WITH RATIONALES LATEST UPDATES ALREADY GRADED WITH
100% PASS.
,TI RN MENTAL HEALTH 2019 WITH NGN 100% PASS WITH
RATIONALES LATEST UPDATES QUESTION AND ANSWERS
ALREADY GRADED.
A nurse is caring for a group of patients. For which of the following situations
should the nurse complete an incident report? - answer-A client was
administered one-half of the prescribed dose of medication
Rationale: An incident report is a recording of any occurrence that does not
meet the standard of care. The nurse should report medication errors using
the facility's incident or occurrence form.
A nurse is caring for a group of patients. Which of the following findings is
the nurse required to report? - answer-A client who has borderline
personality disorder threatened to harm their roommate
Rationale: Signs and symptoms of BPD include interpersonal relationships
accompanied by threats and other-directed violence. While it is important for
the nurse to maintain the patients confidentiality, when another individual
might be in danger, the nurse is required by law to report it to authorities.
A nurse is caring for a patient who has borderline personality disorder. Which
of the following goals is the priority when planning care for this patient?
a. The patient will take the prescribed medications as scheduled
b. The patient will express feelings of frustration
c. The patient will refrain from self-mutilation
d. The patient will participate in group therapy - answer-c. The client will
refrain from self-mutilation
Rationale: The greatest risk to the patient is injury to self and others.
Therefore, the priority goal is for the patient to refrain from self-mutilation
a. Taking prescribed medications as scheduled to maintain therapeutic blood
levels is an important goal. However, this is not the priority goal
b. Expressing feelings of frustration to acknowledge these feelings is an important goal.
However, this is not the priority goal
d. Participating in group therapy as part of the treatment plan is an
important goal. However, this is not the priority goal
A nurse is discussing the home care of a patient who has advanced
Alzheimer's disease. The patient's caregiver is planning to go out of town for
several days. Which of the following resources should the nurse
recommended to the caregiver?
,a. Respite care
b. Partial hospitalization
c. Adult day care program
d. Geropsychiatric unit - answer-a. Respite care
Rationale: Respite care programs allow the patient to stay in a nursing
facility for a set number of days, allowing the caregivers to go on vacation or
have some time to themselves
b. Partial hospitalization provides services for several hours during the day,
but they are not designed to offer 24-hr care. A patient with advanced
Alzheimer's disease is unable to safely remain at home unattended
c. Adult day care programs can provide services throughout the day to
patient's with Alzheimer's disease, allowing the caregiver the ability to work
or have a break. The patient's return home in the evening. A patient who has
advanced Alzheimer's disease is unable to safely remain at home
unattended.
d. A geropsychiatric unit provides care for patients requiring acute psychiatric
services due to sudden mental status changes, psychosis, or other mental
health services. These services are ideal for patients who are at risk of
harming themselves or others
A nurse is caring for an older adult patient who has dementia and has
wandered into the day room looking for their deceased partner. Which of the
following actions should the nurse take?
a. Move the patient to a room near the nurses' station
b. Limit visitors until the patient is oriented to the environment
c. Tell the patient their partner is deceased
d. Talk with the patient about activities they enjoyed with their partner -
answer-Talk with the patient about activities they enjoyed with their partner
Rationale:
Talking about positive experiences can help distract the patient from their
disorientation
a. When caring for a patient with dementia, avoid placing them in
unfamiliar settings when possible.
b. Family members should be encouraged to interact with the patient
regardless of the patient's state of dementia
c. Confrontation should not be used for a disoriented patient
A nurse is admitting a patient with schizophrenia to an acute care setting.
When the nurse questions the patient regarding their admission, the client
states, "I'm red, in the head, and I'm going to bed!" The nurse should
document the client's speech pattern as which of the following?
a. Clang association
b. Word salad
c. Neologism
, d. Echolalia - answer-a. Clang association
Rationale: The nurse should document that the patients speech uses clang
associations which often rhyme or contain a string of words that can have a
similar sound
b. In word salad, words are completely meaningless and disorganized.
c. Neologism consists of words that are made up by the patient
d. In echolalia, the patient repeats the words of another person
A nurse is assessing a patient who has schizophrenia. Which of the following
findings should the nurse document as a negative symptom of this disorder?
a. Delusions
b. Neologisms
c. Anhedonia
d. Echopraxia - answer-Anhedonia
Rationale:
Positive symptoms of schizophrenia usually appear suddenly and are
alteration in behavior, perception, speech, and thought. Delusions, inability
to think abstractly, neologisms (made up words), echolalia (repeating of
someone else's words, motor agitation, and echopraxia (mimicking someone
else's movements) are all positive symptoms of schizophrenia.
Negative symptoms of schizophrenia affect a person's ability to interact with
others and are less dominant than positive symptoms. Negative symptoms
develop over time.
Examples of negative symptoms include flat affect, anergia (lack of energy),
anhedonia (inability to enjoy otherwise pleasurable activities), and thought
blocking (inability to think, speak, or move in response to outside stimuli)
A nurse is delegating patient care tasks to a licensed practical nurse (LPN)
and an assistive personnel. Which of the following tasks should the nurse
assign to the LPN? - answer-Change the dressing of a client who has
borderline personality disorder and superficial self-inflicted wounds
Rationale: A patient who has borderline personality disorder is at risk for self-
mutilation such as cutting, self-inflicted wounds, scratching or picking at
wounds. It is within the LPNs scope of practice to change the dressing,
cleanse the wound, and collect data regarding the healing of the wound.
A nurse is assessing a school-age child who has conduct disorder. Which of
the following characteristics should the nurse expect the child to
demonstrate?
a. Feelings of remorse
b. Extended periods of depression
c. Deficits in intellectual functioning
d. Aggression towards animals - answer-d. Aggression toward animals