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326 Exam 1- 287 Complete Questions and Answers
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326 Exam 1- 287 Complete Questionsand Answers
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
-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
-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
-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
-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
-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
-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
-Mrs. Jones was started on Sertraline (Zoloft) two weeks ago. What is
important for the nurse to educate her on regarding this medication?
A. report any thoughts of suicidal ideation, avoid alcohol, and notify provider
if rash occurs
B. report any thoughts of suicidal ideation and notify provider of increased
sex drive
C. Expect weight loss, nausea, increased heart rate and unusual bleeding
D. Avoid activities outdoors in the sun or that cause excessive sweating - -A
report thoughts of suicide, avoid alcohol, notify provider of rash
-A client has been prescribed a medication to treat depression that has
specific food- drug interactions. The client has been advised to avoid foods
containing tyramine.
The astute ASU nursing student recognizes that the client has been
prescribed a medication from this medication classification or med group:
A. SSRIs (Selective Serotonin ReuptakeInhibitors
B. MAOIs (Monoamine oxidase inhibitors)
C. Tricyclics
D. Benzodiazipines - -B. MAOIs
-The nurse documents that a client diagnosed with schizophrenia is
expressing a flat affect. Which statement BEST describes this symptom?
A. The client laughs when told of the death of his mother.
B. The client sits alone and does not interact with others.
C. The client exhibits no emotional expression.
, D. The client experiences no emotional feelings. - -C. No emotional
expression
-An adolescent whose peer recently committed suicide, decides to attempt
suicide himself and is admitted to an inpatient mental health unit. He is
considered high risk for self-harm and suicidal ideation. Which of the
following nursing actions are most appropriate? Select All that Apply
A. Allow him to have all of his belongings
B. Place him on 1:1 observation
C. Have client sign contract for safety
D. Place client on 15 minute checks
E. Remove any belongings that may be considered a risk - -B and E.
1:1 observation and remove risky belongings
-People most at risk for suicide include which of the following? Select all that
apply
A. Health care workers, first responders, and military
B. People who drink socially and have a strong support system
C. People with few protective factors who suffer from depression
D. People over the age of 60 and those in their 20's - -A, C, D.
Health care workers, first responders, military
Few protective factors n depression
Over 60 and in their 20s
-What is the first line pharmacological choice for treating depression?
A. ECT
B. CBT
C. SSRI
D. MAOI - -C.
SSRI
-Jonathan, a 22 year old male comes to the ED after reportedly being up for
48 hours, driving to Las Vegas where he gambled his last paycheck. He
appears disheveled, rapid speech, and is asking for pain medication for his
chronic back pain. Based on this assessment, Jonathan may be experiencing?
A. PTSD
B. Manic episode
C. psychosis
D. Anger from a recent loss - -B
Manic episode
-As the RN, you identify a grieving client to be using maladaptive coping
when you witness?
A. The client participating in pet therapy
B. The client isolating and using statements of self-harm
C. The client taking routine naps and discussing feelings with peers
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