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Psychiatric Nursing

1. Before eating a meal, a female client with obsessive-compulsive disorder (OCD) must wash his
hands for 18 minutes, comb his hair 444 strokes, and switch thebathroom lights 44 times. What is
the most appropriate goal of care for this client?

a. Omit one unacceptable behavior each day


b. Increase the client’s acceptance of therapeutic drug use
c. Allow ample time for the client to complete all rituals before each meal
d. Systematically decrease the number of repetitions of rituals and the amount of time spent
performing them.

When caring for a client with OCD, the goal is to systematically decrease the undesirable behavior.
(Therapy may not completely extinguish certain behaviors.) Expecting to omit one behavior each
day is unrealistic because the client may have used ritualistic behavior would perpetuate the
undesirable behavior.

2. The nurse closely observes the client who has been displaying aggressive behavior. The nurse
observes that the client’s anger is escalating. Which approach is least helpful for the client at this
time?

a. Acknowledge the client’s behavior


b. Maintain a safe distance from the client
c. Assist the client to an area that is quiet
d. Initiate confinement measures

The proper procedure for dealing with harmful behavior is to first try to calm patient verbally. When
verbal and psychopharmacologic interventions are not adequate to handle the aggressiveness,
seclusion or restraints may be applicable. Options A, B and C are appropriate approaches during the
escalation phase of aggression.

3. Clients who are suspicious primarily use projection for which purpose:

a. deny reality
b. to deal with feelings and thoughts that are not acceptable
c. to show resentment towards others
d. manipulate others

Projection is a defense mechanism where one attributes ones feelings and inadequacies to others to
reduce anxiety. Option A, is not true in all instances of projection. Options C and D focuses on the
self rather than others.

4. A 26 year old writer is admitted for the second time accompanied by his wife. He is demanding,
arrogant talked fast and hyperactive. Initially the nurse should plan this for a manic client:

a. set realistic limits to the client’s behavior


b. repeat verbal instructions as often as needed
c. allow the client to get out feelings to relieve tension
d. assign a staff to be with the client at all times to help maintain control

The manic client is hyperactive and may engage in injurious activities. A quiet environment and
consistent and firm limits should be set to ensure safety. Option B, clear, concise directions are
given because of the distractibility of the client but this is not the priority. Option C, the manic client
tend to externalize hostile feelings, however only non-destructive methods of expression should be
allowed. Option D, nurses set limit as needed. Assigning a staff to be with the client at all times is
not realistic.

5. A client with borderline personality disorder is admitted to the psychiatric unit. Initial nursing
assessment reveals that the client's wrists are scratched from a recent suicide attempt. Based on
this finding, the nurse should formulate a nursing diagnosis of:

a. Ineffective individual coping related to feelings of guilt.


b. Situational low self-esteem related to feelings of loss of control.
c. Risk for violence: Self-directed related to impulsive mutilating acts.
d. Risk for violence: Directed toward others related to verbal threats.
The predominant behavioral characteristic of the client with borderline personality disorder is
impulsiveness, especially of a physically self-destructive sort. The observation that the client has
scratched wrists doesn't substantiate the other options.

6. Which assessment finding is most consistent with early alcohol withdrawal?

a. Heart rate of 120 to 140 beats/minute


b. Heart rate of 50 to 60 beats/minute
c. Blood pressure of 100/70 mm Hg
d. Blood pressure of 140/80 mm Hg

Tachycardia, a heart rate of 120 to 140 beats/minute, is a common sign of alcohol withdrawal. Blood
pressure may be labile throughout withdrawal, fluctuating at different stages. Hypertension typically
occurs in early withdrawal. Hypotension, although rare during the early withdrawal stages, may
occur in later stages. Hypotension is associated with cardiovascular collapse and most commonly
occurs in clients who don't receive treatment. The nurse should monitor the client's vital signs
carefully throughout the entire alcohol withdrawal process.

7. A client is admitted to the psychiatric clinic for treatment of anorexia nervosa. To promote the
client's physical health, the nurse should plan to:
a. severely restrict the client's physical activities.
b. weigh the client daily, after the evening meal.
c. monitor vital signs, serum electrolyte levels, and acid-base balance.
d. instruct the client to keep an accurate record of food and fluid intake

An anorexic client who requires hospitalization is in poor physical condition from starvation and may
die as a result of arrhythmias, hypothermia, malnutrition, infection, or cardiac abnormalities
secondary to electrolyte imbalances. Therefore, monitoring the client's vital signs, serum electrolyte
level, and acid base balance is crucial. Option A may worsen anxiety. Option B is incorrect because a
weight obtained after breakfast is more accurate than one obtained after the evening meal. Option
D would reward the client with attention for not eating and reinforce the control issues that are
central to the underlying psychological problem; also, the client may record food and fluid intake
inaccurately.

8. Daisy Caparas is a 35 year old woman with two young children. She had been admitted with
severe depression. During the initial phase of the nurse-patient relationship, the most helpful
nursing intervention for Mrs. Caparas is:

a. alleviating symptoms
b. assessing anxiety
c. providing sympathy
d. setting limits

During the initial phase of the nurse-patient relationship in this situation, tasks include establishing
boundaries of the relationship, identifying problems, assessing anxiety levels, and identifying
expectations. All other responses aren’t part of this phase of the relationship.
9. The best way to promote communication with Mrs. Caparas is to:

a. allow her to remain isolated in her room


b. ask for clarification and restate or paraphrase her statements
c. place strict time limits on her efforts at communication
d. tell her what you think is going on

Asking for clarification and restating or paraphrasing the patient’s statements are techniques used
to further elicit and clarify the patient’s feelings. The other options aren’t recommended methods for
promoting communication.

10. Techniques that may help Mrs. Caparas regain self-awareness include:

a. discouraging comparison with other episodes in her life


b. discouraging her assessment of emotions
c. encouraging her to cry as frequently as needed
d. encouraging reflection
Encouraging the patient to reflect enables her to think about the events and feelings and reach a
conclusion. This may be help her gain confidence in making assessments and decisions, and it may
encourage self-reliance.

11. The nurse is assessing a 16-year-old female who is being admitted for treatment of anorexia
nervosa. Which clinical manifestation is the nurse most likely to find?

a. Tachycardia
b. Warm, flushed extremities
c. Parotid gland tenderness
d. Coarse hair growth

Frequent vomiting causes tenderness and swelling of the parotid glands. The reduced metabolism
that occurs with severe weight loss produces bradycardia and cold extremities. Soft, downlike hair
(called lanugo) may cover the extremities, shoulders, and face of an anorexic client.

12. The nurse formulates a nursing diagnosis of “impaired verbal communication” for a male patient
with schizotypal personality disorder. Based on this nursing diagnosis, which nursing intervention is
most appropriate?

a. Helping the patient to participate in social interactions


b. Establishing a one-on-one relationship with the patient
c. Establishing alternative forms of communication
d. Allowing the patient to decide when he wants to participate in verbal communication with you

By establishing a one-to-one relationship, the nurse helps the patient learn how to interact with
other people in new situations. The other options are appropriate but should take place only after
the nurse-patient relationship is established.

13. A 27-year-old woman reports losing her sight in both eyes. She’s diagnosed as having conversion
disorder and is admitted to the psychiatric unit. Which nursing intervention would be most
appropriate for this client?

a. Not focusing on his blindness


b. Providing self-care for him
c. Telling him that his blindness isn’t real
d. Teaching eye exercises to strengthen his eyes

Focusing on the client’s blindness can positively reinforce the blindness and further promote the use
of maladaptive behaviors to obtain secondary gains. The client should be encouraged to participate
in his own care as much as possible to avoid fostering dependency. To promote self-esteem, give
positive reinforcement for what the client can do. Blindness and other physical symptoms in a
conversion disorder aren’t under the client’s control and are real to him. Eye exercises won’t resolve
the client’s blindness because no organic pathology is causing the symptoms.

14. The client is arrogant and manipulative. In ensuring a therapeutic milieu, the nurse does one of
the following:

a. Agree on a consistent approach among the staff assigned to the client.


b. Suggest that the client take a leading role in the social activities
c. Provide the client with extra time for one on one sessions
d. Allow the client to negotiate the plan of care

Agree on a consistent approach among the staff assigned to the client. A consistent firm approach is
appropriate. This is a therapeutic way of to handle attempts of exploiting the weakness in others or
create conflicts among the staff. Bargaining should not be allowed. Option B, this is not therapeutic
because the client tends to control and dominate others. Option C, limits are set for interaction time.
Option D, allowing the client to negotiate may reinforce manipulative behavior.

15. Jade Gomez is a 33 year old housewife. She has been diagnosed with clinical depression. In a
therapeutic relationship, the nurse assumes which role with Mrs. Gomez?

a. Doer
b. Friend
c. Helper
d. Listener

A therapeutic relationship is a helping relationship.

16. when beginning a therapeutic relationship with Mrs. Gomez, the first phase of nurse-patient
interactions is known as the:

a. helping phase
b. orientation phase
c. talking phase
d. working phase

During the orientation phase of the therapeutic relationship, the nurse and patient make an
agreement that they will be working together to solve one or more of the patient’s problems.

17. Which statement about patient touch is true?

a. Most patients prefer not to be touched.


b. Most patients prefer to be touched.
c. Nurse-patient touching is an issue that requires sensitivity on the part of the nurse.
d. Patients should never be touched.

Touch has many meanings to patients. Although many patients are eager for human touch, others
may perceive touch as human-boundary violation. Therefore, touching requires sensitivity on the
part of the nurse.

18. Tourette syndrome is characterized by the presence of multiple motor and vocal tics. A vocal tic
that involves repeating one's own sounds or words is known as:

a. echolalia.
b. palilalia.
c. apraxia.
d. aphonia.

Palilalia is defined as the repetition of sounds and words. Echolalia is the act of repeating the words
of others. Apraxia is the inability to carry out motor activities, and aphonia is the inability to speak.

19. Anxiety is caused by:

a. an objective threat
b. a subjectively perceived threat
c. hostility turned to the self
d. masked depression

Anxiety is caused by a subjectively perceived threat. Option A, Fear is caused by an objective threat.
Option C, a depressed client internalizes hostility. Option D, mania is due to masked depression.

20. A 29 year old client newly diagnosed with breast cancer is pacing, with rapid speech headache
and inability to focus with what the doctor was saying. The nurse assesses the level of anxiety as:

a. Mild
b. Moderate
c. Severe
d. Panic

The client’s manifestations indicate severe anxiety. Option A, mild anxiety is manifested by slight
muscle tension, slight fidgeting, alertness, ability to concentrate and capable of problem solving.
Option B, moderate muscle tension, increased vital signs, periodic slow pacing, increased rate of
speech and difficulty in concentrating are noted in moderate anxiety. Option D, panic level of
anxiety is characterized immobilization, incoherence, feeling of being overwhelmed and
disorganization

21. Winnie Cruz is a 33 year old woman who is admitted to the hospital for observation after she
attempted suicide. The nurse includes a psychosocial assessment that includes Mrs. Cruz’s marital
relationship, based on the nurse’s knowledge that:
a. spouses are often the first to be aware of a potential suicide
b. spouses may be able to intervene in future suicide attempts
c. suicide attempts may adversely affect the marital relationship
d. the number one risk factor for suicide in adult woman is spousal abuse

Information regarding the patient’s relationship with her spouse is important because spousal abuse
is the leading cause of attempted and actual suicides in adult women.
22. Psychiatric follow-up for Mrs. Cruz is essential because she:

a. is definitely depressed
b. is probably angry that she’ll still alive
c. may try to commit suicide again
d. obviously hates her life

Patients who have attempted suicide are at much higher risk for repeat attempts in the future.

23. Kevin, a 21 year old college student fell from a train and sustained a spinal cord injury, leaving
him paralyzed below the waist. He’s in a spinal cord rehabilitation program and is refusing to do
things for himself or practices in his prescribed program. One of Kevin’s nursing diagnosis is self-
esteem disturbance. Which of the following is the most therapeutic nursing intervention?

a. asking his friends to encourage self-care


b. enlisting him in the planning of his own care
c. moving him to a different hospital environment
d. teaching him to perform self-care measures

Encouraging a patient to be as independent as possible will promote self-reliance and self-


confidence, both of which are components of a healthy self-esteem. An effective means of
encouraging this independence is enlisting the patient in the planning of his won care. Teaching self-
care measures and eliciting his peers to encourage him will be beneficial, but they are not as
focused on fostering a healthy self-esteem. Moving Mr. Kevin to a different hospital environment
isn’t indicated based on the data given.

24. The nurse says to Kevin, “Tell me about your plans after hospitalization.” Mr. Kevin replies, “I
think in a few months I’ll pick up where I left off- back in college doing what I was doing before.”
Which stage of the grief process is Mr. Kevin demonstrating?

a. Acceptance
b. Anger
c. Bargaining
d. Denial

Mr. Kevin is going through the grief-loss process because he has permanently lost the use of his legs
due to paralysis. His comment suggests that he’s in denial, the first stage of the process. Denial is a
coping mechanism that allows the individual time to assimilate the major changes associated with
body function loss.

25. Which is the drug of choice for treating Tourette syndrome?

a. fluoxetine (Prozac)
b. fluvoxamine (Luvox)
c. haloperidol (Haldol)
d. paroxetine (Paxil)

Haloperidol is the drug of choice for treating Tourette syndrome. Prozac, Luvox, and Paxil are
antidepressants and aren't used to treat Tourette syndrome.