Unit 4: Foundations of Psychiatric Nursing || with 100%
correct answers.
During the mental status examination, a client may be asked to explain such proverbs as "Don't
cry over spilled milk." The purpose of this is to evaluate the client's ability to think: correct
answers abstractly.
Abstract thinking is the ability to conceptualize and interpret meaning. It's a higher level of
intellectual functioning than concrete thinking, in which the client explains the proverb by its
literal meaning. Rational thinking involves the ability to think logically, make judgments, and be
goal-directed. Tangential thinking is scattered, non-goal-directed, and hard to follow. Clients
with such conditions as organic brain disease and schizophrenia typically can't conceptualize and
comprehend abstract meaning. They interpret such statements as "Don't cry over spilled milk" in
a literal sense, such as "Even if you spill your milk, you shouldn't cry about it."
A client is complaining to other clients about not being allowed by staff to keep food in the
client's room. What should the nurse do? correct answers Set limits on the behavior.
The nurse needs to set limits on the client's manipulative behavior to help the client control
dysfunctional behavior. The manipulative client bends rules to have needs met without regard for
rules or the needs or rights of others. A consistent approach by the staff is necessary to decrease
manipulation. Ignoring the client's behavior reinforces or promotes the continuation of the
client's manipulative behavior. Reprimanding the client may be perceived as a threat, resulting in
aggressive behavior. Allowing the client to keep a snack in the client's room reinforces the
dysfunctional behavior.
A nurse is counseling a married woman who has two children under 4 years of age and is a
victim of spousal abuse. Before the client leaves the clinic, what is the most important thing the
nurse should do? correct answers Help the client develop a safety plan.
It is most important for the nurse to help the client develop a safety plan because the abuse will
occur again, and the client will need a plan to seek a safe environment for herself and her
children.Teaching about the cycle of violence is not as important as the client's safety and the
,safety of her children.Discussing the abuser's behaviors is not as important as the client's safety
and the safety of her children.Giving the client the name of a domestic violence shelter can be
part of the safety plan, but the nurse needs to assure other safety measures are in place until the
woman is ready to leave the abusive partner.
Which intervention(s) should the nurse include in the plan of care for a school-age child with an
autism spectrum disorder who has been admitted to the hospital? Select all that apply. correct
answers Allow a family member in the room 24 hours per day.
Limit the number of health care providers and nurses interacting with the child.
Dim lights and keep noise levels low.
Show medical equipment to the child before procedures.
Have family member bring possessions from home.
Children with an autism spectrum prefer routine and familiarity. Having a family member in the
room 24 hours a day may decrease the child's anxiety. Limiting the number of different health
care providers and nurses that interact with the child may also help reduce anxiety. Dimming
lights and keeping noise levels low will reduce sensory stimulation. Introducing a child with an
autism spectrum disorder to equipment prior to a procedure may help reduce anxiety. Bringing in
possessions from home will help with routine and familiarity. People with an autism spectrum
disorder often have a limited ability to communicate. Health care providers need to approach a
child with an autism spectrum disorder carefully with minimal touch and clear and concise
instructions; their interactions should be brief.
A nurse is assessing military personnel who have experienced combat and are diagnosed with
posttraumatic stress disorder. Which client statement requires immediate intervention? correct
answers I cannot stop the nightmares, even the extra oxycodone pills I take do not work. It is not
worth it."
Client safety is the priority. Increased use of opioids and stating "it is not worth it" can be
considered suicidal. A client who increased lorazepam intake requires follow up, but this client is
not the priority. Increasing benzodiazepine will cause fatigue, so afternoon naps are expected.
Increasing the frequency of visits to a therapist are encouraged; there are no immediate concerns
with seeing a therapist more often. Avoiding alcohol with posttraumatic stress disorder is
,encouraged; however, there's nothing immediately concerning with an adult having one glass of
wine with supper.
The charge nurse in an acute care setting assigns a client who is on one-on-one suicide
precautions to a psychiatric aide. This assignment is considered: correct answers reasonable
nursing practice because one-on-one requires the total attention of a staff member
A psychiatric aide may sit with a client to ensure safety. The nurse is still responsible for
assessing the client and ensuring that one-on-one supervision occurs. Aides are capable of
providing one-to-one observation. It isn't illegal to delegate observation to an aide.
During an assessment interview, a depressed 15-year-old client reports "I can't sleep at night."
The nurse begins to explore factors that might contribute to this situation by asking if the client is
sexually active. The client changes the subject. What should the nurse suspect based on the
client's response to the assessment question? correct answers sexual abuse
Victims of sexual abuse commonly refuse to talk about the abuse or change the subject because
they have been threatened by their abuser. Although there may be other explanations for the
adolescent's inability to sleep at night, such as noise, anxiety, spiritual distress, pain, or other
disturbances, adolescents are typically willing to discuss these factors as contributors to their
inability to sleep. An adolescent with narcolepsy would experience brief periods of deep sleep
followed by periods of feeling refreshed and wouldn't complain of being unable to sleep at night.
A client lives in a group home and visits the community mental health center regularly. During
one visit with the nurse, the client states, "The voices are telling me to hurt myself again." Which
question by the nurse is most important to ask? correct answers Are you going to hurt yourself?"
The nurse needs to ask the client whether he is going to hurt himself to determine the client's
ability to cope with the voices and to assess the client's impulse control. The nurse's assessment
will then determine the course of action to take regarding the client's safety. Asking when the
client hears the voices and how long the client has heard them is important but not as important
as determining whether the client will act on what the voices are saying. Asking, "Why are the
voices starting again?" would be inappropriate because the client may not know why and may
not be able to answer the nurse.
, An older adult experiences short-term memory problems and occasional disorientation a few
weeks after her husband's death. She also is not sleeping, has urinary frequency and burning, and
sees rats in the kitchen. The home care nurse calls the woman's health care provider to discuss
the client's situation and background, assess, and give recommendations. The nurse concludes
that the client most likely has which problem? correct answers delirium and a urinary tract
infection (UTI)
Delirium is commonly due to a medical condition such as a UTI in the older adult. Delirium
often involves memory problems, disorientation, and hallucinations. It develops rather quickly.
There are not enough data to suggest Alzheimer's disease especially given the quick onset of
symptoms. Delayed grieving and adjusting to being alone are unlikely to cause hallucinations.
A client has been involuntarily committed to a hospital because he has been assessed as being
dangerous to self or others. The client has lost which right? correct answers the right to leave the
hospital against medical advice
An involuntarily admitted client loses the right to leave the hospital until the condition is stable
enough that the client no longer poses a danger to self or others. While hospitalized, the client
retains all civil rights such as receiving mail, making phone calls, refusing treatment, and also
receiving the least restrictive treatment. Should the involuntarily admitted client refuse treatment
once admitted, he will be evaluated for the need to receive treatment against wishes in order to
decrease the risk for self-harm or harm to others.
A client who is suspicious of others, including staff, is brought to the hospital wearing a wrinkled
dress with stains on the front. Assessment also reveals a flat affect, confusion, and slow
movements. Which goal should the nurse identify as the initial priority when planning this
client's care? correct answers helping the client feel safe and accepted
The initial priority for this client is to help her overcome suspiciousness of others, including
staff, and thereby feel safe and accepted. Introducing the client to others, giving the client
information about the program, and providing clean clothes are important, but these are of lower
priority than helping the client feel safe and accepted.
correct answers.
During the mental status examination, a client may be asked to explain such proverbs as "Don't
cry over spilled milk." The purpose of this is to evaluate the client's ability to think: correct
answers abstractly.
Abstract thinking is the ability to conceptualize and interpret meaning. It's a higher level of
intellectual functioning than concrete thinking, in which the client explains the proverb by its
literal meaning. Rational thinking involves the ability to think logically, make judgments, and be
goal-directed. Tangential thinking is scattered, non-goal-directed, and hard to follow. Clients
with such conditions as organic brain disease and schizophrenia typically can't conceptualize and
comprehend abstract meaning. They interpret such statements as "Don't cry over spilled milk" in
a literal sense, such as "Even if you spill your milk, you shouldn't cry about it."
A client is complaining to other clients about not being allowed by staff to keep food in the
client's room. What should the nurse do? correct answers Set limits on the behavior.
The nurse needs to set limits on the client's manipulative behavior to help the client control
dysfunctional behavior. The manipulative client bends rules to have needs met without regard for
rules or the needs or rights of others. A consistent approach by the staff is necessary to decrease
manipulation. Ignoring the client's behavior reinforces or promotes the continuation of the
client's manipulative behavior. Reprimanding the client may be perceived as a threat, resulting in
aggressive behavior. Allowing the client to keep a snack in the client's room reinforces the
dysfunctional behavior.
A nurse is counseling a married woman who has two children under 4 years of age and is a
victim of spousal abuse. Before the client leaves the clinic, what is the most important thing the
nurse should do? correct answers Help the client develop a safety plan.
It is most important for the nurse to help the client develop a safety plan because the abuse will
occur again, and the client will need a plan to seek a safe environment for herself and her
children.Teaching about the cycle of violence is not as important as the client's safety and the
,safety of her children.Discussing the abuser's behaviors is not as important as the client's safety
and the safety of her children.Giving the client the name of a domestic violence shelter can be
part of the safety plan, but the nurse needs to assure other safety measures are in place until the
woman is ready to leave the abusive partner.
Which intervention(s) should the nurse include in the plan of care for a school-age child with an
autism spectrum disorder who has been admitted to the hospital? Select all that apply. correct
answers Allow a family member in the room 24 hours per day.
Limit the number of health care providers and nurses interacting with the child.
Dim lights and keep noise levels low.
Show medical equipment to the child before procedures.
Have family member bring possessions from home.
Children with an autism spectrum prefer routine and familiarity. Having a family member in the
room 24 hours a day may decrease the child's anxiety. Limiting the number of different health
care providers and nurses that interact with the child may also help reduce anxiety. Dimming
lights and keeping noise levels low will reduce sensory stimulation. Introducing a child with an
autism spectrum disorder to equipment prior to a procedure may help reduce anxiety. Bringing in
possessions from home will help with routine and familiarity. People with an autism spectrum
disorder often have a limited ability to communicate. Health care providers need to approach a
child with an autism spectrum disorder carefully with minimal touch and clear and concise
instructions; their interactions should be brief.
A nurse is assessing military personnel who have experienced combat and are diagnosed with
posttraumatic stress disorder. Which client statement requires immediate intervention? correct
answers I cannot stop the nightmares, even the extra oxycodone pills I take do not work. It is not
worth it."
Client safety is the priority. Increased use of opioids and stating "it is not worth it" can be
considered suicidal. A client who increased lorazepam intake requires follow up, but this client is
not the priority. Increasing benzodiazepine will cause fatigue, so afternoon naps are expected.
Increasing the frequency of visits to a therapist are encouraged; there are no immediate concerns
with seeing a therapist more often. Avoiding alcohol with posttraumatic stress disorder is
,encouraged; however, there's nothing immediately concerning with an adult having one glass of
wine with supper.
The charge nurse in an acute care setting assigns a client who is on one-on-one suicide
precautions to a psychiatric aide. This assignment is considered: correct answers reasonable
nursing practice because one-on-one requires the total attention of a staff member
A psychiatric aide may sit with a client to ensure safety. The nurse is still responsible for
assessing the client and ensuring that one-on-one supervision occurs. Aides are capable of
providing one-to-one observation. It isn't illegal to delegate observation to an aide.
During an assessment interview, a depressed 15-year-old client reports "I can't sleep at night."
The nurse begins to explore factors that might contribute to this situation by asking if the client is
sexually active. The client changes the subject. What should the nurse suspect based on the
client's response to the assessment question? correct answers sexual abuse
Victims of sexual abuse commonly refuse to talk about the abuse or change the subject because
they have been threatened by their abuser. Although there may be other explanations for the
adolescent's inability to sleep at night, such as noise, anxiety, spiritual distress, pain, or other
disturbances, adolescents are typically willing to discuss these factors as contributors to their
inability to sleep. An adolescent with narcolepsy would experience brief periods of deep sleep
followed by periods of feeling refreshed and wouldn't complain of being unable to sleep at night.
A client lives in a group home and visits the community mental health center regularly. During
one visit with the nurse, the client states, "The voices are telling me to hurt myself again." Which
question by the nurse is most important to ask? correct answers Are you going to hurt yourself?"
The nurse needs to ask the client whether he is going to hurt himself to determine the client's
ability to cope with the voices and to assess the client's impulse control. The nurse's assessment
will then determine the course of action to take regarding the client's safety. Asking when the
client hears the voices and how long the client has heard them is important but not as important
as determining whether the client will act on what the voices are saying. Asking, "Why are the
voices starting again?" would be inappropriate because the client may not know why and may
not be able to answer the nurse.
, An older adult experiences short-term memory problems and occasional disorientation a few
weeks after her husband's death. She also is not sleeping, has urinary frequency and burning, and
sees rats in the kitchen. The home care nurse calls the woman's health care provider to discuss
the client's situation and background, assess, and give recommendations. The nurse concludes
that the client most likely has which problem? correct answers delirium and a urinary tract
infection (UTI)
Delirium is commonly due to a medical condition such as a UTI in the older adult. Delirium
often involves memory problems, disorientation, and hallucinations. It develops rather quickly.
There are not enough data to suggest Alzheimer's disease especially given the quick onset of
symptoms. Delayed grieving and adjusting to being alone are unlikely to cause hallucinations.
A client has been involuntarily committed to a hospital because he has been assessed as being
dangerous to self or others. The client has lost which right? correct answers the right to leave the
hospital against medical advice
An involuntarily admitted client loses the right to leave the hospital until the condition is stable
enough that the client no longer poses a danger to self or others. While hospitalized, the client
retains all civil rights such as receiving mail, making phone calls, refusing treatment, and also
receiving the least restrictive treatment. Should the involuntarily admitted client refuse treatment
once admitted, he will be evaluated for the need to receive treatment against wishes in order to
decrease the risk for self-harm or harm to others.
A client who is suspicious of others, including staff, is brought to the hospital wearing a wrinkled
dress with stains on the front. Assessment also reveals a flat affect, confusion, and slow
movements. Which goal should the nurse identify as the initial priority when planning this
client's care? correct answers helping the client feel safe and accepted
The initial priority for this client is to help her overcome suspiciousness of others, including
staff, and thereby feel safe and accepted. Introducing the client to others, giving the client
information about the program, and providing clean clothes are important, but these are of lower
priority than helping the client feel safe and accepted.
