ARELLANO UNIVERSITY COURSE AUDIT 2 PSYCHIATRIC NURSING QUIZ 1 Set A/B 1/13. When planning the discharge of a client with chronic anxiety, the nurse directs the goal at promoting a safe environment at home. The appropriate maintenance goal should focus on which of the following? a. Ignoring feelings of anxietyc. Continued contact with a crisis counselor b. Identifying anxiety-producing situations.d. Eliminating all anxiety from daily situations ANSWER: BRecognizing situations that produce anxiety allows the client to prepare to cope with anxiety or avoid specific stimulus. Counselors will not be available for all anxiety-producing situations, and this option does not encourage the development of internal strengths. Ignoring feelings will not resolve anxiety. Eliminationof all anxiety from life is impossible. 2/21. A woman comes into the emergency in a severe state of anxiety following a car accident. The appropriate nursing intervention is to: a. Remain with client.c. Teach the client deep breathing. b. Put a client in a quiet room.d. Encourage the client to talk about their feelings and concerns. ANSWER: A If a client with severe anxiety is left alone, the client may feel abandoned and become overwhelmed. Placing the client in a quiet room is also important, but nurse must stay with the client. Teaching the client deep breathing or relaxation is not possible until the anxiety decreases. Encouraging the client to discuss concerns and feelings would not take place until the anxiety has decrease. 3/16. The client is unwilling to go out of the house for fear of doing something crazy in public. Because of this fear, the client remains homebound, except when accompanied outside by the spouse. Based on this data, the nurse determines that the client is experiencing: a. Agoraphobia b. Social phobia c. Claustrophobiad. Hypochondriasis ANSWER: A Agoraphobia is the fear of open spaces and the fear of being trapped in a situation from which there may not be an escape. Agoraphobia includes the possibility of experiencing a sense of helplessness or embarrassment if an attack occurs. Avoidance of such situations usually results in the reduction of social and professional interactions. Social phobia focuses more on specific situations, such as fear of speaking, performing or eating in public. Claustrophobia is a fear of closed places. Clients who have hypochondriacal symptoms focus their anxiety on physical complaints and preoccupied with their health. 4/14. A client is admitted to a medical nursing unit with a diagnosis of acute blindness. Many tests are performed, and there seems to be no organic reason why his client cannot see. The nurse later learns that the client became blind after witnessing a hit-and-run car accident, when a family of three was killed. The nurse suspects that the client may be experiencing a: a. Psychosisb. Repression c. Conversion disorder d. Dissociative disorder ANSWER: C A conversion disorder is the alteration or loss of a physical function that cannot be explained by any known pathophysiological mechanism. A conversion is thought to be an expression of a physiological need or conflict. In this situation, the client witnessed an accident that was so physiologically painful that the client became blind. A dissociative disorder is a disturbance or alteration in the normally integrative functions of which identity, memory or consciousness. Psychosis is a state of which a persons capacity to recognize reality, communicate, and relate to others is impaired, thus, interfering with the persons ability to deal with lifes demands. Repression is coping mechanism in which unacceptable feelings are kept out of awareness. 5/22. A client reports experiencing nightmares and constant worry about the weather since typhoon Ondoy destroyed the clients house. The nurse assesses that this client is experiencing: a. Hallucinationsb. Panic attacksc. flashbacksd. delusions ANSWER: C A client who repeatedly experiences nightmares and constantly worries about the weather since a typhoon destroyed his house is experiencing flashbacks. Clients who have flashbacks have recurrent intrusive recollections of the traumatic event. Clients with delusions, hallucinations, and panic attacks wouldreexperience the traumatic event. Reference: Mary Ann Boyd. Psychiatric Nursing. 4th edition. Page 428-429 6/17. A 30 year old male employee frequently complains of low back pain that leads to frequent absences from work. Consultation and tests reveal negative results. The client has which somatoform disorder?a. Somatization Disorder b. Hypochondriaisis c. Conversion Disorderd. Somatoform Pain DisorderANSWER: DThis is characterized by severe and prolonged pain that causes significant distress. Option A: This is a chronic syndrome of somatic symptoms that cannot be explained medically and is associated with psychosocial distress. Option B: This is an unrealistic preoccupation with a fear of having a serious illness. Option C: Characterized by alteration or loss in sensory or motor function resulting from a psychological conflict. Reference: Mary Ann Boyd. Psychiatric Nursing. 4th edition. Page 497 7/15. The nurse is assessing a parent who abused her child. Which of the following risk factors would the nurse suspect to find in this case? a. Flexible role functioning between parentsc. Single parent home situation b. History of parent having been abused as childd. Presence of parental mental illness ANSWER: B One of the most important risk factors is history of childhood abuse in the parent who abuses. Family violence follows a multigenerational pattern. Parents who are flexible in their roles are characteristic of healthy functioning, not abuse. Single parent households and a history of mental illness are not established risk factors for child abuse by a parent. Reference: Mary Ann Boyd. Psychiatric Nursing. 4th edition. Page 865-866 8/19. Incidents of a child molestation that come out years later when the victims is an adult are best explained the ego defense mechanism of: a. Repression b. Regression c. Rationalizationd. Reaction formation ANSWER: A Repression is a coping mechanism in which unacceptable feelings are kept out of conscious awareness; later under stress or anxiety, thoughts or feelings surface and come into ones conscious awareness Reference: Videbeck. Psychiatric Mental Health Nursing. 3rd edition. Page 51-52 9/12. A nurse working in the emergency department is conducting an interview with a victim of spousal abuse. Which step should the nurse take first? a. Contact appropriate legal service b. Ensure privacy for interviewing the victim away from the abuser c. Establish rapport with the victim and abuser d. Call security guard ANSWER: B Privacy away from the abuser is important. This allows the victim to discuss the problem freely, without fear of reprisal from the abuser. Option A: It is not the responsibility of the nurse to call the legal service, it is up to the woman to make that decision. However if injury is inflicted the nurse is obligated to report the abuse. Option C: Although the nurse would want to establish rapport with the victim, her initial concern would not be to establish rapport with the abuser. The situation does not describe the abuser as currently violent, requesting a security is inappropriate at this time. Reference. Ann Isaacs. Psychiatric Nursing. Page 175 10/23. The depressed client verbalizes feelings of low self-esteem and self-worth typified by statements such as Im such a failure. I cant do anything right. The best nursing response would be to: a. Tell the client that this is not true, that we all have a purpose inlife.b. Identify recent behaviors or accomplishments that demonstrate the clients skill.c. Reassure the client that you know how the client is feeling and that things will get better.d. Remain with the client and sit in silence; this will encourage the client to verbalize feelings. ANSWER: B Feeling of low self-esteem and worthlessness are common symptoms of the depressed client. An effective plan of care to enhance the clients personal self-esteem is to provide experiences for the client that are challenging but that will not be met with failure. Reminders of clients past accomplishments or personal successes are ways to interrupt the clients negative self-talk, and distorted cognitive view of self. Silence may be interpreted as agreement. Options A and C give advice and devalue the clients feelings. 11/18. A client with a diagnosis of major depression, recurrent, with psychotic features is admitted to the mental health unit. To create a safe environment for the client, the nurse most importantly devises a plan of care that deals specifically with the clients:a. Self-care deficit.b. Imbalanced nutrition. c. Deficient knowledge. d. Disturbed thought processes. ANSWER: D Major depressions, recurrent, with psychotic features, alert the nurse that in addition to the criteria that designate the diagnosis of major depression, one also must deal with clients psychosis. Psychosis is defined as a state in which a persons mental capacity to recognize reality and communicate and relate to others is impaired, thus, referring with the persons ability to deal with the demands of life. Disturbed thought processes generally indicate a state of increased anxiety in which hallucinations and delusions prevail. Although all the nursing diagnosis may be appropriate because the client is experiencing psychosis, option D is the correct option. 12/24. The nurse assesses a client with the admitting diagnosis of bipolar affective disorder, mania. The symptom presented by the client that requires the nurses immediate intervention is the clients: a. Outlandish behaviors and inappropriate dress b. Nonstop physical therapy and nutritional intake c. Grandiose delusions of being a royal descendent of King Arthur d. Constant, incessant talking that includes sexual innuendos and teasing the staff ANSWER: B Mania is a mood characterized by excitement, euphoria, hyperactivity, excessive energy, decreased need for sleep, and impaired ability to concentrate or complete a single trend of thought. Mania is a period when the mood is predominantly elevated, expansive, or irritable. All options reflect a clients symptomatology. Option 2, however, clearly presents a problem that compromises physiological integrity and needs to be addressed immediately. 13/20. A client who has been raped tells the nurse that the rape was her fault because she walked down an alley on her way to school. Which response by the nurse would be best in this situation? a. Accept the clients statement that this was risk-taking behavior b. Ask the client what other behaviors may have been risky c. Emphasize that the rapist, not the client is responsible d. Suggest that the client discuss this issue later ANSWER: C The clients feeling of self-blame is a common response to rape-trauma crisis. However, this is not realistic perception of the event, and the nurse should point out reality (telling the victim that the rapist is responsible). The responses in options A and B would only serve to reinforce the clients misperception that her own behavior caused the rape and, therefore, are incorrect. The response in option D is incorrect because it avoids addressing the clients distress and is unsupportive to the situation. Reference: Norman Keltner. Psychiatric Nursing. 5th edition. Page 612-613 14/25. The client is admitted to the mental health unit with a diagnosis of schizophrenia. A nursing diagnosis formulated for the client is thought processes, disturbed related to paranoia. In formulating nursing interventions with the members of the health care team, the nurse provides instructions to: a. Increase socialization of the client with peers. b. Avoid laughing or whispering in front of the client.c. Begin to educate the client about social supports in the community. d. Have the client sign a release of information to appropriate parties so that adequate date can be obtained forassessment purposes. ANSWE: B Disturbed thought process related to paranoia is the clients problem, and the plan of care must address this problem. The client is experiencing paranoia and is distrustful and suspicious of others. The members of the health care team need to establish a rapport and trust with the client. therefore, laughing or whispering in front of the client would be counterproductive. Options A, C and D ask the client to trust on a multitude of levels. These options are actions that are too intrusive of levels. These options are actions that are too intrusive for a client who is paranoid. 15/11. A client is admitted to a psychiatric unit with a diagnosis of undifferentiated schizophrenia. Which of the following defense mechanism is probably used? a. Projection b. Rationalizationc. Regression d. RepressionAnswer: CRegression, a return to earlier behavior to reduce anxiety, is the basic defense mechanism in schizophrenia. Repression is the basic defense mechanism in the neuroses. Rationalization is a defense mechanism used to justify ones action. Projection is a defense mechanism in which one blames others and attempts to justify actions; its used primarily by people with paranoid schizophrenia and delusional disorder. 16/6. A client with a diagnosis of schizophrenia, paranoid type, is admitted to an acute-care psychiatric hospital unit. In anticipation of the clients needs, what nursing diagnosis would be given the highest priority? a. Altered thought processes c. Social isolationb. Impaired verbal communication d. Risk for violence directed at self or at othersAnswer:D Safety is always the highest priority when caring for a client with a diagnosis of schizophrenia, paranoid type. Clients with diagnosis are potentially violent and can quickly become aggressive as a result of their psychosis. The other options (A,B and C) of diagnoses are appropriate for the clients care plan but are not given the highest priority. 17/1. A clients disruptive behavior on the ward has been increasingly annoying to the other patients.One approach by the nurse might be to a. Tell her she is annoying others and confine her to her room b. Ignore her behavior, realizing it is consistent with her illness c. Set limits on her behavior and be consistent in approach d. Make a rigid structured plan that she will have to follow Answer:C Set limits on her behavior and be consistent in approach this is important to avoid rejection of the other patients with subsequent lowering of self esteem. 18/5. A clients illness can best be understood as the egos attempt to compensate for an assault against it and fear of the punitive superego.What underlying condition would be the source of the mania? a. Delusions of grandeurb. Depressionc. Fear of lossd. Malformed superego Answer:BDepression is a result of the assault on the ego and the mania covers the depression. 19/9. During a manic state, a client paced around the dayroom for 3 days. He talked to the furniture, proclaimed he was a king, and refused to partake in unit activities. Which of the following nursing diagnoses has priority? a. Hypertension related to hyperactivityc. Altered nutrition related to hyperactivity b. Risk for violence related to manic stated. Ineffective individual coping related to manic state Answer: C During a manic state, clients are at risk for malnutrition due to not taking in enough calories for the energy theyre expending. This client isnt showing violent behavior. Individual coping issues arent the primary concern at this time. Hypertension isnt an approved nursing diagnosis. 20/2. Which word best describes the type of schizophrenia identified by marked negativism, rigidity, excitement, stupor or posturing? a. Catatonicb. Disorganized c. Undifferentiated d. ParanoidAnswer:A Catatonic schizophrenia is a state of psychologically induced immobilization, which is, at times, interrupted by episodes of extreme agitation, such as negativism, rigidity, excitement, stupor, or posturing. Undifferentiated schizophrenia occurs when no single clinical presentation dominates (paranoid, disorganized, or catatonic). Disorganized schizophrenia is characterized by disorganized speech, disorganized behavior, and inappropriate affect. The dominant theme in paranoid schizophrenia is one of delusions and hallucinations. 21/7. The neuroleptic malignant syndrome was under control, which of the following statement if made by the client would indicate an understanding of the resumption of antipsychotic medications? a. After three days I will resume my medicationc. I can restart my medication after 2 to 3 weeks b. Immediately after the resolution of NMSd. I can resume anytime I feel like taking the medications ANSWER: Antipsychotics should not be reinstituted for at least 2 weeks after complete resolution of NMS. Reference:Norman Keltner. Psychiatric Nursing. 5th edition. Page 221 22/3. The nurse is caring for a client with schizophrenia. Which of the following outcomes is the least desirable? a. The client spends more time by himself. b. The client doesn't engage in delusional thinking. c. The client doesn't harm himself or others. d. The client demonstrates the ability to meet his own self-care needs. ANSWER: A The client with schizophrenia is commonly socially isolated and withdrawn; therefore, having the client spend more time by himself wouldn't be a desirable outcome. Rather, a desirable outcome would specify that the client spend more time with other clients and staff on the unit. Delusions are false personal beliefs. Reducing or eliminating delusional thinking using talking therapy and antipsychotic medications would be a desirable outcome. Protecting the client and others from harm is a desirable client outcome achieved by close observation, removing any dangerous objects, and administering medications. Because the client with schizophrenia may have difficulty meeting his or her own self-care needs, fostering the ability to perform self-care independently is a desirable client outcome. Reference: Ann Isaacs. Mental health and Psychiatric Nursing.4th edition. Page 131 23/10. A client diagnosed with schizophrenia is displaying flat affect, slowed thinking and a lack of motivation. The nurse interprets these as which of the following? a. Delusions b. Positive symptoms c. hallucinationsd. negative symptoms ANSWER: D Negative symptoms such as flattened affect, slowed thinking and lack of motivation are observed and in many ways are more debilitating Unlike positive clinical manifestations, negative symptoms are behaviors fundamentally different from behaviors exhibited by many people. They are more common and severe in schizophrenia. They are particularly obvious when contrasted to how the client was before the onset of the disorder. Delusions and hallucinations are positive symptoms because they must be self reported by the client. Reference:Norman Keltner. Psychiatric Nursing. 5th edition. Page 342-343 24/8. Mike tells nurse Gener that the Actress in the teleserye is sending a secret message to him. Nurse Gener suspects that Mike is experiencing: a. A delusion b. Flight of ideas c. Delusions of referenced. A hallucination ANSWER: C 25/4. According to the hypothesis in Biochemical theory of schizophrenia, treatment is directed towards correcting the chemical imbalance. Which neurotransmitter would the nurse identify as being the target for antipsychotic medications?a. Dopamineb. Serotoninc. Acetylcholine d. Norepinephrine ANSWER: A