NU249/NUR2488 Section 06 Mental Health Nursing

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NU249/NUR2488 Section 06 Mental Health Nursing  Question 1 0 out of 1 points A fully developed outcome for a client goal would include: (SATA) Selected Answers: Time sensitive Measurable terms... Initial assessment Attainable for client Answers: Time sensitive Measurable terms Initial assessment Identifying data Attainable for client Response Feedback: No. Outcomes need to take into account the patient's culture, values, and ethical beliefs. Specifically, outcomes are stated in attainable and measurable terms and include a time estimate for attainment".  Question 2 0 out of 1 points The nurse understands a client could be at risk for serotonin syndrome when taking which of the following medications in addition to over the counter medications or herbal supplements? Selected Answer: Haloperidol Answers: Sertraline Haloperidol Trazadone Venlafaxine Response Feedback: No. Sertraline (Zoloft) is an SSRI, and when combined with over the counter medications or herbal supplements could increase the clients risk for developing serotonin syndrome.  Question 3 0 out of 1 points A 4-year-old child grabs toys from siblings, saying, “I want that toy now!” The siblings cry and the child‟s parent becomes upset with the behavior. Using Freudian theory, a nurse can interpret the child‟s behavior as a product of impulses originating in the: Selected Answer: Ego Answers: Id Ego SuperegoPreconscious Response Feedback: No. The id operates on the pleasure principle, seeking immediate gratification of impulses. The ego acts as a mediator of behavior and would weigh the consequences of the action, perhaps determining that taking the toy is not worth the parent‟s wrath. The superego would oppose the impulsive behavior as “not nice.” The preconscious is a level of awareness.  Question 4 1 out of 1 points Which expected client outcome should a nurse identify as being correctly formulated? Selected Answer: Client will initiate interaction with one peer during free time within 2 days. Answers: Client will feel happier by discharge. Client will demonstrate two relaxation techniques. Client will verbalize triggers to anger by end of session. Client will initiate interaction with one peer during free time within 2 days. Response Feedback: Yes. The statement “Client will initiate interaction with one peer during free time within 2 days” is an example of a correctly formulated expected outcome. Outcomes should be measurable, realistic, client-focused goals that include a time frame. Appropriate nursing interventions are guided by client outcomes.  Question 5 1 out of 1 points A voluntarily hospitalized patient tells the nurse, “Get me the forms for discharge against medical advice so I can leave now.” Which is the nurse‟s best response? Selected Answer: “I will get them for you, but let‟s talk about your decision to leave treatment.” Answers: “I can‟t give you those forms without your health care provider‟s knowledge.” “I‟ll get the forms for you right now and bring them to your room.” “Since you signed your consent for treatment, you may leave if you desire.” “I will get them for you, but let‟s talk about your decision to leave treatment.” Response Feedback: Yes. A patient who has been voluntarily admitted as a psychiatric inpatient has the right to demand and obtain release in most states. However, as a patient advocate, the nurse is responsible for weighing factors related to the patient‟s wishes and best interests. By asking for information, the nurse may be able to help the patient reconsider the decision. The statement that discharge forms can‟t be given without the health care provider‟s knowledge is not true. Facilitating discharge without consent is not in the patient‟s best interests before exploring the reason for the request. Question 6 0 out of 1 points The client is being admitted to the inpatient psychiatric unit. The nurse conducts a mental status examination. Which of the following items are included in this examination? (Select all that apply) Selected Answers: Appearance Mood and Affect Physical Exam Cognition Answers: Appearance Mood and Affect Thought Physical Exam Cognition Response Feedback: Personal information, appearance, behavior, speech, mood and affect, thought, perceptual disturbances and cognition are all parts of a mental status exam. Physical assessment would not be included with the MSE. (Chapter 7, p 103-104)  Question 7 1 out of 1 points A client with schizophrenia has recently begun a new medication, clozapine (Clozaril). Which signs and symptoms of a potentially fatal side effect will the nurse teach the client about? Selected Answer: Blurring vision and muscular weakness Answers: Blurring vision and muscular weakness Sore throat, fever, and malaise Tremor, shuffling gait, and neck stiffness Fine tremor, tinnitus, and nausea Response Feedback: Yes. These are symptoms of agranulocytosis, which is a potentially fatal disorder in which the client's white blood cell count drops to extremely low levels. This places the client at great risk for infections.  Question 8 0 out of 1 points Which information suggests that caution is necessary in prescribing a benzodiazepine to an anxious client? Selected Answer: The client has a history of diabetes mellitus. Answers: The client has a history of alcohol dependence. The client has a history of diabetes mellitus. The client has a history of schizophrenia. The client has a history of hypertension.Response Feedback: No. Tolerance and psychological dependence are common problems with the long-term use of benzodiazepines. They should be used cautiously with clients who have a history of substance abuse.  Question 9 1 out of 1 points A brother calls to speak to his sister who has been admitted to the psychiatric unit. The nurse connects him to the community phone and the sister is summoned. Later the nurse realizes that the brother was not on the client‟s approved call list. What law has the nurse broken? Selected Answer: The Health Insurance Portability and Accountability Act Answers: The National Alliance for the Mentally Ill Act The Tarasoff Ruling The Health Insurance Portability and Accountability Act The Good Samaritan Law Response Feedback: The nurse has violated the Health Insurance Portability and Accountability Act (HIPAA) by revealing that the client had been admitted to the psychiatric unit. The nurse should not have provided any information without proper consent from the client.  Question 10 1 out of 1 points The client attempted suicide by overdosing on pain medication. Once the client ingested the medication, she decided that she did not want to die and she sought immediate treatment. Once the client recovered from the physical effects of overdose, the client voluntarily sought inpatient mental health treatment. Which of the following statements is true of voluntary admission? Selected Answer: The client retains the right to request release Answers: The client is required to stay a minimum of 72 hours The client must have certification by two or more physicians Only a judge can determine if the client is able to be discharged The client retains the right to request release Response Feedback: Yes. Release from the hospital depends on the patient‟s admission status. All clients have the right to request release; thereby negating a 72 hour length of stay. It may not be granted if there is a civil commitment process. Certification is required by physicians or judges in a commitment process. (Chapter 6 pp 82- 83)  Question 11 1 out of 1 points A nurse says to a client, “Things will look better tomorrow after a good night‟s sleep.” This is an example of which communication technique?Selected Answer: The nontherapeutic technique of giving reassurance Answers: The therapeutic technique of giving advice The therapeutic technique of defending The nontherapeutic technique of presenting reality The nontherapeutic technique of giving reassurance Response Feedback: Yes. The nurse‟s statement, “Things will look better tomorrow after a good night‟s sleep,” is an example of the nontherapeutic communication technique of giving reassurance. Giving reassurance indicates to the client that there is no cause for anxiety, thereby devaluing the client‟s feelings.  Question 12 1 out of 1 points A patient is involuntarily admitted to a psychiatric unit after calling a friend and saying, “I‟ve got a gun and I‟m going to shoot myself.” Which of the following rights has the patient lost temporarily? Selected Answer: The right to leave the hospital without medical approval Answers: The right to communicate with family members Freedom of speech The right to refuse medications The right to leave the hospital without medical approval Response Feedback: Yes. If a patient is admitted involuntary, she cannot leave without medical or court approval. The patient still retains the rights to communicate with family, refuse medication and speak her mind.  Question 13 1 out of 1 points A depressed client states, “I have a chemical imbalance in my brain. I have no control over my behavior. Medications are my only hope to feel normal again.” Which nursing response is appropriate? Selected Answer: “Medications are one way to address chemical imbalances. Environmental and interpersonal factors can also have an impact on biological factors.” Answers: “Medications are one way to address chemical imbalances. Environmental and interpersonal factors can also have an impact on biological factors.” “Because biological factors are the sole cause of depression, medications will improve your mood.” “Environmental factors have been shown to exert the most influence in the development of depression.” “Researchers have been unable to demonstrate a link between nature (biologyand genetics) and nurture (environment).” Response Feedback: Yes. The nurse should advise the client that medications are one treatment approach to address biological factors, but there are other factors that affect mood. The nurse should educate the client on environmental and interpersonal factors that can lead to depression and the potential for psychological treatments to have a positive impact on biological factors  Question 14 1 out of 1 points During an intake interview, which question would assist the nurse in gathering data about the client‟s judgment? Selected Answer: “If you found a stamped, addressed envelope in the street, what would you do?” Answers: “Do you know what day and season it is now?” “On a scale of 1 to 10, how would you rate your stress level?” “What does the phrase „a rolling stone gathers no moss‟ mean to you?” “If you found a stamped, addressed envelope in the street, what would you do?” Response Feedback: Yes. In the assessment phase of the nursing process, the nurse collects comprehensive health data that are pertinent to the client‟s health or situation. The nurse presents a situation that requires the client to make a judgment call and can assess appropriate judgment on the basis of the client‟s action choice.  Question 15 1 out of 1 points A nursing instructor asks a student to describe the nursing process when initiating care of a client. The student nurse understands the nursing process order to be correctly identified as: Selected Answer: Assessment, Nursing Diagnosis, Outcomes, Planning, Implementation, Evaluation Answers: Assessment, Nursing Diagnosis, Outcomes, Planning, Implementation, Evaluation Assessment, Medical Diagnosis, Implementation, Planning, Outcomes and Evaluation Assessment, Nursing Diagnosis, Implementation, Planning, Outcomes, and Evaluation Assessment, Medical Diagnosis, Planning, Outcomes, Implementation and Evaluation Response Feedback: Yes. The nursing process as is follows: assessment, nursing diagnosis, outcomes, planning, implementation, and evaluation. It should not include medical diagnoses. Identifying the outcomes allows for planning followed byimplementation. Evaluations needs to occur after nursing interventions have been implemented.  Question 16 0 out of 1 points During an intake assessment, a nurse asks both physiological and psychosocial questions. The client angrily responds, “I‟m here for my heart, not my head problems.” Which is the nurse‟s best response? Selected Answer: “Why are you concerned about these types of questions?” Answers: “It‟s just a routine part of our assessment. All clients are asked these questions, you need to answer them.” “Why are you concerned about these types of questions?” “Psychological factors, like excessive stress, have been found to affect medical conditions.” “We can skip these questions, if you like. It isn‟t imperative that we complete this section.” Response Feedback: No. The nurse should attempt to educate the client on the negative effects of excessive stress on medical conditions. It is not appropriate to skip either physiological or psychosocial questions, as this would lead to an inaccurate assessment.  Question 17 0 out of 1 points A mother rescues two of her four children from a house fire. In an emergency department, she cries, “I should have gone back in to get them. I should have died, not them.” Which of the following responses by the nurse is an example of reflection? Selected Answer: “The smoke was too thick. You couldn‟t have gone back in.” Answers: “The smoke was too thick. You couldn‟t have gone back in.” “You‟re feeling guilty because you weren‟t able to save your children.” “Focus on the fact that you could have lost all four of your children.” “It‟s best if you try not to think about what happened. Try to move on.” Response Feedback: No. The best response by the nurse is, “You‟re experiencing feelings of guilt because you weren‟t able to save your children.” This response utilizes the therapeutic communication technique of reflection, which identifies a client‟s emotional response and reflects these feelings back to the client so that they may be recognized and accepted.  Question 18 1 out of 1 points An entry level registered nurse works with patients in a community setting. Which groups should this nurse expect to lead? (Select all that apply.)Selected Answers: Symptom management Family therapy Psychotherapy Self-care Answers: Symptom management Family therapy Medication education Psychotherapy Self-care Response Feedback: Yes. Symptom management, medication education, and self-care groups represent psychoeducation, which is provided by the basic level registered nurse. Family therapy and psychotherapy would be provided by advanced practice registered nurses  Question 19 1 out of 1 points A client has been involuntarily admitted to an inpatient behavioral health unit. During this admission, which of the following rights does the client still retain? (Select all that apply.) Selected Answers: The right to refuse medications The right to informed consent Answers: The right to refuse medications The right to keep all personal items The right to informed consent The right to choose the nurse assigned to them Response Feedback: Yes. The patient has a right to refuse medication and the right to informed consent even during an involuntary admission. The patient may not be able to keep all personal items if those items would present a safety risk to himself or others. Choosing which staff are assigned to you is not a patient right  Question 20 1 out of 1 points A mother who is notified that her child was killed in a tragic car accident states, “I can‟t bear to go on with my life.” Which nursing statement conveys empathy? Selected Answer: “It must be horrible to lose a child, and I‟ll stay with you until your husband arrives.” Answers: “This situation is very sad, but time is a great healer.” “You are sad, but you must be strong for your other children.” “Once you cry it all out, things will seem so much better.” “It must be horrible to lose a child, and I‟ll stay with you until your husband arrives.”Response Feedback: The nurse‟s response, “It must be horrible to lose a child, and I‟ll stay with you until your husband arrives,” conveys empathy to the client. Empathy is the ability to see the situation from the client‟s point of view. Empathy is considered to be one of the most important characteristics of the therapeutic relationship  Question 21 1 out of 1 points During the implementation phase of the nursing process, a nurse is teaching an adult depressed patient with a cochlear implant about medications. Which modification in the teaching plan would be the most appropriate for this client? Selected Answer: Speaking directly face-to-face Answers: Using repetition Speaking directly face-to-face Employing the use of sign language Providing large-print materials Response Feedback: Yes. Speaking face-to-face is an appropriate way to teach individuals with alterations in hearing.  Question 22 1 out of 1 points A 22 year old college student is admitted to a hospital following a suicide attempt and states, “No one will ever love a loser like me.” According to Erikson‟s theory of personality development, a nurse should recognize a deficit in which developmental stage? Selected Answer: Intimacy versus isolation Answers: Trust versus mistrust Ego integrity versus despair Intimacy versus isolation Initiative versus guilt Response Feedback: Yes. The nurse should recognize that the client who states, “No one will ever love a loser like me” has not adequately completed the intimacy versus isolation stage of development. The intimacy versus isolation stage is presumed to occur in young adulthood between the ages of 20 and 30 years. The major developmental task in this stage is to establish intense, lasting relationships or commitment to another person, cause, institution, or creative effort.  Question 23 0 out of 1 points A nursing instructor is teaching about the monoamine category of neurotransmitters. Which student statement indicates that learning about the function of norepinephrine has occurred? Selected Answer: Norepinephrine functions to regulate arousal, libido, and appetite.Answers: Norepinephrine functions to regulate movement, coordination, and emotions. Norepinephrine functions to regulate mood, cognition, and perception. Norepinephrine functions to regulate arousal, libido, and appetite. Norepinephrine functions to regulate pain, inflammatory response, and wakefulness. Response Feedback: No. The functions of norepinephrine include the regulation of mood, cognition, perception, locomotion, and cardiovascular function. Norepinephrine has also been implicated in certain mood disorders such as depression and mania, anxiety states, and schizophrenia.  Question 24 1 out of 1 points A nurse is educating a patient about the difference between mental health and mental illness. Which statement by the patient reflects an accurate understanding of mental health? Selected Answer: Mental health is successful adaptation to stressors in the internal and external environment. Answers: Mental health is the absence of any stressors. Mental health is successful adaptation to stressors in the internal and external environment. Mental health is incongruence between thoughts, feelings, and behavior Mental health is a diagnostic category in the DSM-5. Response Feedback: Yes. Several definitions of mental health exist, but this definition highlights concepts of successful adaptation to stressors, including thoughts, feelings, and behaviors that are age-appropriate and congruent with cultural and societal norms.  Question 25 0 out of 1 points The nurse understands a client taking which medication could place a client at high risk for a life-threatening hypertensive crisis if tyramine is ingested? (Select All That Apply) Selected Answers: A client taking tranylcypromine (Parnate) A client taking phenelzine (Nardil) A client taking sertraline (Zoloft) Answers: A client taking tranylcypromine (Parnate) A client taking isocarboxazid (Marplan) A client taking venlafaxine (Effexor) A client taking phenelzine (Nardil) A client taking sertraline (Zoloft) Response Feedback: No. Isocarboxazid, tranylcypromine, and phenelzine are all MAOIs, andingesting foods containing tyramine could place the client at risk for a life threatening hypertensive crisis.  Question 26 1 out of 1 points A client was recently admitted to the inpatient unit after a suicide attempt and has not responded to SSRIs or tricyclic antidepressants. The client asks the nurse, “I heard about MAOIs (monoamine oxidase inhibitors). Why can't they be added to what I am on now? Wouldn't adding one help?” Which is the appropriate nursing response? Selected Answer: “Combined use can lead to a life-threatening condition called a hypertensive crisis.” Answers: “Electroconvulsive therapy (ECT) is your best option at this point.” “Combined use can lead to a life-threatening condition called a hypertensive crisis.” “There is no reason why an MAOI couldn‟t be added to your therapy.” “They can't be used together because their mechanisms of action are very different.” Response Feedback: Yes. If MAOIs are taken with other antidepressants, a hypertensive crisis could result.  Question 27 0 out of 1 points A 29-year-old client living with parents has few interpersonal relationships. The client states, “I have trouble trusting people.” Based on Erikson‟s developmental theory, which should the nurse recognize as true statements about the client? (Select All That Apply) Selected Answers: The client not has progressed beyond the trust versus mistrust developmental stage. Developmental deficits in earlier life stages have impaired the client‟s adult functioning. The client cannot move to the next developmental stage until mastering all earlier stages Answers: The client not has progressed beyond the trust versus mistrust developmental stage. Developmental deficits in earlier life stages have impaired the client‟s adult functioning. The client cannot move to the next developmental stage until mastering all earlier stages The client‟s developmental problems began in the intimacy versus isolation stage. Response Feedback: No. Many individuals with mental health problems are still struggling to achieve tasks from a number of developmental stages. Nurses can plan care to assist these individuals to complete these tasks and move on to a higher developmentallevel  Question 28 1 out of 1 points A patient discloses several concerns and associated feelings. If the nurse wishes to seek clarification, which comment would be most appropriate? Selected Answer: “Am I correct in understanding that . . .” Answers: “What are the common elements here?” “Tell me again about your experiences.” “Am I correct in understanding that . . .” “Tell me everything from the beginning.” Response Feedback: Yes. Asking, “Am I correct in understanding that…” permits clarification to ensure that both the nurse and patient share mutual understanding of the communication. Asking about common elements encourages comparison rather than clarification. The remaining responses are implied questions that suggest the nurse was not listening. @No. Asking, “Am I correct in understanding that…” permits clarification to ensure that both the nurse and patient share mutual understanding of the communication. Asking about common elements encourages comparison rather than clarification. The remaining responses are implied questions that suggest the nurse was not listening.  Question 29 1 out of 1 points The health care provider prescribes an antidepressant for an elderly client, but nurse notices that the dosage is greater than the usual adult dosage. Which of the following best describes what action the nurse should take? Selected Answer: Hold the medication until clarified with the health care provider Answers: Consult a drug reference guide Implement the order as written Administer the usual geriatric dosage Hold the medication until clarified with the health care provider Response Feedback: Yes. The dosage of antidepressants for older adult patients is often less than the usual adult dosage. The nurse should withhold the medication and consult the health care provider who wrote the order. The nurse‟s duty is to intervene and protect the patient. Consulting a drug reference is unnecessary because the nurse already knows the dosage is excessive. Implementing the order is negligent. Giving the usual geriatric dosage would be wrong; a nurse without prescriptive privileges cannot change the dosage. Question 30 1 out of 1 points Which intervention by a psychiatric nurse best utilizes the ethical principle of autonomy? The nurse: Selected Answer: Explores alternative solutions with a patient, who then makes a choice Answers: Stays with a patient who is demonstrating a high level of anxiety Suggests that two patients who were fighting be restricted to the unit Explores alternative solutions with a patient, who then makes a choice Intervenes when a self-mutilating patient attempts to harm self Response Feedback: Autonomy is the right to self-determination, that is, to make one‟s own decisions. By exploring alternatives with the patient, the patient is better equipped to make an informed, autonomous decision. Staying with a highly anxious patient or intervening with a self-mutilating patient demonstrates beneficence and fidelity. Suggesting that two fighting patients be restricted to the unit demonstrates the principles of fidelity and justice.  Question 31 1 out of 1 points Which of the following should the nurse plan to include in the assessment of an older adult client? Selected Answer: Identify physical needs and necessary accommodations for this client. Answers: Ask all questions in the order they are presented on the formal assessment tool. Interpret all data objectively without consideration of context of the client‟s spiritual or cultural beliefs. Share all pertinent information with the family after leaving the patient. Identify physical needs and necessary accommodations for this client. Response Feedback: Yes. Any physical needs and necessary accommodations, such as for hearing loss or pain, must be addressed so that the assessment is valid. Sharing all information with the family automatically without the patient present would be a breach of confidentiality unless the patient has expressly granted this permission in writing. Following the exact order of a formal assessment tool does not allow for individual variation and the client may present important information out of context that may need to be addressed immediately. Spiritual and cultural beliefs are an important part of an assessment.  Question 32 0 out of 1 points A patient is about to be released and tells the staff nurse “I‟m glad I‟m getting out of here; I swear the first thing I‟ll do is kill my ex-wife and that stupid boyfriend of hers.” Which of the following is the staff nurse‟s legal duty?Selected Answer: Warn the patient‟s ex-wife and boyfriend. Answers: Obtain an order for an increase in the patient‟s medication before discharge. Warn the patient‟s ex-wife and boyfriend. Keep this information confidential to avoid legal action. Report the threat to the treatment team and document the statement Response Feedback: No. The team has a duty to warn any third party who has threats made against them by a patient (Tarasoff warning). Increasing his medication is not guaranteed to prevent violence. There is no requirement to keep this information confidential. Transferring the patient to another state may not be legal and does not guarantee safety for the ex-wife and her boyfriend.  Question 33 1 out of 1 points A client tells a nurse that he hates his doctor and plans to hurt the doctor, but she did not report this prior to leaving. When the nurse returns to work the next day, she finds that the physician has been brutally beaten by the client and the physician is hospitalized. Which of the following best represents the nurse‟s failure to act by not reporting the client‟s intent? Selected Answer: Negligence Answers: Carelessness Assault and battery Negligence Slander Response Feedback: Yes. Negligence is an omission to act and can be charged if the nurse does not report a foreseeable harm and it results in injury; in this case the client told the nurse what he intended to do. Breach of duty is conduct that exposes the patient to harm. The client committed assault and battery, not the nurse. Slander involves damaging someone‟s reputation or divulging confidential information by the spoken word.  Question 34 1 out of 1 points A newly admitted patient is hyperactive, restless, and disorganized. The patient goes to the dining room and begins to throw food. Verbal intervention is ineffective. Seclusion is instituted for the primary purpose of: Selected Answer: Reducing environmental stimuli that negatively affect the patient. Answers: Isolating the patient until his prn medication can take effect. Reducing environmental stimuli that negatively affect the patient. Limit setting and encouraging the patient to follow unit rules.Preventing other patients from observing the behavior. Response Feedback: Yes. Seclusion can help reduce overwhelming stimuli when less restrictive measures have failed to helped the patient maintain control. Setting limits regarding unit rules would not be effective or appropriate during a manic episode. Seclusion is not an appropriate or legal method to use to prevent other patient‟s from viewing the behavior. Seclusion may not be used to isolate the patient until his medication takes effect, unless he presents a danger to himself or others.  Question 35 1 out of 1 points A Mexican American patient puts a picture of the Virgin Mary on the bedside table. Under which section of the assessment should the nurse document this behavior? Selected Answer: Culture Answers: Ethnicity Culture Verbal communication Non-verbal communication Response Feedback: Yes. Cultural heritage is expressed through language, works of art, music, dance, ethnic clothing, customs, traditions, diet, and expressions of spirituality. This patient‟s prominent placement of the picture is an example of expression of cultural heritage.  Question 36 1 out of 1 points Which one of the following best represents a potential liability issue for the professional nurse? Selected Answer: Placing a patient who talks constantly and loudly into a secluded room alone. Answers: Restraining a combative patient who is stabbing himself with a pencil. Reporting threats of violence made by a patient against his employer. Calling the psychiatric nurse practitioner to clarify an order for an antipsychotic. Placing a patient who talks constantly and loudly into a secluded room alone. Response Feedback: Yes. Restraining a patient is allowed if he presents an immediate threat to himself or others. Talking constantly and loudly is not a threat to the patient or anyone around him, and would be considered false imprisonment. It‟s appropriate to contact the prescriber to clarify an order before giving it. The nurse has a duty to warn a third party if a patient makes threats against them (Tarasoff warning) Question 37 1 out of 1 points A researcher tells the nurse that she would like a patient to participate in a study on the effects of a new medication. The nurse‟s responsibility in regard to this study is: Selected Answer: To assess whether the patient has the ability and legal right to give informed consent. Answers: To tell the patient about the benefits of the study and encourage participation. To gather data that the researcher requests. To assess whether the patient has the ability and legal right to give informed consent. To coach the patient in how she should answer questions and behave during the study. Response Feedback: Yes. Consent is not informed consent if the patient is not cognitively able to understand what she is consenting to do; a patient may also not be able to sign a consent if someone else is her power of attorney for health care. The researcher, not the nurse, gathers the data. It is not within the nurse‟s role and is not ethical to try to convince a patient to participate in a research study. The researcher, not the nurse, prepares the patient for the research study; no one should; coach the patient about what to say or do during the study, as that could result in inaccurate data  Question 38 0 out of 1 points A nurse is performing a mental health assessment on an adult client. According to Maslow‟s hierarchy of needs, which client action would demonstrate the highest achievement in terms of mental health? Selected Answer: Maintaining a long-term, faithful, intimate relationship Answers: Maintaining a long-term, faithful, intimate relationship Achieving a sense of self-confidence Possessing a feeling of self-fulfillment and realizing full potential Developing a sense of purpose and the ability to direct activities Response Feedback: No. The nurse should identify that the client who possesses a feeling of selffulfillment and realizes his or her full potential has achieved self-actualization, the highest level on Maslow‟s hierarchy of needs.  Question 39 0 out of 1 points A nurse explains to the family of a mentally ill patient how the nurse-patient relationship differs from other interpersonal relationships. Which is the nurse‟s best explanation? Selected Answer: “The focus shifts from nurse to patient as the relationship develops. Advice isgiven by both and solutions are implemented.” Answers: “The focus is on the patient. Problems are discussed by the nurse and patient; but solutions are implemented by the patient.” “The focus is creation of a partnership in which each member is concerned with being a “friend”. “The focus of the relationship is socialization. Mutual needs are met and feelings are shared openly.” “The focus shifts from nurse to patient as the relationship develops. Advice is given by both and solutions are implemented.” Response Feedback: No. Only the first response describes elements of a therapeutic relationship. The remaining responses describe events that occur in social or intimate relationships  Question 40 1 out of 1 points A client who is very dirty and has an offensive odor refused to take a shower when he was admitted to the psychiatric inpatient unit of the hospital. He yelled, “No, no, no bath!” when two staff members carried him into the shower and made him wash himself thoroughly before allowing him to leave the shower area. Which of these statements is correct regarding this patient‟s rights? Selected Answer: This was a violation of patient rights because the patient was restrained by force. Answers: There was no violation because an intake shower is required for all new patients, not just this patient There was no violation of patient rights because this is considered a potential threat to self, due to inappropriate hygiene. This was a violation of patient rights because the patient was restrained by force. There was a rights violation due to excessive verbal interventions. Response Feedback: Yes. Being dirty is not a situation that calls for restraining a patient; forcing him to get into the shower violated his rights. Inappropriate hygiene is not considered an immediate threat to self. Even if an intake shower is required, it does not allow the use of force. There is no indication that excessive, or any, verbal interventions were attempted; verbal interventions would the preferred method for getting the patient to take a shower  Question 41 0 out of 1 points The nurse is assessing a client who has a diagnosis of schizophrenia and takes a typical antipsychotic agent daily. Which assessment finding should alert the nurse to a potential adverse effect of a typical antipsychotic medications?Selected Answer: Excess salivation Answers: Respirations of 22 breathes/minute Weight gain of 8 pounds in 2 months Temperature of 101oF Excess salivation Response Feedback: No. A fever could be one of the first signs of an infection caused by reduced immunity from agranulocytosis secondary to antipsychotic medication.  Question 42 0 out of 1 points Using Erickson‟s theory of personality development, which of the following task occur with teenagers during puberty? Selected Answer: Forming sexual relationships Answers: Develop abstract thinking Forming sexual relationships Identifying oneself from one‟s parents Sensing the flow of time, past, present and future Type MA: Response Feedback: No. The differentiation from parents leads to fidelity or sense of self. This task typically occurs in 12 to 20 year olds. Abstract thinking refers to Piaget. Sullivan discusses the formation of sexual relationships. Sensing the flow of time is in Erickson‟s stage of generativity versus stagnation.  Question 43 0 out of 1 points According to Freud, which statement should a nurse associate with predominance of the superego? Selected Answer: “No one is looking, so I will take three cigarettes from Mom‟s pack.” Answers: “No one is looking, so I will take three cigarettes from Mom‟s pack.” “I don‟t ever cheat on tests; it is wrong.” “I think I may skip school today, I need a break.” “Dad won‟t miss this little bit of vodka.” Response Feedback: No. The nurse should associate the statement “I don‟t ever cheat on tests; it is wrong” as indicative of the predominance of the superego. Freud described the superego as the part of the personality that internalizes the values and morals set forth by primary caregivers. The superego can be referred to as the “perfection principle.” Question 44 1 out of 1 points An inpatient psychiatric physician treating clients omits treatment options for those without insurance. Which violation of an ethical principle should a nurse recognize in this situation? Selected Answer: Justice Answers: Autonomy Beneficence Non-maleficence Justice Response Feedback: Yes. The nurse should determine that the ethical principle of justice has been violated by the physician‟s actions. The principle of justice requires that individuals should be treated equally regardless of race, sex, marital status, medical diagnosis, social standing, economic level, or religious belief.  Question 45 1 out of 1 points During a nurse–client interaction, which nursing statement may belittle the client‟s feelings and concerns? Selected Answer: “Don‟t worry. Everything will be alright.” Answers: “Don‟t worry. Everything will be alright.” “You appear uptight.” “I notice you have bitten your nails to the quick.” “Tell me more about your feelings.” Response Feedback: Yes. This nursing statement is an example of the nontherapeutic communication block of belittling feelings. Belittling feelings occurs when the nurse misjudges the degree of the client‟s discomfort, suggesting a lack of empathy and understanding.  Question 46 1 out of 1 points A nurse assessed a patient who participated reluctantly, answered questions with minimal responses, and rarely made eye contact. What data should be included when documenting the assessment? Selected Answer: A description of the patient‟s behavior during the interview Answers: Only data obtained from the patient‟s verbal responses The observation that the patient was uncooperative Analysis of why the patient did not respond openly during the interview A description of the patient‟s behavior during the interviewResponse Feedback: Yes. 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.  Question 47 1 out of 1 points Which client action should a nurse expect during the working phase of the nurse-client relationship? Selected Answer: The client gains insight and incorporates alternative behaviors. Answers: The client gains insight and incorporates alternative behaviors. The client establishes rapport with the nurse builds trust. The client explores feelings related to reentering the community. The client outlines problems to be discussed. Response Feedback: The nurse should expect that that the client will gain insight and incorporate alternative behaviors during the working phase of the nurse-client relationship. The client may also overcome resistance, problem-solve, and continually evaluate progress toward goals  Question 48 0 out of 1 points The nurse is conversing with a client in a locked in-patient psychiatric unit. The client states,” Please don‟t tell anyone about my sexual abuse.” Which nursing response clearly outlines the professional nurse‟s responsibility related to confidentiality? Selected Answer: “Yes, I will keep this information confidential.” Answers: “Yes, I will keep this information confidential.” “All of the health-care team is focusing on helping you. I will bring information to the team that can assist them in planning your treatment.” “Why don‟t you want the team to know about your sexual abuse? It is essential information.” “Let‟s talk about your feelings about your history of sexual abuse?” Response Feedback: No. The nurse is being honest and open with the client and giving information about the client focus of the treatment team. This builds trusts and sets limits on potentially manipulative behaviors by the client. Although talking about feelings is a positive intervention, in this situation, the nurse needs to deal with the concerns of the client and give information about the treatment team. The nurse cannot promise to keep this important information secret, and by requesting an explanation may put the client on the defensive.  Question 490 out of 1 points Within professional scope of practice, which function is exclusive to the advanced nurse practice specialty? Selected Answer: Providing case management to coordinate continuity of health services Answers: Teaching about the side effects of MAOI medications. Using psychotherapy to improve mental health status Using milieu therapy to structure a therapeutic environment Providing case management to coordinate continuity of health services Response Feedback: No. The advanced practice psychiatric nurse is authorized to use psychotherapy to improve mental health. This includes individual, couples, group, and family psychotherapy. It is within the scope of practice of a registered psychiatric mental health nurse generalist to provide education, case management, and milieu therapy.  Question 50 1 out of 1 points A physically healthy, 35-year-old single client lives with parents who provide total financial support. According to Erikson‟s theory, which developmental task should a nurse assist the client to accomplish? Selected Answer: Establishing a career, personal relationships, and societal connections Answers: Establishing the ability to control emotional reactions Establishing a strong sense of ethics and character structure Establishing and maintaining self-esteem Establishing a career, personal relationships, and societal connections Response Feedback: Yes. The nurse should assist the client in establishing a career, personal relationships, and societal connections. According to Erikson, non-achievement in the generativity versus stagnation stage results in self-absorption, including withdrawal from others and having no capacity for giving of the self to others. Monday, March 6, 2017 5:15:42 PM CST [Show More]

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