Psych exam 3
A 25-year-old patient complains that most of the staff do not like her. She states “except you, you are the only one who cares about me.” At a group therapy session, you inform this patient and your group that you will be on vacation for the next 2 sessions. The patient storms out of group yelling “I believe you were the one who cared.” During rounds you find this patient scratching her wrists with a paper clip. Given this presentation which personality disorder would you suspect?
Borderline
What is the nurse’s priority focused assessment for side effects in a child taking methylphenidate for ADHD?
Sleep disturbances and weight loss
A new patient at the sleep disorders clinic tells the nurse, “I have not slept well in a year, so I never feel good. I do not expect things will ever improve or be any different.” Interventions the nurse should consider include. (Select all that apply)
Providing instruction in relaxation techniques
Health teaching regarding factors that influence sleep
Counseling the patient to address cognitive distortions
A patient who was responding to auditory hallucinations earlier in the morning now approaches the nurse shaking a fist and shouts, “Back off” and then goes to the dayroom. While following the patient into the dayroom, the nurse should:
Make sure there is adequate physical space between the nurse and patient.
What is the priority nursing diagnosis for a patient with fluctuating levels of
consciousness, disturbed orientation, and visual and tactile hallucinations?
Risk for injury related to altered cerebral function, fluctuating levels of
consciousness, disturbed orientation, and misperception of the environment
The staff development coordinator plans to teach use of physical management techniques for use when patients become assaultive. Which topic should the coordinator emphasize?
Practice and teamwork
The diathesis-stress model of theory states which of the following?
A biological of genetic predisposition to mental illness, but their environment
determines whether or not they will actually become mentally ill
A nurse reviews vital signs for a patient admitted with an injury
sustained while intoxicated. The medical record shows these blood
pressure and pulse reading at the times listed: TB
0200: 118/78
mmHg and 72 beats/minute
0400: 126/80 mmHg and 76 beats/minute 0600: 128/82 mmHg and 72 beats/minute 0800: 132/88 mmHg and 80 beats/minute 1000: 148/94 mmHg and 96 beats/minute What is the nurse’s priority action?
Begin the detox protocol
A survivor of physical spousal abuse was treated in the emergency department for a broken wrist. The patient said, “I’ve considered leaving, but I made a vow and I must keep it no matter what happens.” Which outcome should be met before discharge?
Name two community resources for help
An older adult drove to a nearby store but was unable to remember how to get home or state an address. When police intervened, they found that this adult was wearing a heavy coat and hat, even though it was July. Which stage of Alzheimer’s disease is evident?
Middle
A 35-year-old patient diagnosed with depression began treatment with a SSRI medication one week ago. This patient complains of continued difficulty sleeping. The nurse includes which of the following in educating this patient. (Select all that apply)
Sleeping problems are a common symptom of depression
Therapeutic response to SSRIs may take several weeks
The nurse can assist a patient to prevent substance abuse relapse by (Select all that apply)
A patient receiving risperidone (Risperdal) reports severe muscle stiffness at 1030. By 1200, the patient has difficulty swallowing and is drooling. By 1600, vital signs are 102.8F; pulse 110; respirations 26; 150/90. The patient is diaphoretic. Select the nurse’s best analysis and action
Neuroleptic malignant syndrome, notify health care provider stat.
Which personality disorders are generally associated behaviors that are considered “odd or eccentric”? (Select all that apply)
Schizoid, Paranoid
During morning care, a nurse asks a patient diagnosed with dementia, “How was your night?” The patient replies, “it was lovely. I went out to dinner and a movie with my friend.” Which term applies to the patient’s response?
Confabulation
Which rationale best explains why a nurse should be aware of personal feelings while working with a family experiencing family violence
Strong negative feelings intervene with assessment and judgement
Which assessment finding would cause the nurse to consider a child to be most at risk for development of mental illness? The child:
Has been raised by a parent with recurring major depressive disorder
A patient with a history of alcohol use disorder has been prescribed disulfiram (Antabuse) as an adjunct therapy to maintain sobriety. Which physical effects support patient has relapsed?
The treatment team discusses the discharge plan for a patient with schizophrenia. The primary nurse comments. “His symptoms have vastly improved, the hallucinations have responded to the medication. He’s calmer and no longer paranoid. Only one thing troubles me, I don’t think he’s going to follow through with the treatment plan. He still doesn’t think there’s anything wrong with him.” This scenario describes which symptom:
Anosognosia
Sleep deprivation is considered a safety issue that results in loss of life and property. Psychomotor impairments of sleep deprivation are similar to symptoms caused by
Alcohol consumption
A patient with a history of command hallucinations approaches the nurse yelling obscenities. Which nursing action is most likely to be effective in de-escalation for this scenario?
A 15-year-old ran away from home six times and was arrested for shoplifting. The parents told the Court, “We can’t manage our teenager.” The adolescent is physically abusive to the mother and defiant with the father. Which diagnosis is supported by this adolescent’s behavior?
Conduct Disorder (CD)
What are the primary distinguishing factors between the behavior of persons diagnosed with ODD (Oppositional Defiant Disorder) and those with Conduct Disorder (CD)? The person diagnosed with (Select all that apply)
A new patient acts out so aggressively that seclusion is required before the admission assessment is completed or orders written. Immediately after safely secluding the patient, which action is the nurse’s priority?
Notify the health care provider to obtain a seclusion order
Select the best therapeutic approach for a nurse working with a patient beginning treatment for alcohol addiction. (TB original, select the most therapeutic manner for a nurse working with a patient beginning treatment for alcohol addiction)
Empathetic and supportive
What safety related responsibility does the nurse have in any situation of suspected abuse?
Report the suspected abuse to the proper authorities
An emergency department nurse realizes that the spouse of a patient is becoming increasingly irritable while waiting. Which intervention should the nurse use to prevent further escalation of the spouse’s anger?
Let the spouse know that you will periodically provide an update and progress report on the patient
when preparing to interview a patient diagnosed with narcissistic personality disorder, a nurse can anticipate the assessment findings will include
grandiosity, self-importance, and a sense of entitlement
Which of these is an example of protective factor?
supportive family and friends
which finding constitutes a negative symptom associated with schizophrenia?
Poverty of thought
a new patient at the asleep disorders clinic tells the nurse, "I have not slept well in a year, so I never feel good. I do not expect things will improve or be any different." interventions the nurse should include (SATA)
Which intervention should a nurse use when helping a patient who is expressing anger in an inappropriate manner (SATA)
which assessment findings mark the prodromal stage of schizophrenia?
withdrawal, misinterpreting, poor concentration, and preoccupation with religion
a patient has had difficulty keeping a job because of arguing with co-workers and accusing them of conspiracy. Today this patient shouts, "they're all plotting to destroy me. Isn't that true?" select the nurse’s most therapeutic response
"feeling that people want to destroy you must be very frightening."
which assessment finding supports the diagnosis of Oppositional Defiant Disorder? (TB original: which assessment findings support a diagnosis of ODD?)
Negative, hostile, and spiteful towards parents. Blames others for misbehavior
a patient has a history of impulsive acting-out anger by striking others. Select the most appropriate intervention for avoiding similar incidents
help the patient identify incidents that trigger impulsive anger
Shortly after the parents announced that they were divorcing, a 15-year-old became truant from school and assaulted a friend. The Adolescent told the school nurse, "I'd rather stay in my room and listen to music. It's easier than thinking about what is happening in my family." which diagnosis is most applicable?
Defensive coping related to adjustment to changes in family relationships
A community health nurse visits a family with four children. The father behaves angrily, finds fault with the oldest child, and ask twice, "why are you such a stupid kid?" the wife says, "I have difficulty disciplining the children. It's so frustrating." which comments by the nurse will facilitate an interview with these parents? (SATA)
See who is in a severely abusive relationship and fears for her life is admitted to a psychiatric inpatient unit. A staff nurse asked, "why doesn't she just leave him?" which is the nursing supervisor's most appropriate response? Patients who experienced intimate violence
are paralyzed into an action by a combination o physical threats and a sense of powerlessness
one month ago a patient diagnosed with borderline personality disorder and history of self- mutilation began dialectical behavior therapy. Today the patient's phone to say, "I feel empty and want to hurt myself." the nurse should
assisted patient to choose coping strategies for triggering situations
which assessment findings are likely for an individual who recently injected heroin?
Drowsiness, constricted pupils, slurred speech
a child/adolescent psychiatric and mental health clinical nurse specialist counsels the parent of a preschool age child who has fetal alcohol syndrome. When I asked how to manage a child excitability, the nurse advises the parent to
begin and end each play activity with less Action
a patient diagnosed with borderline personality disorder has a history of self-mutilation and suicide attempts. The patient reviews feelings of depression and anger with life. Which type of medication would the nurse expect to be prescribed
mood stabilizing medication
a nurse assesses a 3-year-old diagnosed with an autism spectrum disorder. Which finding is most associated with the child disorder? the child:
continuously rocks in place for 30 minutes
a patient diagnosed with Alzheimer's disease calls the fire department saying, "my smoke detectors are going off." firefighters investigate and discover that the patient misinterpreted the telephone ringing. Which problem is this patient experiencing?
Agnosia
for the past 18 months, an eight-year-old child has exhibited involuntary, purposeless, rapid recurrent movements of the arms and face as well as spontaneous unintelligible vocalizations. When receiving verbal cues that child could decrease and sometimes extinguish erratic movements for several minutes. The diagnosis is
Tourette disorder
a patient asked for information about AA. select the nurse’s best response
Self-help group for which the goal is sobriety
an older adult is prescribed digoxin and Hydrochlorothiazide daily as well as Lorazepam as needed for anxiety. Over 2 days, the patient developed confusion, slurred speech, an unsteady gait, and fluctuating levels of orientation. What is the most likely reason for the page change in mental status?
Drug actions and interactions
an elderly patient is admitted with delirium secondary to a urinary tract infection. The family asks whether the patient will ever recover. Select the nurse’s best response
the confusion will likely get better as we treat the infection
A nurse works with an adolescent who was placed in a residential program after multiple episodes of violence at school. Establishing rapport with this adolescent is a priority because