A patient has just been told by the physician that she has stage III uterine cancer. The patient says to the nurse, “I don’t know what to do. How do I tell my husband?” and begins to cry. Which of the following responses by the nurse is the MOST therapeutic?
-"why do you think this is happening to you?'
-"It seems to me that this is a lot to handle. I'll stay here with you."
-"I think this will be easier to deal with than you think."
-"How do you think would be best to tell your husband?"
-"it seems to me that this is a lot to handle. I'll stay here with you."
Reflection (observing how the patient feels/what they say) is most therapeutic and staying with the patient is a plus. Never ask why or refer back to yourself immediately.
The mother of a two-year-old and a four-year-old becomes frustrated and asks the nurse for advice on how to handle time-out situations for her children. Which of the following guidelines, if given by the nurse, is CORRECT?
-“The two-year-old should get a time-out for two minutes and the four-year-old should get a time-out of four minutes.”
-“Both children should be given spankings instead of time-out. It’s more effective.”
-“The two-year-old should get a time-out for four minutes and the four-year-old should get a time-out of two minutes.”
-“The two-year-old should get a spank on the bottom, and the four-year-old should get a time-out of five minutes.”
-“The two-year-old should get a time-out for two minutes and the four-year-old should get a time-out of four minutes.”
Spankings are not appropriate for the nurse to recommend. The best rule of thumb for time-outs is one minute for each year of the child’s age.
Which of the following situations on a psychiatric unit are an example of a trusting patient-nurse relationship?
-The nurse gives the patient his daily medications right on schedule.
-The patient tells the nurse that he feels suicidal.
-The nurse offers to contact the doctor if the patient has a headache.
-The nurse enforces rules strictly on the unit.
-The patient tells the nurse that he feels suicidal.
The trusting relationship between the patient and nurse means that the patient feels he can express his feelings in a safe environment.
A patient with antisocial personality disorder enters the private meeting room of a nursing unit as a nurse is meeting with a different patient. Which of the following statements by the nurse is BEST?
-“You may sit with us as long as you are quiet.”
-“I need you to leave us alone.”
-“I’m sorry, but HIPPA says that you can’t be here. Do you mind leaving?”
-“Please leave and I will speak with you when I am done.”
“Please leave and I will speak with you when I am done.”
For any patient with a personality disorder, it is best to be polite yet firm. Do not phrase it as a question or say “do you mind?”
The nurse cares for a client diagnosed with bipolar disorder on the psychiatric unit. Which of the following, if noted by the nurse, is an unexpected outcome for this patient?
-The patient is able to sit and eat a meal for a period of five minutes at a time.
-The patient’s migraine headaches disappear.
-The patient sleeps four hours per night and complains of insomnia.
-The patient refrains from inappropriate behavior on the unit.
-The patient’s migraine headaches disappear.
Migraine headaches that disappear are good for the patient, yet have nothing to do with bipolar disorder and is therefore an unexpected outcome.
A patient with postpartum depression is scheduled for discharge today. Which of the following statements by the patient would indicate the postpartum depression has RESOLVED?
-“I’ve missed my baby so much.”
-“That scary fog that was clouding my head has disappeared. I feel much more supported and able to care for my baby.”
-“I feel great, so much better!”
-“I feel a little stressed, but I might be able to care for my baby safely.”
-“That scary fog that was clouding my head has disappeared. I feel much more supported and able to care for my baby.”
Patients often describe postpartum depression as a kind of “crazy thinking” or “fog” that resolves into clearer thinking. Support is needed when this patient goes home to prevent stress.
An older patient is scheduled for hip replacement surgery in twelve hours. As the nurse reviews the health history, she notes that the patient has a history of alcoholism. Which of the following actions should be taken to best care for this patient?
-Ask the patient when he had his last drink.
-Ask the patient for a urine BAC prior to surgery.
-Alert the physician that further assessment is required.
-Care for the patient here and now despite his history.
-Ask the patient when he had his last drink.
It is important to check that this patient has not relapsed. It is crucial that prior, during, and post surgery, the status of the patient’s alcoholism is known to prevent withdrawal from complicating his health status.
The nurse cares for a ninety-two year-old patient whose wife recently passed away. Which of the following statements, if made by the patient to the nurse, requires further investigation?
-“Since her death, I just haven’t felt like eating much.”
-“Sometimes I think I feel my wife’s presence in the house. It makes me feel better to think she’s still looking after me.”
-“I gave away my favorite watch to my nephew the other day. I wanted him to have it, in case I’m not around for much longer.”
-“Without my wife, life is so tasteless. I keep asking God why this happened to me.”
-“I gave away my favorite watch to my nephew the other day. I wanted him to have it, in case I’m not around for much longer.”
Giving away valuable possessions and making vague statements like “I may not be around” are signs of suicidal ideations. This comment needs to be further addressed.
A 22-year-old patient and her husband come to the ER after a fall down the stairs. The patient has a black eye, avoids looking at the nurse, and gives yes/no answers to the nurse’s assessment questions. Which of the following actions should the nurse take NEXT?
-Report the patient’s husband for abuse to the nurse’s immediate supervisor.
-Ask the patient to produce a urine sample in the presence of the nurse.
-Ask the patient how she fell down the stairs.
-Ask the patient if she hit her head when she fell.
-Ask the patient to produce a urine sample in the presence of the nurse.
The goal is to get the patient away from her potential abuser and ask her, face to face, “Are you being abused?” If so, you can offer help. You may NEVER report a capable adult unless they ask for it.
The wife of a client with PTSD (post traumatic stress disorder) communicates to the nurse that she is having trouble dealing with her husband’s condition at home. Which of the following suggestions made by the nurse is CORRECT?
-“Discourage your husband from exercising, as this will worsen his condition.”
-“Encourage your husband to avoid regular contact with outside family members.”
-“Do not touch or speak to your husband during an active flashback. Wait until it is finished to give him support.”
- “Keep your cupboards free of high-sugar and high-fat foods.”
-“Do not touch or speak to your husband during an active flashback. Wait until it is finished to give him support.”
A patient with PTSD may accidentally hurt someone if interrupted during a flashback. Leave the patient alone until it has ended. A regular exercise routine and family support can help.
The nurse observes that a preschooler who was admitted to the unit three days ago has enuresis. His mother is very upset and says, “But he hasn’t done that in years!” Which of the following responses, if made by the nurse to the mother, is MOST appropriate?
-“It is very common for children who have been admitted to the hospital to experience regression, where they fall back on old childhood habits. It is usually very temporary.”
- “I remember when my child used to do that. We had her in pull-ups forever!”
-“This behavior is unusual for a child for this age. I’ll call the doctor.”
-“Sometimes that happens. It’s okay, I’ll clean him up.”
-“It is very common for children who have been admitted to the hospital to experience regression, where they fall back on old childhood habits. It is usually very temporary.”
Children who have been admitted to the hospital may deal with this stress by regressing, or falling back on former behaviors. This is normal and temporary.
In a mental health facility, clients are allowed to eat together in the dining room to promote social interaction. The nurse is caring for a manic client in the seclusion room, and it is time for lunch. Which of the following actions should the nurse take?
-As a reward, inform the client he may go to the dining room when he controls his behavior.
-Hold the meal until dinner or until the client is able to come out of seclusion.
-Allow the client to eat together with the other residents with strict 1:1 supervision.
-Serve the meal to the client in the seclusion room.
-Serve the meal to the client in the seclusion room.
When manic client are placed into seclusion, it is because the client is extremely distractible and responses to even the slightest stimuli are exaggerated. A milieu unit such as the dining room may be too stimulating. Client is at risk for injury to self and others.
The nurse cares for a client diagnosed with conversion reaction. The nurse identifies the client is utilizing which of the following defense mechanisms?
-Repression
-Identification
-Introjection
-Displacement
-Repression
The patient is repressing their stressful thoughts and converting them into a physical symptom (conversion reaction).
A client who has sustained damage to the bladder is being prepared for diagnostic tests. The client asks, “If I have my bladder removed, how will I ever be able to urinate?” The most therapeutic answer by the nurse is?
-"I know you're upset, but there are alternatives to removing your bladder."
-"You can still function normally without a bladder."
-"I am sure this is very upsetting but it will be over soon."
-"The test will help to determine if your bladder has to be removed."
-"I know you're upset, but there are alternatives to removing your bladder."
This response offers the best combination of factual information and emotional support.
The nurse works on a medical/surgical unit that has a shift with an unusually high number of admissions, discharges, and call bells ringing. A nurse’s aide, who looks increasingly flustered and overwhelmed with the workload, finally announces “This is impossible! I quit!” and stomps toward the break room. Which of the following statements, if made by the nurse to the nurse’s aide, is BEST?
-“It seems to me that you feel frustrated. What can I help you with to care for our patients?”
-“Fine, we’re better off without you anyway.”
-“I can understand why you’re upset, but I’m tired too and I’m not quitting.”
-“Why don’t you take a dinner break and come back? It will seem more manageable with a normal blood sugar.”
-“It seems to me that you feel frustrated. What can I help you with to care for our patients?”
This statement uses reflection and offers help to a fellow member of the patient care team. Do not refer back to yourself or offer a break. Offer to directly solve the cause of the problem.
On a psychiatric unit, the preferred milieu environment is BEST described as:
-Providing an environment that is safe for the patient to express feelings.
-Fostering a sense of well-being and independence in the patient.
-Providing an environment that will support the patient in his or her therapeutic needs.
-Fostering a therapeutic social, cultural, and physical environment.
-Fostering a therapeutic social, cultural, and physical environment.
The milieu environment includes the whole spectrum of environments a patient interacts with. This answer has the most correct range.
A patient learns that she has uterine fibroids and becomes very upset. The patient asks the nurse, “Will I ever be able to have children? Do I have to get a hysterectomy?” Which of the following responses by the nurse is MOST correct?
-“Many women with uterine fibroids are able to have children and do not necessarily need a hysterectomy.”
-“I’m afraid so. Adoption is always a possibility if you want children.”
-“You will most likely be infertile, but your uterus does not need to be removed.”
-“I will get the doctor to answer your questions for you.”
-“Many women with uterine fibroids are able to have children and do not necessarily need a hysterectomy.”
This is the most factual information for this patient. Uterine fibroids do not necessarily cause infertility and do not always require a hysterectomy.
The nurse cares for a patient on the psychiatric unit who has been diagnosed with depression. Which of the following statements, if made by the patient to the nurse, would require IMMEDIATE intervention?
-“I believe I am feeling better.”
-“I feel sad today.”
-“I know that yesterday I felt sad, but today I feel great!”
-“Sometimes I think that I will never get better.”
-“I know that yesterday I felt sad, but today I feel great!”
This sudden turn-around and complete 180 degree reversal may indicate suicidal thoughts and intentions and should be further assessed.
A patient is admitted in the first trimester of pregnancy with steady cramping, bleeding, and dilation of the cervix to 3 centimeters. The patient looks panicked and says, “Am I going to lose my baby?” Which of the following responses by the nurse is BEST?
-“I believe that, using medications, we still have a chance to save this baby.”
-“I’m afraid that, due to dilation of the cervix, it may be too late to save this pregnancy. I am here for you to answer any questions you may have.”
-“It appears so. Does that frighten you?”
-“No, you’re not going to lose the baby. Bleeding during the first trimester is normal.”
-“I’m afraid that, due to dilation of the cervix, it may be too late to save this pregnancy. I am here for you to answer any questions you may have.”
Once the cervix is dilated, with bleeding and cramping pain, a spontaneous abortion is occurring. This happens at a higher rate in the first trimester than all others, most likely due to there being some inherent problem with the developing fetus that would not cause it to be viable later in pregnancy.
A patient with a history of schizophrenia is admitted to the acute psychiatric care unit. He mutters to himself as the nurse attempts to take a history and yells, “I don’t want to answer any more questions! There are too many voices in this room!” Which of the following assessment questions should the nurse ask NEXT?
-“Who else is talking in this room? It’s just you and me.”
-“Do you feel as though you want to harm yourself or anyone else?”
- “I don’t hear any other voices.”
-“Are the voices telling you to do things?”
-“Are the voices telling you to do things?”
We need to assess for command hallucinations to determine if this patient is at increased risk for harming himself or others.
The nurse cares for a patient whose baby was born with unexpected spina bifida. Which of the following statements is MOST therapeutic to say to the parents?
-“Spina bifida is not a big deal. It’s completely curable, so you shouldn’t be upset.”
-“I know it is shocking to see a child this way, but you will get used to it.”
- “Let’s talk about the different ways you can help your baby to lead a great life.”
-“Although spina bifida can’t be fixed, you should know that you’re not alone.”
- “Let’s talk about the different ways you can help your baby to lead a great life.”
Parents will be grieving the loss of the “perfect child” and need to hear what actions they can take so as not to feel helpless. The damage to the spinal cord done by spina bifida cannot be fixed.
A new mother is admitted to the acute psychiatric unit with severe postpartum depression. She is tearful and states, “I don’t know why this happened to me! I was so excited for my baby to come, but now I don’t know!” Which of the following responses by the nurse is MOST therapeutic?
-“What happened once you brought the baby home? Did you feel nervous?”
-“Having a new baby is stressful, and the tiredness and different hormone levels don’t help. It happens to many new mothers and is very treatable.”
-“Maybe you weren’t ready for a child after all.”
- “Has your husband been helping you with the housework at all?”
-“Having a new baby is stressful, and the tiredness and different hormone levels don’t help. It happens to many new mothers and is very treatable.”
Postpartum depression is often hormonally-based and also has to do with support systems. Blaming the husband is not appropriate, nor is blaming the patient.
A nurse is teaching a primipara patient how to correctly breastfeed her infant for the first time. The patient states, “Why is this so hard? I feel like a bad mother already!” Which of the following responses is best?
- “I think your baby is the problem, not you.”
-“Even though breast-feeding seems like it should be natural, it needs practice to be good at.”
-“Breast-feeding is a natural act. I’m not sure why it’s so hard for you.”
-“When I had my first child, I found it hard to breast-feed at first too.”
-“Even though breast-feeding seems like it should be natural, it needs practice to be good at.”
Breast-feeding requires patience and practice- it’s not a natural skill for most mothers. Knowing this can be comforting as they struggle to care for their infant.
Which of the following statements to the nurse, made by a patient who will be undergoing hip surgery, indicates a readiness for the procedure?
-“Why is it that I will be unable to drive for six weeks after surgery?”
-“I am looking forward to using the trapeze above the bed to lift myself onto a bedpan after surgery.”
-“I am not looking forward to the pain I will experience with this surgery.”
- “My children are bringing me flowers to put in my hospital room and cheer me up.”
-“I am looking forward to using the trapeze above the bed to lift myself onto a bedpan after surgery.”
Knowing what is coming and preparing mentally for it is an important part of psychosocial coping.
An adolescent male being treated for depression arrives with his family at the Adolescent Day Treatment Center for an initial therapy meeting with the staff. The nurse explains that one of the goals of the family meeting is to encourage the adolescent to:
(A) trust the nurse who will solve his problem.
(B) learn to live with anxiety and tension
(C) accept responsibility for his actions and choices.
(D) use the members of the therapeutic milieu to solve his problems.
accept responsibility for his actions and choices.
A 23-year-old-woman comes to the emergency room stating that she had been raped. Which of the following statements BEST describes the nurse’s responsibility concerning written consent?
(A) The nurse should explain the procedure to the patient and ask her to sign the consent form.
(B) The nurse should verify that the consent form has been signed by the patient and that it is attached to her chart.
(C) The nurse should tell the physician that the patient agrees to have the examination.
(D) The nurse should verify that the patient or a family member has signed the consent form.
The nurse should verify that the consent form has been signed by the patient and that it is attached to her chart.
The nurse cares for an elderly patient with moderate hearing loss. The nurse should teach the patient’s family to use which of the following approaches when speaking to the patient?
(A) Raise your voice until the patient is able to hear you.
(B) Face the patient and speak quickly using a high voice.
(C) Face the patient and speak slowly using a slightly lowered voice.
(D) Use facial expressions and speak as you would normally.
Face the patient and speak slowly using a slightly lowered voice.
A 52-year-old man is admitted to a hospital after sustaining a severe head injury in an automobile accident. When the patient dies, the nurse observes the patient’s wife comforting other family members. Which of the following interpretations of this behavior is MOST justifiable?
(A) She has already moved through the stages of the grieving process.
(B) She is repressing anger related to her husband’s death.
(C) She is experiencing shock and disbelief related to her husband’s death.
(D) She is demonstrating resolution of her husband’s death.
She is experiencing shock and disbelief related to her husband’s death
-denial first stage; inability to comprehend reality of situation
After two weeks of receiving lithium therapy, a patient in the psychiatric unit becomes depressed. Which of the following evaluations of the patient’s behavior by the nurse would be MOST accurate?
(A) The treatment plan is not effective; the patient requires a larger dose of lithium.
(B) This is a normal response to lithium therapy; the patient should continue with the current treatment plan.
(C) This is a normal response to lithium therapy; the patient should be monitored for suicidal behavior.
(D) The treatment plan is not effective; the patient requires an antidepressant.
This is a normal response to lithium therapy; the patient should be monitored for suicidal behavior
-delay of 1-3 weeks before med benefits seen
Considering the physical developmental period of a 1 y/o, hospitalization may affect or delay his progression with
-walking
-crawling
-running
-sitting
walking
A client makes a suicide attempt on the evening shift. The staff intervenes in time to prevent harm. In assessing the situation, the most important rational for the staff to discuss the incident is that
-the staff need to file an incident report so that the hospital administration is kept informed
-they need to reenact the attempt so that they understand exactly what happened
-because the client made one suicide attempt, there is a high probability that he will make a second attempt in the immediate future
-the staff needs to discuss the client's behavior to determine what cues in his behavior might have warned them that he was contemplating suicide
the staff needs to discuss the client's behavior to determine what cues in his behavior might have warned them that he was contemplating suicide
-the most important task is to assess the client's behavior and to identify cues that may indicate another impending suicide attempt
Trust may develop in the nurse-client relationship when the nurse
-encourages the client to use "testing' behaviors
-uses consistency when approaching the client
-tells the client how he should behave
-avoids limit setting
uses consistency when approaching the client
-one of the most important elements of trust is consistency
A 20 y/o male client is admitted to the psychiatric unit with a diagnosis of schizophrenia, acute episode. He is having auditory hallucinations and seems disoriented to time and place. The nurse knows that an hallucination can be explained as a(n)
-distortion of real auditory or visual hallucination
-sensory experience without foundation in reality
-voice that is heard by the client but is not really there
-idea without foundation in reality
sensory experience without foundation in reality
-hallucinations may involve any sense and they have no basis in reality
A student failed her psychology final exam and spent the entire evening berating the teacher and the course. This behavior would be an example of which defense mechanism?
-compensation
-acting out
-reaction-formation
-projection
projection
-the student is placing blame on others and not taking responsibilty for her own behavior
While working with an alcoholic client, the most important approach by the nurse would be to
-explicitly outline expectations of the client
-establish strict guidelines of behavior
-set up a working nurse-client relationship
-maintain a nonjudgemental attitude toward the client
maintain a nonjudgemental attitude toward the client
-the most important nursing attitude which underlies all interactions w/this client, including a nurse-client relationship, would be to maintain an nonjudgmental approach
In working with a depressed client, the nurse should understand that the depression is most directly related to a person's
-having experienced a sense of loss
-remembering his traumatic childhood
-stage in life
-experiencing poor interpersonal relationships with others
having experienced a sense of loss
-depressed people often suffer from a sense of loss (status, relationships, sig other, etc)
Three days after admission for depression, a 54 y/o female client approached the nurse and says, 'I know I have cancer of the uterus. Can't you let me stay in bed and have some peace before I die?' In responding, the nurse must keep in mind that
-the client must be postmenopausal
-thoughts of disease are common in depressed clients
-antidepressant medications frequently cause vaginal spotting
-clients suffering from depression can be demanding, making many requests of the nurse
thoughts of disease are common in depressed clients
-concern with having a life-threatening disease is a common issue w/depressed clients
The nurse has been interviewing a client who has not been able to discuss any feelings. Today, 5 minutes before the time is over, the client begins to talk about important feelings. The intervention is to
-tell the client that it is time to end the session now, but another nurse will discuss his feelings with him
-end just as agreed, but tell the client that these are very important feelings and he can continue tomorrow.
-go over the agreed upon time, as the client is finally able to discuss important feelings
-set an extra meeting time a little later to discuss these feelings
end just as agreed, but tell the client that these are very important feelings and he can continue tomorrow.
-he may be trying to manipulate, it is important to end the interview at the agreed-upon time
When encouraged to join an activity, a depressed client on the psychiatric unit refuses and says, 'What's the use?' The approach by the nurse that would be most effective is to
-tell her that this is a self defeating attitude and it will only make her feel worse
-sit down beside her and ask her how she is feeling
-convince her how helpful it will be to engage in the activity
-tell her it is time for the activity, help her out of the chair, and go with her to the activity
tell her it is time for the activity, help her out of the chair, and go with her to the activity
-the nursing intervention is directed toward mobilizing the client w/o asking her to make a decision or trying to convince her to go.
The nurse is in the day room with a group of clients when a client who has been quietly watching TV suddenly jumps up screaming and runs out of the room. The nurses priority intervention would be to
-turn off the TV, and ask the group what they think about the client's behavior
-send another client out of the room to check on the agitated client
-ignore the incident because these outbreaks are frequent
-follow after the client to see what has happened
follow after the client to see what has happened
-the immediate priority is to find the client and assess what further intervention may be needed
A client with a diagnosis of paranoid personality disorder is admitted to the psychiatric unit. As the nurse approached the client with medication, he refuses it, accusing the nurse of trying to kill him. The nurses best strategy would be to tell him that
-'I will give you an injection is necessary.'
-'You may decide if you want to take the medication my mouth or injection, but you must take it.'
-'It is not poison and you must take the medication.'
-'It's alright if you don't take the medication right now.'
'You may decide if you want to take the medication my mouth or injection, but you must take it.'
-giving the client a choice of how he would like to take his medication, while being firm that he must take it, gives the client a sense of control and helps to reduce the power struggle
A male client on the psychiatric unit becomes upset and breaks a chair when a visitor does not show up. The first nursing intervention should be to
-set limits and restrict the clients behavior
-ask direct questions about the clients behavior
-stay with the client during the stressful time
-plan with the client for how he can better handle frustration
set limits and restrict the clients behavior
-the first intervention is to set firm, clear limits on his behavior. The nurse would also remain with the client until he calms down and then encourage him to discuss his feelings rather than act out.