PSYCHIATRIC NURSING EXAM 2
(TESTBANK) WITH COMPLETE
SOLUTIONS.
A patient became severely depressed when the last of six children moved
out of the home 4 months ago. The patient repeatedly says, No one cares
about me. Im not worth anything. Which response by the nurse would be the
most helpful?
a. Things will look brighter soon. Everyone feels down once in a while.
b. The staff here cares about you and wants to try to help you get better.
c. It is difficult for others to care about you when you repeatedly say
negative things about yourself.
d. Ill sit with you for 10 minutes now and return for 10 minutes at lunchtime
and again at 2:30 this afternoon. - Correct Answer- d
A patient became depressed after the last of six children moved out of the
home 4 months ago. The patient has been self-neglectful, slept poorly, lost
weight, and repeatedly says, No one cares about me anymore. Im not worth
anything. Select an appropriate initial outcome for the nursing diagnosis:
Situational low self-esteem, related to feelings of abandonment. The patient
will:
a. verbalize realistic positive characteristics about self by (date)
b. consent to take antidepressant medication regularly by (date)
c. initiate social interaction with another person daily by (date)
d. identify two personal behaviors that alienate others by (date). - Correct
Answer- a
A nurse wants to reinforce positive self-esteem for a patient diagnosed with
major depressive disorder. Today, the patient is wearing a new shirt and has
neat, clean hair. Which remark is most appropriate?
a. You look nice this morning.
b. You are wearing a new shirt.
c. I like the shirt youre wearing.
,d. You must be feeling better today. - Correct Answer- b
An adult diagnosed with major depressive disorder was treated with
medication and cognitive behavioral therapy. The patient now recognizes
how passivity contributed to the depression. Which intervention should the
nurse suggest?
a. Social skills training
b. Relaxation training classes
c. Use of complementary therapy
d. Learning desensitization techniques - Correct Answer- a
A priority nursing intervention for a patient diagnosed with major depressive
disorder is:
a. distracting the patient from self-absorption.
b. carefully and inconspicuously observing the patient around the clock.
c. allowing the patient to spend long periods alone in self-reflection.
d. offering opportunities for the patient to assume a leadership role in the
therapeutic milieu. - Correct Answer- b
When counseling patients diagnosed with major depressive disorder, an
advanced practice nurse will address the negative thought patterns by using:
a. psychoanalytic therapy.
b. desensitization therapy.
c. cognitive behavioral therapy.
d. alternative and complementary therapies. - Correct Answer- c
A patient says to the nurse, My life does not have any happiness in it
anymore. I once enjoyed holidays, but now theyre just another day. How
would the nurse document the complaint?
a. Vegetative symptom
b. Anhedonia
c. Euphoria
d. Anergia - Correct Answer- b
A patient diagnosed with major depressive disorder is taking a tricyclic
antidepressant. The patient says, I dont think I can keep taking these pills.
They make me so dizzy, especially when I stand up. The nurse should:
a. explain how to manage postural hypotension, and educate the patient that
side effects go away after several weeks.
,b. tell the patient that the side effects are a minor inconvenience compared
with the feelings of depression.
c. withhold the drug, force oral fluids, and notify the health care provider to
examine the patient.
d. teach the patient how to use pursed-lip breathing. - Correct Answer- a
A patient diagnosed with major depressive disorder is receiving imipramine
(Tofranil) 200 mg every night at bedtime. Which assessment finding would
prompt the nurse to collaborate with the health care provider regarding
potentially hazardous side effects of this drug?
a. Dry mouth
b. Blurred vision
c. Nasal congestion
d. Urinary retention - Correct Answer- d
A patient diagnosed with major depressive disorder tells the nurse, Bad
things that happen are always my fault. To assist the patient in reframing
this overgeneralization, the nurse should respond:
a. I really doubt that one person can be blamed for all the bad things that
happen.
b. Lets look at one bad thing that happened to see if another explanation
exists.
c. You are being exceptionally hard on yourself when you say those things.
d. How does your belief in fate relate to your cultural heritage? - Correct
Answer- b
A nurse worked with a patient diagnosed with major depressive disorder who
was severely withdrawn and dependent on others. After 3 weeks, the patient
did not improve. The nurse is at risk for feelings of:
a. overinvolvement.
b. guilt and despair.
c. interest and pleasure.
d. ineffectiveness and frustration. - Correct Answer- d
A patient diagnosed with major depressive disorder begins selective
serotonin reuptake inhibitor (SSRI) antidepressant therapy. Priority
information given to the patient and family should include a directive to:
a. avoid exposure to bright sunlight.
b. report increased suicidal thoughts.
c. restrict sodium intake to 1 g daily.
, d. maintain a tyramine-free diet. - Correct Answer- b
A nurse teaching a patient about a tyramine-restricted diet would approve
which meal?
a. Mashed potatoes, ground beef patty, corn, green beans, apple pie
b. Avocado salad, ham, creamed potatoes, asparagus, chocolate cake
c. Macaroni and cheese, hot dogs, banana bread, caffeinated coffee
d. Noodles with cheddar cheese sauce, smoked sausage, lettuce salad, yeast
rolls - Correct Answer- a
What is the focus of priority nursing interventions for the period immediately
after electroconvulsive therapy treatment?
a. Supporting physiologic stability
b. Reducing disorientation and confusion
c. Monitoring pupillary responses
d. Assisting the patient to identify and test negative thoughts - Correct
Answer- a
A nurse provided medication education for a patient who takes phenelzine
(Nardil) for depression. Which behavior indicates effective learning? The
patient:
a. monitors sodium intake and weight daily.
b. wears support stockings and elevates the legs when sitting.
c. consults the pharmacist when selecting over-the-counter medications.
d. can identify foods with high selenium content, which should be avoided. -
Correct Answer- c
A patients employment is terminated and major depressive disorder results.
The patient says to the nurse, Im not worth the time you spend with me. Im
the most useless person in the world. Which nursing diagnosis applies?a.
Powerlessness
b. Defensive coping
c. Situational low self-esteem
d. Disturbed personal identity - Correct Answer- c
A patient diagnosed with major depressive disorder does not interact with
others except when addressed and then only in monosyllables. The nurse
wants to show nonjudgmental acceptance and support for the patient. Select
the nurses most effective approach to communication.
a. Make observations.
(TESTBANK) WITH COMPLETE
SOLUTIONS.
A patient became severely depressed when the last of six children moved
out of the home 4 months ago. The patient repeatedly says, No one cares
about me. Im not worth anything. Which response by the nurse would be the
most helpful?
a. Things will look brighter soon. Everyone feels down once in a while.
b. The staff here cares about you and wants to try to help you get better.
c. It is difficult for others to care about you when you repeatedly say
negative things about yourself.
d. Ill sit with you for 10 minutes now and return for 10 minutes at lunchtime
and again at 2:30 this afternoon. - Correct Answer- d
A patient became depressed after the last of six children moved out of the
home 4 months ago. The patient has been self-neglectful, slept poorly, lost
weight, and repeatedly says, No one cares about me anymore. Im not worth
anything. Select an appropriate initial outcome for the nursing diagnosis:
Situational low self-esteem, related to feelings of abandonment. The patient
will:
a. verbalize realistic positive characteristics about self by (date)
b. consent to take antidepressant medication regularly by (date)
c. initiate social interaction with another person daily by (date)
d. identify two personal behaviors that alienate others by (date). - Correct
Answer- a
A nurse wants to reinforce positive self-esteem for a patient diagnosed with
major depressive disorder. Today, the patient is wearing a new shirt and has
neat, clean hair. Which remark is most appropriate?
a. You look nice this morning.
b. You are wearing a new shirt.
c. I like the shirt youre wearing.
,d. You must be feeling better today. - Correct Answer- b
An adult diagnosed with major depressive disorder was treated with
medication and cognitive behavioral therapy. The patient now recognizes
how passivity contributed to the depression. Which intervention should the
nurse suggest?
a. Social skills training
b. Relaxation training classes
c. Use of complementary therapy
d. Learning desensitization techniques - Correct Answer- a
A priority nursing intervention for a patient diagnosed with major depressive
disorder is:
a. distracting the patient from self-absorption.
b. carefully and inconspicuously observing the patient around the clock.
c. allowing the patient to spend long periods alone in self-reflection.
d. offering opportunities for the patient to assume a leadership role in the
therapeutic milieu. - Correct Answer- b
When counseling patients diagnosed with major depressive disorder, an
advanced practice nurse will address the negative thought patterns by using:
a. psychoanalytic therapy.
b. desensitization therapy.
c. cognitive behavioral therapy.
d. alternative and complementary therapies. - Correct Answer- c
A patient says to the nurse, My life does not have any happiness in it
anymore. I once enjoyed holidays, but now theyre just another day. How
would the nurse document the complaint?
a. Vegetative symptom
b. Anhedonia
c. Euphoria
d. Anergia - Correct Answer- b
A patient diagnosed with major depressive disorder is taking a tricyclic
antidepressant. The patient says, I dont think I can keep taking these pills.
They make me so dizzy, especially when I stand up. The nurse should:
a. explain how to manage postural hypotension, and educate the patient that
side effects go away after several weeks.
,b. tell the patient that the side effects are a minor inconvenience compared
with the feelings of depression.
c. withhold the drug, force oral fluids, and notify the health care provider to
examine the patient.
d. teach the patient how to use pursed-lip breathing. - Correct Answer- a
A patient diagnosed with major depressive disorder is receiving imipramine
(Tofranil) 200 mg every night at bedtime. Which assessment finding would
prompt the nurse to collaborate with the health care provider regarding
potentially hazardous side effects of this drug?
a. Dry mouth
b. Blurred vision
c. Nasal congestion
d. Urinary retention - Correct Answer- d
A patient diagnosed with major depressive disorder tells the nurse, Bad
things that happen are always my fault. To assist the patient in reframing
this overgeneralization, the nurse should respond:
a. I really doubt that one person can be blamed for all the bad things that
happen.
b. Lets look at one bad thing that happened to see if another explanation
exists.
c. You are being exceptionally hard on yourself when you say those things.
d. How does your belief in fate relate to your cultural heritage? - Correct
Answer- b
A nurse worked with a patient diagnosed with major depressive disorder who
was severely withdrawn and dependent on others. After 3 weeks, the patient
did not improve. The nurse is at risk for feelings of:
a. overinvolvement.
b. guilt and despair.
c. interest and pleasure.
d. ineffectiveness and frustration. - Correct Answer- d
A patient diagnosed with major depressive disorder begins selective
serotonin reuptake inhibitor (SSRI) antidepressant therapy. Priority
information given to the patient and family should include a directive to:
a. avoid exposure to bright sunlight.
b. report increased suicidal thoughts.
c. restrict sodium intake to 1 g daily.
, d. maintain a tyramine-free diet. - Correct Answer- b
A nurse teaching a patient about a tyramine-restricted diet would approve
which meal?
a. Mashed potatoes, ground beef patty, corn, green beans, apple pie
b. Avocado salad, ham, creamed potatoes, asparagus, chocolate cake
c. Macaroni and cheese, hot dogs, banana bread, caffeinated coffee
d. Noodles with cheddar cheese sauce, smoked sausage, lettuce salad, yeast
rolls - Correct Answer- a
What is the focus of priority nursing interventions for the period immediately
after electroconvulsive therapy treatment?
a. Supporting physiologic stability
b. Reducing disorientation and confusion
c. Monitoring pupillary responses
d. Assisting the patient to identify and test negative thoughts - Correct
Answer- a
A nurse provided medication education for a patient who takes phenelzine
(Nardil) for depression. Which behavior indicates effective learning? The
patient:
a. monitors sodium intake and weight daily.
b. wears support stockings and elevates the legs when sitting.
c. consults the pharmacist when selecting over-the-counter medications.
d. can identify foods with high selenium content, which should be avoided. -
Correct Answer- c
A patients employment is terminated and major depressive disorder results.
The patient says to the nurse, Im not worth the time you spend with me. Im
the most useless person in the world. Which nursing diagnosis applies?a.
Powerlessness
b. Defensive coping
c. Situational low self-esteem
d. Disturbed personal identity - Correct Answer- c
A patient diagnosed with major depressive disorder does not interact with
others except when addressed and then only in monosyllables. The nurse
wants to show nonjudgmental acceptance and support for the patient. Select
the nurses most effective approach to communication.
a. Make observations.
