Test Bank For Foundations of Psychiatric-Mental Health Nursing A Clinical Approach 8th Edition By Varcarolis' Complete Chapter 1-36 (2024)

A nurse documents: ―Patient is mute despite repeated efforts to elicit speech. Makes no eye contact. Inattentive to staff. Gazes off to the side or looks upward rather than at speaker.‖ Which nursing diagnosis should be considered? a. Defensive coping b. Decisional conflict c. Risk for other-directed violence d. Impaired verbal communication ANS: D The defining characteristics are more related to the nursing diagnosis of impaired verbal communication than to the other nursing diagnoses. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Pages 7-16, 17 TOP: Nursing Process: Diagnosis/Analysis MSC: Client Needs: Psychosocial Integrity 176 25. A nurse prepares to assess a new patient who moved to the United States from Central America 3 years ago. After introductions, what is the nurse‘s next comment? 177 a. ―How did you get to the United States?‖ b. ―Would you like for a family member to help you talk with me?‖ c. ―An interpreter is available. Would you like for me to make a request for these services?‖ d. ―Are you comfortable conversing in English, or would you prefer to have a translator present?‖ ANS: D The nurse should determine whether a translator is needed by first assessing the patient for language barriers. Accuracy of the assessment depends on the ability to communicate in a language that is familiar to the patient. Family members are not always reliable translators. An interpreter may change the patient‘s responses; a translator is a better resource. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Pages 7-8, 9 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 26. The nurse records this entry in a patient‘s progress notes: Patient escorted to unit by ER nurse at 2130. Patient‟s clothing was dirty. In interview room, patient sat with hands over face, sobbing softly. Did not acknowledge nurse or reply to questions. After several minutes, abruptly arose, ran to window, and pounded. Shouted repeatedly, “Let me out of here.” Verbal intervention unsuccessful. Order for stat dose 2 mg haloperidol PO obtained; medication administered at 2150. By 2215, patient stopped shouting and returned to sit wordlessly in chair. Patient placed on one-to-one observation. How should this documentation be evaluated? a. Uses unapproved abbreviations b. Contains subjective material c. Too brief to be of value d. Excessively wordy e. Meets standards ANS: E This narrative note describes patient appearance, behavior, and conversation. It mentions that less-restrictive measures were attempted before administering medication and documents patient response to medication. This note would probably meet standards. A complete nursing assessment would be in order as soon as the patient is able to participate. Subjective material is absent from the note. Abbreviations are acceptable. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Pages 7-24, 25, 40 (Table 7-4), 51 (Box 7-6) TOP: Nursing Process: Evaluation MSC: Client Needs: Safe, Effective Care Environment 178 MULTIPLE RESPONSE 179 1. A nurse assessed a patient who reluctantly participated in activities, answered questions with minimal responses, and rarely made eye contact. What information should be included when documenting the assessment? (Select all that apply.) a. The patient was uncooperative b. The patient‘s subjective responses c. Only data obtained from the patient‘s verbal responses d. A description of the patient‘s behavior during the interview e. Analysis of why the patient was unresponsive during the interview ANS: B, D Both content and process of the interview should be documented. Providing only the patient‘s verbal responses would create a skewed picture of the patient. Writing that the patient was uncooperative is subjectively worded. An objective description of patient behavior would be preferable. Analysis of the reasons for the patient‘s behavior would be speculation, which is inappropriate. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Pages 7-24, 25, 40 (Table 7-4), 51 (Box 7-6) TOP: Nursing Process: Assessment MSC: Client Needs: Safe, Effective Care Environment 2. A nurse performing an assessment interview for a patient with a substance use disorder decides to use a standardized rating scale. Which scales are appropriate? (Select all that apply.) a. Addiction Severity Index (ASI) b. Brief Drug Abuse Screen Test (B-DAST) c. Abnormal Involuntary Movement Scale (AIMS) d. Cognitive Capacity Screening Examination (CCSE) e. Recovery Attitude and Treatment Evaluator (RAATE) ANS: A, B, E Standardized scales are useful for obtaining data about substance use disorders. The ASI, BDAST, and RAATE are scales related to substance abuse. AIMS assesses involuntary movements associated with antipsychotic medications. The CCSE assesses cognitive function. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Pages 7-15, 34 (Table 7-1) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 3. What information is conveyed by nursing diagnoses? (Select all that apply.) a. Medical judgments about the disorder b. Unmet patient needs currently present c. Goals and outcomes for the plan of care 180 d. Supporting data that validate the diagnoses e. Probable causes that will be targets for nursing interventions 181 ANS: B, D, E Nursing diagnoses focus on phenomena of concern to nurses rather than on medical diagnoses. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Pages 7-16, 17 TOP: Nursing Process: Diagnosis/Analysis MSC: Client Needs: Safe, Effective Care Environment 4. A patient is very suspicious and states, ―The FBI has me under surveillance.‖ Which strategies should a nurse use when gathering initial assessment data about this patient? (Select all that apply.) a. Tell the patient that medication will help this type of thinking. b. Ask the patient, ―Tell me about the problem as you see it.‖ c. Seek information about when the problem began. d. Tell the patient, ―Your ideas are not realistic.‖ e. Reassure the patient, ―You are safe here.‖ ANS: B, C, E During the assessment interview, the nurse should listen attentively and accept the patient‘s statements in a nonjudgmental way. Because the patient is suspicious and fearful, reassuring safety may be helpful, although trust is unlikely so early in the relationship. Saying that medication will help or telling the patient that the ideas are not realistic will undermine development of trust between the nurse and patient. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Pages 7-4, 5, 11, 47 (Box 7-4) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity Chapter 08: Therapeutic Relationships Halter: Varcarolis’ Foundations of Psychiatric Mental Health Nursing: A Clinical Approach, 8th Edition MULTIPLE CHOICE 1. A nurse assesses a confused older adult. The nurse experiences sadness and reflects, ―This patient is like one of my grandparents … so helpless.‖ Which response is the nurse demonstrating? a. Transference b. Countertransference 182 c. Catastrophic reaction d. Defensive coping reaction 183 ANS: B Countertransference is the nurse‘s transference or response to a patient that is based on the nurse‘s unconscious needs, conflicts, problems, or view of the world. See relationship to audience response question. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Pages 8-10 to 12, 35 (Table 8-2) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 2. Which statement shows a nurse has empathy for a patient who made a suicide attempt? a. ―You must have been very upset when you tried to hurt yourself.‖ b. ―It makes me sad to see you going through such a difficult experience.‖ c. ―If you tell me what is troubling you, I can help you solve your problems.‖ d. ―Suicide is a drastic solution to a problem that may not be such a serious matter.‖ ANS: A Empathy permits the nurse to see an event from the patient‘s perspective, understand the patient‘s feelings, and communicate this to the patient. The incorrect responses are nursecentered (focusing on the nurse‘s feelings rather than the patient‘s), belittling, and sympathetic. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Pages 8-22, 23 TOP: Nursing Process: Evaluation MSC: Client Needs: Psychosocial Integrity 3. After several therapeutic encounters with a patient who recently attempted suicide, which occurrence should cause the nurse to consider the possibility of countertransference? a. The patient‘s reactions toward the nurse seem realistic and appropriate. b. The patient states, ―Talking to you feels like talking to my parents.‖ c. The nurse feels unusually happy when the patient‘s mood begins to lift. d. The nurse develops a trusting relationship with the patient. ANS: C Strong positive or negative reactions toward a patient or over-identification with the patient indicate possible countertransference. Nurses must carefully monitor their own feelings and reactions to detect countertransference and then seek supervision. Realistic and appropriate reactions from a patient toward a nurse are desirable. One incorrect response suggests transference. A trusting relationship with the patient is desirable. See relationship to audience response question. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Pages 8-10 to 12, 35 (Table 8-2) TOP: Nursing Process: Evaluation MSC: Client Needs: Psychosocial Integrity 184 4. A patient says, ―Please don‘t share information about me with the other people.‖ How should the nurse respond? a. ―I will not share information with your family or friends without your permission, but I will share information about you with other staff.‖ b. ―A therapeutic relationship is just between the nurse and the patient. It is up to you to tell others what you want them to know.‖ c. ―It depends on what you choose to tell me. I will be glad to disclose at the end of each session what I will report to others.‖ d. ―I cannot tell anyone about you. It will be as though I am talking about my own problems, and we can help each other by keeping it between us.‖ ANS: A A patient has the right to know with whom the nurse will share information and that confidentiality will be protected. Although the relationship is primarily between the nurse and patient, other staff needs to know pertinent data. The other incorrect responses promote incomplete disclosure on the part of the patient, require daily renegotiation of an issue that should be resolved as the nurse–patient contract is established, and suggest mutual problem solving. The relationship must be patient centered. See relationship to audience response question. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Pages 8-18, 19 TOP: Nursing Process: Implementation MSC: Client Needs: Safe, Effective Care Environment 5. A nurse is talking with a patient, and 5 minutes remain in the session. The patient has been silent most of the session. Another patient comes to the door of the room, interrupts, and says to the nurse, ―I really need to talk to you.‖ The nurse should a. invite the interrupting patient to join in the session with the current patient. b. say to the interrupting patient, ―I am not available to talk with you at the present time.‖ c. end the unproductive session with the current patient and spend time with the interrupting patient. d. tell the interrupting patient, ―This session is 5 more minutes; then I will talk with you.‖ ANS: D When a specific duration for sessions has been set, the nurse must adhere to the schedule. Leaving the first patient would be equivalent to abandonment and would destroy any trust the patient had in the nurse. Adhering to the contract demonstrates that the nurse can be trusted and that the patient and the sessions are important. The incorrect responses preserve the nurse–patient relationship with the silent patient but may seem abrupt to the interrupting patient, abandon the silent patient, or fail to observe the contract with the silent patient. PTS: 1 DIF: Cognitive Level: Apply (Application) 185 REF: Pages 8-18, 19, 35 (Table 8-2) | Page 8-39 (Table 8-3) TOP: Nursing Process: Implementation MSC: Client Needs: Safe, Effective Care Environment 186 6. Termination of a therapeutic nurse–patient relationship has been successful when the nurse a. avoids upsetting the patient by shifting focus to other patients before the discharge. b. gives the patient a personal telephone number and permission to call after discharge. c. discusses with the patient changes that happened during the relationship and evaluates outcomes. d. offers to meet the patient for coffee and conversation three times a week after discharge. ANS: C Summarizing and evaluating progress help validate the experience for the patient and the nurse and facilitate closure. Termination must be discussed; avoiding discussion by spending little time with the patient promotes feelings of abandonment. Successful termination requires that the relationship be brought to closure without the possibility of dependency-producing ongoing contact. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Pages 8-20, 21 TOP: Nursing Process: Evaluation MSC: Client Needs: Safe, Effective Care Environment 7. What is the desirable outcome for the orientation stage of a nurse–patient relationship? The patient will demonstrate behaviors that indicate a. self-responsibility and autonomy. b. a greater sense of independence. c. rapport and trust with the nurse. d. resolved transference. ANS: C Development of rapport and trust is necessary before the relationship can progress to the working phase. Behaviors indicating a greater sense of independence, self-responsibility, and resolved transference occur in the working phase. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Pages 8-17 to 19 TOP: Nursing Process: Outcomes Identification MSC: Client Needs: Psychosocial Integrity 8. During which phase of the nurse–patient relationship can the nurse anticipate that identified patient issues will be explored and resolved? a. Preorientation b. Orientation c. Working d. Termination ANS: C 187 During the working phase, the nurse strives to assist the patient in making connections among dysfunctional behaviors, thinking, and emotions and offers support while alternative coping behaviors are tried. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Pages 8-19, 20 TOP: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity 9. At what point in the nurse–patient relationship should a nurse plan to first address termination? a. During the orientation phase b. At the end of the working phase c. Near the beginning of the termination phase d. When the patient initially brings up the topic ANS: A The patient has a right to know the conditions of the nurse–patient relationship. If the relationship is to be time-limited, the patient should be informed of the number of sessions. If it is open-ended, the termination date will not be known at the outset, and the patient should know that the issue will be negotiated at a later date. The nurse is responsible for bringing up the topic of termination early in the relationship, usually during the orientation phase. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Pages 8-17, 18 TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity 10. A nurse introduces the matter of a contract during the first session with a new patient because contracts a. specify what the nurse will do for the patient. b. spell out the participation and responsibilities of each party. c. indicate the feeling tone established between the participants. d. are binding and prevent either party from prematurely ending the relationship. ANS: B A contract emphasizes that the nurse works with the patient rather than doing something for the patient. ―Working with‖ is a process that suggests each party is expected to participate and share responsibility for outcomes. Contracts do not, however, stipulate roles or feeling tone, and premature termination is forbidden. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Pages 8-17 to 19 TOP: Nursing Process: Planning MSC: Client Needs: Safe, Effective Care Environment 188 11. As a nurse escorts a patient being discharged after treatment for major depression, the patient gives the nurse a necklace with a heart pendant and says, ―Thank you for helping mend my broken heart.‖ Which is the nurse‘s best response? a. ―Accepting gifts violates the policies and procedures of the facility.‖ b. ―I‘m glad you feel so much better now. Thank you for the beautiful necklace.‖ c. ―I‘m glad I could help you, but I can‘t accept the gift. My reward is seeing you with a renewed sense of hope.‖ d. ―Helping people is what nursing is all about. It‘s rewarding to me when patients recognize how hard we work.‖ ANS: C Accepting a gift creates a social rather than therapeutic relationship with the patient and blurs the boundaries of the relationship. A caring nurse will acknowledge the patient‘s gesture of appreciation, but the gift should not be accepted. See relationship to audience response question. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Pages 8-4 to 6, 34 (Table 8-1) TOP: Nursing Process: Implementation MSC: Client Needs: Safe, Effective Care Environment 12. Which remark by a patient indicates passage from orientation to the working phase of a nurse– patient relationship? a. ―I don‘t have any problems.‖ b. ―It is so difficult for me to talk about problems.‖ c. ―I don‘t know how it will help to talk to you about my problems.‖ d. ―I want to find a way to deal with my anger without becoming violent.‖ ANS: D Thinking about a more constructive approach to dealing with anger indicates a readiness to make a behavioral change. Behavioral change is associated with the working phase of the relationship. Denial is often seen in the orientation phase. It is common early in the relationship, before rapport and trust are firmly established, for a patient to express difficulty in talking about problems. Stating skepticism about the effectiveness of the nurse– patient relationship is more typ