Nursing process: Evaluation MSC: Client Needs: Safe, Effective Care Environment 35. A student states, “I do not see the value of process recordings.” The response to this concern should be based on what information related to process recording? a. It is a tool for analyzing communication. b. It is a verbatim record of a patient interview. c. It is a legal document that becomes part of the medical record. d. It is a note written at the time of a patient interview to provide information to team members. ANS: A A process recording is a tool for the nurse to learn about the effectiveness of communication and interventions during an interpersonal interaction. It is more than a verbatim record. It is for use by the nurse, rather than the interdisciplinary team. It is not placed into the medical record. DIF: Cognitive level: Understanding TOP: Nursing process: Implementation MSC: Client Needs: Psychosocial Integrity 36. What is the most effective outcome for a nurse to include in the care plan for a withdrawn patient who says, “I would like to have more friends”? Within 3 days: a. the patient will be more outgoing. b. the patient will develop gNreUatRerSiIndNepGeTndBCe.OM c. the patient will participate in one group activity. d. the patient will increase socialization with others. ANS: C This outcome is behavioral, measurable, and related directly to the problem of social isolation. The other outcomes are neither measurable nor relevant to socialization. DIF: Cognitive level: Applying TOP: Nursing process: Outcome Identification MSC: Client Needs: Psychosocial Integrity 37. Following the admission interview, a spouse of a patient asks the nurse, “Why did you ask my partner all those questions? Some of them had nothing to do with the current problems.” The nurse’s best response is based on what assessment focus of the mental status examination (MSE)? a. The patient’s current status b. The complete family history c. The patient’s past experiences d. What the patient’s prognosis will be ANS: A The mental status examination (MSE) is designed to provide information about the patient’s current level of functioning. Other specific information might be obtained that contributes to the overall picture. The MSE does not provide information relating to the other options. DIF: Cognitive level: Applying TOP: Nursing process: Implementation MSC: Client Needs: Psychosocial Integrity 38. The nurse performing a mental status examination wants to assess for hallucinations. The nurse should ask which question? a. “Can you tell me where you are now?” b. “Do you hear or see things when others don’t?” c. “Do your moods shift more than those of other people?” d. “What would you do if you found a stamped, addressed letter on the floor?” ANS: D Hallucinations are false sensory perceptions. The correct answer directly inquires about possible hallucinations. The other options seek information about other aspects of the MSE. DIF: Cognitive level: Applying TOP: Nursing process: Assessment MSC: Client Needs: Psychosocial Integrity 39. During a mental status examination (MSE) a patient says, “I am a special messenger sent to provide the world a cure for cancer.” The patient’s statement indicates the presence of what form of dysfunctional thought content? a. Phobia b. Delusion c. Hypervigilance d. Loose associations ANS: B Delusions are false beliefs. Grandiose delusions are beliefs that one possesses greatness or special powers. A phobia is aNn exRcesIsiveGfeaBr..HCypeMrvigilance refers to being hyperalert and suspicious. Loose associations refer to a thought disorder in which ideas are only loosely connected. DIF: Cognitive level: Understanding TOP: Nursing process: Assessment MSC: Client Needs: Psychosocial Integrity MULTIPLE RESPONSE 1. A psychiatric aide asks, “Can you give me some examples of how we provide structure for patients?” The nurse should offer which suggestions? (Select all that apply.) a. Set limits on destructive behavior. b. Direct a patient to go to a quiet place. c. Sit with a withdrawn, isolated patient. d. Distract a patient who is hallucinating. e. Help a patient contemplate needed change. ANS: A, B, C, D Providing structure means that staff members meet patient needs for organizing elements in the environment to produce specific outcomes. Contemplating change is the only option that would not be considered an example of structuring. DIF: Cognitive level: Analyzing TOP: Nursing process: Implementation MSC: Client Needs: Safe, Effective Care Environment 2. A patient tells the nurse, “I want to have sex with you.” Which nursing responses are appropriate? (Select all that apply.) a. “I will forget you said that.” b. “Your suggestion frightens me.” c. “You must keep your distance.” d. “Sex is not part of our relationship.” e. “We are here to work on your problems.” ANS: D, E The correct responses provide information to the patient about the purpose of the relationship and recognize the underlying need. The other options are ineffective. DIF: Cognitive level: Applying TOP: Nursing process: Implementation MSC: Client Needs: Psychosocial Integrity 3. A nurse plans to teach a group of patients the basics of the change process. How should the elements be sequenced for the presentation? (Select all that apply.) a. Assess the success of new behaviors. b. Observe to gain awareness. c. Draw conclusions about the problem. d. Test new behaviors. e. Assume that change is necessary. ANS: A, B, C, D This sequence proceeds logically from assessment of the problem to analysis of the problem to determining that change is necessary to testing new behaviors and evaluating their efficacy. It is inappropriate to assume NthUatRcShaInNgeGisTnBCssOarMy. DIF: Cognitive level: Applying TOP: Nursing process: Implementation MSC: Client Needs: Psychosocial Integrity

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