As a patient diagnosed with a mental illness is being discharged from a facility, a nurse invites the patient to the annual staff picnic. What is the best analysis of this scenario?
A nurse is caring for a client who has a substance use disorder. Which of the following statements by the nurse is an example of patient-centered care?
A nurse is caring for a client who reports spending 12 hr daily playing video games online. The client has spent a significant amount of money betting on these games. They lost their job due to missed work, and they filed for bankruptcy because of their gambling debts. Their partner was supporting them financially until the partner left the client out of frustration with their behavior. Which of the following manifestations of non-substance addiction is characteristic of the client's behavior?
A nurse in an outpatient facility is teaching a client about the development of mental illness. Which of the following statements by the nurse describes the role of a vulnerability gene?
A nurse is leading a group about relapse prevention. Which of the following statements appropriately describes the principles of the self-help groups Alcoholics Anonymous and Narcotics Anonymous?
In a team meeting, a nurse says, 'I'm concerned whether we are behaving ethically by using restraint to prevent one patient from self-mutilation while the care plan for another patient who has also self-mutilated calls for one-on-one supervision.' Which ethical principle most clearly applies to this situation?
A patient with schizophrenia is exhibiting signs of agitation, disorganized speech, and paranoia. Which medication is most likely to be prescribed for this patient?
A public health nurse is applying for a grant related to suicide prevention. When describing social groups at highest risk, which of the following should the nurse include?
A nurse is reviewing assessment findings for a 9-year-old child whose family home was destroyed in a wildfire. The nurse should identify that which of the following behaviors is related to the traumatic experience?
A nurse is caring for a patient diagnosed with bipolar disorder who is in the manic phase. The patient states, 'I don't need any help. I can do everything myself!' Which response is the most therapeutic?
A nurse is caring for a patient diagnosed with anorexia nervosa. The patient states, 'I think I'm too fat, even though I've lost 30 pounds.' Which of the following is the most appropriate response by the nurse?
A nurse is assessing a patient diagnosed with bulimia nervosa. The patient states, 'I feel like I have no control over my eating.' Which of the following interventions is most appropriate for the nurse to implement?
A nurse is assessing a patient diagnosed with generalized anxiety disorder. The patient states, 'I feel constantly anxious, and I can't calm down.' Which of the following is the most appropriate nursing diagnosis?
A school age child tells the school nurse, 'Other kids call me mean names and will not sit with me at lunch. Nobody likes me.' Select the nurse's most therapeutic response.
A nurse is assessing a patient diagnosed with bulimia nervosa. The patient states, 'I feel so ashamed after I eat.' What is the priority nursing intervention?
A nurse is caring for a patient diagnosed with anorexia nervosa. The patient states, 'I don't need to eat. I feel fine.' What is the priority nursing intervention?
A Filipino American patient had a nursing diagnosis of situational low self-esteem related to poor social skills as evidenced by lack of eye contact. Interventions were applied to increase the patient's self-esteem but after 3 weeks, the patient's eye contact did not improve. What is the most accurate analysis of this scenario?
A nurse leads a psychoeducational group for patients experiencing depression. The nurse plans to implement an exercise regime for each patient. The rationale to use when presenting this plan to the treatment team is that exercise
A patient says, 'I will never be happy until I'm as successful as my older sister.' The nurse asks the patient to reassess this statement and reframe it. Which reframed statement by the patient is most likely to promote coping?
A patient with an abdominal mass is scheduled for a biopsy. The patient has difficulty understanding the nurse's comments and asks, 'What do you mean? What are they going to do?' Assessment findings include tremulous voice, respirations 28, and pulse 110. What is the patient's level of anxiety?
A patient with a somatic symptom disorder has the nursing diagnosis Interrupted family processes related to patient's disabling symptoms as evidenced by spouse and children assuming roles and tasks that previously belonged to patient. An appropriate outcome is that the patient will
An 11-year-old diagnosed with ODD becomes angry over the rules at a residential treatment program and begins cursing at the nurse. Select the best method for the nurse to defuse the situation.
A patient has talked constantly throughout the group therapy session, often repeating the same comments. Other members were initially attentive then became bored, inattentive, and finally sullen. Which comment by the nurse leader would be most effective?
Select the best response for the nurse who receives a question from another health professional seeking to understand the difference between a Diagnostic and Statistical Manual of Mental Disorders (DSM-5) diagnosis and a nursing diagnosis.
A nurse begins work in an agency that provides care to members of a minority ethnic population. The nurse will be better able to demonstrate cultural competence after:
A nurse notices a patient sitting quietly alone, eyes downcast, and looking sad. The nurse says to the patient, 'You look like something is bothering you.' Which pattern of knowing did the nurse use to respond to the patient?
The nurse must be alert to the nonverbal expressions of the client. Because the meaning attached to nonverbal behavior is subjective, it is important for the nurse to
A patient experiencing psychosis asks a psychiatric technician, 'What’s the matter with me?' The technician replies, 'Nothing is wrong with you You just need to use some self-control' The nurse who overheard the exchange should take action based on:
A client who has depression is admitted to treatment on a voluntary basis. While in the hospital, the client makes several comments about wanting to 'end it all.' The client decides one day to leave against medical advice. Which of the following would be the most appropriate action by the nursing staff?
The physician has prescribed Haldol 10 mg for a severely psychotic client. The client refuses the medication. Which nursing intervention is an appropriate response?
The nurse is attending an in-service training on safe take-down techniques for aggressive clients. Preparation for safe physical handling prepares the nurse to practice which ethical principle?
A patient diagnosed with schizophrenia tells the nurse, The CIA is monitoring us through the fluorescent lights in this room. Be careful what you say. Which response by the nurse would be most therapeutic?
A Filipino American patient had a nursing diagnosis of situational low self-esteem related to poor social skills as evidenced by lack of eye contact. Interventions were used to raise the patient’s self-esteem, but after 3 weeks, the patient’s eye contact did not improve. What is the most accurate analysis of this scenario?
Mood is considered to have a role in perseverative psychopathologies such as OCD. One such account is the Mood as input hypothesis, which suggests that OCD suffers persevere with their compulsive activities because:
Mrs. R., the mother of a young schizophrenic patient, seeks you out and begins to cry. She expresses concern over her daughters behavior. Your best response to this woman is:
A patient is expressing anger when the nurse attempts to make him take a medication that he is refusing. If the nurse pushes to give the medication against his will, the nurse is:
A student recently moved from the Middle East and is attending a new school in the United States, where he is excluded from conversations pertaining to the Christmas holidays. The students assume that the new student doesnt understand anything about the holiday. The students are most likely doing what to this new student?
You find a patient on the floor at shift change. She is awake and alert. She is confused now and was not confused prior to the being found on the floor. What is your first step in the nursing process in this situation?
Defense mechanisms are methods used for reducing anxiety. Defense mechanisms unconsciously assist a person in handling stressful events in an effective manner. People have a group of defense mechanisms learned from childhood. The following are defense mechanisms (Select one that does not apply):
An older adult with Alzheimer’s disease lives with family and goes to day care on weekdays. The nurse at the center observed an unkempt appearance and multiple bruises. The nurse discussed these observations with the daughter, who became defensive and said, 'My mother is so difficult to manage. She wanders all night. Last night she fell down the stairs. Sometimes I just can’t bear to care for her.' Which nursing diagnosis has priority?
Emma is a 40-year-old married female who has found it increasingly difficult to leave her home due to agoraphobia. Emma's family is appropriately concerned and suggests that she seek psychiatric care. After investigating her options, Emma decides to try:
A nurse is caring for a client who screams, 'I can read your minds!' The nurse should identify this finding as a manifestation of which of the following personality disorders?
A nurse on a mental health unit is caring for a client who has a new diagnosis of borderline personality disorder. The client states 'I will just see my regular doctor at my annual checkup after I am discharged.' Which of the following responses should the nurse make?
A nurse is caring for a client who has dementia and has a prescription for levodopa. Which of the following types of dementia should the nurse identify that the client has?
A nurse is caring for a patient with major depressive disorder who has been prescribed a selective serotonin reuptake inhibitor (SSRI). The nurse is teaching the patient about the medication. Which of the following should the nurse include in the teaching plan?
A nurse is working with a patient diagnosed with bulimia nervosa. The patient says, 'I can't stop eating even when I feel full.' Which of the following is the most appropriate nursing diagnosis?
As a nurse escorts a patient being discharged after treatment for major depression, the patient gives the nurse a necklace with a heart pendant and says, 'Thank you for helping mend my broken heart.' Which is the nurse's best response?
Documentation in a patient's chart shows, 'Throughout a 5-minute interaction, patient fidgeted and tapped left foot, periodically covered face with hands, and looked under chair while stating, 'I enjoy spending time with you.' Which analysis is most accurate?
A nurse is caring for a patient diagnosed with bipolar disorder who is in the manic phase. The patient states, 'I'm going to buy a new car and take a trip to Paris.' Which of the following is the priority nursing intervention?
A person speaking about a rival for a significant other's affection says in an emotional, syrupy voice, 'What a lovely person. That's someone I simply adore.' The individual is demonstrating
A child has a history of multiple hospitalizations for recurrent systemic infections. The child is not improving in the hospital, despite aggressive treatment. Factitious disorder imposed on another is suspected. Which nursing interventions are appropriate? (Select all that apply.)
An adolescent comes to the crisis clinic and reports sexual abuse by an uncle. The adolescent told both parents about the uncle's behavior, but the parents did not believe the adolescent. What type of crisis exists?
A patient in a support group says, "I'm tired of being sick. Everyone always helps me, but I will be glad when I can help someone else." This statement reflects
A college student said, Most of the time I'm happy and feel good about myself. I have learned that what I get out of something is proportional to the effort I put into it. Which number on this mental health continuum should the nurse select?
A suspicious, socially isolated patient lives alone, eats one meal a day at a local shelter, and spends the remaining daily food allowance on cigarettes. Select a community psychiatric nurses best initial action.
A nurse makes an initial visit to a homebound patient diagnosed with a serious mental illness. A family member offers the nurse a cup of coffee. Select the nurses best response.
A nurse speaks with family members of a Chinese American parent recently diagnosed with major depression. Which comment by the nurse will the family find most comforting? The nursing staff will:
A patient begins a new program to assist with building social skills In which part of the plan of care should a nurse record the item, 'Encourage patient to attend one psychoeducational group daily'?
The nurse has completed the psychosocial assessment. Which of the following is the best approach toward analysis of the data to identify nursing diagnoses and develop an appropriate plan of care?
Select an option. Use Strike to cross one out.
Rationale
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