Behavioral Health Nursing: Exam 1 practice questions With collect Answers

which of the following situations would meet the criteria for involuntary commitment of a pt? select all that apply - the pt has left his child home for days at a time - the pt has schizophrenia and lives alone w out a caregiver - the pt threatened to kill his children - the pt voiced plans to harm himself - the pt is depressed and does not enjoy life - ANSWERS- the pt has threatened to kill his children - the pt voiced plans to harm himself in a psych unit, which of the following CANNOT be assigned to a CNA? select all that apply - administering ziprasidone - admission assessment - checking room/pt for sharp objects - putting the pt's belongings in lockup - ANSWERS- administering ziprasidone - admission assessment a nurse is planning an educational program for families of pts who have attempted suicide. the nurse should include what in her teaching? select all that apply - suicidal pts display subtle changes in behavior - suicidal pts do not generally display changes in behavior - suicidal pt may be noted to put affairs in order - suicidal pts usually give many overt clues - suicidal pts will often completely isolate themselves immediately prior to the attempt - ANSWERS- suicidal pts display subtle changes in behavior - suicidal pt may be noted to put affairs in order a mental heath nurse answers the phone and the police office asks if a pt is still being treated on the unit, and the nurse says they were discharged. What is correct regarding the nurse's response? - was a breach of confidentiality - response was correct, the nurse did not give out any pt info - response was correct, nurse only released info regarding pt's location - response was illegal b/c nurse is withholding in about the pt - ANSWERS- response was breach of pt confidentiality the major problems w large state institutions are.... select all that apply - attendants were accused of abusing the residents - clients were geographically isolated from fam/community - increasing financial costs to individual residents - stigma w residence in insane asylum - ANSWERS- attendants were accused of abusing the residents - clients were geographically isolated from fam/community which of the following statements about the neurological causes of mental illness is most accurate? - genetics and heredity can explain all causes of mental illness - viral infection has been proven to be the cause of schizophrenia - there is no evidence that the immune system is r/t mental illness - several mental disorders may be linked to genetic and non genetic factors - ANSWERSseveral mental disorders may be linked to genetic and non genetic disorders which of the following increases the risk for neuroleptic malignant syndrome - over hydration - intake of vitamins - dehydration -vegetarian diet - ANSWERSdehydration which of the following considerations should have the most influence in the nurse's choice of the treatment for the client? - the client's feelings and perceptions about his/her situation - the nurse's belief about the theories of psychological development - the nurse's familiarity w the type of treatment - any approach to treatment should work w the client - ANSWERSthe client's feelings and perceptions about his/her situation the priority of in patient care for ppl w severe mental illness is - fam issues - insight to illness - social skills -symptom management - ANSWERSsymptom management which of the following are components; select all that apply - what the client is thinking - abstract thinking abilities - how the client is thinking - clarity of loss - self harm or suicide urges - ANSWERS- what the client is thinking - how the client is thinking - clarity of ideas - self-harm of suicide urges a pt on a psych unit approaches a nurse in the hallway, he is dizzy, anxious and short of breath. the nurse should...; select all that apply - administer lorazepam as prescribed - guide the pt into the common area so he may talk to other pts - guide the pt to his room - immediately assess the pt's mental status - in a quiet area, guide the pt through a relaxation technique - ANSWERS- guide the pt to his room - in a quiet area, guide the pt through a relaxation technique a pt receiving multiple electroconvulsive treatment states to the nurse, "I can't remember where I put anything. I am always confused and lose everything." Which of the following responses by the nurse is most appropriate? - this was an unexpected side effect - you still really need this treatment - I understand that your memory loss and confusion are upsetting to you. Please tell me more about this - your memory will get better - ANSWERS- I understand that your memory loss and confusion are upsetting you. Please tell me more about this group members have worked very hard, and the nurse reminds them that termination is approaching. termination is considered successful if group members - decide to continue - elevate group process - focus on positive experience - stop attending prior to termination - ANSWERSfocus on positive experience the nurse is assigned a pt who is arrogant and manipulative. to ensure a therapeutic milieu, the nurse does the following - agree on a consistent approach amongst all staff members assigned to a client - suggest the client take the lead role in group activities - provide client w additional one on one sessions - allow client to negotiate the POC - ANSWERSagree on a consistent approach amongst all staff members assigned to the client which statement indicates that a pt is ready to terminate intensive psychiatric case management services? - I miss our weekly sessions, I get so lonely - I just can't go outside, I get so anxious - I am no longer suicidal and group therapy is helping - I am not the only one who has ever felt like this - ANSWERSI am no longer suicidal and group therapy is helping which example below demonstrates the therapeutic technique of exploring - why did you run away from home - do you want to talk about when you ran away from home - tell me about when you ran away from home - when did you run away from home - ANSWERStell me more about when you ran away from home a nurse assesses an elderly pt who was found wandering the unit. the nurse feels sympathetic and states, "she's like my grandmother.... so helpless". Which term best applies to the nurse's response? - transference - counter transference - acceptance - positive regard - ANSWERScounter transference the nurse understands that empathy is essential to the therapeutic relationship. When a pt make the statement, "I am just devastated that my marriage is falling apart, " the nurse can best show empathy through which of the following responses? - I feel so bad for what you are going through - You feel like your world is falling apart right now - I have been divorced too, I know how hard it is - It will get better; let's talk about it - ANSWERSYou feel like your world is falling apart right now which of the following behaviors by the nurse demonstrates positive regard? select all that apply - communicating judgments about the client's behavior - calling the client by name - spending time w the client - respond openly - considering the cleint's ideas and preference when planning care - ANSWERS- calling the client by name - spending time w the client - responding openly - considering the client's ideas and preferences when planning care a pt states, "It's been so long since I've been w my fam". Which statement by the nurse is an example of restating - you say you haven't seen your fam in a while - tell me when you last saw your fam - go on, tell me more - when was the last time you saw your fam - ANSWERSyou say you haven't seen your fam in a while a 7 yr old w cystic fibrosis dies unexpectedly while in the hospital. after the pt's death, the staff closest to the pt have been having trouble coping. who should be consulted to help the nursing staff cope? - the chaplain, they can provide strategies for handling death and grief - the nurse manager, seh can give out vacation - the pt's fam, they can provide mutual comfort - the physician, he can provide educational materials about cystic fibrosis - ANSWERS- the chaplain, they can provide strategies for handling death and grief a pt being admitted to the ICU asks why he must sign a document stating his wishes regarding life support. Which of the following is the best response? - all pt must sign that form - if you die, we would like to use your body for medical research - we think something might go wrong, so we want to be safe - we want to respect your advance directive decisions in case you are unable to make these decisions later - ANSWERS- we want to respect your advance directive decisions in case you are unable to make these decisions later a fam member of a pt on a psych unit informs a nurse that another pt is being sexually inappropriate w other pts. the nurse tells the fam member to locate the pt's nurse and inform her. which of the following terms describe the nurse's actions - negligent -organized -practical -prioritization - ANSWERSnegligent an adult recently dx w lung CA states, "I've lived my life according to the Bible, I don't understand why God has forsaken me". What is the priority nursing action? - state "smoking caused your lung CA" - ask "what can we do to meet your spiritual needs" - ask the primary care provider to consider adding an antidepressant - ask the pt, "would you like me to pray for you? - ANSWERS- ask "what can we do to meet your spiritual needs" what nursing intervention demonstrates false imprisonment? - A confused and combative patient says, "I'm getting out of here and no one can stop me." The nurse bring the patient back to the room and assigns a 1:1 nursing assistant to stay with the patient. - An involuntary hospitalized patient with suicidal ideation runs out of the psychiatric unit. The nurse rushes out with the patient and convinces the patient to return to the unit - A patient has been irritating to the staff and attention-seeking much of the day. The nurse escorts the patient down the hall and states, "Stay in your room or you'll be put in the padded seclusion room." - An involuntary hospitalized patient with homicidal ideation attempts to leave the facility. The nurse calls the security team to prevent the patient from leaving. - ANSWERS- A patient has been irritating to the staff and attention-seeking much of the day. The nurse escorts the patient down the hall and states, "Stay in your room or you'll be put in the padded seclusion room." An Orthodox Jew is admitted to the hospital. Which nursing response would illicit the most information regarding the patient's culture? - Would you like me to notify your rabbi that you would like a visit? - Are there any medications or treatments that your religion does not allow?" - Do you follow any dietary restrictions?" - What can we do to meet your spiritual and cultural needs and preferences?" - ANSWERS- What can we do to meet your spiritual and cultural needs and preferences?" Which intervention by a nurse best applies the ethical principal of autonomy? - Inform the patient about different treatment options - Suggest that two patients who were fighting be brought back to their rooms. - Intervene when a patient is cutting himself. - Stay with the patient who is experiencing a panic attack - ANSWERSInform the patient about different treatment options Which of the following statements about spirituality are true? Select all that apply. - Many clients with mental disorders have disturbing religious delusions. - Religious activities have been shown to be linked with better health and a sense of well-being. - Spirituality only involves religion. - Hope and faith are two critical factors in psychiatric and physical rehabilitation. -Spirituality may include a relationship with environment - ANSWERS- Many clients with mental disorders have disturbing religious delusions. - Religious activities have been shown to be linked with better health and a sense of well-being. -Hope and faith are two critical factors in psychiatric and physical rehabilitation. -Spirituality may include a relationship with environment Which of the following dilemmas involve the ethical principle of fidelity? Select all that apply. - When the nurse is unable to agree with the policies or common practices of an agency -When the nurse is faced with a decision to violate a policy that is harmful to the client - When the nurse is certain that clients of different racial and ethnic backgrounds are being treated the same as other clients - When the nurse understands that a combative client must be secluded against their will to prevent harm to others - When the client refuses to take medication and the nurse respects the client's right to refuse medication - ANSWERS- When the nurse is unable to agree with the policies or common practices of an agency -When the nurse is faced with a decision to violate a policy that is harmful to the client Which of the following are criteria that must be adhered to when instituting the short-term use of restraint or seclusion? Select all that apply. - The client is aggressive - The client is being punished - The client is imminently dangerous to himself or herself or to others. - The client is physically and emotionally self-controlled - All other means of calming the client have been unsuccessful - ANSWERS- The client is aggressive - The client is imminently dangerous to himself or herself or to others. - All other means of calming the client have been unsuccessful During assessment, the patient tells the nurse that he can no longer work because he spends most of his day aligning and realigning all the items in his apartment. The nurse identifies this behavior as indicative of - Acute stress disorder - Generalized anxiety disorder - Obsessive-Compulsive disorder - Panic disorder - ANSWERSObsessive-Compulsive disorder A patient is admitted to the psychiatric unit for acute agitation and anxiety. The physician orders a long-acting benzodiazepine. The nurse expects to administer which of the following? - Clonazepam -Diazepam -Lorazepam -Midazolam - ANSWERSdiazepam A 20-year-old woman is admitted to the psychiatric unit of the hospital after ruling out a medical cause for her persistent complaints of headache, fatigue, and difficulty in swallowing. The patient says to the nurse, "The doctor doesn't believe me when I say I am sick. He doesn't know that the tests don't show everything." The nurse should use which of these approaches in responding to the patient? - Ask the patient to repeat her conversation with the physician -Explain to the patient that her complaints are not symptoms of a specific illness -Inform the patient that an error in diagnostic test results is unlikely -Show acceptance of the patient's opinion - ANSWERSShow acceptance of the patient's opinion A patient is prescribed lorazepam for anxiety. The nurse should include which of the following as possible side effects in the patient's education? Select all that apply. - Barking cough -Confusion -Diarrhea -Dizziness -Increased risk of infections -Lethargy - ANSWERS- confusion - dizziness - lethargy After discharge from the hospital, the patient develops an intense fear of being alone. This is known as - Compulsion -Obsession -Phobia -Somatization - ANSWERSphobia The nurse is caring for a patient with posttraumatic stress disorder. What are some typical symptoms the nurse might expect to see? Select all that apply. - Difficulty concentrating -Flashbacks to the event -Lethargic behavior -Nightmares - ANSWERS-Difficulty concentrating -Flashbacks to the event -Nightmares The nurse is caring for a patient with posttraumatic stress disorder. While working with the patient during a flashback, the nurse: "I know you are scared, but you are in a safe place. Do you see the bed in your room? Do you feel the chair you are sitting on?" The nurse is using which of the following techniques? - Distraction -Grounding -Reality orientation -Relaxation - ANSWERSgrounding The nurse is admitting a patient with severe anxiety. When assessing the patient, the nurse's questions should be - Avoided until the anxiety is gone -Open-ended -Postponed until the patient volunteers information -Specific, simple and direct - ANSWERS-Specific, simple and direct The nurse is caring for a patient with a dissociative disorder resulting in a sudden identity disturbance owing to the inability to recall significant personal information. This is called - Depersonalization disorder -Dissociative amnesia -Dissociative fugue -Dissociative identity disorder - ANSWERSDissociative amnesia Before eating a meal, a patient with obsessive compulsive disorder must wash her hands for 20 minutes, comb her hair with 200 strokes, and switch the bathroom light on and off 50 times. What is the most appropriate goal of care for this patient? - Allow ample time for the patient to complete all rituals before each meal since it is not harmful to others -Identifies and uses at least three effective coping strategies to manage anxiety -Increase the patient's acceptance of therapeutic drug use -Omit one unacceptable behavior each day to gradually decrease the patient's obsessions - ANSWERSIdentifies and uses at least three effective coping strategies to manage anxiety A 7-year-old foster child is brought to the clinic. The child was abused by her parents before going into foster care. As part of a psychosocial assessment to rule out any chronic dissociative pattern of coping, the nurse would ask about which of the following? Select all that apply. - 24 hour nutritional intake