The nurse interviewed a pt who participated reluctantly, answering questions with minimal responses & rarely making eye contact. When documenting the baseline data obtained during the interview the nurse should include: a) only data obtained from client verbal responses b) a disclaimer that the pt was uncooperative & provided minimal data c) both the content derived from pt subjective responses & a description of the client’s behavior during the interview d) speculation regarding the reason the client was unwilling to respond opening during the interview C --> Both content & process of the interview should be documented While working with a pt to establish outcomes for treatment, the nurse believes that an outcome suggested by the pt is not in the client’s best interest. The best action for the nurse would be to: a) remain silent b) tell the client that the outcome is not realistic c) formulate a different, appropriate outcome for the client d) explore the consequences that might occur if the outcome is achieved D --> The nurse should not impose outcomes on the client; however,
the nurse has a responsibility to help the client evaluate what is in his or her best interest. Exploring possible consequences is an acceptable approach. When the nurse begins the assessment interview with a 62 y/o pt she notes that the pt gives answers to questions that seem somewhat vague/slightly unrelated to the question. The pt also leans forward & frowns as she listens An appropriate question for the nurse to ask would be: a) “ I notice you are frowning. Are you feeling annoyed?” b) “Are you able to hear clearly when I speak in this tone? c) “How can I make this interview a bit easier for you?” d) “ You seem to be having some trouble focusing on what I’m saying. Is something distracting you?” B --> The client’s behaviors indicate she may have difficulty hearing. Identifying any physical need the client may have at the onset of the interview and making accommodations are important considerations During scheduled sessions the pt frequently asks the nurse for cigarettes & money, implying that he will be more willing to talk with the nurse if the requested items are forthcoming. The nurse should assess this behavior as: a) typical of transference reactions b) indicative of feelings of insecurity c) reflecting
resistance to involvement d) testing the nurse’s clinical competence D --> Clients often unconsciously use testing behaviors to determine whether the nurse is able to set limits or will abandon them if they behavior in an unlikeable way The events listed below occurred in the first few days of the nurse-client relationship. The
development of a positive relationship was hampered when the : a) nurse had to cancel their second and third sessions because of short staffing b) nurse let the pt set the pace during the initial interview c) Pt used the nurse as a sounding board while discussing recent work problems. d) Nurse’s initial impression was that the client would be interesting to work with. A --> Inconsistency and unavailability are specific factors that
hamper the development of positive nurse-client relationships. The other events listed are considered positive indicators of a satisfying relationship The nurse can best communicate to the client that she or he is interested in listening by: a) restating the feeling or thought the client has expressed b) making a judgement about the client’s problem c) asking a direct question, such as “did you feel angry?” d) saying “ I understand what you are saying” A --> restating allows the client to validate the nurse’s understanding of what has been communicated. B: judgements should be suspended in a nurse-client relationships. C: Close-ended questions ask for specific info rather than showing understanding. D: states that the nurse understands, but the client has no way of measuring the understanding. A male AA pt says to a white nurse “There’s no sense in talking with you. You wouldn’t understand because you live in a white world.” The best response for the nurse: a) explain that the nurse can understand because everyone goes through the same experiences b) ask the client to give an example of something he thinks the nurse wouldn’t understand c) reassure him that nurses are trained to deal with people from all cultures
d) gently change the subject B --> Having the pt speak in specifics rather than globally will help the nurse understand the client’s perspective. This approach will help the nurse draw out the client. A pt tells the nurse that one result of his chronic stress is that he has considerable fatigue. He has tried setting his alarm to give
himself an extra 30 mins of sleep each morning but feels no better. The nurse should suggest that: a) “you need to speak to your Dr about taking a sedative.” b) “keep doing what you have started. It takes a while to develop new sleep habits.” c) “Try going to bed a half hour earlier than usual and getting up at your regular time” d) “Waking up to music, rather than an alarm, is often helpful in promoting relaxation.” C --> Sleeping later in the morning is rarely helpful. It often disturbs circadian rhythms. Going to bed earlier and arising at the usual time alleviates fatigue more effectively A pt has been assessed as having moderate anxiety. He says “ I feel undone.” An appropriate response for the nurse a) “Why do you suppose you are feeling anxious? b) “What would you like me to do to help you?” c) “I’m not sure I understand. Give me an example.” d) “ you need to get your feelings under control.” C --> Increased anxiety results in scattered thoughts and an inability to articulate clearly. Clarifying helps the client identify thoughts and feelings The nurse plans to encourage an anxious pt to talk about his feelings & concerns. The rationale for this is: a)
offering hope allays the client’s anxiety b) concerns stated aloud become less overwhelming and can serve as the basis for problem solving c) anxiety can be reduced by focusing on and validating what is occurring in the environment d) encouraging clients to explore alternatives increases the sense of control and lessens anxiety B --> All principles listed are valid, but the only principle directly related to the intervention of
assisting the client to talk about his feelings and concerns is option b A pt with severe anxiety who has been pacing the hall suddenly begins to run, shouting “I’m going to explode!” The nurse who has been walking with him should: a) run after the pt & call out for them to stop running b) capture him in a basket hold when he runs back c) Ask “I’m not sure what you mean. Give me an example” d) Assemble a show of force & state “ We will help you regain control” D --> Safety needs of the client and other clients are a priority. The client is less likely to hurt himself or others when several staff take responsibility for providing limits. The explanation given the client should be simple and neutral. Simply being told that others can provide the control he is losing may be sufficient to help the client regain control. A pt who has been unable to leave his home for more than a month because of symptoms of severe anxiety tells the nurse “ I know it’s probably crazy, but I just can’t bring myself to leave my apartment alone” . An appropriate nursing intervention for the nurse to include: a) teach the client to use positive self talk b) assist the client to apply for disability benefits c) reinforce the irrationality of the client’s fears d) advise the pt to accept the situation & use a companion A --> This intervention, a form of cognitive restructuring, replaces negative thoughts such as “ I can’t leave my apartment” with positive thoughts such as “ I can control my anxiety.” This technique helps the client gain mastery over his symptoms. The nurse caring for a pt diagnosed as having GAD tells a preceptor “ I find myself feeling uncomfortable & anxious around the pt. When he starts trembling, perspiring, & pacing, I find myself with cold, clammy hands & my pulse races. I worry if I will be able to help him stay in control” In such an interaction the pt will most likely experience: a) fatigue b) claustrophobia c) increased anxiety d) improved self esteem C --> Anxiety is transmissible interpersonally. The client who “tunes in” to the nurse’s anxiety usually experiences heightening of his or her own anxiety For planning purposes, the nurse caring for a pt with a social phobia should know that an effective treatment for this disorder is: a) analysis b) thought stopping c) cognitive therapy d) response prevention C --> Cognitive therapy assists the client to identify automatic, negative beliefs that cause anxiety, reevaluate the situation, and replace negative self-talk with supportive ideas. An insurance agent sitting in his office after returning from a physical examination in which he was pronounced “in good health” suddenly experiences a feeling of terror. His heart pounds, he feels as though he cannot breathe, & he cannot focus on what is being said to him. Several earlier episodes & the fear of their repetition had prompted the visit to the doctor. This experience is a possible: a) panic attack b) phobic reaction c) dissociative reaction d) obsessive- compulsive crisis A --> Panic attacks cause symptoms of sympathetic nervous system arousal and occur without warning, as described in the scenario. Option b:
a phobic reaction involves excessive fear. Option c: a dissociative reaction involves separation of an event from conscious awareness A nurse has been counseling a pt with GAD to increase the pt’s anxiety self control. The pt has identified several stressful situations that cause physical & psychological manifestations of anxiety. The indicator the nurse should monitor relative to the outcome of anxiety self control is: a) plans coping strategies for stressful situations b) identifies situations that precipitate hostility c) refrains from destroying property d) identifies alternatives to aggression A --> This indicator is directly related to having identified situations that precipitate anxiety. The other options are indicators of aggression self –control. A pt who is concerned about a serious heart disease seeks help at the mental health center after a referral saying she has no physical illness. The pt reports she's had chest tightness & the sensation of her heart missing a beat. She has missed time from work. Her social life has been restricted b/c she believes she must rest each evening. The pt can be assessed as having symptoms consistent with: a) somatization disorder b) dysthymic disorder c) antisocial disorder d) hypochondriasis D --> Hypochondriasis involves preoccupation with fears of having a serious disease even when evidence to the contrary is available. The preoccupation causes impairment in social or occupational functioning. Option a: somatization disorder involves a variety of physical symptoms. Option b: dysthymic disorder is a disorder of lowered mood. Option c: antisocial disorder applies to a personality disorder in which the individual has little regard for the rights of others The pt tells the nurse that her roommate has urged her to seek a therapist’ about strange behavior the client can't remember. The roommate has seen her leaving wearing seductive clothing & returning 12-24 hrs later. The pt & her roommate have also argued about household matters & the pt will sit on the floor in the kitchen & speak like a young child. The client’s problem can be assessed as: a) antisocial personality b) borderline personality c) dissociative identity disorder d) body dysmorphic disorder C --> Dissociative identity disorder involves the existence of two or more distinct subpersonalities, each with its own patterns of relating, perceiving, and thinking. At least two of the subpersonalities take control of the person’s behavior but leave the individual unable to remember the periods of time in which the subpersonality was in control. A client with depersonalization disorder tells the nurse “ It’s starting again. I feel as though I’m going to float away.” The nurse should help the client by: a) advising her to begin meditating b) administering an as needed anxiolytic c) helping her visualize a pleasant scene d) staying with her to help her focus on the here and now D --> Talking with someone who can help the client focus on reality allows the client to interrupt the stimulus to dissociate. Options a, b, and c, foster detachment A pt being counseled for somatoform pain disorder states his pain is the result of an undiagnosed injury. He says he can't adhere to his plan for care involving performing own ADLs, walking 20 mins daily, & using pain meds only at bedtime. He says he feels like a baby because his wife & kids must provide care for him. It is important to assess: a) mood b) cognitive style c) secondary gain d) identity and memory C --> Secondary gain should be assessed. The client’s dependency needs may be begin met through care from his family. When secondary gains are prominent, the client is more resistant to giving up the symptom A woman is 5’7”, 160 pounds & wears a size 8 shoe. She says, “My feet are huge. I’ve asked three orthopedists to surgically reduce my feet.” This person tries to buy shoes to make her feet look smaller & in social settings, conceals both feet under a table. Which health problem is likely? A. Social anxiety disorder B. Body dysmorphic disorder C. Separation anxiety disorder D. Obsessive compulsive disorder to do a medical condition B --> Body dysmorphic disorder refers to a preoccupation with an imagined defect in appearance in a normal appearing person. The patient’s feet are proportional to the rest of the body A patient experiencing moderate anxiety says, “I feel undone.” An appropriate response for the nurse would be: A. What would you like me to do to help you? B. Why do you suppose you are feelings anxious? C. I’m not sure I understand. Give me an example. D. You must get your feelings under control before we can continue. C --> Increased anxiety results in scattered thoughts and an inability to articulate clearly. Clarifying helps the patient identify thoughts and feelings. A pt checks & rechecks electrical cords related to an obsessive thought that the house may burn down. The nurse & pt explore the likelihood of a fire. The pt states this event is not likely. This counseling demonstrates: A. Flooding B. Desensitization C. Relaxation techniques D. Cognitive restructuring D --> Cognitive restructuring involves
the pt in testing automatic thoughts & drawing new conclusions. Desensitization involves graduated exposure to a feared object. Relaxation training teaches the pt to produce the opposite of the stress response. Flooding exposes the pt to a large amount of an undesirable stimulus in an effort to extinguish the anxiety response. A pt with an abdominal mass is scheduled for a biopsy. The pt has difficulty understanding the nurse’s comments & asks, “What do you mean? What are they going to do?”. Assessment findings include tremulous voice, respirations 28, and pulse 110. What is the patient’s level of anxiety? A. Mild B. Moderate C. Severe D. Panic B --> Moderate anxiety causes the individual to grasp less information & reduces problem solving ability to a less than optimal level. Mild anxiety heightens attention & enhances problem solving. Severe anxiety causes great reduction in the perceptual field. Panic level anxiety results in disorganized behavior A patient is experiencing moderate anxiety. The nurse encourages the patient to talk about feelings and concerns. What is the rationale for this intervention? A. Offering hope allays and defuses the patient’s anxiety B. Concerns stated aloud become less overwhelming and help problem solving begin C. Anxiety is reduced by focusing on and validating what is occurring in the environment D. Encouraging patients to explore alternatives increases the sense of control and lessens anxiety. B --> All principles listed are valid, but the only rationale directly related to the intervention of assisting the patient to talk about feelings and concerns is the one that states that concerns spoken aloud become less overwhelming and help problem solving begin. Two staff nurses applied for a charge nurse position. After the promotion was announced, the nurse who was not promoted said, “The nurse manager had a headache the day I was interviewed.” Which defense mechanism is evident? A. Introjection B. Conversion C. Projection D. Splitting C --> Projection is the hallmark of blaming, scapegoating, prejudicial thinking & stigmatizing others. Conversion involves the unconscious transformation of anxiety into a physical symptom .Introjection involves intense, unconscious identification with another person. Splitting is the inability to integrate the positive and negative qualities of oneself or others into a cohesive image. A student says “Before taking a test, I feel very alert and a little restless.” The nurse can correctly assess the student’s experience as: A. Culturally influenced B. Displacement C. Trait anxiety D. Mild anxiety D --> Mild anxiety is rarely obstructive to the task at hand. It may be helpful to the patient because it promotes study and increases awareness of the nuances of questions. The incorrect responses have different symptoms. A student says’ “Before taking a test, I feel very alert and a little restless.” Which nursing intervention is most appropriate to assist the student?” A. Explain that the symptoms result from mild anxiety and discuss the helpful aspects. B. Advise the student to discuss the event with a HCP C. Encourage the student to begin antioxidant vitamin supplements D. Listen attentively, using silence in a therapeutic way. A --> Teaching about symptoms of anxiety, their relation to precipitating stressors, and, in this case, the positive effects of anxiety will serve to reassure the patient A person who has been unable to leave home for more than a week because of severe anxiety says, “ I know it does not make sense, but I just can’t bring myself to leave my apartment alone.”Which nursing intervention is appropriate? A. Help the person use online video calls to provide interaction with others B. Tell them to accept the situation & use a companion C. Ask the person to explain why the fear is so disabling D. Teach the person to use positive self-talk techniques D --> Positive self-talk, a form of cognitive restructuring, replaces negative thoughts such as “I can’t leave my apartment “with positive thoughts such as “I can control my anxiety.” This technique helps the patient gain mastery over the symptoms. A nurse assesses an individual who commonly experiences anxiety. Which comment by this person indicates the possibility of obsessive-compulsive disorder? A. “I check where my car keys are eight times.” B. “My legs often feel weak and spastic.” C. “I’m embarrassed to go out in public.” D. “I keep reliving a car accident.” A --> Recurring doubt (obsessive thinking) & the need to check (compulsive behavior) suggest OCD. The repetitive behavior is designed to decrease anxiety but fails & must be repeated. Which assessment finding best supports dissociative fugue? The patient states: A. “I cannot recall why I’m living in this town.” B. “I feel as if I’m living in a fuzzy dream state.” C. “I feel like different parts of my body are at war.” D. “I feel very anxious and worried about my problems.” A --> The pt in a fugue state frequently relocates & assumes a new identity while not recalling previous identity or places previously inhabited. A child drowned while swimming in a local lake 2 years ago. Which behavior indicates the child’s parents have adapted to their loss? The parents: A. Visit their child’s grave daily B. Maintain their child’s room as the child left it 2 yrs ago. C. Keep a place set for the dead child at the dinner table D. Throw flowers on the lake at each anniversary date of the accident. D --> Resilience refers to the positive adaptation or the ability to maintain or regain mental health despite adversity. Loss of a child is among the highest risk situations for an adjustment disorder and maladaptive grieving. The parents who throw flowers on the lake on each anniversary date of the accident are openly expressing their feelings A store clerk was killed during a robbery 2 weeks ago. His widow, who has a long history of schizoaffective disorder, cries spontaneously when talking about his death. Select the nurse’s most therapeutic response: A. “Are you taking your meds as they are prescribed?” B. “This loss is harder to accept because of your mental illness. Do you think you should be hospitalized? C. “I’m worried about how much you are crying. Your grief over yours husband’s death has gone on too long.” D. “The unexpected death of your husband is very painful. I’m glad you are able to talk about your feelings.” D --> The pt is expressing feelings related to the loss & this is an expected & healthy behavior. This pt is at risk for a maladaptive response because of the history of a serious mental illness, but the nurse’s priority intervention is to form a therapeutic alliance & support the pt’s expression of feelings. Crying at 2 weeks after his death is expected and normal. The nurse who is counseling a patient with dissociative identity disorder should understand that the assessment of highest priority is: A. Risk for self-harm B. Cognitive function C. Memory impairment D. Condition of self esteem A --> Assessments that relate to pt safety take priority. Pts with dissociative disorders may be at risk for suicide or self-mutilation, so the nurse must be alert for indicators of risk for self-injury. The other options are important assessments but rank below safety The tech says to the nurse, “That patient with amnesia looks fine, but when I talk to her, she seems vague. What should I be doing for her?” Select the nurse’s best reply. A. “Spend as much time with her as you can and ask questions about her life.” B. “Use short, simple sentences and keep the environment calm and protective.” C. “Provide more information about her past to reduce the mysteries that are causing anxiety.” D. “Structure her time with activities to keep her busy, stimulated, and regaining concentration.” B --> Disruptions in ability to perform ADLs, confusion, & anxiety are often apparent in pts with amnesia. Offering simple directions to promote ADLs & reduce confusion helps increase feelings of safety & security. A calm, secure, predictable, protective environment is also helpful when a person is dealing with a great deal of uncertainty. Recollection of memories should proceed at its own pace, & the pt should only gradually be given info about her past. Asking questions that require recall that the pt does not possess will only add frustration. Quiet, undemanding activities should be provided as the pt tolerates them & should be balanced with rest periods; the pt’s time should not be loaded with demanding or stimulating activities. A pt diagnosed with depersonalization disorder tells the nurse, “It’s starting again. I feel as though I’m going to float away.” Which intervention would be most appropriate? A. Notify the HCP of this change in the patient’s behavior. B. Engage the pt in a physical activity such as exercise C. Isolate the patient until the sensation has diminished D. Administer a PRN dose of anti-anxiety medication B --> Helping the pt apply a grounding technique, such as exercise, assists the pt to interrupt the dissociative process. Medication can help reduce anxiety but does not directly interrupt the dissociative process. Isolation would allow the sensation to overpower the patient. It is not necessary to notify the health care provider Two wks ago, a soldier returned to the US from active duty in a combat zone in Afghanistan. The soldier was diagnosed with PTSD. Which comment by the soldier requires the nurse’s immediate attention? A “It’s good to be home. I missed my home family & friends. B. “I saw my best friend get killed by a roadside bomb. I don’t understand why it wasn’t me.” C. “Sometimes I think I hear bombs exploding, but it’s just the noise of traffic in my hometown.” D. “I want to continue my education, but I’m not sure how I will fit in with other college students.” B --> The correct response indicates the soldier is thinking about death & feeling survivor’s guilt. These emotions may accompany suicidal ideation, which warrants the nurse’s follow up assessment. Suicide is a high risk among military personnel diagnosed with PTSD. One distracter indicates flashbacks, common with people with PTSD, but not solely indicative that further problems exist. The other distracters are normal emotions associated with returning home and change A soldier served in combat zones in Iraq during 2010 & was deployed to Afghanistan in 2013. When is most important for the nurse to screen for signs & symptoms of PTSD? A. Immediately upon return to the US from Afghanistan B. Before departing Afghanistan to return to the US C. One year after returning from Afghanistan D. Screening should be ongoing Answer: PTSD can have a very long lag time, months to years. Screening should be ongoing For a patient experiencing panic, which nursing intervention should be implemented first? A. Teach relaxation techniques B. Administer a prn medication C. Prepare to implement physical controls D. Provide calm, brief, directive communication D --> Calm, brief, directive verbal interaction can help the patient gain control of overwhelming feelings and impulses related to anxiety. Patients experiencing panic level anxiety are unable to focus on relaxation A pt fearfully runs from chair to chair crying, “They’re coming, they’re coming?” The patient does not follow the staff’s directions to respond to verbal interventions. Which nursing diagnosis has the highest priority? A. Fear B. Risk for injury C. Self-care deficit D. Disturbed thought processes B --> A pt experiencing panic level anxiety is at high risk for injury related to increased non goal directed motor activity, distorted perceptions & disordered thoughts. Data are not present to support a nursing diagnosis of self-care deficit or disturbed thought processes. The patient may have fear, but the risk for injury has a higher priority A person was online continuously for over 24 hrs, posting rhymes on official government websites & inviting politicians to join social networks. The person has not slept or eaten for 3 days. What features of mania are evident? A. Increased muscle tension and anxiety B. Vegetative signs and poor grooming C. Poor judgment and hyperactivity D. Cognitive deficits and paranoia C --> Hyperactivity (activity without sleep) & poor judgment (posting rhymes on government websites) are characteristic of manic episodes. The distracters do not specifically apply to mania A pt diagnosed with bipolar disorder is dressed in a red leotard & bright scarves. The pt twirls & shadow boxes. The pt says gaily, “Do you like my scarves? Here; they are my gift to you.” How should you document the pt’s mood? A. Euphoric B. Irritable C. Suspicious D. Confident A --> The pt has demonstrated clang associations & pleasant, happy behavior. Excessive happiness indicates euphoria. Irritability, belligerence, excessive happiness, & confidence are not the best terms for the pt’s mood. Suspiciousness is not evident A person was directing traffic on a busy street, rapidly shouting, “To work, you jerk, for perks” & making obscene gestures at cars. The person has not slept or eaten for 3 days. Which assessment findings will have priority? A. Insulting, aggressive behavior B. Pressured speech and grandiosity C. Hyperactivity; not eating and sleeping D. Poor concentration and decision making C --> Hyperactivity, poor nutrition, hydration & not sleeping take priority in terms of the needs listed above because they threaten the physical integrity of the patient A pt diagnosed with acute mania has distributed pamphlets about a new business venture on a street corner for 2 days. Which nursing diagnosis has priority? A. Risk for injury B. Ineffective coping C. Impaired social interaction D. Ineffective therapeutic regimen management A --> Although each of the nursing diagnoses listed is appropriate for a pt having a manic episode, the priority lies with the pt’s physiological safety. Hyperactivity & poor judgment put the pt at risk for injury A pt diagnosed with bipolar disorder becomes hyperactive after discontinuing lithium. The pt threatens to hit another pt. Which comment by the nurse is appropriate? A. “Stop that! No one did anything to provoke you.” B. “If you do that one more time, you will be secluded immediately.” C. “Do not hit anyone. If you are unable to control yourself, we will help you.” D. “You know we will not let you hit anyone. Why do you continue this behavior?” C --> When the pt is unable to control his or her behavior & violates or threatens to violate the rights of others, limits must be set in an effort to de-escalate the situation. Limits should be set in simple, concrete terms. The incorrect responses do not offer appropriate assistance to the pt, threaten the pt with seclusion as punishment & ask a rhetorical question This nursing diagnosis applies to a pt with acute mania: Imbalanced nutrition: less than body requirements related to insufficient caloric intake & hyperactivity as evidenced by 5 lb weight loss in 4 days. Select an appropriate outcome. The patient will: A. Ask staff for assistance with feeding within 4 days. B. Drink 6 servings of a high-calorie, high-protein drink each day. C. Consistently sit with others for at least 30 minutes at meal time within 1 week. D. Consistently wear appropriate attire for age and sex within 1 week while on the psychiatric unit B --> High-calorie, high-protein food supplements will provide the additional calories needed to offset the pt’s extreme hyperactivity. Sitting with others or asking for assistance does not mean the patient ate or drank. The other indicator is unrelated to the nursing diagnosis A pt demonstrating characteristics of acute mania relapsed after discontinuing lithium. New orders are written to resume lithium BID & begin olanzapine (Zyprexa). What is the rationale for the addition of olanzapine to the regimen? A. Minimize the side effects of lithium. B. Bring hyperactivity under rapid control. C. Enhance the antimanic actions of lithium. D. Be used for long-term control of hyperactivity. B --> Manic symptoms are controlled by lithium only after a therapeutic serum level is attained. Because this takes several days to accomplish, a drug with rapid onset is necessary to reduce the hyperactivity initially. Antipsychotic drugs neither enhance lithium’s antimanic activity nor minimize the side effects. Lithium will be used for long-term control A pt diagnosed with bipolar disorder commands other pts, “Get me a book. Take this stuff out of here,” & other similar demands. The nurse wants to interrupt this behavior without entering into a power struggle. Which initial approach should the nurse select? A. Distraction: “Let’s go to the dining room for a snack.” B. Humor: “How much are you paying servants these days?” C. Limit setting: “You must stop ordering other pts around.” D. Honest feedback: “Your controlling behavior is annoying others.” A --> The distractibility characteristic of manic episodes can assist the nurse to direct the pt toward more appropriate activities without entering into power struggles. Humor usually backfires by either encouraging the pt or inciting anger. Limit setting and honest feedback may seem heavy-handed and may incite anger Consider these three anticonvulsant meds: divalproex (Depakote), carbamazepine (Tegretol) & gabapentin (Neurontin). Which med also belongs to this classification? A. Clonazepam (Klonopin) B. Risperidone (Risperdal) C. Lamotrigine (Lamictal) D. Aripiprazole (Abilify) C --> The three drugs in the stem of the question are all anticonvulsants. Lamotrigine is also an anticonvulsant. Clonazepam is an anxiolytic; aripiprazole and risperidone are antipsychotic drugs. See relationship to audience response question. When a hyperactive pt diagnosed with acute mania is hospitalized, what is the initial nursing intervention? A. Allow the patient to act out feelings. B. Set limits on patient behavior as necessary. C. Provide verbal instructions to the pt to remain calm. D. Restrain the pt to reduce hyperactivity and aggression B --> This intervention provides support through the nurse’s presence & provides structure as necessary while the pt’s control is tenuous. Acting out may lead to loss of behavioral control. The pt will probably be unable to focus on instructions & comply. Restraint is used only after other interventions have proved ineffective A pt became severely depressed when the last of the family’s 6 kids moved out of the home 4 months ago. The pt repeatedly says, “No one cares about me. I’m not worth anything.” Which response would be most helpful? A. “Things will look brighter soon. Everyone feels down once in a while.” B. “Our staff members care about you and want to try to help you get better.” C. “It is difficult for others to care about you when you repeatedly say the same negative things.” D. “I’ll sit with you for 10 minutes now and 10 minutes after lunch to help you feel better.” D --> Spending time with the pt at intervals throughout the day shows acceptance by the nurse & will help the pt establish a relationship with the nurse. The therapeutic technique is “offering self.” Setting definite times for the therapeutic contacts & keeping the appointments show predictability on the part of the nurse, an element that fosters trust building A pt diagnosed with major depression says, “No one cares about me anymore. I’m not worth anything.” Today the pt is wearing a new shirt & has neat, clean hair. Which remark supports building a positive self-esteem for this pt? A. “You look nice this morning.” B. “You’re wearing a new shirt.” C. “I like the shirt you are wearing.” D. “You must be feeling better today.” B --> Pts with depression usually see the negative side of things. The meaning of compliments may be altered to “I didn’t look nice yesterday” or “They didn’t like my other shirt.” Neutral comments such as making an observation avoid negative interpretations. Saying, “You look nice” or “I like your shirt” gives approval (non-therapeutic techniques). Priority interventions for a pt diagnosed with major depression and feelings of worthlessness should include: A. Distracting the patient from self-absorption. B. Careful unobtrusive observation around the clock. C. Allowing the pt to spend long periods alone in meditation. D. Opportunities to assume a leadership role in the therapeutic milieu B --> Approximately 2/3 of people with depression contemplate suicide. Pts with depression who exhibit feelings of worthlessness are at higher risk. Regular planned observations of the pt diagnosed with depression may prevent a suicide attempt on the unit When counseling patients diagnosed with major depression, an advanced practice nurse will address the negative thought patterns by using: A. Psychoanalytic therapy. B. Desensitization therapy. C. Cognitive behavioral therapy. D. Alternative and complementary therapies C --> Cognitive behavioral therapy attempts to alter the pt’s dysfunctional beliefs by focusing on positive outcomes rather than negative attributions. The pt is also taught the connection between thoughts & resultant feelings. Research shows that CBT involves the formation of new connections between nerve cells in the brain & that it is at least as effective as medication. A pt says to the nurse, “My life doesn’t have any happiness in it anymore. I once enjoyed holidays, but now they’re just another day.” The nurse documents this report as: A. Dysthymia. B. Anhedonia. C. Euphoria. D. Anergia. B --> Anhedonia is a common finding in many types of depression. It refers to feelings of a loss of pleasure in formerly pleasurable activities. Dysthymia is a diagnosis. Euphoria refers to an elated mood. Anergia means “without energy." A pt diagnosed with major depression began taking a tricyclic antidepressant 1 wk ago. Today the patient says, “I don’t think I can keep taking these pills. They make me so dizzy, especially when I stand up.” The nurse will: A. Limit the patient’s activities to those that can be performed in a sitting position. B. Withhold the drug, force oral fluids, & notify the HCP C. Teach the pt strategies to manage postural hypotension. D. Update the patient’s mental status examination. C --> Drowsiness, dizziness & postural hypotension usually subside after the first few wks of therapy with tricyclic antidepressants. Postural hypotension can be managed by teaching the pt to stay well hydrated & rise slowly. Knowing this info may convince the pt to continue the medication. Activity is an important aspect of the pt’s treatment plan & shouldn't be limited. Withholding the drug, forcing oral fluids & notifying the HCP are unnecessary. Updating a mental status examination is unnecessary. A pt diagnosed with major depression tells the nurse, “Bad things that happen are always my fault.” Which response will best assist the pt to reframe this overgeneralization? A. “I really doubt that one person can be blamed for all the bad things that happen.” B. “Let’s look at one bad thing that happened to see if another explanation exists.” C. “You are being extremely hard on yourself. Try to have a positive focus.” D. “Are you saying that you don’t have any good things happen?” B --> By questioning a faulty assumption, the nurse can help the pt look at the premise more objectively & reframe it as a more accurate representation of fact. The incorrect responses cast doubt but do not require the patient to evaluate the statement A nurse worked with a pt diagnosed with major depression, severe withdrawal & psychomotor retardation. After 3 wks the pt did not improve. The nurse is most at risk for feelings of: A. Guilt and despair. B. Over-involvement. C. Interest and pleasure. D. Ineffectiveness and frustration. D --> Nurses may have expectations for self & pts that are not wholly realistic, especially regarding the pt’s progress toward health. Unmet expectations result in feelings of ineffectiveness, anger, or frustration. Nurses rarely become over-involved with pts with depression because of the pt’s resistance. Guilt & despair might be seen when the nurse experiences the pt’s feelings because of empathy. Interest is possible, but not the most likely result. A pt diagnosed with depression begins selective serotonin reuptake inhibitor (SSRI) antidepressant therapy. The nurse should provide information to the pt & family about: A. Restricting sodium intake to 1 gram daily. B. Minimizing exposure to bright sunlight. C. Reporting increased suicidal thoughts. D. Maintaining a tyramine-free diet. C --> Some evidence indicates that suicidal ideation may worsen at the beginning of antidepressant therapy; thus, close monitoring is necessary. Avoiding exposure to bright sunlight & restricting sodium intake are unnecessary. Tyramine restriction is associated with monoamine oxidase inhibitor (MAOI) therapy A nurse taught a patient about a tyramine-restricted diet. Which menu selection would the nurse approve? A. Macaroni and cheese, hot dogs, banana bread, caffeinated coffee B. Mashed potatoes, ground beef patty, corn, green beans, apple pie C. Avocado salad, ham, creamed potatoes, asparagus, chocolate cake D. Noodles with cheddar cheese sauce, smoked sausage, lettuce salad, yeast rolls B --> The correct answer describes a meal that contains little tyramine. Veggies & fruits contain little or no tyramine. Fresh ground beef & apple pie are safe. The other meals contain various amounts of tyramine-rich foods or foods that contain vasopressors: avocados, ripe bananas (banana bread), sausages/hot dogs, smoked meat (ham), cheddar cheese, yeast, caffeine drinks, and chocolate From a cognitive theory perspective, which is a possible cause of panic disorder? 1. Inability of the ego to intervene when conflict occurs. 2. Abnormal elevations of blood lactate and increased lactate sensitivity. 3. Increased involvement of the neurochemical norepinephrine. 4. Distorted thinking patterns that precede maladaptive behaviors. 4. Distorted thinking patterns that precede maladaptive behaviors relate to the cogni- tive theory perspective of panic disorder development. An overuse or ineffective use of ego defense mechanisms, which results in a maladap- tive response to anxiety, is an example of the ___________________ theory of general- ized anxiety disorder development. An overuse or ineffective use of ego defense mechanisms, which results in a maladaptive response to anxiety, is an example of the psychodynamic theory of generalized anxiety disorder development. A pt diagnosed with PTSD is close to discharge. Which pt statement would indicate that teaching about the psychosocial cause of PTSD was effective? 1. “I understand that the event I experienced, how I deal with it, &my support system all affect my disease process.” 2. “I have learned to avoid stressful situations as a way to decrease emotional pain.” 3. “So, natural opioid release during the trauma caused my body to become ‘addicted.’” 4. “Because of the trauma, I have a negative perception of the world and feel hopeless.” 1. When the client verbalizes understanding of how the experienced event, individual traits, and available support systems affect his or her diagnosis, the client demonstrates a good understanding of the psychosocial cause of PTSD Counselors have been sent to a location that has experienced a natural disaster to assist the population to deal with the devastation. This is an example of __________________ prevention Sending counselors to a natural disaster site to assist individuals to deal with the devastation is an example of primary prevention. Primary prevention reduces the incidence of mental disorders, such as PTSD, within the population by helping people to cope more effectively with stress early in the grieving process. It's extremely important for individuals who experience any traumatic event, such as a rape, war,hurricane, tornado, or school shooting Which of the following statements explains the etiology of OCD from a biological theory perspective? 1. Individuals diagnosed with OCD have weak & underdeveloped egos. 2. Obsessive & compulsive behaviors are a conditioned response to a traumatic event. 3. Regression to the pre-Oedipal anal sadistic phase produces the clinical symptoms of OCD. 4. Abnormalities in various regions of the brain have been implicated in the cause of OCD. 4. The belief that abnormalities in various regions of the brain cause OCD is an explanation of OCD etiology from a bio- logical theory perspective After being diagnosed with pyrophobia, the client states, “I believe this started at the age of 7 when I was trapped in a house fire.” When examining theories of phobia etiology, this situation would be reflective of ____________ theory. When examining theories of phobia etiology, this situation would be reflective of learning theory. Some learning theorists believe that fears are conditioned responses & they are learned by imposing rewards for certain behaviors. In the instance of phobias, when the individual avoids the phobic object, he or she escapes fear, which is a powerful reward. This client has learned that avoiding the stimulus of fire eliminates fear A client diagnosed with social phobia has an outcome that states, “Client will voluntarily participate in group activities with peers by day 3.” Which would be an appropriate intrapersonal intervention by the nurse to assist the client to achieve this outcome? 1. Offer PRN lorazepam (Ativan) 1 hour before group begins. 2. Attend group with client to assist in decreasing anxiety. 3. Encourage discussion about fears related to socialization. 4. Role-play scenarios that may occur in group to decrease anxiety. 3. Encouraging discussion about fears is an intrapersonal intervention Using psychodynamic theory, which intervention would be appropriate for a client diagnosed with panic disorder? 1. Encourage the pt to evaluate the power of distorted thinking. 2. Ask the client to include his or her family in scheduled therapy sessions. 3. Discuss the overuse of ego defense mechanisms and their impact on anxiety. 4. Teach the client about the effect of blood lactate level as it relates to the client’s panic attacks 3. The nurse discussing the overuse of ego defense mechanisms illustrates a psycho- dynamic approach to address the client’s behaviors related to panic disorder.Definition Which nursing diagnosis reflects the intrapersonal theory of the etiology of obsessive compulsive disorder? 1. Ineffective coping R /T punitive superego. 2. Ineffective coping R /T active avoidance. 3. Ineffective coping R /T alteration in serotonin. 4. Ineffective coping R /T classic conditioning. 1. Ineffective coping R /T punitive superego reflects an intrapersonal theory of the etiology of OCD. The punitive superego is a concept contained in Freud’s psychosocial theory of personality development. The nurse is using an intrapersonal approach to assist a client in dealing with survivor’s guilt. Which intervention would be appropriate? 1. Encourage the client to attend a survivor’s group. 2. Encourage expression of feelings during one-to-one interactions with the nurse. 3. Ask the client to challenge the irrational beliefs associated with the event. 4. Administer regularly scheduled paroxetine (Paxil) to deal with depressive symptoms 2. Encouraging expressions of feelings during one-to-one interactions with the nurse is an intrapersonal approach to interventions that treat survivor’s guilt associated with PTSD. A pt diagnosed with posttraumatic stress disorder states to the nurse, “All those wonderful people died, and yet I was allowed to live.” Which is the client experiencing? 1. Denial. 2. Social isolation. 3. Anger. 4. Survivor’s guilt. 4. The client in the question is experiencing survivor’s guilt. Survivor’s guilt is a common situation that occurs when an individual experiences a traumatic event in which others died and the individual survived Clients diagnosed with obsessive-compulsive disorder commonly use which mechanism? 1. Suppression. 2. Repression. 3. Undoing. 4. Denial. 3. Undoing is a defense mechanism commonly used by individuals diagnosed with OCD. Undoing is used symbolically to negate or cancel out an intolerable previous action or experience. An pt diagnosed with OCD experiencing intolerable anxiety would use the defense mechanism of undoing to undo this anxiety by substituting obsessions or compulsions or both. Other commonly used defense mechanisms are isolation, displacement, and reaction formation Which of the following would the nurse expect to assess in a client diagnosed with PTSD? Select all that apply. 1. Dissociative events. 2. Intense fear and helplessness. 3. Excessive attachment and dependence toward others. 4. Full range of affect. 5. Avoidance of activities that are associated with the trauma. 1. A client diagnosed with PTSD may have dissociative events in which the client feels detached from the situation or feelings. 2. A client diagnosed with PTSD may have intense fear
and feelings of helplessness. 5. A client diagnosed with PTSD avoids activ- When treating individuals with posttraumatic stress disorder, which variables are included in the recovery environment? 1. Degree of ego strength. 2. Availability of social supports. 3. Severity and duration of the stressor. 4. Amount of control over reoccurrence. 2. Availability of social supports is part of environmental variables. Others include cohesiveness & protectiveness of family & friends, attitudes of society regarding the experience, & cultural & subcultural influences A newly admitted client is diagnosed with posttraumatic stress disorder. Which behavioral symptom would the nurse expect to assess? 1. Recurrent, distressing flashbacks. 2. Intense fear, helplessness, and horror. 3. Diminished participation in significant activities. 4. Detachment or estrangement from others. 3. Diminished participation in significant activities is a behavioral symptom of PTSD Which of the following assessment data would support the disorder of acrophobia? 1. A pt is fearful of basements because of seeing spiders 2. A pt refuses to go to Europe because of fear of flying. 3. A pt is unable to commit to marriage after a 10-year engagement. 4. A pt refuses to leave home during stormy weather. 2. Acrophobia is the fear of heights. An individual experiencing acrophobia may be unable to fly because of this fear In which situation would the nurse suspect a medical diagnosis of social phobia? 1. A client abuses marijuana daily and avoids social situations because of fear of humiliation. 2. An 8-year-old child isolates from adults because of fear of embarrassment, but has good peer relationships in school. 3. A pt diagnosed with Parkinson’s avoids social situations because of embarrassment regarding tremors & drooling 4. A college student avoids taking classes that include an oral presentation because of fear of being scrutinized by others 4. A student who avoids classes because of the fear of being scrutinized by others meets the criteria for a diagnosis of social phobia A client experiencing a panic attack would display which physical symptom? 1. Fear of dying. 2. Sweating and palpitations. 3. Depersonalization. 4. Restlessness and pacing. 2. Sweating & palpitations are physical symptoms of a panic attack. A client newly admitted to an in-patient psychiatric unit is diagnosed with OCD. Which behavioral symptom would the nurse expect to assess? 1. The pt uses excessive hand washing to relieve anxiety. 2. The pt rates anxiety at 8/10. 3. The pt uses breathing techniques to decrease anxiety. 4. The pt exhibits diaphoresis and tachycardia. 1. Using excessive hand washing to relieve anxiety is a behavioral symptom exhibited by clients diagnosed with OCD A pt with a history of GAD enters the emergency department complaining of restlessness, irritability & exhaustion. Vital signs are BP 140/90 mm Hg, pulse 96 & respirations 20. Based on this assessed info, which assumption would be correct? 1. The pt is exhibiting S&Ss of an exacerbation of GAD. 2. The pt’s S&S are due to an underlying medical condition. 3. A physical examination is needed to determine the etiology of the client’s problem. 4. The client’s anxiolytic dosage needs to be increased. 3. Physical problems should be ruled out before determining a psychological cause for this client’s symptoms Anxiety is a symptom that can result from which of the following physiological conditions? Select all that apply. 1. Chronic obstructive pulmonary disease. 2. Hyperthyroidism. 3. Hypertension. 4. Diverticulosis. 5. Hypoglycemia. 1. CPOD causes shortness of breath. Air deprivation causes anxiety, sometimes to the point of panic. 2. Hyperthyroidism involves excess stimulation of the sympathetic nervous system & excessive levels of thyroxine. Anxiety is a symptoms brought on by this 3. Hypertension may be caused by anxiety, in contrast to anxiety being the result of hypertension. 4. No 5. Marked irritability and anxiety are some of the many symptoms associated with hypoglycemia. Which assessment data would support a physician’s diagnosis of an anxiety disorder in a client? 1. A pt experiences severe levels of anxiety in one area of functioning. 2. A pt experiences an increased level of anxiety in one area of functioning for a 6-month period. 3. A pt experiences ↑ levels of anxiety that affect functioning in more than one area of life over a 6-months 4. A client experiences increased levels of anxiety that affect functioning in at least three areas of life 3. For a client to be diagnosed with an anxiety disorder, the client must experience symptoms that interfere in a minimum of two areas, such as social, occupational, or other important functioning. These symptoms must be experienced for durations of 6 months or longer. Which of the following symptom assessments would validate the diagnosis of GAD? Select all that apply. 1. Excessive worry about items difficult to control. 2. Muscle tension. 3. Hypersomnia. 4. Excessive amounts of energy. 5. Feeling “keyed up” or “on edge.” A client diagnosed with OCD is newly admitted to an inpatient psychiatric unit. Which cognitive symptom would the nurse expect to assess? 1. Compulsive behaviors that occupy more than 4 hrs per day 2. Excessive worrying about germs and illness. 3. Comorbid abuse of alcohol to decrease anxiety. 4. Excessive sweating and an increase in BP and pulse. 2. Excessive worrying about germs and illness is a cognitive symptom experienced by clients diagnosed with OCD A newly admitted client diagnosed with PTSD is exhibiting recurrent flashbacks, nightmares, sleep deprivation, & isolation from others. Which nursing diagnosis takes priority? 1. Posttrauma syndrome R /T a distressing event AEB flashbacks and nightmares. 2. Social isolation R /T anxiety AEB isolating because of fear of flashbacks. 3. Ineffective coping R /T flashbacks AEB alcohol abuse and dependence. 4. Risk for injury R /T exhaustion because of sustained levels of anxiety. 4. Risk for injury is the priority nursing diagnosis for this client. In the question, the pt is exhibiting recurrent flashbacks, nightmares & sleep deprivation that can cause exhaustion and lead to injury. It is important for the nurse to prioritize the nursing diagnosis that addresses safety. A pt leaving home for the first time in a year arrives on the psych in-patient unit wearing a surgical mask, white gloves, & crying, “The germs in here are going to kill me.” Which nursing diagnosis addresses this client’s problem? 1. Social isolation R /T fear of germs AEB continually refusing to leave the home. 2. Fear of germs R /T obsessive-compulsive disorder, resulting in dysfunctional isolation. 3. Ineffective coping AEB dysfunctional isolation R /T unrealistic fear of germs. 4. Anxiety R /T the inability to leave home, resulting in dysfunctional fear of germs. 1. According to the NANDA, the nursing diagnosis format must contain three essential components: (1) identification of the health problem, (2) presentation of the etiology (or cause) of the problem (3) description of a cluster of S&S known as “defining characteristics.” A pt seen in an out-pt clinic for ongoing management of panic attacks states, “I have to make myself come to these appointments. It is hard because I don’t know when an attack will occur.” Which nursing diagnosis takes priority? 1. Ineffective breathing patterns R /T hyperventilation. 2. Impaired spontaneous ventilation R /T panic levels of anxiety. 3. Social isolation R /T fear of spontaneous panic attacks. 4. Knowledge deficit R /T triggers for panic attacks. 3. Social isolation is seen frequently with individuals diagnosed with panic attacks. The pt in the question expresses anticipatory fear of unexpected attacks, which affects the others. A pt newly admitted to an in-patient psychiatric unit is diagnosed with OCD. Which correctly stated nursing diagnosis takes priority? 1. Anxiety R /T obsessive thoughts AEB ritualistic behaviors. 2. Powerlessness R /T ritualistic behaviors AEB statements of lack of control. 3. Fear R /T a traumatic event AEB stimulus avoidance. 4. Social isolation R /T increased levels of anxiety AEB not attending groups. 1. Anxiety is the underlying cause of the diagnosis of OCD, therefore, anxiety R/T obsessive thoughts is the priority nursing diagnosis for the client newly admitted for the treatment of this disorder. During an assessment, a pt diagnosed with GAD rates anxiety as 9/10 & states, “I have thought about suicide because nothing ever seems to work out for me.” Based on this information, which nursing diagnosis takes priority? 1. Hopelessness R /T anxiety AEB client’s stating, “Nothing ever seems to work out.” 2. Ineffective coping R /T rating anxiety as 9/10 AEB thoughts of suicide. 3. Anxiety R /T thoughts about work AEB rates anxiety 9/10. 4. Risk for suicide R /T expressing thoughts of suicide. 4. Because the client is expressing suicidal ideations, the nursing diagnosis of risk for suicide takes priority at this time. Client safety is prioritized over all other client problems. A hospitalized pt diagnosed with PTSD has a diagnosis of ineffective coping R/T history of rape AEB abusing alcohol. Which is the expected short-term outcome for this pt prob: 1. The pt will recognize triggers that precipitate alcohol abuse by day 2. 2. The pt will attend follow-up weekly therapy sessions after discharge. 3. The pt will refrain from self-blame regarding the rape by day 2. 4. The pt will be free from injury to self throughout the shift 1. It is a realistic expectation for a client who copes with previous trauma by abusing alcohol to recognize the triggers that precipitate this behavior. This outcome should be developed mutually early in treatment. Which pt would the charge nurse assign to an agency nurse who is new to a psychiatric setting? 1. A pt diagnosed with PTSD currently experiencing flashbacks. 2. A newly admitted pt diagnosed with GAD beginning benzodiazepines for the first time. 3. Pt admitted 4 days ago with the diagnosis of algophobia 4. A newly admitted pt with obsessive-compulsive disorder 3. A pt admitted 4 days ago with a diagnosis of algophobia, fear of pain, would be an appropriate assignment for the agency nurse. Of the pts presented, this pt would pose the least challenge to a nurse unfamiliar with psychiatric clients. A newly admitted pt diagnosed with social phobia has a nursing diagnosis of social isolation R/T fear of ridicule. Which outcome is appropriate for this client? 1. The pt will participate in two group activities by day 4. 2. The pt will use relaxation techniques to decrease anxiety. 3. The pt will verbalize one (+) self-attribute by discharge 4. The pt will request buspirone (BuSpar) PRN to attend group by day 2. 1. Expecting the client to participate in a set number of group activities by day 4 directly relates to the stated nursing diagnosis of social isolation and is a measurable outcome that includes a timeframe When a client experiences a panic attack, which outcome takes priority? 1. The client will remain safe throughout the duration of the panic attack. 2. The client will verbalize an anxiety level less than 2/10. 3. The client will use learned coping mechanisms to decrease anxiety. 4. The client will verbalize the positive effects of exercise by day 2. 1. Remaining safe throughout the duration of the panic attack is the priority outcome for the client. The nurse has received evening report. Which client would the nurse need to assess first? 1. A newly admitted client with a history of panic attacks. 2. A client who slept 2 to 3 hours last night because of flashbacks. 3. A client pacing the halls & stating that his anxiety is an 8/10. 4. A client diagnosed with generalized anxiety disorder awaiting discharge. 3. A client pacing the halls and experiencing an increase in anxiety commands immediate assessment. If the nurse does not take action on this assessment, there is a potential for client injury to self or others. A pt was admitted to an in-patient psych unit 4 days ago for the treatment of OCD. Which outcome takes priority? 1. The client will use a thought-stopping technique to eliminate obsessive/compulsive behaviors. 2. The client will stop obsessive and/or compulsive behaviors. 3. The client will seek assistance from the staff to decrease obsessive or compulsive behaviors. 4. The client will use one relaxation technique to decrease obsessive or compulsive behaviors. 4. By day 4, it would be realistic to expect the client to use one relaxation technique to decrease obsessive or compulsive behaviors. This would be the current priority outcome. A pt diagnosed with GAD has a nursing diagnosis of panic anxiety R/T altered perceptions. Which of the following short-term outcomes is most appropriate for this client? 1. The client will be able to intervene before reaching panic levels of anxiety by discharge. 2. The client will verbalize decreased levels of anxiety by day 2. 3. The client will take control of life situations by using problem-solving methods effectively. 4. The client will voluntarily participate in group therapy activities by discharge. 1. The client’s being able to intervene before reaching panic levels of anxiety by discharge is measurable, relates to the stated nursing diagnosis, has a time frame, and is an appropriate short-term outcome for this client. 2. is not specific or measurable A pt on an in-patient psych unit is experiencing a flashback. Which intervention takes priority? 1. Maintain & reassure the pt of his/her safety & security 2. Encourage the client to express feelings. 3. Decrease extraneous external stimuli. 4. Use a nonjudgmental and matter-of-fact approach. 1. During a flashback, the pt is experiencing severe-to-panic levels of anxiety; the priority nursing intervention is to maintain & reassure the pt of his or her safety and security. The pt’s anxiety needs to decrease before other interventions are attempted. A pt diagnosed with panic attacks is being admitted for the fifth time in 1 year because of hopelessness & helplessness. Which precaution would the nurse plan to implement? 1. Elopement precautions. 2. Suicide precautions. 3. Homicide precautions. 4. Fall precautions. 2. Any client who is exhibiting hopelessness or helplessness needs to be monitored closely for suicide intentions A pt diagnosed with OCD has been hospitalized for the last 4 days. Which intervention would be a priority at this time? 1. Notify the client of the expected limitations on compulsive behaviors. 2. Reinforce the use of learned relaxation techniques. 3. Allow the client the time needed to complete the compulsive behaviors. 4. Say “stop” to the client as a thought-stopping technique. 2. It is important for the pt to learn techniques to reduce overall levels of anxiety to decrease the need for compulsive behaviors. The teaching of these techniques should begin by day 4 The nurse on the in-patient psych unit should include which of the following interventions when working with a newly admitted pt with OCD? Select all that apply. 1. Assess previously used coping mechanisms and their effects on anxiety. 2. Allow time for the pt to complete compulsions. 3. With the pt’s input, set limits on ritualistic behaviors. 4. Present the reality of the impact the compulsions have on the pt’s life. 5. Discuss pt feelings about the obsessions & compulsions 1, 2, 5 *the others are done later in the treatment process A pt diagnosed with GAD complains of feeling out of control & states, “I just can’t do this anymore.” Which nursing action takes priority at this time? 1. Ask the pt, “Are you thinking about harming yourself?” 2. Remove all potentially harmful objects from the milieu. 3. Place the pt on a one-to-one observation status. 4. Encourage pt to verbalize feelings during the next group. 1. The nurse should recognize the statement, “I can’t do this anymore,” as evidence of hopelessness and assess further the potential for suicidal ideations During an intake assessment, a pt diagnosed with GAD rates mood at 3/10, rates anxiety at 8/10, & states, “I’m thinking about suicide.” Which intervention takes priority 1. Teach the client relaxation techniques. 2. Ask the client, “Do you have a plan to commit suicide?” 3. Call the physician to obtain a PRN order for an anxiolytic medication. 4. Encourage the client to participate in group activities. 2. It is important for the nurse to ask the pt about a potential plan for suicide to intervene in a timely manner. Pts who have developed suicide plans are at higher risk than pts who may have vague suicidal thoughts. A pt diagnosed with PTSD has a nursing diagnosis of disturbed sleep patterns R /T nightmares. Which evaluation would indicate that the stated nursing diagnosis was resolved? 1. The pt shows feelings about the nightmares during group 2. The pt asks for PRN trazodone (Desyrel) before bed. 3. The pt states that they feel rested when awakening & denies nightmares. 4. The pt avoids napping during the day to help enhance sleep 3. The pt’s feeling rested on awakening & denying nightmares are the evaluation data needed to support the fact that the nursing diagnosis of disturbed sleep patterns R/T nightmares has been resolved. The nurse teaches an anxious pt diagnosed with PTSD a breathing technique. Which action by the client would indicate that the teaching was successful? 1. The pt eliminates anxiety by using the breathing technique. 2. The pt performs ADLs independently by discharge. 3. The pt recognizes S&S of escalating anxiety. 4. The pt maintains a 3/10 anxiety level without meds. 4. A pt’s ability to maintain an anxiety level of 3/10 without meds indicates that they are using breathing techniques successfully to reduce anxiety. The nurse is using a cognitive intervention to decrease anxiety during a pt’s panic attack. Which phrase by the pt would indicate that the intervention has been successful? 1. “I reminded myself that the panic attack would end soon, and it helped.” 2. “I paced the halls until I felt my anxiety was under control.” 3. “I felt my anxiety increase, so I took lorazepam (Ativan) to decrease it.” 4. “Thank you for staying with me. It helped to know staff was there.” 1. This statement is an indication that the cognitive intervention was successful. By remembering that panic attacks are self-limiting, the pt is applying the information gained from the nurse’s cognitive intervention. Which of the following medications can be used to treat clients with anxiety disorders? Select all that apply. 1. Clonidine hydrochloride (Catapres). 2. Fluvoxamine maleate (Luvox). 3. Buspirone (BuSpar). 4. Alprazolam (Xanax). 5. Haloperidol (Haldol). 1, 2, 3, 4 *5 is used to treat thought disorders, not anxiety disorders A pt is prescribed alprazolam (Xanax) 2 mg bid & 1.5 mg q6h PRN for agitation. The maximum daily dose of alprazolam is 10 mg/d. The pt can receive _____ PRN doses of alprazolam within a 24-hour period. Which teaching need is important when a pt is newly prescribed buspirone (BuSpar) 5 mg tid? 1. Encourage the pt to avoid drinking alcohol while taking this med because of the additive CNS depressant effects. 2. Encourage the pt to take the med continually as prescribed because onset of action is delayed 2 to 3 weeks. 3. Encourage the pt to monitor for S&S of anxiety to determine need for additional buspirone (BuSpar) PRN. 4. Encourage the client to be compliant with monthly lab tests to monitor for medication toxicity. 2. It is important to teach the pt that the onset of action for buspirone (BuSpar) is 2-3 wks. Often the nurse may see a benzodiazepine, such as clonazepam, prescribed because of its quick onset of effect, until the buspirone begins working. A pt diagnosed with GAD is prescribed paroxetine (Paxil) 30 mg QHS. Paroxetine is supplied as a 20-mg tablet. The nurse would administer ______tablets A pt is prescribed lorazepam (Ativan) 0.5 mg qid & 1 mg PRN q8h. The maximum daily dose of lorazepam should not exceed 4 mg QD. This pt would be able to receive ______ PRN doses as the maximum number of PRN lorazepam doses. Which nursing diagnosis supports the psychoanalytic theory of development of major depressive disorder? 1. Social isolation R / T self-directed anger. 2. Low self-esteem R / T learned helplessness. 3. Risk for suicide R / T neurochemical imbalances. 4. Imbalanced nutrition less than body requirements R / T weakness. 1. Social isolation R/T self-directed anger supports the psychoanalytic theory in the development of major depressive disorder (MDD). Freud defines melancholia as a profoundly painful dejection & cessation of interest in the outside world, which culminates in a delusional expectation of punishment. He observed that melancholia occurs after the loss of a love object. Another way to state this concept is that the client turns anger toward self. Which pt statement is evidence of the etiology of major depressive disorder from a genetic perspective? 1. “My maternal grandmother was diagnosed with bipolar affective disorder.” 2. “My mood is a 7/10, and I won’t harm myself or others.” 3. “I am angry that my father left our family when I was 6.” 4. “I just can’t do anything right. I am worthless.” 1. A family history of mood disorder indicates a genetic predisposition to the development of major depressive disorder. Twin, family, and adoptive studies further support a genetic link as an etiological influence in the development of mood disorders. During an intake assessment, which pt statement is evidence of the etiology of major depressive disorder from an object-loss theory perspective? 1. “I'm so angry all the time & seem to take it out on myself.” 2. “My grandmother & grandfather also had depression.” 3. “I just don’t think my life is ever going to get better. I can’t do anything right.” 4. “I don’t know about my biological family; I was in foster care as an infant.” 4. Object-loss theorists suggest that depressive illness occurs as a result of being abandoned by or otherwise separated from a significant other during the first 6 months of life. The client in the question experienced parental abandonment, & according to object loss theory, this loss has led to the diagnosis of MDD Which statement is from a biochemical perspective? 1. Family studies have shown that if one parent is diagnosed with bipolar disorder, the risk for the child=28% 2. In bipolar disorder, there may be possible alterations in normal electrolyte transfer across cell membranes, resulting in elevated levels of intracellular Ca & Na 3. Imaging studies have revealed enlarged 3rd ventricles, subcortical white matter & periventricular hyperintensity in individuals diagnosed with bipolar disorder. 4. Twin studies have indicated a concordance rate among monozygotic twins of 60% to 80%. 2. Alterations in normal electrolyte transfer across cell membranes, resulting in elevated levels of intracellular calcium & sodium, is an example of a biochemical perspective in the development of bipolar disorder Which statement describes a difference between a pt with MDD & a pt diagnosed with dysthymic disorder? 1. A client diagnosed with dysthymic disorder is at higher risk for suicide. 2. A client diagnosed with dysthymic disorder may experience psychotic features. 3. A client diagnosed with dysthymic disorder experiences excessive guilt. 4. A client diagnosed with dysthymic disorder has symptoms for at least 2 years. 4. An individual suspected to have dysthymic disorder needs to experience symptoms for at least 2 yrs before a diagnosis can be made. The essential feature is a chronically depressed mood (or possibly an irritable mood in children & adolescents) for most of the day, more days than not, for at least 2 years (1 year for children & adolescents). Pts with a diagnosis of MDD show impaired social & occupational functioning for at least 2 wks A pt expresses frustration & hostility toward the nursing staff regarding the lack of care his or her recently deceased parent received. According to Kubler-Ross, which stage of grief is this client experiencing? 1. Anger. 2. Disequilibrium. 3. Developing awareness. 4. Bargaining. 1. The pt in the question is exhibiting anger surrounding the death of a parent. Kubler-Ross describes anger as the 2nd stage in the normal grief response. This stage occurs when pts experience the reality of the situation. Feelings associated with this stage include sadness, guilt, shame, helplessness, & hopelessness A pt plans & follows through with the wake & burial of a child lost in an automobile accident. Using Engel’s model of normal grief response, in which stage would this pt fall 1. Resolution of the loss. 2. Recovery. 3. Restitution. 4. Developing awareness. 3. The pt in the question is exhibiting signs associated with the stage of restitution. Restitution is the 3rd stage of Engel’s model of the normal grief response. In this stage, the various rituals associated with loss within a culture are performed. Ex: funerals, wakes, special attire, a gathering of friends & family & religious practices customary to the spiritual beliefs of the bereaved Which chart entry accurately documents a pt’s mood? 1. “The pt expresses an elevation in mood.” 2. “The pt appears euthymic & is interacting with others.” 3. “The pt isolates self and is tearful most of the day.” 4. “The pt rates mood at a 2 out of 10.” 4. The use of a mood scale objectifies the subjective symptom of mood as a pain scale objectifies the subjective symptom of pain. The use of scales is the most accurate way to assess subjective data. Which pt is at highest risk for the diagnosis of major depressive disorder? 1. A 24-year-old married woman. 2. A 64-year-old single woman. 3. A 30-year-old single man. 4. A 70-year-old married man. 1. Research indicates that depressive symptoms are highest among young, married women of low socioeconomic backgrounds. Compared with the other pts presented, this pt is at highest risk for the diagnosis of MDD A pt is admitted to an in-patient psych unit with a diagnosis of MDD. Which of the following data would the nurse expect to assess? Select all that apply. 1. Loss of interest in almost all activities & anhedonia. 2. A change of more than 5% of body weight in 1 month. 3. Fluctuation between increased energy & loss of energy. 4. Psychomotor retardation or agitation. 5. Insomnia or hypersomnia. A pt is exhibiting behavioral symptoms of depression. Which charting entry would appropriately document these symptoms? 1. “Rates mood as 4/10.” 2. “Expresses thoughts of poor self-esteem during group.” 3. “Became irritable and agitated on waking.” 4. “Rates anxiety as 2/10 after receiving lorazepam (Ativan).” 3. When the pt becomes irritable & agitated on awakening, they are exhibiting behavioral symptoms of depression. Other behavioral symptoms include, but are not limited to, tearfulness, restlessness, slumped posture & withdrawal Which symptom is an example of physiological alterations exhibited by pts diagnosed with moderate depression? 1. Decreased libido. 2. Difficulty concentrating. 3. Slumped posture. 4. Helplessness. 1. Decreased libido is a physiological alteration exhibited by clients diagnosed with moderate depression. Which symptom is an example of an affective alteration exhibited by pts diagnosed with severe depression? 1. Apathy. 2. Somatic delusion. 3. Difficulty falling asleep. 4. Social isolation. 1. Apathy is defined as indifference, insensibility & lack of emotion. Apathy is an affective alteration exhibited by pts diagnosed with severe depression. 2. Somatic delusion is a cognitive, not affective, alteration exhibited by clients diagnosed with severe depression. 3. Difficulty falling asleep is a physiological, not affective, alteration seen in pts diagnosed with severe depression. 4. Social isolation is a behavioral, not affective, alteration exhibited by clients diagnosed with severe depression. Major depressive disorder would be most difficult to detect in which of the following clients? 1. A 5-year-old girl. 2. A 13-year-old boy. 3. A 25-year-old woman. 4. A 75-year-old man. 2. Assessment of depressive disorders in 13 y/o children would include feelings of sadness, loneliness, anxiety & hopelessness. These symptoms may be perceived as normal emotional stresses of growing up. Many teens whose symptoms are attributed to the “normal adjustments” of adolescence, are not accurately diagnosed & do not get the help they need. Which is the key to understanding if a child or adolescent is experiencing an underlying depressive disorder? 1. Irritability with authority. 2. Being uninterested in school. 3. A change in behaviors over a 2-week period. 4. Feeling insecure at a social gathering. 3. Change in behavior is an indicator that differentiates mood disorders from the typical stormy behaviors of adolescence. Depression can be a common manifestation of the stress & independence conflicts associated with the normal maturation process. Assessment of normal baseline behaviors would help the nurse recognize changes in behaviors that may indicate underlying depressive disorders. The nurse in the ED is assessing a pt suspected of being suicidal. Number the following assessment questions, beginning with most critical & ending with least critical. ___ “Are you currently thinking about suicide?” ___ “Do you have a gun in your possession?” ___ “Do you have a plan to commit suicide?” ___ “Do you live alone? Do you have local friends or family?” 1. 3. 2. 4. (1) Assessment of suicidal ideations must occur before any other assessment data. If the pt is not considering suicide, continuing with the suicide assessment is unnecessary. (2) A pt’s risk for suicide increases if they have a plan. (3) If a pt has a loaded gun available to him or her at home, the nurse would be responsible to assess this information & initiate actions to decrease the client’s access. (4) If a pt has an involved support system, even if a suicide attempt occurs, there is a potential for rescue. Which nursing charting entry is documentation of a behavioral symptom of mania? 1. “Thoughts fragmented, flight of ideas noted.” 2. “Mood euphoric and expansive. Rates mood a 10/10.” 3. “Pacing halls throughout the day. Exhibits poor impulse control.” 4. “Easily distracted, unable to focus on goals.” 3. When the nurse documents, “Pacing halls throughout the day. Exhibits poor impulse control,” the nurse is charting a behavioral symptom of mania. Psychomotor activities & uninhibited social and sexual behaviors are classified as behavioral symptoms. A nurse on an in-patient psych unit receives report at 1500 hours. Which pt would need to be assessed first? 1. A pt on one-to-one status because of suicidal ideations. 2. A pt pacing the hall, experiencing irritability & flight of ideas. 3. A pt diagnosed with hypomania monopolizing time in the milieu. 4. A pt with a history of mania who is to be discharged in the morning. 2. Most assaultive behavior that occurs on an in-patient unit is preceded by a period of increasing hyperactivity. A pt’s behavior of pacing the halls & experiencing irritability should be considered emergent & warrant immediate attention. Because of these symptoms, this pt would need to be assessed first. A nurse is planning to teach about appropriate coping skills. The nurse would expect which pt to be at the highest level of readiness to participate? 1. A newly admitted pt with anxiety 8/10 & racing thoughts 2. A client admitted 6 days ago for a manic episode refusing to take medications. 3. A newly admitted client experiencing suicidal ideations with a plan to overdose. 4. A client admitted 6 days ago for suicidal ideations following a depressive episode. 4. A pt admitted 6 days ago for suicidal ideations has begun to stabilize because of the treatment received during this time frame. Compared with the other pts described, this pt would have the highest level of readiness to participate in instruction. A newly admitted pt has been diagnosed with MDD. Which nursing diagnosis takes priority? 1. Social isolation R / T poor mood AEB refusing visits from family. 2. Self-care deficit R / T hopelessness AEB not taking a bath for 2 weeks. 3. Anxiety R / T hospitalization AEB anxiety rating of an 8/10. 4. Risk for self-directed violence R / T depressed mood. 4. Risk for self-directed violence is the priority diagnosis for a newly admitted pt with MDD. Risk for self-directed violence is defined as behaviors in which the individual demonstrates that he or she can be physically harmful to self. This is a life-threatening problem that requires immediate prioritization by the nurse. A pt’s outcome states, “The pt will make a plan to take control of one life situation by discharge.” Which nursing diagnosis documents the pt’s problem that this outcome addresses? 1. Impaired social interaction. 2. Powerlessness. 3. Knowledge deficit. 4. Dysfunctional grieving. 2. Powerlessness is defined as the perception that one’s own action would not significantly affect an outcome—a perceived lack of control over a current situation or immediate happening. Because the pt outcome presented in the question addresses the lack of control over life situations, the nursing diagnosis of powerlessness documents this pt’s problem Which nursing diagnosis takes priority for a pt immediately after ECT? 1. Risk for injury R / T altered mental status. 2. Impaired social interaction R / T confusion. 3. Activity intolerance R / T weakness. 4. Chronic confusion R / T side effect of ECT. 1. Immediately after ECT, risk for injury R / T altered mental status is the priority nursing diagnosis. The most common side effect of ECT is memory loss and confusion, and these place the client at risk for injury. A pt diagnosed with MDD has been newly admitted to an in- patient psych unit. The pt has a history of two suicide attempts by hanging. Which diagnosis takes priority? 1. Risk for violence directed at others R / T anger turned outward. 2. Social isolation R / T depressed mood. 3. Risk for suicide R / T history of attempts. 4. Hopelessness R / T multiple suicide attempts. 3. Risk for suicide R / T history of attempts is a priority nursing diagnosis for a pt who is diagnosed with major depression & has a history of two suicide attempts by hanging. A history of a suicide attempt increases a pt’s risk for future attempts. Because various means can be used to hang oneself, the pt is at risk for accessing these means. These factors would cause the nurse to prioritize this safety concern. A pt diagnosed with cyclothymia is admitted to an in-patient psych unit. The pt has a history of irritability & grandiosity & is currently sleeping 2 hours a night. Which nursing diagnoses takes priority? 1. Altered thought processes R / T biochemical alterations. 2. Social isolation R / T grandiosity. 3. Disturbed sleep patterns R / T agitation. 4. Risk for violence: self-directed R / T depressive symptoms. 3. Disturbed sleep patterns is defined as a time-limited disruption of sleep amount & quality. Because the pt is sleeping only 2 hours a night, the client is meeting the defining characteristics of the nursing diagnosis of disturbed sleep patterns. This sleep problem is usually due to excessive hyperactivity and agitation. A pt diagnosed with bipolar I disorder & experiencing a manic episode is admitted to the in-patient psych unit. Which nursing diagnosis is a priority at this time? 1. Risk for violence: other-directed R / T poor impulse control. 2. Altered thought process R / T hallucinations. 3. Social isolation R / T manic excitement. 4. Low self-esteem R / T guilt about promiscuity. 1. Risk for violence: other-directed is defined as behaviors in which an individual demonstrates that he or she can be physically, emotionally, or sexually harmful to others. Because of poor impulse control, irritability, & hyperactive psychomotor behaviors experienced during a manic episode, this client is at risk for violence directed toward others. Keeping all pts in the milieu safe is a priority. A pt admitted with MDD has a nursing diagnosis of ineffective sleep pattern R / T aches and pains. Which is an appropriate short-term outcome for this client? 1. The client will express feeling rested on awakening. 2. The client will rate pain level at or below a 4/10. 3. The client will sleep 6 to 8 hours at night by day 5. 4. The client will maintain a steady sleep pattern while hospitalized. 3. The appropriate short-term outcome for the nursing diagnosis of ineffective sleep pattern R/T aches & pains is to expect the pt to sleep 6-8 hrs a night by day 5. This outcome is pt-specific, realistic, & measurable, & includes a time frame. Which pt would the charge nurse assign to an agency nurse working on the in-pt psych unit for the first time? 1. A client experiencing passive suicidal ideations with a past history of an attempt. 2. A client rating mood as 3/10 and attending but not participating in group therapy. 3. A client lying in bed all day long in a fetal position & refusing all meals. 4. A client admitted for the first time with a diagnosis of major depression. 2. Although this pt rates mood low, there is no indication of suicidal ideations, & the pt is attending groups in the milieu. Because this pt is observable in the milieu by all staff members, assignment to an agency nurse would be appropriate. A pt has a nursing diagnosis of risk for suicide R / T a past suicide attempt. Which outcome would the nurse prioritize? 1. The pt will remain free from injury while hospitalized. 2. The client will set one realistic goal related to relationships by day 3. 3. The pt will verbalize one (+) attribute about self by day 4. 4. The client will be easily redirected when discussion about suicide occurs by day 5. 1. Remaining free from injury throughout hospitalization is a priority outcome for the nursing diagnosis of risk for suicide R / T a past suicide attempt. Because this outcome addresses client safety, it is prioritized. A pt diagnosed with bipolar I disorder has a nursing diagnosis of disturbed thought process R / T biochemical alterations. Based on this diagnosis, which outcome would be appropriate? 1. The pt will not experience injury throughout the shift. 2. The pt will interact appropriately with others by day 3. 3. The pt will be compliant with prescribed medications. 4. The pt will distinguish reality from delusions by day 6. 4. Distinguishing reality from delusions by day 6 is an appropriate outcome for the nursing diagnosis of disturbed thought processes R/T biochemical alterations. Altered thought processes have improved when the client can distinguish reality from delusions. The nurse is reviewing expected outcomes for a pt diagnosed with bipolar I disorder. # the outcomes presented in the order in which the nurse would address them. ___ The client exhibits no evidence of physical injury. ___ The client eats 70% of all finger foods offered. ___ The client is able to access available out-patient resources. ___ The client accepts responsibility for own behaviors. A pt diagnosed with bipolar II disorder has a nursing diagnosis of impaired social interactions R / T egocentrism. Which short-term outcome is an appropriate expectation? 1. The client will have an appropriate one-on-one interaction with a peer by day 4. 2. The client will exchange personal information with peers at lunchtime. 3. Pt will verbalize desire to interact with peers by day 2. 4. The client will initiate an appropriate social relationship with a peer. 1. A pt’s having an appropriate one-on- one interaction with a peer is a successful outcome for the nursing diagnosis of impaired social interaction. The test taker should note that this outcome is specific, pt-centered, positive, realistic & measurable, & includes a time frame A suicidal Jewish-American pt is admitted to an in-patient psych unit 2 days after the death of a parent. Which intervention must the nurse include in the care ? 1. Allow the client time to mourn the loss during this time of shiva. 2. To distract the client from the loss, encourage participation in unit groups. 3. Teach the pt alternative coping skills to deal with grief. 4. Discuss positive aspects the client has in his or her life to build on strengths. 1. In the Jewish faith, the 7-day period beginning with the burial is called shiva. During this time, mourners do not work, & no activity is permitted that diverts attention from thinking about the deceased. Because this pt’s parent died 2 days ago, the client needs time to participate in this religious ritual. A pt denying suicidal ideations comes into the ED complaining about insomnia, irritability, anorexia & depressed mood. Which intervention would the nurse implement first? 1. Request a psychiatric consultation. 2. Complete a thorough physical assessment including lab tests. 3. Remove all hazardous materials from the environment. 4. Place the client on a one-to-one observation. 2. Numerous physical conditions can contribute to symptoms of insomnia, including irritability, anorexia & depressed mood. It is important for the nurse to rule out these physical problems before assuming that the symptoms are psychological in nature. The nurse can do this by completing a thorough physical assessment including lab tests. A pt diagnosed with MDD has a nursing diagnosis of low self- esteem R / T negative view of self. Which cognitive intervention by the nurse would be appropriate? 1. Promote attendance in group therapy to assist client to socialize. 2. Teach assertiveness skills by role-playing situations. 3. Encourage the client to journal to uncover underlying feelings. 4. Focus on strengths & accomplishments to minimize failures. 4. Focusing on strengths & accomplishments to minimize failures is a cognitive intervention by the nurse. Cognitive interventions focus on altering distortions of thoughts & (-) thinking. A newly admitted pt diagnosed with MDD isolates self in room & stares out the window. Which nursing intervention would be the most appropriate to implement initially, when establishing a nurse-client relationship? 1. Sit with the client and offer self frequently. 2. Notify the client of group therapy schedule. 3. Introduce the client to others on the unit. 4. Help the client to identify stressors of life that precipitate life crises. 1. Offering self is one technique to generate the establishment of trust with a newly admitted pt diagnosed with MDD. Trust is the basis for the establishment of any nurse- client relationship A pt diagnosed with MDD is being considered for ECT. Which client teaching should the nurse prioritize? 1. Empathize with the client about fears regarding ECT. 2. Monitor for any cardiac alterations to avoid possible negative outcomes. 3. Discuss with the client and family expected short-term memory loss. 4. Inform the client that injury related to induced seizure commonly occurs. 3. An expected & acceptable side effect of ECT is short-term memory loss. It is important for the nurse to teach the pt and family members this information to avoid unnecessary anxiety about this symtpom Which intervention takes priority when working with newly admitted pts experiencing suicidal ideations? 1. Monitor the client at close, but irregular, intervals. 2. Encourage the client to participate in group therapy. 3. Enlist friends and family to assist the client to remain safe after discharge. 4. Remind the client that it takes 4 to 6 weeks for antidepressants to be fully effective. A pt notifies a staff member of current suicidal ideations. Which intervention by the nurse would take priority? 1. Place the pt on a one-to-one observation. 2. Determine if the pt has a specific plan to commit suicide. 3. Assess for past history of suicide attempts. 4. Notify all staff & place the client on suicide precautions. A pt seen in the ED is experiencing irritability, pressured speech, and increased levels of anxiety. Which would be the nurse’s priority intervention? 1. Place the client on a one-to-one to avoid injury. 2. Ask the physician for a psychiatric consultation. 3. Assess vital signs, and complete physical assessment. 4. Reinforce relaxation techniques to decrease anxiety. A pt experiencing mania states, “Everything I do is great.” Using a cognitive approach, which nursing response would be most appropriate? 1. “Is there a time in your life when things didn’t go as planned?” 2. “Everything you do is great.” 3. “What are some other things you do well?” 4. “Let’s talk about the feelings you have about your childhood.” 1. By asking, “Is there a time in your life when things didn’t go as planned?” the nurse is using a cognitive approach to challenge the thought processes of the client. Which action should the nurse take first when caring for a person experiencing anxiety?Listening is one of the most important steps. It enables the patient to feel respected and more confident in your care. Your day is busy and you have many more patients, but when you are with each patient, they should feel as if they are your only one. Consider how your body language might appear.
What can be said about the comorbidity of anxiety disorders?Many people are affected by more than one anxiety disorder concurrently, known as comorbidity. Surveys have shown that GAD is the most comorbid of anxiety disorders. The coexistence or overlap of disorders increases the complexities of diagnosis and treatment for both the psychiatrist and the patient.
|
For a patient experiencing panic, which nursing intervention should be implemented first?
zusammenhängende Posts
Urheberrechte © © 2024 nguoilontuoi Inc.
