The nurse will expect to ask an advanced practice nurse to perform which action for patients?

Prescribe psychotropic medications

Which statement made by a pt during an initial asmt. interview should serve as the priority focus for the plan of care?

"I hear evil voices that tell me to do bad things"

A nurse wants to assess an adult patient's recent memory. Which question would best yield the desired information?

What did you have for breakfast this morning?

Select the example of a tort.

nurse gives antipsych drug to angry pt because unit is short staffed

Teen pt: "why should i tell you anything? youll just tell my parents" Which response by the nurse is appropriate?

What you say is private, but not about things like suicidal thinking

Termination of a therapeutic nurse-pat relationship has been successful when the nurse:

discusses pt changes that happened during relatiobship and evaluate outcome

Hosp. Teen: "I'm going to kill my father, but you can't tell anyone." Select the nurse's best response.

"I am obligated to share that information with the treatment team"

Which patient meets criteria for involuntary hospitalization for psychiatric treatment? The patient who...

threatens to harm self and others

Which actions violate the civil rights of a psychiatric patient? The nurse..

opens and reads a letter a pt left at the nurses station to be mailed

A nurse wants to demonstrate genuineness with a patient diagnosed with schizophrenia. The nurse should:

Use congruent communication strategies

Which nursing intervention demonstrates false imprisonment?

nurse takes pt to room, says to stay put or be put in seclusion

After formulating the nursing diagnoses for a new patient, what is a nurse's next action?

determining goals and outcome criteria

Before assessment a nurse if told by another HCW "i know him, never improvement by dischage" the nurse's responsibility

document the other worker's assessment of the patient

Nursing behaviors associated with the implementation phase of nursing process are concerned with:

carrying out interventions and coordinating care

A patient says, "Please don't share information about me with the other people." How should the nurse respond?

"I will not share info w your family, but I share info about you with staff

Which descriptors exemplify consistency regarding nurse-patient relationships SATA

Setting a time for regular sessions with a patient, Providing a schedule of daily activities to a patient, Having the same nurse care for a patient on a daily basis

Nurse explains how nurse-pt relationship differs from social. Which is the best explanation?

"The focus is on the pt, solutions are implemented by the patient"

quality and safety education for nurses

"any time that the treatment team is justified in violating pts right to confidentiality?" nurse should reply...

if the pt threatens the life of another person

A person asks, "Why aren't people with mental illness kept in state institutions anymore?" Select the best response

Less restrictive settings are now available for those with mental illness

which occurrence should cause the nurse to consider the possibility of countertransference?

The nurse feels unusually happy when the patient's mood begins to lift

Which individual diagnosed with a mental illness may need involuntary hospitalization? An individual

who takes 38 tylenol tablets after stock portfolio becomes worthless

Med is prescribed for elderly pt but dose is more than normal geriatric dose. The nurse should...

withhold the medication and confer with the health care provider

Which action by a psychiatric nurse best applies the ethical principle of autonomy?

Exploring alternative solutions with the patient, who then makes a choice.

pt in alcohol rehab says "i feel terrible for SAing my 6y/o before admitting", select nurses most important action

Anonymously report the abuse by phone to the local child protection agency.

Nurse finds a psych adv dir in the medl record of a patient currently experiencing psychosis. The directive was execute

ensure that the directive is respected in treatment planning.

Which behavior shows that a nurse values autonomy? The nurse:

Discusses options and helps the patient weigh the consequences

Which statement shows a nurse has empathy for a patient who made a suicide attempt?

You must have been very upset when you tried to hurt yourself

Which individual diagnosed with mental illness may need emergency or involuntary admission? The individual who

throws a heavy plate at a waiter at the direction of command hallucinations

Which action by a nurse constitutes a breach of a patient's right to privacy?

releasing information to the pts employer without consent

Older pt in ED: I can't find my way home." The pt is confused and unable to answer questions. Select the best action.

Obtain important info from family member that brough him in

Which remark by a patient indicates passage from orientation to the working phase of a nurse-patient relationship?

"I want to find a way to deal with my anger without becoming violent"

2 hosp. pts fight when together, nurse insists both pts should be secluded for safety, this assertion...

violates the civil rights of both patients.

What is the desirable outcome for the orientation stage of a nurse-patient relationship? The pt will demonstrate:

Rapport and trust with the nurse

Vol. hosp. pt tells nurse "Get me the forms for discharge. I want to leave now." Select the nurse's best response.

I will get them, but let's talk about your decision to leave treatment

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Mental Health Nursing Exam 1

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Questions 45

Answers

1
The nurse will expect to ask an advanced practice nurse to perform which action for patients?
Establish therapeutic relationships
Perform mental health assessment interviews
Individualize nursing care plans
Prescribe psychotropic medications
2
Which statement made by a pt during an initial asmt. interview should serve as the priority focus for the plan of care?
"I can always trust my family"
"I hear evil voices that tell me to do bad things"
"You never know who will turn against you"
"It seems like I always have bad luck"
3
A nurse wants to assess an adult patient's recent memory. Which question would best yield the desired information?
A few minutes ago I told you my name, can you remember it?
Can you name the current president of the United States
What did you have for breakfast this morning?
Where did you go to elementary school?
4
Select the example of a tort.
plan of care for a pt is not complete within 24 hr of the pt's admission
nurse gives antipsych drug to angry pt because unit is short staffed
pt status changed from involuntary to voluntary after hallucination stopped
APN recommends hospitalization for pt who is dangerous to himself and other
5
At what point in AI would a nurse ask, "How does your faith help you in stressful situations?" During the assessment of
Educational background
Childhood growth and development
Substance use and abuse
Coping strategies
6
Teen pt: "why should i tell you anything? youll just tell my parents" Which response by the nurse is appropriate?
Yes, your parents may find out, but its important they know your problems
What you say is private, but not about things like suicidal thinking
That isn't true, what you tell us is private, your parents have no rights
It sounds as though you are not ready to work on your problems
7
Termination of a therapeutic nurse-pat relationship has been successful when the nurse:
give pt a personal phone # and tells them to call after d/c
offers to meet the pt for coffee and convo 3x/week after d/c
avoids upsetting the pr by shifting forcus to other pts before the d/c
discusses pt changes that happened during relatiobship and evaluate outcome
8
Hosp. Teen: "I'm going to kill my father, but you can't tell anyone." Select the nurse's best response.
"I am obligated to share that information with the treatment team"
"Those thoughts will make your hospitalization longer
"You should share this with your psychiatrist"
"You are right. Fed law requires me to keep clinical info private"
9
Which patient meets criteria for involuntary hospitalization for psychiatric treatment? The patient who...
is noncompliant with treatment regimen
sold and distributed illegal drugs
threatens to harm self and others
fraudulently files for bankruptcy
10
Which actions violate the civil rights of a psychiatric patient? The nurse..
Performs checks after hearing pt say theyve been spitting out their meds
opens and reads a letter a pt left at the nurses station to be mailed
places pts expensive watch in the hospital business office safe
begin suicide precautsions before pt is assessed by health care provider
11
A nurse wants to demonstrate genuineness with a patient diagnosed with schizophrenia. The nurse should:
Use self-revelation in patient interactions
Restate what the patient says
Consistently interpret the patient's behaviors
Use congruent communication strategies
12
Which nursing intervention demonstrates false imprisonment?
Confused pt says hes leaving, nurse restrains pt and aquires order
homicidal pt tries to leave, nurse calls security and uses protocols
nurse takes pt to room, says to stay put or be put in seclusion
pt runs off of the unit, nurse chases and convinces the pt to return
13
After formulating the nursing diagnoses for a new patient, what is a nurse's next action?
completing spiritual assessment
implementing the nursing plan of care
Designing interventions to include in the plan of care
determining goals and outcome criteria
14
Before assessment a nurse if told by another HCW "i know him, never improvement by dischage" the nurse's responsibility
assess the pt based on data collected from all sources
discuss worker's impression with the pt during the assessment interview
document the other worker's assessment of the patient
validate the worker's impression by contacting pts significant other
15
Nursing behaviors associated with the implementation phase of nursing process are concerned with:
gathering accurate and sufficient patient-centered data
participating in mutual identification of patient outcomes
comparing patient responses and expected outcomes
carrying out interventions and coordinating care
16
A patient says, "Please don't share information about me with the other people." How should the nurse respond?
I cant tell anyone about you
"I will not share info w your family, but I share info about you with staff
"A therapeutic relationship is between nurse and pt, its up to you to tell"
"I will be glad to disclose at the end of the session what I will report"
17
Which descriptors exemplify consistency regarding nurse-patient relationships SATA
Setting a time for regular sessions with a patient
Providing a schedule of daily activities to a patient
Having the same nurse care for a patient on a daily basis
Encouraging a patient share initial impressions of staff
18
Nurse explains how nurse-pt relationship differs from social. Which is the best explanation?
"The focuse of the relationship is socialization. Mutual needs are met"
"The focus is on the pt, solutions are implemented by the patient"
"The focus shifts from nurse to pt as relationship develops"
"Focus is creation of a partnership each member is concerned with growth"
19
Nurse takes pt on tour of unit, explains rules and daily schedule. The nurse is engaged in...
Psychological intervention
Mileu management
Counseling
Health teaching
20
What phase of the nurse-pt relationship can the nurse assume that identified pt issues will be explored and resolved?
Working
Orientation
Termination
Preorientation
21
Pt w/depression, lost 20lbs, plan for suicide. Which nursing intervention has the highest priority?
Assist the pt to identify 3 personal strengths
Implement suicide precautions
Offer high-calorie snacks and fluids frequently
Observe the pt for therapeutic effects of antidepressant medication
22
At what point in the nurse-patient relationship should a nurse plan to first address termination?
When the patient initially brings up the topic
At the end of the working phase
During the orientation phase
Near the beginning of the termination phase
23
"QSEN" refers to:
quick standards essential for nurses
qualitative standardized excellence in nursing
quality and safety education for nurses
qualitative effectiveness in nursing
24
"any time that the treatment team is justified in violating pts right to confidentiality?" nurse should reply...
when questions are asked by law enforcement
if the pt threatens the life of another person
at the discretion of the psychiatrist
under no circumstances
25
A person asks, "Why aren't people with mental illness kept in state institutions anymore?" Select the best response
Less restrictive settings are now available for those with mental illness
psychiatric institutions violated patients' rights
there are fewer persons with mental illness, so less beds are needed
most people with mental illness are still in psychiatric institutions
26
which occurrence should cause the nurse to consider the possibility of countertransference?
The nurse feels unusually happy when the patient's mood begins to lift
"Talking to you feels like talking to my parents"
The patient's reactions toward the nurse seem realistic and appropriate
27
Which individual diagnosed with a mental illness may need involuntary hospitalization? An individual
diagnosed with major depression who stops taking antidepressants
with visions of demons emerging from cemetary plots
who has a panic attack after her child is lost in a shopping mall
who takes 38 tylenol tablets after stock portfolio becomes worthless
28
1 pt in restraints for SI 1 pt on 1 on 1 for SI. Which ethical principle most clearly applies to this situation?
Fidelity
Justice
Beneficence
Autonomy
29
Med is prescribed for elderly pt but dose is more than normal geriatric dose. The nurse should...
consult a reliable drug reference
teach the pt about possible side effects and adverse effects
encourage the pr to increase oral fluids to reduce drug concentration
withhold the medication and confer with the health care provider
30
Legal significance of nurse's action when administering meds to a pt after they refused and objected?
committed malpractice.
The nursea. has been negligent.
fulfilled the standard of care.
can be charged with battery.
31
Which action by a psychiatric nurse best applies the ethical principle of autonomy?
Staying with a patient demonstrating a high level of anxiety.
Suggesting that two patients who were fighting be restricted to the unit.
Intervening when a self-mutilating patient attempts to harm self.
Exploring alternative solutions with the patient, who then makes a choice.
32
pt in alcohol rehab says "i feel terrible for SAing my 6y/o before admitting", select nurses most important action
File a written report with the agency's ethics committee.
Respect nurse-patient relationship confidentiality.
Reply, "I'm glad you feel comfortable talking to me about it."
Anonymously report the abuse by phone to the local child protection agency.
33
Pt states "i'm not worth anything, i want to go to sleep and never wake up" Which intervention is highest priority?
anxiety self-control measures
suicide precautions
sleep enhancement activities
self-esteem building activities
34
Nurse finds a psych adv dir in the medl record of a patient currently experiencing psychosis. The directive was execute
review the directive with the patient to ensure it is current.
encourage the patient to revise the it in light of current health problem.
consider the directive only if there is a cardiac or respiratory arrest.
ensure that the directive is respected in treatment planning.
35
Which behavior shows that a nurse values autonomy? The nurse:
Suggest one-on-one supervision to suicidal patient
Informs patient that spouse will not be in during visiting hours
Discusses options and helps the patient weigh the consequences
Sets limits on a patient's romantic overtures toward the nurse
36
Which statement shows a nurse has empathy for a patient who made a suicide attempt?
It makes me sad to see you going through such a difficult experience
You must have been very upset when you tried to hurt yourself
If you tell me what is troubling you, I can help you solve your problems
Suicide is a drastic solution to a problem that may not be so serious
37
Which individual diagnosed with mental illness may need emergency or involuntary admission? The individual who
does not keep an outpatient appointment with the mental health nurse.
resumes using heroin while still taking naltrexone
throws a heavy plate at a waiter at the direction of command hallucinations
reports hearing angels playing harps during thunderstorms.
38
Which standardized scare will the nurse include in the assessment of a newly admitted pt dx with depressive disorder?
Beck Inventory
Global assessment of functioning scale (GAF)
Mini-mental state examination (MMSE)
Body attitude test
39
Which action by a nurse constitutes a breach of a patient's right to privacy?
Document pts daily behavior during hospitalization
asking family to share info about pts prehospitalization behavior
releasing information to the pts employer without consent
discussing the pts hx with other staff during care planning
40
Pt w/depression has gained 20 lbs and has suicidal ideation. Select priority nursing diagnosis
Risk for suicide
Chronic low self-esteem
Imbalanced nutrition
Hopelessness
41
Older pt in ED: I can't find my way home." The pt is confused and unable to answer questions. Select the best action.
Obtain important info from family member that brough him in
Call for mental health advocate to maintain patient's rights
Ask an APN to perform the assessment interview
Record pts answers on nursing assessment form
42
Which remark by a patient indicates passage from orientation to the working phase of a nurse-patient relationship?
"I don't know how it will help to talk to you about my problems"
"I don't have any problems"
"I want to find a way to deal with my anger without becoming violent"
"It is so difficult for me to talk about problems"
43
2 hosp. pts fight when together, nurse insists both pts should be secluded for safety, this assertion...
reinforces the autonomy of the two patients.
violates the civil rights of both patients.
correctly places emphasis on safety.
represents the intentional tort of battery.
44
What is the desirable outcome for the orientation stage of a nurse-patient relationship? The pt will demonstrate:
Self-responsibility and autonomy
A greater sense of independence
Rapport and trust with the nurse
Resolved transference
45
Vol. hosp. pt tells nurse "Get me the forms for discharge. I want to leave now." Select the nurse's best response.
I cannot give you those forms without your health care providers permission
I will get them, but let's talk about your decision to leave treatment
Since you signed your consent for treatment, you may leave if you desire
I will get the forms for you right now and bring them to your room

Mental Health Nursing Exam 1 Flashcards | StudBud