NUR 2488 MH exam2.

•Question 1 A fully developed outcome for a client goal would include: (SATA) 0 out of 1 points Selected Answers: Time sensitive Measurable terms Initial assessment Attainable for client Answers: Time sensitive Measurable terms Initial assessment Identifying data Attainable for client Response Feedback: No. Outcomes need to take into account the patient's culture, values, and ethical beliefs. Specifically, outcomes are stated in attainable and measurable terms and include a time estimate for attainment". •Question 2 The nurse understands a client could be at risk for serotonin syndrome when taking which of the following medications in addition to over the counter medications or herbal supplements? 0 out of 1 points Selected Answer: Haloperid ol Answers: Sertraline Response Feedback: Haloperid ol Trazadon e Venlafaxi ne No. Sertraline (Zoloft) is an SSRI, and when combined with over the counter medications or herbal supplements could increase the clients risk for developing serotonin syndrome. •Question 3 0out of 1 points A 4-year-old child grabs toys from siblings, saying, “I want that toy now!” The siblings cry and the child’s parent becomes upset with the behavior. Using Freudian theory, a nurse can interpret the child’s behavior as a product of impulses originating in the: Selected Answer: Ego Answers: Id Ego Superego Preconsci ous Response Feedback : No. The id operates on the pleasure principle, seeking immediate gratification of impulses. The ego acts as a mediator of behavior and would weigh the consequences of the action, perhaps determining that taking the toy is not worth the parent’s wrath. The superego would oppose the impulsive behavior as “not nice.” The preconscious is a level of awareness. •Question 4 1out of 1 points Which expected client outcome should a nurse identify as being correctly formulated? Selected Answer: Client will initiate interaction with one peer during free time within 2 days. Answers: Client will feel happier by discharge. Client will demonstrate two relaxation techniques. Client will verbalize triggers to anger by end of session. Response Feedback : Client will initiate interaction with one peer during free time within 2 days. Yes. The statement “Client will initiate interaction with one peer during free time within 2 days” is an example of a correctly formulated expected outcome. Outcomes should be measurable, realistic, client-focused goals that include a time frame. Appropriate nursing interventions are guided by client outcomes. •Question 5 A voluntarily hospitalized patient tells the nurse, “Get me the forms for 1 out of 1 points discharge against medical advice so I can leave now.” Which is the nurse’s best response? Selected Answer: “I will get them for you, but let’s talk about your decision to leave treatment.” Answers: “I can’t give you those forms without your health care provider’s knowledge.” “I’ll get the forms for you right now and bring them to your room.” “Since you signed your consent for treatment, you may leave if you desire.” “I will get them for you, but let’s talk about your decision to leave treatment.” Response Feedback : Yes. A patient who has been voluntarily admitted as a psychiatric inpatient has the right to demand and obtain release in most states. However, as a patient advocate, the nurse is responsible for weighing factors related to the patient’s wishes and best interests. By asking for information, the nurse may be able to help the patient reconsider the decision. The statement that discharge forms can’t be given without the health care provider’s knowledge is not true. Facilitating discharge without consent is not in the patient’s best interests before exploring the reason for the request. •Question 6 The client is being admitted to the inpatient psychiatric unit. The nurse 0 out of 1 points conducts a mental status examination. Which of the following items are included in this examination? (Select all that apply) Selected Answers: Appearance Mood and Affect Physical Exam Cognition Answers: Appearance Mood and Affect Thought Physical Exam Cognition Response Feedback: Personal information, appearance, behavior, speech, mood and affect, thought, perceptual disturbances and cognition are all parts of a mental status exam. Physical assessment would not be included with the MSE. (Chapter 7, p 103-104) •Question 7 A client with schizophrenia has recently begun a new medication, 1 out of 1 points clozapine (Clozaril). Which signs and symptoms of a potentially fatal side effect will the nurse teach the client about? Selected Answer: Blurring vision and muscular weakness Answers: Blurring vision and muscular weakness Sore throat, fever, and malaise Tremor, shuffling gait, and neck stiffness Fine tremor, tinnitus, and nausea Response Feedback: Yes. These are symptoms of agranulocytosis, which is a potentially fatal disorder in which the client's white blood cell count drops to extremely low levels. This places the client at great risk for infections.