Foundations of Psychiatric Mental Health Nursing

MULTIPLE CHOICE 1. An emergency code was called after a client pulled a dinner knife from a pocket and threatened, “I will kill anyone who tries to get near me.” The client was safely disarmed and placed in seclusion. What is the justification for this use of seclusion? a. The client was threatening to others. b. The client was experiencing psychosis. c. The client presented an undeniable escape risk. d. The client presented a clear and present danger to others. ANS: D The clien...

MULTIPLE CHOICE 1. Which features should be present in a therapeutic milieu for a client experiencing a hallucinogen overdose? a. Simple and safe b. Active and bright c. Stimulating and colorful d. Confrontational and challenging ANS: A Because the individual who has ingested a hallucinogen is probably experiencing feelings of unreality and altered sensory perceptions, the best environment is one that does not add to the stimulation. A simple, safe environment is a better choice tha...

MULTIPLE CHOICE 1. The family of a child diagnosed with an impulse control disorder needs help to function more adaptively. Which aspect of the child‘s plan of care will be provided by an advanced practice nurse rather than a staff nurse? a. Leading an activity group b. Providing positive feedback c. Formulating nursing diagnoses d. Dialectical behavioral therapy (DBT) ANS: D The advanced practice nurse role includes individual, group, and family psychotherapist; educator of nurs...

MULTIPLE CHOICE 1. Which statement made by a client diagnosed with borderline personality disorder indicates the treatment plan is effective? a. “I think you are the best nurse on the unit.” b. “I’m never going to get high on drugs again.” c. “I felt empty and wanted to hurt myself, so I called you.” d. “I hate my mother. I called her today, and she wasn’t home.” ANS: C Seeking a staff member instead of impulsively self-mutilating shows an adaptive coping strateg...

MULTIPLE CHOICE 1. An older adult client in the intensive care unit is experiencing visual illusions. Which intervention will be most helpful? a. Apply the client’s glasses. b. Place personally meaningful objects in view. c. Position large clocks and calendars on the wall. d. Assure that the room is brightly lit but very quiet at all times. ANS: A Illusions are sensory misperceptions. Glasses and hearing aids help clarify sensory perceptions. Without glasses, clocks, calendars, an...

MULTIPLE CHOICE 1. Which comment by a client who recently experienced a myocardial infarction indicates use of maladaptive, ineffective coping strategies? a. “My employer should have paid for a health club membership for me.” b. “My family will see me through this. It won’t be easy, but I will never be alone.” c. “My heart attack was no fun, but it showed me up the importance of a good diet and more exercise.” d. “I accept that I have heart disease. Now I need to decide if...

MULTIPLE CHOICE 1. The gas pedal on a person’s car became stuck on a busy interstate highway, causing the car to accelerate rapidly. For 20 minutes, the car was very difficult to control. In the months after this experience, afterward, which assessment finding would the nurse expect? a. Weight gain b. Flashbacks c. Headache d. Diuresis ANS: B The scenario depicts a frightening, traumatic, and stressful situation. Severe dissociation or “mind flight” may occur for those who hav...

MULTIPLE CHOICE 1. Which season would be most associated with increased periods of wakefulness in the general population? a. Summer b. Winter c. Spring d. Fall ANS: A Circadian drive is associated with physiology. Light is the main exogenous factor that drives wakefulness. Days are longest in summer. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 2. Normally, most people sleep at night. W...

MULTIPLE CHOICE 1. A nurse provides care for an adolescent client diagnosed with an eating disorder. Which behavior by this nurse indicates that additional clinical supervision is needed? a. The nurse interacts with the client in a protective fashion. b. The nurse’s comments to the client are compassionate and nonjudgmental. c. The nurse teaches the client to recognize signs of increasing anxiety and ways to intervene. d. The nurse refers the client to a self-help group for individuals ...

MULTIPLE CHOICE 1. A nurse sits with a client diagnosed with schizophrenia. The client starts to laugh uncontrollably, although the nurse has not said anything funny. What is the nurse’s most therapeutic response? a. “Why are you laughing?” b. “Please share the joke with me.” c. “I don’t think I said anything funny.” d. “You’re laughing. Tell me what’s happening.” ANS: D The client is likely laughing in response to inner stimuli, such as hallucinations or fan...