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NUR 326 Psych/MH Exam 1
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NUR 326 Psych/MH Exam 1
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NUR 326 Psych/MH Exam 11. A suicidal patient is found by the nurse as he tries to hang himself from
the shower in the bathroom. What nursing intervention would address the
patient's need for safety while maintaining his self-esteem?
a. Assign a staff member to remain with him at all times.
b. Place him in the seclusion room with 15 minute checks
c. Request that he remain with the patient group at all times.
d. Tell him he may use the bathroom only with staff supervision. - -A
1. The nursing student learned of a high school classmate who recently
committed suicide. The classmate's death surprised the student, because
the classmate had always seemed very confident and popular. The student
knows, however, that suicide is usually:
a. An act with a message and purpose
b. An impulsive act without meaning
c. A random act of selfishness
d. A random act without meaning or purpose - -a
1. A voluntary patient mutilates herself whenever she leaves the unit. The
nurse suggests use of four-point restraint to prevent the patient from further
harming herself. What question should be considered before this measure is
undertaken?
a. Is this the least restrictive measure possible?
b. Can four-point restraint be used for voluntary patients?
c. What litigation is likely to follow from this action?
d. What documentation will be necessary after restraint application? - -a
1. A patient, who has recently lost a spouse, calls the crisis line stating the
occurrence of suicidal ideations that involve jumping off a bridge over the
river when no one is around. What level of lethality would a nurse assess for
this plan?
a. Low
b. Moderate
c. High
d. Lethality cannot be determined from this data - -c
1. Which of the following symptoms indicates Neuroleptic Malignant
Syndrome (NMS), a potentially fatal side effect of an antipsychotic
medication such as Haldol (haloperidol)?
a) Photosensitivity and an itchy rash on face, neck, chest and extremities
b) Hyperthermia and muscle rigidity
c) Blurred vision, constipation, and urinary retention
d) Tongue protrusion, lip smacking, and grimacing - -b
,1. The nurse using cognitive behavior techniques when working with patients
knows that attributions are meanings the patient gives to events or
circumstances that:
a. may or may not be objectively accurate
b. support a sense of autonomy
c. promote rigidity and chaos
d. isolate family members from each other - -a
1. A patient was the driver of a car that struck and killed a child. The patient
tells a nurse, "I killed a child! I'm haunted by the sight of the body being
thrown into the air. If I hadn't been drinking I might have been able to stop. I
don't know how I can go on living with myself!" The crisis nurse should give
priority to assessing the patient's:
a. suicidal risk.
b. physical condition.
c. recent drug dependency.
d. current alcohol consumption. - -a
1. A patient who was savagely attacked by a bear has no memory of the
event. Which statement best explains the patients inability to remember the
attack?
a.
The woman lost consciousness and was not cognitively aware of what
happened during the attack
b.
The brain has produced a chemical anemia that will repress the memories of
the attack indefinitely.
c.
The patient is unconsciously using a defense mechanism to protect against
the repeated memory of the attack.
d.
It is a temporary suppression of the attack; her memory will return when she
is physically and emotionally ready to handle the memories. - -c
Defense mechanisms are used unconsciously to protect us from threats to
the physical, mental, and social aspects of ourselves. The memory of the
event may or may not come back but this is not generally related to the
patients ability to handle the memories. Memory may be lost or impaired as
a result of brain trauma but not as likely from a chemical alteration.
2. Which assessment finding exhibited by a patient being assessed for
posttraumatic stress disorder (PTSD) would be considered a defining
behavior and support such a diagnosis?
a.
Can describe the attack in great detail
b.
,Experiences dramatic swings in affect
c.
Describes vivid flashbacks of being attacked
d.
Is preoccupied with the need to tell someone about the attack - -c
One defining behavior that is seen when an individual has PTSD is that the
person re-experiences the traumatic event. This takes place by having
recurrent and intrusive disturbing recollections of the trauma, including
thoughts, images, or perceptions about the incident. The person sometimes
experiences recurrent dreams of the incident and acts or feels as though the
event was recurring in the present (flashback). Generally the PTSD patient
cannot remember all the details of the trauma nor are they particularly
interested in re-telling the events of the trauma. The patient generally has a
very limited range of affect.
3. What is the basis for assessing a male patient who is agoraphobic for
panic attacks?
a.
Men are more likely to experience panic attacks.
b.
An overwhelming number of agoraphobic patients also have panic attacks.
c.
Patients are often unaware that the symptoms they are experiencing are
those of panic.
d.
Panic attacks are generally the cause of a patient developing phobias like
agoraphobia. - -b
Almost all patients who present with agoraphobia in clinical samples have a
current diagnosis or history of panic disorder. Males are not more likely than
females to experience panic attacks. Patients are not usually unaware of
panic attack symptoms. Panic attacks dont cause, but are often triggered by,
phobias.
4. Discharge preparation for a patient includes the administration of the
Hamilton Anxiety Scale (HAS). When asked by the patient to explain the
purpose of the assessment the nurse responds:
a.
It is an assessment tool used to evaluate the symptoms of anxiety.
b.
The tool is used to help confirm the diagnosis of anxiety disorder.
c.
This tool helps determine if your symptoms have improved with treatment.
d.
, It helps identify the presence of any other disorder associated with anxiety. -
-c
The HAS is a valid and time-tested tool that gives the most objective
measure of the degree to which anxiety has been effectively treated. The
HAS does not evaluate for symptoms of anxiety or act as a diagnosis tool for
anxiety or another other associated disorder.
5. A patient is admitted for treatment for persistent, severe anxiety. Which
nursing diagnosis would help effectively direct patient care?
a.
Disturbed sensory perception related to narrowed perceptual field
b.
Risk for injury related to closed perception
c.
Hopelessness related to total loss of control
d.
Risk for other-directed violence related to combative behavior - -a
A narrowed perceptual field occurs with severe anxiety; therefore this
diagnosis should be considered. Data are not present to support the other
diagnoses.
8. Which question would assist the nurse in determining whether the patient
has been experiencing anxiety?
a.
Have you had difficulty concentrating lately?
b.
Have you been feeling sad and especially lonely?
c.
Do you have a history of failed personal relationships?
d.
Do you frequently experience difficulty controlling your anger? - -a
Concentration difficulties occur when moderate or greater levels of anxiety
are present. Loneliness is more related to mood. A failed personal
relationship is more related to poor self-esteem. Inability to control anger is
related to poor impulse control.
9. The nurse working with patients diagnosed with posttraumatic stress
disorder (PTSD) is aware of the need to intervene early in order to de-
escalate a patients increasing anxiety level. Which patient behavior is likely
an early indication of escalating anxiety?
a.
Talking rapidly
b.
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