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Review Questions
Terms in this set (63)
Which assessment is most important when evaluating signs and symptons of mental illness?
The decreased amount of creativity a client exhibits
Which is an example of an interpersonal intervention for a client on an in-patient psychiatric unit?
Ask the client to use a journal to record thoughts he or she is having before acting out behaviors occur.
Which is an example of appropriate psychosexual development?
An 18-month old relieves anxiety by the use of a pacifier
In which client situation is ego development evident?
A client exhibits the ability to assert himself or herself without anger or aggression.
AFter studying the concepts of personality development, the nursing studen understand that Freud is to psychoanalytic theory as Peplau is to?
Nursing theory
Nursing theorsits have identified that the nurse-client relationship is central to the practive of nursing. After studying these concepts of nursing theory, the nursing theory, the nursing student understands that Peplau is to the phases of the nurse-client relationship as Watson is to:
Seven assumptions about the science of caring
After studying nursing interventions in the context of nursing theory, the nursing student understands that Neuman is to primary, secondary, or tertiary prevention as Roy is to:
Interventions that seek to alter or manage stimuli so that adaptive responses can occur.
The statement, "Growth involves resolution of critical tasks through the eight stages of the life cycle," is a concept of which therapeutic model.
Intrapersonal
A mother bring her 2-year-old child to a well-baby clinic for a physical. The child does not attempt to do things independently and continually looks to the mother for meeting all needs. Which outcome reflects this child's developmental task assessment as described by Erickson?
Shame and doubt
A seven year old boy is active in sports and has recieved a most improved player award at his baseball tournament. Which outcome reflects this child's developmental tak assessment as described by Erickson?
Industry
Which scenario describes an individual in Erickson's developmental stage of "old age" exhibiting a negative outcome of despair?
A 70 year old woman angry about where her life as ended up
Which initial information gathered by the nurse is most important when assessing Erickson's stages of development?
The chronological age of the individual
According to Maslow's hierarchy of needs, which client action would be considered most basic?
A client discusses the need for oder in his or her life and freedom from fear
According to Maslow's hierarchy of needs, which client action would be an example of a highly evolved, mature client?
A client begins to discuss feelings of self-fulfillment
According to Maslow's hierarchy of needs, which situation on an in-patient psychiatric unit would require priority intervention?
A client exhibits hostile and angry behaviors toward another client
According to Maslow's hierarchy of needs, which situation exhibits the highest level of attainment?
An individual demonstrates an ability to discuss objectively all points of view and possesses a strong sense of ethics.
Looking at a client's hisotry and physical examination, the nursing student notes that borderline personality disorder is placed on Axis III. Based on the knowledge of the DSM-IV-TR, which is a correct statement.
This information is incorrectly placed because Axis III reports medical diagnosis
Based on the nurse's knowledge of the DSM-IV-TR, it is understood that mental retardation is to Axis II as schixophrenia is to
Axis I
Based on the nurse's knowledge of the DSM-IV-TR, it is understood that chronic obstructive pulmonary disease is to Axis III as the Global Assessment of Functioning is to
Axis V
A client is being admitted to an in-patient psychiatric unit for the second time in two months. The nurse understands the GAF score, given under Axis V at previous discharge, is important to this admission for which reason?
To understand the amount of growth that may be expected from this client during hospitalization
The client's GAF score on involuntary admission to an in-patient psychiatric unit is less than 30. Which observed symptom would reflect this score?
Failure to maintain minimal hygiene
Which member of the mental healt-care team in an in-patient setting is responsible for completing all areas of the multiaxial client assessment, as described in the DSM-IV-TR? (2)
Psychiatrist
Nurse
Practioner
Which is the overall, priority goal of in-patient psychiatric treatment?
Stabilization and return to the community
In the ER, the nurse is assessing a client who is aggressive and is experiencing auditory and visual hallucinations. The client states, "I believethat the CIA is plotting to kill me." To which mental health setting would the nurse expect this client to be admitted.
Short-term in-patient, locked unit
On an in-patient psychiatric unit, a client diagnosed with major depressive disorder states, "I'm so glad that the Zoloft that my doctor just prescribed will quickly help me with my mood." Which nursing response reflects the role of teacher?
"This medication will probably take 2 to 4 weeks to be effective
On an in-patient psychiatric unit, a client diagnosed with major depressive disorder is anxious and distressed, and states, "God has abandoned me." Which action by the nurse would initiate collaboration with the member of the mental health care team who can assist this client with assessed probelm?
Consult with the chaplic and describe the client's concerns
A client states, "My wife is unfaithful. I think I am not worth anything." Which of the following describes this assessment information?
The subjective information of "chief complaint"
A client who is a welder by trade and has recently lost his arm in a motor vehicle accident is beind admitted to an in-patient psychiatric facility. The client states, "I'm useless. I can't support my family anymore!" Which nursing diagnosis is most reflective of this client's presenting problem?
Ineffective role performance related to loss of job
An 85 year old client has become agitated and physically aggressive after having a stroke with right-sided weakness. The client is started on Risperdal
PO 0.5mg QHS. Which is a priorty nursing diagnosis for this client?
Risk for falls related to right-sided weakness and sedation from Risperdal
An in-patient psychiatric client recently diagnosed with bipolar disorder has been prescribed lithium carbonate. When the nurse is functioning in the role of teacher, which nursing intervention takes priority?
Teaching the benefits of taking this medication as prescribed
A client diagnosed with schizophrenia is about to be discharged and is facing the stressor of acquiring independent employment. For the nurse using a behavioral approach, which nursing intervention is most appropriate in meeting this client's needs.
Role-playing a job interview with the client
A client diagnosed with bipolar has a nursing diagnosis of sleep pattern disturbance. Which intervention should the nurse implement initially?
Assess normal sleep pattern
A nursing student has a special feeling toward a client that is based on acceptance, warmth, and a nonjudgmental attitude;.; The studen is experiencing which characteristic that enhances the achievement of the nurse-client relationship.
Rapport
The nurse's ability to be open, honest, and real in interactions with clients is described as which characteristic that enhances the achievement of the nurse-client relationship?
Genuineness
In a psychiatric in-patient setting, the nurse observes an adolescnet client's peers calling the client names. In this context, which statement by the nurse exemplifies the concept of empathy.
"I can see that you are upset. Tell me how you feel."
Which is the goal for the orientation phase of the nurse-client relationship.
Establish trust
On an in-patient psychiatric unit, the goals of ptherapy have been met, but the client cries and states, "I have to keep coming back to therapy to handle my anger better." This interaction occurs in which phase of the nurse-client relationship.
Termination phase
On an inpatient psychiatric unit, the nurse explores feelings about working iwht a woman who continually has allowed her husband to abuse her and her children psychially and verbally. This interaction would occur in which phase of the nurse-client relationship?
Pre-interaction phase
The nurse reviews a client's record in preperation for client care. This actinon is one of the tasks that occur in a stage of the nurse-client relationship. What is the purpose of this stage.
Understanding the signs and symptoms of the client's diagnosis, and evaluating the nurse's attitudes.
A client states, "I don't know what the pills are for or why I am taking them, so I don't want them." Which is an example of the therapeutic communication technique of "giving information"?
"Let me tell you about your medication"
A client on an in-patient psychiatric unit asks the evening shift nurse, "How do you feel about my refusing to attend group therapy this morning?" The nurse responds, "How did your refusing to attend group make you feel?"Which communication technique is the nurse using in this situation?
Therapeutic use of "reflection"
Which is an example of the nontherapeutic technique of "giving reassurance?"
"Don't worry, everything will work out"
Which nurse-client communication-centered skill implies "respect"?
The nurse communicates regard for the client as a person of worth who is valued and accepted without qualification
Which nurse-client communication-centered skill implies "empathetic understanding"?
The nurse communicates an understanding of the client's world from the client's internal frame of reference, with sensitivity to the client's current feelings, and the internal frame of reference, with sensitivity to the client's current feelings, and the ability to communicate this understanding in a language attuned to the client.
An instructor overhears the nursing student ask a client, "This is your third admission. Why did you stop taking your medications?" Which statement by the instructor would be appropriately related to the student's question?
"Your question implied criticism and could have the effect of making the lcient feel defensive."
When the nurse focuses on a client's specifc behavior rather than on the client himself or herself, the nurse is using a strategy of nonthreatening feedback. Which nursing statement is an example of this strategy?"
"It's okay to be angry, but throwing the book was unacceptable behavior."
Culture-specific syndromes occur in individuals who are especially vulnerable to stressful life events. Which culture-specific syndrome would be reflective of the term "voodoo"?
With hexing, withcraft, and the evil influences of another person, illness and even death may result
A latino american client who has a 10:00am appointment at an out-patient psychiatric clinic arrives at noon, states, "I was visiting with my mther." How shold the nurse interpret the lcient's filure to arrive on time?
The lcient is a memebr of a clultural group that is present oriented
Which of the following are true statements about neurottransmitters?
Neurotrasmitters are responsible for essental functions in human emotion and behavior
Neurotrasmitters are targets for the mechanism of action of many psychotropic medicaitons
Risperdal is to hallucinations as Klonopin is to
Anxiety
A client has been prescribed Geodon 40mg BID. Which of the following interventions are important related to this medication? (3)
Obtain a baseline EKG initially and periodically throughout treatment
Teach the client to take the medication with meals
Monitor the licent's pulse because of the possibility of palpaitations
A client prescribed Seroquel 50mg BID has a nursing diangosis of risk for inury related to sedation. Which nursing intervention appropriately addresses this client's problem?
Remove clutter from the environement to avid injury
Which atypical antipsychotic medication has the most potential for a client to experience sedation, weight gain, and hypersalivation
Clozapine (Clozaril)
A client is exhibiting sedation, auditory hallucinations, dystonia, and grandiosity;. The client is prescribed Haldol 5mg TID and Artane 4mg BID. Which statmeent about these medicaitons is accurate
Haldol would assist the client to decrease grandiosity
A client is prescibed Abilify 10mg QAM. The client complains of sedaiton and dizzines. The client's vital signs are blood pressure 100/60, pulse 80, respiration 20, and temp 97.4. Which nursing diagnosis takes priorty ?
Risk for injury related to rthostatic hypotension
The right to determine one's own destiny is to autonomy as the duty to benefit of promote the good of others is to
Beneficence
Which action should be taken by the clinican when there is reasonable certainty that a client is going to harm somoene? (4)
Assess the threat of violence toward another
Identify the person being threatened
Notify the identified victim
Consider petitioning the court ofor continue commitment
In which situation does a health-care worker have a duty to warn a potential victim
When clients make specific threats toward someone who is identifiable.
A client's husband is visiting hours. A nurse walking by hears him berbally abuse the lcient. Which nursing reponse is appropriate?
Remind the client's husband of the unit rules
On which client would a nurse on an in-patient psychiatric unit appropriately use four point restraints
A client who is hostile and threatening the staff and other clients
Which of the following clients retains the right to give informed consent?
A 21 year old client who is hearing a seeing things that others do not.
Which client does not have the ability to refuse medicaiotns or treatments?
A client who has been deemed incompetent by the court.
A nursing student uses a client's full name on an IPA process recording submitted to the student's instructor. What is the instructor's priority intervention?
Correct and mreind the student of the importance of maintaining client confidentiality
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