MajorDugong1364
A nurse uses motiational interviewing to counsel a patientw ith…
A nurse uses motiational interviewing to counsel a patientw ith substance misuse disorder. Which statement would be appropraite for the nurse to make?
a. What goals would you like to achieve in this experience?
b. It would be helpful for you to go to weekly meetings.
c. you need to stop drinking alcohol immediately.
d. Your alcoholism is having a negative effect on your life.
A nurse intervenes with a patient during a manic episode. The patient was admitted for stabilization of symptoms related to bipolar disorder. Which interventions ar eindicated?
a. Remove dangerous objects from the patient’s surroundings.
b. Offer physical activity curing periods of agitation
c. Wait for agitation to raise to a high level before intervening
d. Ensure adequate staff to ensure control of patient agitation
e. Use restraints as soon as the patient appears agitated.
A nurse and nutrition team work with a patient with anorexia nervosa to establish a realistic and appropraite goals for treatment. What are the best goals for this patient?
a. Patient has vital signs within normal limits.
b. The patient will be more concerned with personal experience.
c. The patient verbalizes importance of adequate nutrition
d. The patient expresses control over life without inappropraite eating behaviors.
e. The patient will achieve and maintain expected body mass index (BMI)
5. The nurse is caring for a patient with cellulitis of the lower leg who was admitted 12 hours ago. The nurse notes that the patient is diaphoretic and has mild hand tremors. The patient is irritable and states “I’m nauseated and cannot sleep.” Their most recent blood pressure was 140/82 and heart rate 101 beats/min. Which action by the nurse is the MOSt important
a. Provide ginger ale and encourage slow deep breathing
b. Ask the patient what and when they last ate
c. Administer zolpidem and dim the lighting
d. Report findings to the health care provider immediately and anticipdate new medication orders.
A patient is admitted to an inpatient rehabilitation center for bulimia nervosa. Which of the following nursing actions are appropraite for this patient? Select all that apply.
a. Encourage the patient to eat in the cafeteria with other patients.
b. Instruct the patient to record food intake and associated feelings in a journal
c. Teach the patient to go for a walk with someone when having negative thoughts.
d. Schedule alone time after meals to think about reasons for negative behaviors
E. Allow the patient to express feelings of loosing control and frustration
The nurse is completing an assessment on a patient suspected of having Alzheimer’s disease. In which areas should the nurse plan to assess the patient for an alteration in functioning? Select all that apply.
a. Motor function (physical momvement)
b. Behavior and personality
c. Memory
D. Visual acuity
E. Exectuive functioning
The nurse on an inpatient psychiatric unit is conducting a group session when a patient with schizphrenia stands up and yells. The dragons are telling me that you all want to hurt me!” What is the nurse;s priority intervention?
a. Remove the patient from group session and move the patient to a quiet area.
b. Teach the patint to command the voice to go away and leave the client alone.
c. Tell the patient the dragons must be frightening, although others do not hear or see them.
d. Promote discussion among group members about how to cope with hallucinations
The school nurse is providing education about an adolescent depression for parents. Which of the following parent statements does the nurse recognize as a sign of possible depression in a healthy adolescent?
a. My child hands pictures of their favorite celebrity movie and music stars all over their bedroom wall.
b. My child stopped hanging out with friends and recently gave away tickets to a favorite music artist’s concernt.
c. My child started asking to spend more time with friends at the mall or at school events.
d. My child has begun complaining of frequent headaches and other body aches.
E. My child has been receiving reports from teachers of an increase in missing assignments and falling asleep in class.
Which comorbid disorder is most commonly associated with anxiety?
a. Primary insomnia
b. Borderline personality disorder
c. Major depressive Disorder
d. PTSD
The nurse is caring for patients on a mental health unit. Which patient behavior is consistent with borderline personality disorder?
a. Believes the other patients are gathering information about the patient for a local news story.
b. States to the nurse, “You’re mean, I hate you. You’re the most incompetent nurse on this unit” after being denied smoking priviliges.
c. Asks the therapist to speak on the patient’s behalf and requires help with everyday decisions
d. Tasks coffee from the staff lounge and states, “I don’t care if its for staff only; I’m thirsty.
The mental health nurse is planning care for a patient being admitted following a suicide attempt. Which interventions should be included in the plan of care? Select all that apply.
a. Maintain one-on-one staff supervision at all times.
b. Provide meal trays with plastic silverware
c. Inspect the client’s belongings for potentially dangerous items.
d. Restrict the client to the unit unless accompanied by a friend or family member.
e. Ensure the client swallows medications when administered.
The nurse is caring for an older patient experiencing dilirium. What health problems associated with delirium should the nurse assess the patient for? Select all that apply.
a. Dehydration
b. Decreased oxygen saturation level
c. Infection
d. Dementia
E. Drug toxicity
The nurse is assessing a patient seeking medical treatment for injuries that are reported to have occured after falling off their bike. Which observation made by the nurse would indicate the patient may be a victim of intimate partner violence?
a. Patient explains falling after turning to avoid a car
b. Clothing torn and streaked with dirt and blood
c. Visible cuts and bruises over both arms and legs.
d. Their spouse demands to stay during the physical exmaination
The nurse receives hand off report on several patients on the mental health unit which client should be seen first?
a. A patient with schizophrenia who is experiencing delusions and is pacing the room and yelling at other patients.
b. A patient with major depression who has suicidal ideation with a plan and is one-to-one observation
c. A patient with OCD who refuses to attend group therapy because it interrupts hand washing rituals.
d. A patient with bulimia nervosa who has been in the restroom for the past hour since breakfast.
A patient has been court-ordered to take antipsychotic medications due to concerns of being a danger to self. In which situation might this action be justified? Select all that apply.
a. To care for a patient who cannot care for themselves.
b. In an emergency sitaution
c. To alleviate suffering
d. To foster the therapeutic relationship
e. When in the patient’s best interest.
The public health nurse is conducting suicide screenings for patients in the community. The nurse understands the which of the following patients are at increased risk for suicide? Select all that apply.
a. A 25-year old patient with multiple sclerosis and chronic pain
b. A 37 year old with GAD seeing a psychiatrist and therapist.
c. A 17 year old patient who identifies as transgender and reports being bullied at school
d. A 32 year old with a history of bipolar disorder and previous suicide attempts.
e. A 58 year old patient with a history of alcohol dependence who started drinking after a recent divorce
The nurse suspects that a patient who was treated for PTSD in the past is experiencing a relapse. Which findings would support evidence of PTSD symptoms?Select all that apply.
a. Difficulty sleeping
b. Working overtime
c. Easily startled
D. Excessive alcohol intake
E. Unusual weight gain
The nurse is planning care for an older adult patient with depression. Which action should the nurse make a priority?
a. Assessing the patient for low-grade depressive symptoms.
b. Assessing to distinguish depressive symptoms from a grief response
c. Promoting physical activity and maintaining meaningful social connections for wellness
D. screening the patient for suicide risk.
During an assessment, a patient reports hearing voices in their head. What should be the priority for the nurse? [ NO ANSWER]
a. Determine if the patient has a disturbance in orientation
b. Determine if the voices are command hallucinations
c. Determine if the voices are fantasy hallucinations
d. Determine if the patient has a disturbance in thought process
The nurse is caring for a patient after disconinuting fentanyl infusion that was administered over the last 2 weeks. Which of the following findings would indicate opioid withdrawal?
Constipation
Restlessness
Tachycardia
Diaphoresis
Hypertension
Which intervention would the nurse include when planning continuing care for a moderatly depressed patient?
a. Offer the patient the opportunity to decide on wearing a red or green shirt
b. Allow the patient to be alone to decide which activities to engage in
c. Encourage the patient to plan four different leisure time activities
d. Relieve the patient of the responsibility of having to make any decisions
The nurse is assessing a 17 year old with restrictive anorexia nervosa. Which of the following findings should the nurse expect? Select all that apply.
a. Erosion of tooth enamel
b. Hypotention
c. Tachycardia
d. Cold intolerance
E. Amenorrhea
The nurse is assessing patients during a screening event for PTSD at a mental health clinic. The nurse recognizes that which of the following client statements are consistent with PTSD? Select all that apply
I feel very disconnected from my spouse and kids, and I struggle to show affection to my spouse.
I sleep a lot. I get 10 hours of sleep every night and often take an afternoon nap, but I’m still tired.
Going out to eat is difficult. I have to sit in the corner of the restaurant and keep everyone in my line of sight.
Out of nowhere I see flashes of images and hear voices. My heart races and I forget who I am
The nightmares remind me that I don’t deserve to be alive. I should have died instead of the others.
The nurse is preparing to assess a patient with mental illness. Which areas should the nurse focus on when assessing the patient’s cognitive functioning during the mental status exmaination? Select all that apply.
Emotional status
Thought processes
Judgement
Memory
Orientation
The nurse working on an inpatient unit is encouraging a patient to attend therapy groups. The patient response, “I don’t need to go to group therapy. The medication has helped my anxiety.” How can the nurse best respond to this client?
Medications will help the anxious feelings but it will not address the cause of your anxiety. Group therapy will help you identify some of the causes and enable you to develop strategies to cope with anxious feelings.
All patients are required to attend group therapy. I will help you overcome your anxiety about interacting with others.
You will become dependent on the medication if you don’t use other strategies such as group therapy.
The mediation will only continue to help you if you attend group therapy and utilize other supportive treatments.
The clinic nurse reinforces eduation about intimiate partner violence for a group of graduate nurses. Which of the following are appropriate for the nurse to include? Select all that apply.
Victim may not leave due to financial concerns or fear of harm by the abuser.
The abusive partner often demonstrates jealousy and possessiveness.
Intimate partner violence is rare in same-sex partnerships.
Intimate partner violence is most common in low-income families
Violence against a female often intensifies during pregnancy.
Which treatment would the nurse anticipate for a patient with severe persistent, intractable, depression and suicidal ideation?
Short-term psychoanalysis
Electroconvulsive therapy
High dose of an anxioloytic medication
Non-directive psychotherapy
The spouse of a patient with borderline personality disoder calls the clinic and reports that the patient has self-inflicted superficial lacerations in the arm. The spouse tells the nurse, when I prepare to travel for work, my spouse does this to stop me from leaving. It’s not an attempt of serious harm. What is the best response by the nurse?
Your spouse is most likely doing this to gain attention, so it is best to ignore the behavior
It sounds like you are having difficult time coping with your spouse’s behavior
Your spouse should be seen in the clinic today
Are you still planning to leave for your trip
The nurse n the mental health unit receives report on 4 patients. Which patient should the nurse see first?
Patinet experiencing a manic episode who reports sleeping only 4 hours last night
Patient diagnosed with major depressive disorder who has consumed no food from the past 2 meal trays
Patient newly admitted with OCD who has spent the last hour counting socks
Patient diagnosed with PTSD who reports a depresed mood and feelings of hopelessness.
A patient with schizophrenia says to the nurse, “I was walking down the stress and really enjoyed the weather, but carrots are probably my favorite vegetable. Did the ocean always look blue? The nurse recognizes this statement as an example of which?
Clang association
Loose association
Concrete thinking
Word salad
A patient with moderate Alzheimer’s disease becomes agitated during meal time and throws a plate of food on the floor. Which of the following responses by the nurse are appropriate? Select all that apply.
Distract and redirect the patient by asking for help folding napkins for the following day’s meals
Promptly obtain another plate of food and insist that unlicensed assistive personnel feed the patient
Inform the patient that the health care probider will be notified about their inappropraite behavior
Use direct eye contact and say to the patient “I can see that you are upset; this is a safe place.”
Administer a dose o prescribed PRN haloperidol before the patients behavvior escalates further
A spouse brings a patient with a history of previous suciide attempts to the emergency department due to erratic behavior and expressions of hopeslessness. When the triage nurse asks if the patient is having suicidal thoughts, the patient shrugs their shoulders. What action should the triage nurse take?
Have the patient remain in triage and frequently observe for changes
Document that this patient is not currently suicidal
Place the patient on a one-to-one observation
Return the patient to the waiting room with their spouse
The nurse is caring for a patient experiencing chronic depression. The patient states he has lost weight, feels as though he cannot move, and is experiencing numerous aches and pains. What aspects of the illness are likely to be responsibile for these findings?
The patient is trying to conceal underlying emotional problems by focusing on physical symptoms
The patient is experiencing physiological changes related to the same neurobiological factors contributing to depression
The patient is engaging in negative thinking that distort the perception of physical well-being
The patient is experiencing adverse effects from a medication used to treat the mood disturbance
A patient is diagnosed with GAD. Which manifestation should the nurse expect to assess in this patient? Select all that apply.
Inability to make decisions
Anhedonia
Hallucinations
Delusions
Irritable affect
The nurse is explaining the difference between bipolar dsorder and major depressive disorder. Which factor should be discussed as being a defining feature of bipolar disorder that is not present in major depressive disorder?
Short duration of symptoms
Mania
Suicidal ideation
Dysthmia
