Foundations of Psychiatric Mental Health Nursing

MULTIPLE CHOICE 1. Shortly after the parents announced that they were divorcing, a 15-year-old became truant from school and assaulted a friend. The adolescent told the school nurse, Id rather stay in my room and listen to music. Its easie than thinking about what is happening in my family. Which nursing diagnosis is most applicable? a. Chronic low self-esteem related to role within the family b. Decisional conflict related to compliance with school requirements c. Ineffective coping relat...

MULTIPLE CHOICE 1. A tearful, anxious patient at the outpatient clinic reports, I should be dead. The initial task of the nurse conducting the assessment interview is to: a. assess lethality of suicide plan. b. encourage expression of anger. c. establish rapport with the patient. d. determine risk factors for suicide. ANS: C This scenario presents a potential crisis. Establishing rapport facilitates a therapeutic alliance that will allow the nurse to obtain relevant assessment d...

MULTIPLE CHOICE 1. Which statement made by a patient diagnosed with borderline personality disorder indicates the treatment plan is effective? a. I think you are the best nurse on the unit. b. Im 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 wasnt home. ANS: C Seeking a staff member instead of impulsively self-mutilating shows an adaptive coping strategy. The incorrec responses dem...

MULTIPLE CHOICE 1. An older adult patient in the intensive care unit has visual and auditory illusions. Which intervention will be most helpful? a. Using the patients glasses and hearing aids b. Placing personally meaningful objects in view c. Placing large clocks and calendars on the wall d. Assuring 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, clock...

MULTIPLE CHOICE 1. The gas pedal on a persons car stuck on a busy interstate highway, causing the car to accelerate rapidly. For 20 minutes, the car was very difficult to control. Afterward, this persons cortisol regulation was compromised. Which assessment finding would the nurse expect associated with the dysregulation of cortisol? a. Weight gain b. Flashbacks c. Headache d. Diuresis ANS: B Cortisol is a hormone released in response to stress. Severe dissociation or mindflight o...

MULTIPLE CHOICE 1. A nurse is anxious about assessing the sexual history of a patient who is considerably older than the nurse is. Which statement would be most appropriate for obtaining information about the patients sexual practices? a. Some people are not sexually active, others have a partner, and some have several partners. What has been your pattern? b. Sexual health can reflect a number of medical problems, so Id like to ask if you have any sexual problems you think we should know ab...

MULTIPLE CHOICE 1. A nurse counsels a patient on ways to determine the persons total sleep requirement. Which instruction would produce the most accurate results? a. For 1 full week, record what you remember about your dream content and related feelings as soon as you wake up. Bring the record to your next appointment. b. While off work for 1 week, go to bed at your usual time and wake up without an alarm. Record how many hours you sleep and then average the findings. c. For 2 full weeks, ...

MULTIPLE CHOICE 1. Which nursing intervention has the highest priority for a patient diagnosed with bulimia nervosa? a. Assist the patient to identify triggers to binge eating. b. Provide corrective consequences for weight loss. c. Assess for signs of impulsive eating. d. Explore needs for health teaching. ANS: A For most patients with bulimia nervosa, certain situations trigger the urge to binge; purging then follows. Often the triggers are anxiety-producing situations. Identificat...

MULTIPLE CHOICE 1. Which comment by a patient 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 wont 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 I will be able to cont...

MULTIPLE CHOICE 1. A patient took trifluoperazine 30 mg po daily for 3 years. The clinic nurse notes that the patient grimaces and constantly smacks both lips. The patients neck and shoulders twist in a slow, snakelike motion. Which problem would the nurse suspect? a. Agranulocytosis b. Tardive dyskinesia c. Tourettes syndrome d. Anticholinergic effects ANS: B Tardive dyskinesia is a neuroleptic-induced condition involving the face, trunk, and limbs. Involuntary movements, such ...