NURS 661 Exam 1 - Questions and Answers (Maryville University)

NURS 661 Exam 1 - Questions and Answers (Maryville University) The nurse in the community mental health clinic assesses a client and determines the presence of an Axis II diagnosis. What conclusions can the nurse draw? 1. The client is in need of further evaluation. 2. The client has a personality disorder. 3. The client will need a special diet. 4. The client is a candidate for the least restrictive environment. A female client disclosed to the nurse that she is in an abusive situation. This information will be used to contribute to: 1. Axis IV. 2. Axis III. 3. Nothing, since this is confidential information and should not be shared. 4. Axis I. The nurse on the inpatient unit is reviewing the record of a client admitted the previous day, and notes the client has an Axis I diagnosis. What inferences can the nurse make about the client? 1. The client has a clinical psychiatric disorder. 2. The client is in need of immediate medical attention. 3. The client has a chronic condition. 4. The client lacks a support system. A client is admitted with the following diagnosis: Axis I: 300.01 Panic disorder without agoraphobia Axis II: 301.83 Borderline personality disorder Axis III: No diagnosis Axis IV: Unemployment What conclusions can the nurse make relative to the clients Axis III information? 1. This client has problems with environment, but they are not related to mental disorder. 2. The client’s environment has not been evaluated. 3. The client’s health status has not been evaluated. 4. The client has no diagnosed physiological health problems relevant to mental disorder at the time of admission. The school nurse, who must be familiar with mental health issues, will find child clinical disorders classified under: 1. Axis II. 2. Axis I. 3. Axis X. 4. Axis VII. Answer: 2 After interviewing a client for admission, the nurse gives the client a score of 50 on the Global Assessment of Functioning Scale (GAF). The nurse selected this score based on the client’s level of functioning: 1. Since being given a psychiatric diagnosis. 2. Within the past week. 3. Since beginning the psychotropic medication. 4. Within the past year. Select the priority nursing diagnosis for a client with a Global Assessment of Functioning (GAF) score of 10. 1. Risk for Impaired Social Interaction 2. Risk for Injury 3. Knowledge Deficit 4. Risk for Communication Deficit The psychiatric home health nurse is evaluating whether a client’s level of functioning has improved since starting the prescribed psychotropic medication. What evidence does the nurse look for? 1. There is no change in the GAF score. 2. There is a significant decrease (by 10 or more points) in the clients GAF score. 3. The client no longer qualifies for a GAF score. 4. There is an increase in the clients GAF score. The nurse is documenting observations of client interactions during a group session. The nurse strives to document the behaviors of the client interactions with: 1. Objectivity. 2. Serendipity. 3. Sympathy. 4. Empathy. The nurse is validating what was observed before documenting in the progress note. Validation is used as a mechanism to ensure which of the following? 1. The clients affect is appropriate to the situation 2. The client’s perception of the response is communicated 3. The clients request is clarified 4. The clients need for further intervention is understood The nurse is developing a plan of care for a client. Which of the following interventions must the nurse be careful to avoid? 1. Discussing expectations with the client 2. Selecting interventions that conflict with the clients value system 3. Identifying the clients perception of the problem 4. Addressing issues related to the clients past experiences The student nurse asks why the nurse is documenting the client’s nonverbal responses in addition to verbal responses during the initial assessment. Which of the following statements made by the nurse reflects the rationale for documenting both verbal and nonverbal responses? 1. It is the hospital policy to document both. 2. It is important to be thorough when documenting. 3. Documenting both permits the reader to compare the behaviors for congruence. 4. Charting verbal and nonverbal helps me remain objective. During a group session, the clients are asked to make one positive statement about their home life. The nurse notices that one of the clients begins to fidget in the chair and interprets this behavior as: 1. A form of nonlanguage vocalization. 2. A therapeutic use of space. 3. An expression of discomfort. 4. An excuse to avoid answering the question. During a group session, a client expresses anger at the nurse. The nurse sits tensely with arms and legs crossed while verbally agreeing that the client’s point of view is correct. Which of the following messages is being sent by the nurse? 1. The nurse is expressing warmth toward the client 2. The nurse is being patient 3. The nurse is demonstrating empathy 4. The nurse is sending a mixed message The nurse observed that during a teaching session, the overall emotional tone of a client remained unchanged. The nurse documents this as: 1. Affect that has range. 2. Flat affect. 3. Incongruent verbal and nonverbal responses. 4. Muted behavior. The nurse is working with a teen admitted with a diagnosis of depression. Which of the following interventions demonstrates that the nurse is sensitive to the client’s needs? 1. Avoiding the use of silence to decrease anxiety 2. Asking for details to demonstrate interest in the client 3. Using closed-ended questions 4. Listening to the clients feelings A working goal for the nurse client relationship is to achieve: 1. Facilitative intimacy. 2. Self-disclosure. 3. Interdependence. 4. Social superficiality During the first interaction with a client, the nurse makes an introduction and identifies the purpose of the interaction. This serves to accomplish which of the following in developing a trusting relationship? 1. Setting goals 2. Building 3. Initiating 4. Maintaining The nurse engaged in a therapeutic relationship with a client uses nonverbal communication to: 1. Enhance verbal messages. 2. Avoid the use of verbal messages. 3. Detract from verbal messages. 4. Terminate the therapeutic relationship. A nurse acknowledges feeling anxious about meeting new people. By acknowledging feelings to the client, the nurse is demonstrating: 1. Sympathy. 2. Genuineness. 3. Empathy. 4. Superficiality. Psychiatricmental health nursing interventions occur at which of the following levels of communication? 1. Public 2. Intrapersonal 3. Interpersonal 4. International