Psychiatric Mental Health Nursing 5th Ed By Fortinash-Test Bank

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Psychiatric Mental Health Nursing 5th Ed By Fortinash-Test Bank

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WITH ANSWERS
Psychiatric Mental Health Nursing 5th Ed By Fortinash-Test Bank

Fortinash: Psychiatric Mental Health Nursing, 5th Edition

 

Chapter 02: Nursing Practice in the Clinical Setting

 

Test Bank

 

MULTIPLE CHOICE

 

  1. Which nursing action is a reflection of Hildegard Peplaus theoretic framework regarding psychiatric mental health nursing?
a. Basing patient outcomes on expected instinctual responses
b. Discussing a patients feelings regarding parents and siblings
c. Providing the patient with clean clothes and wholesome food
d. Centering professional practice in a state run psychiatric facility

 

ANS: B

Peplaus pioneering endeavors and contributions were largely influenced by interpersonal psychotherapy. She believed that disorders evolved in the social context of interpersonal interactions. (i.e., what went on between people). Instinctual responses are more related to intrapersonal interactions. Florence Nightingale was instrumental in the holistic approach to nursing care, whereas Linda Richards practice was centered on institutional care of the mental ill.

 

DIF:   Cognitive Level: Application        REF:  Page 18

TOP:  Nursing Process: Implementation

MSC: NCLEX: Safe, Effective Care Environment, Psychosocial Integrity

 

  1. The nurse is attempting to provide a safe environment for a patient at great risk for self-harm. Which intervention shows an understanding of evidence-based practice (EBP)?
a. Using physical restraints only after all other options have been proven ineffective
b. Referring to the facilitys policies manual for guidelines for applying physical restraints
c. Collecting data regarding the short-term effects of using physical restraints on an aggressive patient
d. Requiring constant monitoring of a patient whose inability to self-regulate anger has required the use of physical restraints

 

ANS: B

Health care systems are participating in the shift in nursing practice by encouraging research in their facilities and by implementing interventions that increase nurses knowledge about EBP. Nurses are participating to make evidence-based nursing practices available for their use, and they are helping to determine the outcomes that will benefit patients. The remaining options are examples of long-standing practice related to the use of physical restraints.

 

DIF:   Cognitive Level: Application        REF:  Page 19

TOP:  Nursing Process: Implementation

MSC: NCLEX: Safe, Effective Care Environment, Psychosocial Integrity

 

  1. Which statement by the patient reflects patient education that was based on the concept of integrated patient care?
a. I know Im anxious when I get a tension headache.
b. My anxiety is a result of stressors I dont cope well with.
c. Medication has helped me tremendously with anxiety control.
d. Anxiety runs in my family; my entire family is trying to deal with it.

 

ANS: A

Integrated patient care is the recognition of the interplay between physical and mental health. In integrated care, these disorders are not treated as separate illnesses; rather, they are treated together. The remaining options make no mention of a relationship between mental and physical illness.

 

DIF:   Cognitive Level: Application        REF:  Page 19          TOP:  Nursing Process: Evaluation

MSC: NCLEX: Psychosocial Integrity

 

  1. The nurse demonstrates objective patient care when:
a. Being sympathetic to the patients recent loss of a spouse
b. Protecting the anxious patient by eliminating stressors in the milieu
c. Responding to the patient by stating, I know exactly how you feel.
d. Facilitating the patients exploration of various stress reduction techniques

 

ANS: D

The nurse demonstrates objectivity by helping the patient to process and organize thoughts that are directed toward the solving of his or her own problems. With sympathy, the nurse loses objectivity and moves into his or her own personal feelings. Removing all stress does not allow the patient to develop necessary coping skills.

 

DIF:   Cognitive Level: Application        REF:  Pages 21- 22

TOP:  Nursing Process: Implementation

MSC: NCLEX: Safe, Effective Care Environment: Management of Care, Psychosocial Integrity

 

  1. Which nursing intervention would be appropriately addressed during the orientation phase of the nursepatient relationship?
a. Self reflection by the nurse regarding personal biases and prejudices regarding the patient
b. Patient works at prioritizing personal needs and develops realistic expected outcomes
c. Establishing the contract between the nurse and the patient regarding mutual needs and expectations
d. Patient commits to the reinforcement of positive personal characteristics while working on problems and concerns

 

ANS: C

A contract or agreement is established during the orientation phase of the relationship. The contract defines limits and expectations of both the patient and the nurse. Self Reflection occurs during the pre-orientation phase while the remaining options are addressed during the working phase of the relationship.

 

DIF:   Cognitive Level: Analysis             REF:  Page 22          TOP:  Nursing Process: Planning

MSC: NCLEX: Safe, Effective Care Environment: Management of Care, Psychosocial Integrity

 

  1. Which action on the part of a novice psychiatric mental health nurse shows a need for future development of altruism?
a. Excusing a patient from attending group because, all that talking makes me so anxious
b. Not permitting two patients who are physically attracted to each other to engage in public displays of affection
c. Placing a physically aggressive patient in restraints when they are unable to internally calm their anger
d. Self-reflecting on why I continue to work with patients who are so emotionally damaged they will never be normal

 

ANS: A

This option shows a misguided kindness that will ultimately have a negative impact on the patients treatment. The remaining options show responsible nursing interventions that include self-reflection of personal motivation for such work.

 

DIF:   Cognitive Level: Application        REF:  Page 24          TOP:  Nursing Process: Evaluation

MSC: NCLEX: Safe, Effective Care Environment: Management of Care, Psychosocial Integrity

 

  1. The greatest negative outcome resulting from a nurses fear of a mentally ill patient is that the:
a. Nurse will reinforce negative stereotyping of the mentally ill.
b. Patient will experience increased bias against the nursing staff.
c. Publics fearfulness of the mentally ill will continue to be exaggerated.
d. Therapeutic alliance between the nurse and patient will not develop effectively.

 

ANS: D

Unrealistic preconceived images, stereotyping, and biases have an effect on nurses that, when resulting in fear, will negatively impact the therapeutic effectiveness of the nurse and the care provided. The remaining options do not have the priority that providing quality patient care has.

 

DIF:   Cognitive Level: Application        REF:  Page 26

TOP:  Nursing Process: Assessment

MSC: NCLEX: Safe, Effective Care Environment: Management of Care, Psychosocial Integrity

 

  1. Which action on the part of a novice mental health nurse will best minimize fear related to effectively working with the psychotic patient?
a. Be knowledgeable about psychotropic medications and their affect on psychosis.
b. Always arrange for staff support when working one-on-one with a psychotic patient.
c. Take advantage of opportunities to attend workshops devoted to the care of the psychotic patient.
d. Recognize that the psychotic patient is not in control of their behaviors due to their altered though processes.

 

ANS: C

Fear breeds avoidance, but knowledge and preparation diminish fear and bring confidence. Being prepared before entering the psychiatric setting includes having knowledge and understanding of mental disorders. The remaining options do not provide confidence but rather means of controlling or avoiding the psychotic patient.

 

DIF:   Cognitive Level: Analysis             REF:  Page 26

TOP:  Nursing Process: Implementation

MSC: NCLEX: Safe, Effective Care Environment: Management of Care, Psychosocial Integrity

 

  1. Which response by the nurse manager to a novice mental health nurse is most effective when the nurse asks, How do I justify not keeping a patients secret?
a. Never promise the patient that you will keep a secret for them.
b. Always stop the patient from telling you something as a secret.
c. Let the patient know that you will not keep a secret that could ultimately cause harm or affect their treatment.
d. Keep reminding yourself that you are not the patients friend but rather a professional mental health provider.

 

ANS: C

Nurses and other healthcare professionals do not keep secrets or make promises to patients when the secret may interfere with the patients treatment or put them or others at risk for harm. The remaining options offer appropriate nursing actions but do not effectively answer the nurses question.

 

DIF:   Cognitive Level: Analysis             REF:  Page 30

TOP:  Nursing Process: Implementation

MSC: NCLEX: Safe, Effective Care Environment, Psychosocial Integrity

 

 

  1. The nurse is effectively facilitating the nurse-patient relationship when:
a. Sharing with an angry patient who is verbally abusive that, Although I can accept that you are angry, I cannot and will not accept your verbal abuse.
b. Focusing on the patients life experience without relating to the similarities of ones own experiences
c. Objectively providing constructive criticism that is directed to helping the patient identify inappropriate behaviors
d. Refraining from abandoning the patient regardless of the frustration the interaction causes

 

ANS: A

Accepting the patients feelings is essential; however, it is not necessary to accept all of the patients behaviors. Assist the patient by setting limits on patient behaviors that are self-defeating or that threaten the patient or others in any way. Setting these limits allows for mutual respect in the therapeutic alliance. The remaining options enhance the patients clinical experience rather than the nurse-patient relationship.

 

DIF:   Cognitive Level: Application        REF:  Page 35

TOP:  Nursing Process: Implementation  MSC: NCLEX: Physiological Integrity

 

  1. An often expressed intrinsic reward of psychiatric mental health nursing is:
a. Seeing the seriously ill recover their health
b. Working with patients of all ages and walks of life
c. Working with well-trained, caring health care providers
d. Having time to really focus on the human who is the patient

 

ANS: D

Psychiatric mental health nurses are able to spend the time to know the patient not only as a patient but as an individual. This is an opportunity most nurses whose practice is based on the physical care of the patient is not afforded. The remaining options are not necessarily unique to psychiatric nursing.

 

DIF:   Cognitive Level: Application        REF:  Page 36          TOP:  Nursing Process: Evaluation

MSC: NCLEX: Psychosocial Integrity

 

  1. Which statement is an example of an inference?
a. He is an alcoholic because his wife nags a lot.
b. He states he binges after arguing with his wife.
c. You say your alcohol intake exceeds a quart a day.
d. So you are saying that you were drinking earlier today.

 

ANS: A

An inference is an interpretation of behavior that is made by finding motive and forming conclusions without having all the necessary information. The nurse interprets the patients behavior, decides on a reason, assigns a motive, and forms a conclusion. The remaining options are validations of observations.

 

DIF:   Cognitive Level: Application        REF:  Page 34

TOP:  Nursing Process: Assessment        MSC: NCLEX: Psychosocial Integrity

 

MULTIPLE RESPONSE

 

  1. Which interactions are likely outcomes of a well-established therapeutic alliance? Select all that apply.
a. The nurse states, Im not here to judge but rather to help.
b. The patient states, I really think I can handle this problem now.
c. The patient asks his abusive father to attend counseling with him.
d. The nurse sets boundaries for a patient who has few social skills.
e. The patient with anger issues voluntarily goes into the seclusion room.

 

ANS: A, B, C, E

The alliance serves as a vehicle that provides patients with an opportunity to freely discuss their needs and problems in the absence of judgment and criticism, to gain insight into their abilities, to practice new coping skills, and to heal emotional wounds. Setting boundaries is not an outcome of such an alliance.

 

DIF:   Cognitive Level: Application        REF:  Page 19

TOP:  Nursing Process: Implementation  MSC: NCLEX: Psychosocial Integrity

 

  1. Which nursing interventions are directly related to the principles on which a therapeutic alliance is based? Select all that apply.
a. Graciously declining to, Come visit when I get discharged.
b. Establishing the topic to be discussed at each group session
c. Explaining to the patient the purpose of terminating the alliance
d. Sharing how the nurse also has experienced the same problems
e. Providing subjective feedback to the patients efforts at therapy

 

ANS: A, B, C

The principles that focus on the development and maintenance of a healthy alliance include: the relationship is therapeutic rather than social; the focus remains on the patients needs and problems rather than on the nurse; the relationship is purposeful and goal directed; the relationship is objective rather than subjective in quality; and the relationship is time-limited rather than open-ended. The sharing of experiencing is not patient centered.

 

DIF:   Cognitive Level: Application        REF:  Page 20

TOP:  Nursing Process: Implementation

MSC: NCLEX: Safe, Effective Care Environment: Management of Care

 

  1. The nurse is attempting to minimize the groups display of resistance during a therapy session. Which patients are at risk for displaying such behavior? Select all that apply
a. The patient who is cognitively impaired
b. The patient who is older and well educated
c. The patient who is aggressive and attention seeking
d. The patient who has attended similar therapy groups in the past
e. The patient who has been diagnosed with paranoid schizophrenia

 

ANS: A, D, E

A patient who redirects the focus away from himself or herself by changing the subject is engaging in resistance behavior. Patients divert the topic for one or more of several reasons: a fear of being judged; avoiding the repetition of material that has been previously discussed; or the inability to stay cognitively focused. The attention-seeking patient may attempt to monopolize the discussion but not necessarily be at risk for resisting the topic. Age and education are not risk factors.

 

DIF:   Cognitive Level: Application        REF:  Pages 20-21

TOP:  Nursing Process: Assessment

MSC: NCLEX: Safe, Effective Care Environment: Management of Care, Psychosocial Integrity

Fortinash: Psychiatric Mental Health Nursing, 5th Edition

 

Chapter 10: Anxiety and Anxiety Disorders

 

Test Bank

 

MULTIPLE CHOICE

 

  1. A patient who was savagely attacked by a bear has no memory of the event. Which statement best explains the patients inability to remember the attack?
a. The woman lost consciousness and was not cognitively aware of what happened during the attack
b. The brain has produced a chemical anemia that will repress the memories of the attack indefinitely.
c. The patient is unconsciously using a defense mechanism to protect against the repeated memory of the attack.
d. It is a temporary suppression of the attack; her memory will return when she is physically and emotionally ready to handle the memories.

 

ANS: C

Defense mechanisms are used unconsciously to protect us from threats to the physical, mental, and social aspects of ourselves. The memory of the event may or may not come back but this is not generally related to the patients ability to handle the memories. Memory may be lost or impaired as a result of brain trauma but not as likely from a chemical alteration.

 

DIF:   Cognitive Level: Application        REF:  Page 187

TOP:  Nursing Process: Implementation  MSC: NCLEX: Psychosocial Integrity

 

  1. Which assessment finding exhibited by a patient being assessed for posttraumatic stress disorder (PTSD) would be considered a defining behavior and support such a diagnosis?
a. Can describe the attack in great detail
b. Experiences dramatic swings in affect
c. Describes vivid flashbacks of being attacked
d. Is preoccupied with the need to tell someone about the attack

 

ANS: C

One defining behavior that is seen when an individual has PTSD is that the person re-experiences the traumatic event. This takes place by having recurrent and intrusive disturbing recollections of the trauma, including thoughts, images, or perceptions about the incident. The person sometimes experiences recurrent dreams of the incident and acts or feels as though the event was recurring in the present (flashback). Generally the PTSD patient cannot remember all the details of the trauma nor are they particularly interested in re-telling the events of the trauma. The patient generally has a very limited range of affect.

 

DIF:   Cognitive Level: Application        REF:  Page 196

TOP:  Nursing Process: Assessment        MSC: NCLEX: Psychosocial Integrity

 

  1. What is the basis for assessing a male patient who is agoraphobic for panic attacks?
a. Men are more likely to experience panic attacks.
b. An overwhelming number of agoraphobic patients also have panic attacks.
c. Patients are often unaware that the symptoms they are experiencing are those of panic.
d. Panic attacks are generally the cause of a patient developing phobias like agoraphobia.

 

ANS: B

Almost all patients who present with agoraphobia in clinical samples have a current diagnosis or history of panic disorder. Males are not more likely than females to experience panic attacks. Patients are not usually unaware of panic attack symptoms. Panic attacks dont cause, but are often triggered by, phobias.

 

DIF:   Cognitive Level: Application        REF:  Page 193

TOP:  Nursing Process: Assessment        MSC: NCLEX: Psychosocial Integrity

 

  1. Discharge preparation for a patient includes the administration of the Hamilton Anxiety Scale (HAS). When asked by the patient to explain the purpose of the assessment the nurse responds:
a. It is an assessment tool used to evaluate the symptoms of anxiety.
b. The tool is used to help confirm the diagnosis of anxiety disorder.
c. This tool helps determine if your symptoms have improved with treatment.
d. It helps identify the presence of any other disorder associated with anxiety.

 

ANS: C

The HAS is a valid and time-tested tool that gives the most objective measure of the degree to which anxiety has been effectively treated. The HAS does not evaluate for symptoms of anxiety or act as a diagnosis tool for anxiety or another other associated disorder.

 

DIF:   Cognitive Level: Application        REF:  Page 202

TOP:  Nursing Process: Implementation  MSC: NCLEX: Psychosocial Integrity

 

  1. A patient is admitted for treatment for persistent, severe anxiety. Which nursing diagnosis would help effectively direct patient care?
a. Disturbed sensory perception related to narrowed perceptual field
b. Risk for injury related to closed perception
c. Hopelessness related to total loss of control
d. Risk for other-directed violence related to combative behavior

 

ANS: A

A narrowed perceptual field occurs with severe anxiety; therefore this diagnosis should be considered. Data are not present to support the other diagnoses.

 

DIF:   Cognitive Level: Analysis             REF:  Page 189        TOP:  Nursing Process: Diagnosis

MSC: NCLEX: Psychosocial Integrity

 

  1. The patient was an awkward child who was ridiculed by his father for his inability to catch a ball. As an adult, the patient developed panic attacks at the time his company established after-work team sporting activities. Which data discussed during the nursing interview provides insight to the possible cause of this anxiety disorder when applying the behavioral model?
a. He always avoids sports because Im short and not the least bit athletic.
b. When in fifth grade, the patient caused his team to lose the big softball game.
c. The company he works for places tremendous emphasis of successful team work.
d. As a child he wore a leg brace that prevented him from participating in school sports.

 

ANS: A

In behavioral models that are based on learning theory, the etiology of anxiety symptoms is a generalization from an earlier traumatic experience to a benign setting or object. As a result, he associates embarrassment and shame with sports events and develops panic attacks. The same kinds of cognitive operations that link embarrassment with sporting events link the cognition of the expectation of embarrassment with the idea of a sporting event, and the individual begins to experience panic attacks while merely thinking about being involved. The remaining options are not as likely to bring about the embarrassment and shame that would produce such a response.

 

DIF:   Cognitive Level: Application        REF:  Page 192

TOP:  Nursing Process: Assessment        MSC: NCLEX: Psychosocial Integrity

 

  1. The nurse is working with the family of a patient with obsessive-compulsive disorder (OCD). Which concept should the nurse incorporate in the teaching plan?
a. The thoughts, images, and impulses are voluntary.
b. The family should pay immediate attention to symptoms.
c. The thoughts, images, and impulses tend to worsen with stress.
d. OCD is a chronic disorder that does not respond to treatment.

 

ANS: C

Stress is known to increase the intensity of OCD symptoms. Families should be taught this relationship and the need to reduce stress in the patients life as much as possible. The symptoms are not under the patients voluntary control. It is nontherapeutic to immediately focus on the symptoms, since to do so contributes to secondary gain. OCD responds well to medication and therapy.

 

DIF:   Cognitive Level: Application        REF:  Page 198        TOP:  Nursing Process: Planning

MSC: NCLEX: Psychosocial Integrity

 

 

  1. Which question would assist the nurse in determining whether the patient has been experiencing anxiety?
a. Have you had difficulty concentrating lately?
b. Have you been feeling sad and especially lonely?
c. Do you have a history of failed personal relationships?
d. Do you frequently experience difficulty controlling your anger?

 

ANS: A

Concentration difficulties occur when moderate or greater levels of anxiety are present. Loneliness is more related to mood. A failed personal relationship is more related to poor self-esteem. Inability to control anger is related to poor impulse control.

 

DIF:   Cognitive Level: Application        REF:  Page 197 | Page 199

TOP:  Nursing Process: Assessment        MSC: NCLEX: Psychosocial Integrity

 

  1. The nurse working with patients diagnosed with posttraumatic stress disorder (PTSD) is aware of the need to intervene early in order to de-escalate a patients increasing anxiety level. Which patient behavior is likely an early indication of escalating anxiety?
a. Talking rapidly
b. Pacing around the unit
c. Staring out the window
d. Refusing to go to therapy

 

ANS: B

Recognize the patients use of relief behaviors (e.g., pacing, wringing of hands) as indicators of anxiety. Talking rapidly is an indicator of manic behavior. Staring is more likely seen in depression. Refusing to attend therapy is seen in aggressive, defiant patients.

 

DIF:   Cognitive Level: Application        REF:  Page 200

TOP:  Nursing Process: Assessment        MSC: NCLEX: Psychosocial Integrity

 

  1. The nurse has been working with a patient who experiences anxiety. Which intervention should the nurse implement initially when the patient is observed pacing and wring her hands?
a. Asking how she has managed anxiety effectively in the past
b. Distracting her by offering to help her make a telephone call
c. Asking her what she believes is causing her increased anxiety
d. Teaching her to take deep, relaxing breaths to manage the anxiety

 

ANS: A

First help the patient to build on the coping methods that the patient used to manage anxiety in the past. Coping methods that were previously successful will generally be effective in subsequent situations. Distraction is not usually successful initially. Assessing for the cause of the anxiety will not, in this situation, be helpful in managing it; often times patients are not aware of the cause. Teaching will not be effective while the patient is experiencing anxiety but should be done when the patient is relaxed and able to focus.

 

DIF:   Cognitive Level: Analysis             REF:  Page 200

TOP:  Nursing Process: Implementation  MSC: NCLEX: Psychosocial Integrity

 

  1. The nurse is working with a patient with an anxiety disorder whose treatment includes cognitive behavioral therapy. Which statement by the patient gives the nurse reason to assume that the patient has an understanding of the basis of this type of therapy?
a. My abusive childhood has resulted in my overreaction to stress.
b. My delusional thoughts of extreme anxiety are what cause my panic attacks.
c. My brain chemistry causes me to overreact to common stress by getting so anxious.
d. Ive learned to react to my daily stress by having anxious thoughts and panic attacks.

 

ANS: D

The success of this approach centers on the patients understanding that the symptoms are a learned response to thoughts or feelings about behaviors that occur in daily life. Cognitive therapy helps patients identify target symptoms and change the cognitions associated with them. This is a psychodynamic model explanation. Anxiety disorders have no relationship to delusions. Brain chemistry is not a usual cause of anxiety but rather can be altered by anxiety.

 

DIF:   Cognitive Level: Application        REF:  Page 201        TOP:  Nursing Process: Evaluation

MSC: NCLEX: Psychosocial Integrity

 

  1. Which verbal intervention would the nurse use when helping a patient who is experiencing severe to panic-level anxiety?
a. I will stay with you to make sure you remain safe.
b. First, you must stop pacing and wringing your hands.
c. How can I help you get control of yourself and this anxiety?
d. Can you tell me what was happening just before you got upset?

 

ANS: A

A patient who is experiencing severe to panic-level anxiety requires brief, directive verbal interchanges aimed at increasing feelings of safety and security. It is not likely the patient will be able to stop the physical behaviors. Severely anxious patients are not able to evaluate their situation and give direction to the nurse or are they able to relate antecedent events to increasing anxiety.

 

DIF:   Cognitive Level: Application        REF:  Page 200

TOP:  Nursing Process: Implementation  MSC: NCLEX: Psychosocial Integrity

 

  1. The nurse notes that a patient being treated for an anxiety disorder is becoming more anxious sitting in a congested, noisy room waiting to see the therapist. Which intervention will the nurse implement initially to assist the patient in de-escalating his anxiety?
a. Offering to reschedule the patients appointment
b. Taking the patient to an unoccupied interview room
c. Notifying the therapist of the need to see the patient stat
d. Requesting oral prn anxiolytic medication for the patient

 

ANS: B

A congested, noisy environment is not conducive to maintenance of low anxiety. Moving the patient to a less stimulating environment may be all that is needed for the patient to lower his anxiety level. The other options may not be necessary if the nurse intervenes effectively.

 

DIF:   Cognitive Level: Application        REF:  Page 201

TOP:  Nursing Process: Implementation  MSC: NCLEX: Psychosocial Integrity

 

  1. A patient is ordered medication therapy to manage the symptoms of anxiety disorder. Which statement by the patient indicates an understanding of the typical classification of medication prescribed for this disorder?
a. Tricyclic antidepressants are particular good for panic attacks.
b. I have to give up beer while taking monamine oxidase inhibitors (MAOIs).
c. Selective serotonin reuptake inhibitors (SSRIs) help with panic attacks as well.
d. Benzodiazepines are usually effective when taken for chronic anxiety like mine.

 

ANS: C

SSRIs are the most widely prescribed medication to treat panic disorder. They are effective and have a low side-effect profile. Tricyclic antidepressants are not effective for panic attacks and have more side effects than SSRIs. MAOIs are effective but require knowledge of and compliance with a special diet and are not the first choice in this situation. Benzodiazepines are effective but produce alterations in sensorium and other side effects and are not used for long-term management.

 

DIF:   Cognitive Level: Application        REF:  Page 201

TOP:  Nursing Process: Implementation  MSC: NCLEX: Psychosocial Integrity

 

  1. A patient with OCD tells the nurse, Thinking these thoughts and doing all my rituals is beyond being silly. I have few friends and I know others laugh behind my back. I sometimes think I can control things, but I always find I cant. I dont know if I can continue to live this way. Which assessment question shows the nurse has an understanding of this patients priority risk?
a. Are you feeling hopeless?
b. Do you think you are socially isolated?
c. Have you been thinking about hurting yourself?
d. Do the rituals affect how you feel about yourself?

 

ANS: C

Patients with anxiety disorders should always be assessed for the presence of depression and suicidal ideation, the priority risk to safety. This patient has admitted feeling powerless to control the symptoms, in addition to wondering if she can continue to live the way she has been. There is ample reason for asking about suicidal ideation. The remaining options address hopelessness, social isolation, and low self-esteem. While appropriate nursing concerns, they dont have the priority self-harm has for this patient.

 

DIF:   Cognitive Level: Analysis             REF:  Page 199

TOP:  Nursing Process: Assessment        MSC: NCLEX: Psychosocial Integrity

 

  1. The head nurse in the ED has received word that a major fire in a high-rise office tower will result in many injured persons being brought to the hospital within the next few minutes. The head nurse tells the staff, You will need to assess for acute stress reactions as well as treating physical problems. Which patient is exhibiting symptoms characteristic of acute stress reaction?
a. A male whose moods swing between mania and depression
b. A female who reports still hearing her daughters pleas for help
c. A male who keeps repeating I dont understand whats going on?
d. A female who is rocking her young son and repeating it will be okay.

 

ANS: C

Acute stress reactions are characterized by indications of dissociation, such as dissociative amnesia. Mood swings are more reflective of a mood disorder. Auditory hallucinations would be consistent with re-living a traumatic event. Comforting and reassuring a child in this manner is not characteristic of an acute stress reaction.

 

DIF:   Cognitive Level: Application        REF:  Page 196

TOP:  Nursing Process: Assessment        MSC: NCLEX: Psychosocial Integrity

 

  1. A nurse is reprimanded by the nurse manager. Shortly thereafter, a patients family member reports that the nurse curtly told them You cant come in now. You know you need to wait until visiting hours. The incidence should be discussed based on the knowledge that the defense mechanism the nurse used was:
a. Displacement
b. Projection
c. Sublimation
d. Suppression

 

ANS: A

Displacement is transferring a response or feeling toward one person onto another less threatening person. Projection is attributing strong faults to another and is not displayed in this scenario. Sublimation is channeling maladaptive thoughts into socially acceptable behaviors. Suppression is intentionally avoiding thinking about problem areas.

 

DIF:   Cognitive Level: Comprehension  REF:  Page 188        TOP:  Nursing Process: Planning

MSC: NCLEX: Psychosocial Integrity

 

  1. During a nursing assessment, a teenage patient smiles and states, I dont care what you say. I want to be just like Mike, the leader of our gang. The nurse understands the defense mechanism being used is:
a. Denial
b. Humor
c. Splitting
d. Identification

 

ANS: D

Identification is wishing or trying to be like someone else. Denial is an unconscious refusal to acknowledge some reality. Humor is not being used. Splitting is viewing oneself and others as all bad or all good.

 

DIF:   Cognitive Level: Comprehension  REF:  Page 188

TOP:  Nursing Process: Assessment        MSC: NCLEX: Psychosocial Integrity

 

  1. A young, married female patient is attracted to a male nurse. When the nurse sets clear boundaries, the patient falsely accuses him of sexual harassment. The nursing supervisor recognizes the defense mechanism of:
a. Projection
b. Splitting
c. Suppression
d. Displacement

 

ANS: A

Projection is attributing strong conflicting feelings to another person. Splitting is seeing others and oneself as all good or all bad. Suppression is incorrect because the person avoids thinking about problem areas. Displacement, or transferring a feeling to a less threatening person, is not being used in this scenario.

 

DIF:   Cognitive Level: Comprehension  REF:  Page 188

TOP:  Nursing Process: Implementation  MSC: NCLEX: Psychosocial Integrity

 

  1. A college-aged patient complains that, when I begin to take a test, I freeze up and my mind goes blank. The nurse will react based on the understanding that this patients anxiety level is:
a. Mild
b. Moderate
c. Severe
d. Panic

 

ANS: C

In severe anxiety, a person may freeze and problem solving is difficult. A person is relatively relaxed and comfortable in mild anxiety. A person in moderate anxiety may feel energized and focused. A person at panic level has total loss of control.

 

DIF:   Cognitive Level: Comprehension  REF:  Page 189        TOP:  Nursing Process: Planning

MSC: NCLEX: Psychosocial Integrity

 

  1. A college student diagnosed with high levels of anxiety is being prepared for discharge. Which discharge criteria is appropriate for this patient?
a. The patient will avoid situations that cause anxiety.
b. The patient will use learned anxiety-reducing strategies.
c. The patient will return to living at home with supportive parents.
d. The patient will state, I know medication is what I need to control my anxiety.

 

ANS: B

Using anxiety-reduction strategies will promote maximal functioning. Trying to avoid stressful situations is impractical and encourages avoidance, therefore limiting activities and not supporting the development of coping mechanisms. Moving back into the parents home promotes dependency, and medication therapy is not necessarily the only treatment for anxiety.

 

DIF:   Cognitive Level: Application        REF:  Page 198        TOP:  Nursing Process: Planning

MSC: NCLEX: Psychosocial Integrity

 

MULTIPLE RESPONSE

 

  1. A patient is being evaluated for a possible diagnosis of panic disorder with agoraphobia. Which nursing assessment findings support this diagnosis? Select all that apply.
a. Patient states, Ive had these fears for more than 6 years.
b. Patient describes having a panic attack several times a month.
c. Patient is embarrassed by the limitations the disorder causes.
d. Stated, I never even think about going shopping in a crowded mall.
e. Condition began after beginning treatment for a chronic intestinal problem.

 

ANS: A, B, C, D

To meet the first DSM-IV-TR criterion for panic disorder with agoraphobia, the person must experience recurrent, unexpected panic attacks, with at least one attack followed by one of the following for a month: (1) persistent concern about having additional attacks; (2) worry about the implications of the panic attacks; or (3) a significant change in behavior as a result of the attacks. The second criterion is that the individual experiences agoraphobia. Agoraphobic fears typically involve being in a crowd. The third criterion is that the person avoids agoraphobic situations or has anxiety about having a panic attack. This person will not go to an area or event where he or she has experienced an agoraphobic reaction. The fourth criterion states that panic attacks are not caused by the direct effects of a substance, a medication, or a medical condition.

 

DIF:   Cognitive Level: Analysis             REF:  Page 195

TOP:  Nursing Process: Assessment        MSC: NCLEX: Psychosocial Integrity

 

  1. The nurse has identified a nursing diagnosis of disturbed thought processes for a patient with obsessive-compulsive disorder. What abilities displayed by the patient would be related to an appropriate outcome for this problem? Select all that apply.
a. Can identify when obsessions are worsening
b. Speaks of obsessions as being embarrassing behaviors
c. Describes lessening anxiety when compulsive rituals are interrupted
d. Plans to ignore obsessive thoughts and so minimizes resulting stress
e. Limits time focusing on obsessive thoughts to 15 minutes, 4 times a day

 

ANS: A, C, E

It is desirable for the patient to experience a sense of being able to identify and control the obsessive thinking and the resulting anxiety. Identifying the behaviors as embarrassing is not showing control nor is ignoring the behaviors.

 

DIF:   Cognitive Level: Application        REF:  Page 200        TOP:  Nursing Process: Evaluation

MSC: NCLEX: Psychosocial Integrity

 

  1. Which lifestyle changes should the nurse incorporate in the nursing care plan for a patient with generalized anxiety disorder? Select all that apply.
a. Stop smoking.
b. Limit caffeine intake.
c. Eliminate stress from your life.
d. Practice a relaxation technique daily.
e. Limit worrying to specific times each day.

 

ANS: A, B, D, E

CNS stimulants, including caffeine and nicotine, increase anxiety symptoms such as heart rate and muscle tension. Relaxation techniques are invaluable in the management of stress and anxiety. Limiting the time to allow worrying will help control the invasive thoughts. One cannot avoid stressful situations and attempting to do so does not help in managing its affects.

 

DIF:   Cognitive Level: Application        REF:  Page 200        TOP:  Nursing Process: Planning

MSC: NCLEX: Psychosocial Integrity

 

  1. A nursing interview for a patient being admitted for depression reveals that the patient has been taking a benzodiazepine for anxiety for 3 years. Which actions by the nurse reflect an understanding of the effects of this classification of drugs? Select all that apply.
a. The nurse asks how much of the drug the patient takes daily.
b. The admitting physician is notified of the patients medication history.
c. The nurse prepares to discuss the process of detoxification with the patient.
d. The nurse suggests to the patient that the dosage is likely to be increased.
e. The patient is interviewed regarding how well the anxiety has been controlled.

 

ANS: A, B, C

Benzodiazepines are relatively safe and effective for short-term use to control the debilitating symptoms of anxiety. However, longer-term treatment with these drugs raises issues of tolerance, abuse, and dependence. The medication dosage would not be increased. The effectiveness of the medication is irrelevant but rather the length of the therapy is the prime concern.

 

DIF:   Cognitive Level: Application        REF:  Page 201        TOP:  Nursing Process: Planning

MSC: NCLEX: Psychosocial Integrity

 

  1. A patient comes to the ED exhibiting severe physical and emotional symptomology. When no physical cause can be found for the symptoms, the patient is diagnosed with severe anxiety with panic attack symptoms. Which assessment data supports this diagnosis? Select all that apply.
a. Blood pressure 158/90; 15 minutes later 130/80
b. Claims that she feels like she going to die
c. Random but controlled thoughts
d. Unable to follow instructions
e. Dry, flushed skin

 

ANS: A, B, D

Blood pressure will begin to drop in a panic attack as the sympathetic nervous system release occurs; the patient may express an emotional sensation of doom and the patient will not be able to concentrate and so will be unable to follow instructions. Thoughts during a panic attack are uncontrolled and the skin is diaphoretic.

 

DIF:   Cognitive Level: Analysis             REF:  Page 193

TOP:  Nursing Process: Assessment        MSC: NCLEX: Psychosocial Integrity

 

 

  1. Which considerations should a nurse include when conducting a mental health assessment on a culturally diverse patient Select all that apply.
a. Men and women are equally likely to seek psychiatric health care.
b. The role that spirits and magic play in a patients belief system is cultural based.
c. Rituals are only deemed obsessive when applied to the patients cultural standards.
d. Agoraphobia is more difficult to assess in cultures that restrict female socialization.
e. The nurse should consider the universal application of the Diagnostic and Statistical Manual (DSM-IVTR).

 

ANS: B, C, D

Some cultures restrict womens participation in public activities; thus agoraphobia is less commonly diagnosed. Fears of magic and spirits are present in many cultures and are pathologic only when they are deemed excessive in the context of that culture. Many cultures have rituals to mark important events in peoples lives. The observation of these rituals is not indicative of OCD unless it exceeds norms for that culture, is exhibited at times or places that are inappropriate for that culture, or interferes with social functioning. Most research that supports the development of the Diagnostic and Statistical Manual, ed 4, text revision (DSM-IVTR) classification occurred in the United States; consequently, symptoms that define disorders are representative of U.S. culture. Overall, women are more likely than men to present for treatment or to come in contact with health care providers.

 

DIF:   Cognitive Level: Application        REF:  Page 193        TOP:  Nursing Process: Planning

MSC: NCLEX: Psychosocial Integrity

Fortinash: Psychiatric Mental Health Nursing, 5th Edition

 

Chapter 20: Sexual Disorders: Sexual Dysfunctions and Paraphilias

 

Test Bank

 

MULTIPLE CHOICE

 

  1. Which of these individuals is experiencing a symptom of the DSM-IV-TR diagnosis sexual aversion disorder?
a. The patient who has genital pain associated with intercourse
b. The patient who avoids genital sexual contact with a partner
c. The patient who has absence of desire to engage in sexual activity
d. The patient who has delayed orgasm following sexual excitement

 

ANS: B

Aversion disorder is characterized by avoidance of genital sexual contact with a partner. Orgasmic disorder, male or female, is characterized by delayed orgasm following sexual excitement. Hypoactive sexual desire disorder is characterized by absence of drive for sexual activity. Dyspareunia refers to genital pain associated with intercourse.

 

DIF:   Cognitive Level: Comprehension  REF:  Page 461

TOP:  Nursing Process: Assessment        MSC: NCLEX: Psychosocial Integrity

 

  1. A patient who has a sexual disorder mentions to the nurse, I dont know why I bother looking for help. They dont know much about sex problems. Which statement best describes the evolution of research on sexuality and should serve as the basis for the nurses response?
a. Increased knowledge about sexual dysfunction has been available since the late 1960s.
b. Masters and Johnson were the first persons to explore the area of sexual dysfunction.
c. Kaplan was instrumental in identifying the need for psychoanalysis in treating sexual dysfunction.
d. Sigmund Freud, a sexologist, based his work on scientific data from studying human sexual behavior.

 

ANS: A

In 1966, research conducted by Masters and Johnson described exactly what happens to the body during erotic stimulation. Since then, there has been considerable research concerning the subject of sexuality and sexual dysfunction. Kaplan identified the need for using behavioral techniques in treating sexual disorders. Freud did not base his work on scientific data. Freud, Newton, and Ellis preceded Masters and Johnson in studying sexual dysfunction.

 

DIF:   Cognitive Level: Application        REF:  Page 459

TOP:  Nursing Process: Implementation  MSC: NCLEX: Psychosocial Integrity

 

  1. A patient who is being treated at the community health clinic complains of lack of sexual desire and mentions the problems this is causing in her marriage. Which of the following data is likely related to her sexual dysfunction?
a. Being an adopted only child
b. Taking an antidepressant medication
c. Growing up in a dysfunctional family
d. Living in an isolated area in the country

 

ANS: B

Antidepressants, especially SSRIs, are known to decrease sexual desire. The other options are not known to be closely related to development of sexual dysfunction.

 

DIF:   Cognitive Level: Application        REF:  Page 460

TOP:  Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies

 

  1. When a patients wife asks the nurse about fetishism, which example could the nurse give as part of an explanation?

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a. Being sexually aroused only by touching female shoes
b. Standing on the street corner exposing genitals to others
c. Feeling sexually attracted to a 10-year-old child who lives next door