are at an increased risk for mental illness. b. The mental health care system is not prepared to deal with family crises. c. Family members are seldom prepared to cope with a chronically ill individual. d. The chronically mentally ill receive care best when delivered in a formal setting. ANS: A When families live with a dominant member who has a persistent and severe mental disorder the outcomes are often expressed as family members who are at increased risk for physical and mental illnesses. The remaining options are not necessarily true. DIF: Cognitive Level: Application REF: Page 3 2. Which nursing activity shows the nurse actively engaged in the primary prevention of mental disorders? a. Providing a patient, whose depression is well managed, with medication on time b. Making regular follow-up visits to a new mother at risk for post-partum depression c. Providing the family of a patient, diagnosed with depression, information on suicide prevention d. Assisting a patient who has obsessive compulsive tendencies prepare and practice for a job interview ANS: B Primary prevention helps to reduce the occurrence of mental disorders by staying involved with a patient. Providing medication and information on existing illnesses are examples of secondary prevention which helps to reduce the prevalence of mental disorders. Assisting a mentally ill patient with preparation for a job interview is tertiary prevention since it involves rehabilitation. DIF: Cognitive Level: Application REF: Page 4 3. Which intervention reflects attention being focused on the patients intentions regarding his diagnosis of severe depression? a. Being placed on suicide precautions b. Encouraging visits by his family members c. Receiving a combination of medications to address his emotional needs d. Being asked to decide where he will attend his prescribed therapy sessions ANS: D A primary factor in patient treatment includes consideration of the patients intentions regarding his or her own care. Patients are central to the process that determines their care as their abilities allow. Under the guidance of PMH nurses and other mental health personnel, patients are encouraged to make decisions and to actively engage in their own treatment plans to meet their needs. The remaining options are focused on specifics of the determined plan of care. DIF: Cognitive Level: Application REF: Page 5 4. When a patients family asks why their chronically mentally ill adult child is being discharged to a community-based living facility, the nurse responds: a. It is a way to meet the need for social support. b. It is too expensive to keep stabilized patients in acute care settings. c. This type of facility will provide the specialized care that is needed. d. Being out in the community will help provide hope and purpose for living. ANS: D Hospitalization may be necessary for acute care, but, when patients are stabilized, they move into community-based, patient-centered settings or are discharged home with continued outpatient treatment in the community. Concentrated efforts are made to reduce the patients sick role by providing opportunities for the development of a purposeful life and instilling hope for each patients future. Although social support is important, such a living arrangement is not the only way to achieve it. Although acute care is expensive, it is not the major concern when determining long-term care options. Community-based facilities are not the only option for specialized care. DIF: Cognitive Level: Application REF: Page 5 5. What is the best explanation to offer when the mother of a chronically ill teenage patient asks, Under what circumstances would he be considered incompetent? a. When you can provide the court with enough evidence to show that he is not able to care for himself safely. b. It is not likely that someone his age would be determined to be incompetent regardless of his mental condition. c. He would have to engage in behavior that would result in harm to himself or to someone else; like you or his siblings. d. If the illness becomes so severe that his judgment is impaired to the point where the decisions he makes are harmful to himself or to others. ANS: D When a person is unable to cognitively process information or to make decisions about his or her own welfare, the person may be determined to be mentally incompetent. Providing self-care is not the only criteria considered. Age is not a factor considered. The decision is often based on the potential for such behavior. DIF: Cognitive Level: Application REF: Page 6 6. Which psychiatric nursing intervention shows an understanding of integrated care? a. A chronically abused woman is assessed for anxiety. b. A manic patient is taken to the gym to use the exercise equipment. c. The older adult diagnosed with depression is monitored for suicidal ideations. d. A teenager who refuses to obey the units rules is not allow to play video games. ANS: A The majority of health disciplines now recognize that mental disorders and physical illnesses are closely linked. The presence of a mental disorder increases the risk for the development of physical illnesses and vice versa. Assessing a chronically abused individual for anxiety call should attention to the psychiatric disorder that could develop from the abuse. The remaining options show interventions that are appropriate for the mental disorder. DIF: Cognitive Level: Application REF: Page 6 7. What reason does the nurse give the patient for the emphasis and attention being paid to the recovery phase of their treatment plan? a. Recovery care, even when intensive, is less expensive than acute psychiatric care. b. Effective recovery care is likely to result in fewer relapses and subsequent hospitalizations. c. Planning for recovery care is time consuming and involves dealing with many complicated details. d. Recovery care is usually done on an outpatient basis and so is generally better accepted by patients. ANS: B Much attention is paid to recovery care since effective recovery care helps improve patient outcomes and thus minimize subsequent hospitalizations. Recovery care is not necessarily less expensive than acute care. Although effective recovery care planning may be time consuming and detail oriented, that is not the reason for implementing it. Recovery care is not necessarily well accepted by patients. DIF: Cognitive Level: Application REF: Page 7 8. The nurse is attending a neighborhood meeting where a half-way house is being proposed for the neighborhood when a member of the community states, We dont want the facility; we especially dont want violent people living near us. The response by the nurse that best addresses the publics concern is: a. In truth, most individuals with psychiatric disorder are passive and withdrawn and pose little threat to those around them. b. The mentally ill seldom behave in the manner they are portrayed by movies; they are people just like the rest of us. c. Patients with psychiatric disorder are so well medicated that they do not display violent behaviors. d. The mentally ill deserve a safe, comfortable place to live among people who truly care for them. ANS: A A major reason for the existence of the stigma placed on persons with mental illness is lack of knowledge. The main fear is of violence, although only a small percentage of patients with mental illness display this behavior. Providing the public with accurate information can help reduce stigma. The remaining options do not directly address the concerns stated. DIF: Cognitive Level: Application REF: Pages 13-14 9. Which activity shows that a therapeutic alliance has been established between the nurse and patient? a. The nurse respects the patients right to privacy when visitors are spending time with the patient. b. The patient is eagerly attending all group sessions and working independently on identifying their personal stressors. c. The patient is freely describing their feelings related to the physical and emotional trauma they experienced as a child with the nurse. d. The nurse dutifully administers the patients medications on time and with appropriate knowledge of the potential side effects. ANS: C A primary aspect of working with patients in any setting and particularly in the psychiatric setting is the development of a therapeutic alliance with the patient. Such an alliance is established on trust. It is a professional bond between the nurse and the patient that serves as a vehicle for patients to freely discuss their needs and problems in the absence of the nurses criticism or judgment. Any nurse has an obligation to respect the patients rights and administer care effectively. The patients willingness to participate in the plan of care reflects self motivation. DIF: Cognitive Level: Application REF: Page 9 10. Mental health care reform has called for parity between psychiatric and medical diagnoses. Which is an example of such parity? a. Depression treatment is not paid for as readily as is treatment for asthma. b. The mentally ill patient will be protected by law against social stigma. c. Medical practitioners are trained to be proficient at treating mental disorders. d. Psychiatric service reimbursement will be equivalent to that of medical services. ANS: D The term parity as used here refers to payments for mental health services that equal payment schedules for medical or surgical conditions. The remaining options(B and C) do not relate to financial reimbursement or funds allocated for mental health care being equal to those of medical diagnoses. DIF: Cognitive Level: Application REF: Page 15 1. Which assessment findings suggest to the nurse that this patient has characteristics seen in an individual who has reached self-actualization? Select all that apply. a. Reports to have, found peace and security in my religious faith b. Effectively changed occupations when a chronic vision problem worsened c. Has consistently earned a six-figure salary as an architect for the last 10 years d. Has been in a supportive, loving relationship with the same individual for 15 years e. Provides free literacy tutoring help at the local homeless shelter 3 evenings a week ANS: A, B, D, E Characteristics of self actualization would include: spiritual well-being, open and flexible, relationally fulfilled, and generosity toward others. Salary doesnt necessarily reflect self-actualization. DIF: Cognitive Level: Application REF: Page 4 2. Which nursing activities represent the tertiary level of mental health care? Select all that apply. a. Providing a depression screening at a local college b. Helping a mental-challenged patient learn to make correct change c. Reporting an incidence of possible elder abuse to the appropriate legal agency d. Regularly assessing a patients understanding of their prescribed antidepressants e. Providing a 6-week parenting class to teenage parents through a local high school ANS: B, D Tertiary prevention reduces the residual effects of the disorder such as depression and mental retardation. There is no quaternary level of prevention. Primary prevention reduces occurrences of mental disorders such as screenings and parenting classes, and secondary prevention reduces the prevalence of disorders as evidenced by assessing knowledge. DIF: Cognitive Level: Application REF: Page 4 3. Which nursing actions indicate an understanding of the priority issues currently facing psychiatric mental health nursing today? Select all that apply. a. Working on the facilitys Safe Use of Restraints Policy revision committee b. Advocating for increased salaries for all levels of psychiatric mental health nurses c. Attending a political rally for increased state funding for mental health service providers d. Offering an in-service to facility staff regarding the cultural implications of caring for the Hispanic patient e. Joining the state nursing committee working on the role and scope of practice of the advanced practice psychiatric nurse ANS: A, C, D, E Priority issues include funding, safety issues in psychiatric treatment centersparticularly the use of patient restraints, quality-of-care issues, access to health care for minority populations, and standardization of advanced practice nurse roles. DIF: Cognitive Level: Application REF: Page 9 4. Which assessment findings describe risk factors that increase the potential risk for mental illness? Select all that apply. a. Possesses high tolerance for stress b. Is very curious about how things work c. Admits to being a member of an ethnic gang d. Only practicing Jew among school classmates e. Has a younger sibling who is mentally challenged ANS: C, D, E Risk factors are internal predisposing characteristics and external influences that increase a persons vulnerability and potential for developing mental disorders. Types of risk factors and examples include the following: having a mentally-challenged family member in the home; belonging to a punitive gang; and being the object of reject or bullying. The remaining options are protective factors. DIF: Cognitive Level: Application REF: Page 11 5. Which nursing actions show a focus on the fundamental goals that guide psychiatric mental health nurses in providing patient care? Select all that apply. a. Offering an informational session of identifying signs of depression at a local senior center b. Attending a workshop on evidence practice interventions for the chronically depressed patient c. Keeping strict but appropriate boundaries with a patient diagnosed with a personality disorder d. Asking a parent who has just experienced the death of a child if they could consider talking with a grief counselor e. Identifying what help a patient diagnosed with Alzheimers disease will need with instrumental activities of daily living (IADLs) ANS: A, B, D, E Standard objectives guide PMH nurses and members of related disciplines in the care of patients (individuals, families, communities, and organizations). The objectives and criteria are as follows: the promotion and protection of mental health, the prevention of mental disorders, the treatment of mental disorders, and recovery and rehabilitation. Keeping appropriate boundaries is a generalized nursing responsibility. DIF: Cognitive Level: Analysis REF: Page 3 Chapter 02: Nursing Practice in the Clinical Setting 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 2. 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 3. 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 4. 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 5. 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 6. 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 7. 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 8. 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 9. 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 10. 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 11. 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 12. 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 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 2. 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 3. 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 Chapter 03: The Nursing Process and Standards of Practice 1. The patient asks the nurse, Ive heard the student nurses talk about the nursing process. Why is there so much emphasis on using the nursing process? The response that explains the need for nurses to understand and use the nursing process is: a. Do you think you have a better method we might use? b. The nursing process is a systematic problem-solving method encompassing all components necessary to care for patients. c. Using the nursing process is a way of legitimizing our profession and placing us on an equal footing with the pure sciences. d. The nursing process is a unidimensional, static, linear approach used to guide nurses as they make clinical judgments. ANS: B This response best explains the importance of the nursing process by description and relationship to patient care. Suggesting that the patient may have a better method is challenging and does not address the question posed by the patient. Providing legitimacy to the profession is a very limited explanation for use of the nursing process. The nursing process is not one-dimensional, static, or linear. DIF: Cognitive Level: Knowledge REF: Page 40 2. When preparing to conduct a nursing history and assessment on a patient transferred from the emergency department (ED) whose family believes the patient to be a questionable historian due to cognitive impairment, the nurse initially begins the interview by: a. Reviewing the ED chart b. Contacting the admitting physician c. Directing the questions to the family members d. Establishing a line of communication with the patient ANS: D The nurse should begin establishing the nursepatient relationship by initially directing the questions to the patient. The nurse can confirm information and/or obtain supplementary information from the sources identified by the other options. DIF: Cognitive Level: Application REF: Page 40 3. The nurse shows the ability to effectively state a nursing diagnosis reflective of the implications of depression on a patients life processes when stating in the patients plan of care that: a. Patient outcomes were partially attained. Implementation of present plan to continue. b. Patient will initiate and support conversation with nurse therapist by (date 3 weeks in future). c. Oral medication for anxiety should be administered when depression is assessed to be at the moderate level. d. Impaired verbal communication r/t impoverished thoughts secondary to depression as evidenced by monosyllabic responses. ANS: D This statement contains the various components of a nursing diagnosis while expressing the existence of an altered life process. The remaining options reflect other steps, such as evaluation and intervention planning. DIF: Cognitive Level: Application REF: Pages 47-48 4. When engaging in outcomes identification, the nurse: a. Interviews and collects patient-focused data b. Re-assesses the patients physical and emotional status evaluation c. Reviews the patients existing problems and projects the results of the nursing care d. Considers the patients presenting symptoms and identifies nursing-related problems ANS: C Outcomes are projections of expected influence that nursing interventions will have on the patient. Interviewing and collecting data is involved in the assessment process, re-assessing is involved in the evaluation process, and identifying related nursing problems is involved in determining appropriate nursing diagnoses. DIF: Cognitive Level: Application REF: Page 49 5. While discussing assessment of suicidal patients, a novice nurse mentions, I was taught to always base my care on concrete, evidence-based scientific reasoning and never to rely on intuition. Which response by the experienced nurse shows understanding of intuitive reasoning? a. Thats wise, because intuition went out of favor with the scientific revolution. b. Critical thinking and intuition are at opposite poles. Keep relying on your expertise. c. Its possible that intuition about suicidality is generated by transfer of feelings from the patient to the nurse. d. Its been determined that intuition is nothing more that extrasensory perception, so some folks have it, and some dont. ANS: C A strong hunch or a gut feeling is an example of intuitive reasoning that is believed to come from the therapeutic relationships sharing of feelings between nurse and patient. Most nurses agree that intuition is compatible with scientific reasoning, because both are likely linked to practice and experience. A nurse learns intuitive reasoning through clinical practice rather than from school or books. DIF: Cognitive Level: Application REF: Page 45 6. A nurse shows effective critical thinking skills directed towards nursing care of a cognitively impaired patient who continues to socially isolate by: a. Clearly stating that the patient must socially interact once daily b. Documenting that the patient continues to resist socialization c. Asking the patient to identify which unit activity they are willing to attend d. Suggesting that staff take the patient with them when running errands off the unit ANS: D Critical thinking in this case involves the creation of alternative solutions to a problem that was not resolved by conventional methods. The remaining options, although not inappropriate, do not show cri
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