Psychiatric Nursing Interventions, Exams of Nursing

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Psychiatric Mental Health Nursing

NCLEX Review Questions Set 1

A 48-year-old Hispanic woman is seen by a psychiatric clinical nurse specialist after receiving a call by her son. According to the son, since his father's death 7 months ago, his mother has lost 30 pounds and can't sleep. During her initial visit, the patient states, 'My husband talks to me in his visits, but his words make no sense to me. I don't understand what he wants me to do.' What is an appropriate nursing diagnosis? A. Ineffective denial. B. Bipolar mood disorder. C. Hyper-religiosity. D. Grieving. - correct answer D. Grieving. Reason: Grieving may be characterized by weight loss, sleep disturbances, and messages from beyond. Your neighbor's husband comes to talk to you. He says his wife has not left the house in 2 weeks, has a flat mood, and has lost interest in her usual activities. You recognize these as the primary symptoms of A. Depression. B. Schizophrenia. C. Suicidal ideation. D. Bipolar manic episodes. - correct answer A. Depression. Reason: Depressed mood and anhedonia (loss of interest or pleasure in activities) are the primary symptoms of major depression. Your patient is ready for discharge after a 30-day hospitalization for manic depression. About 30 minutes before his discharge, his roommate comes to you and says, 'He is talking crazy.' When you ask your patient how he is feeling, he states, 'I feel like Superman. I can do anything. I can fly home today and then become a U.S. Senator.' Which type of mania-related symptoms is this patient exhibiting?

A. Social. B. Cognitive. C. Behavioral. D. Perceptual. - correct answer B. Cognitive. Reason: Cognitive symptoms include inflated self-esteem and grandiosity. You need to assess whether a patient who has a mood disorder is ready for discharge. Which statement would indicate readiness for discharge? A. Right now, I can't bathe myself or dress myself, but I feel good about that. B. Going home will be fun, but if it isn't fun, I can always make my mother help me or tell her to do so. She better help me. C. I will take my medicines as I should and know to call the number you gave me if I have bad thoughts. D. Taking care of myself is important, but it's okay if I don't want to do anything. - correct answer C. I will take my medicines as I should and know to call the number you gave me if I have bad thoughts. Reason: Verbalization of a plan for help and demonstration of care are realistic discharge criteria. An angry patient is in the community room. She picks up a chair and uses it to hit another patient on the head. When you come into the community room, what should your first response to the patient holding the chair be? A. Are you crazy? Hitting people can hurt them! B. Hitting others is unacceptable. Please put the chair completely down on the floor. C. How would you like it if I hit you over the head with a chair? D. You're in big trouble now. It's probably prison you are looking at! - correct answer B. Hitting others is unacceptable. Please put the chair completely down on the floor. Reason: Use words to indicate your lack of acceptance of the patient's behavior in a nonthreatening voice or tone.

A 22-year-old female is admitted to the unit following a suicide attempt. She has a 2-week history of depression as well as a history of abusing multiple substances and anorexia nervosa. What is your first nursing priority? A. Socialization. B. Contracting for eating behavior. C. Safety. D. Administering the Beck depression scale. - correct answer C. Safety. Reason: Safety is the major principle underlying psychiatric nursing. Gerald was admitted to the psychiatric acute care unit because he stood in the center of a main two-way street in his underwear and a T-shirt, shouting, 'I am being held against my will. I have personal rights.' Gerald was diagnosed with bipolar disorder, manic type. Which of the following interventions will add to everyone's safety in the acute care environment? A. Have hectic surroundings. B. Have consistent unit routines. C. Minimize staff interventions. D. Medicate the patient only if he has private health insurance. - correct answer B. Have consistent unit routines. Reason: Quiet environments with consistent routines will help calm patients and add to safety. Your patient has just been physically cleaned up after slicing his left arm 8 times. To show an appropriate evaluative response, which of the following would be your best statement? A. I could care less if you cut yourself. It doesn't hurt me. B. If you wouldn't cut yourself, you would have a much happier life. C. You are lucky someone found you in time. Now you can help us make you better. D. The behavior of cutting is not acceptable. - correct answer D. The behavior of cutting is not acceptable. Reason: Focus on the behavior, not the person. Be neutral, but not indifferent.

A 22-year-old female was admitted to the mental health unit with major depression and suicidal ideation. She has a history of cutting her wrists intermittently throughout the last 2 years. On days 1 and 2, the patient stays in her room and eats only 20% of her meals. On day 3, she eats 80% of her meals and is talking to others in group. The nurse should consider that the patient is A. Showing improvement. B. Highly suicidal. C. Exhibiting mood swings. D. In need of electroshock therapy. - correct answer A. Showing improvement. Reason: The patient improvement is based on increased socialization and increased appetite. A 21-year-old patient has a diagnosis of schizophrenia and is stuporous, yet exhibits sudden, excessive motor activity with repetitive sit-ups. What is this behavior called? A. Delusional. B. Hallucinogenic. C. Paranoid. D. Catatonic. - correct answer D. Catatonic. Reason: Catatonic schizophrenia occurs suddenly and includes motor immobility or excessive motor activity. A 16-year-old girl is admitted for her first psychotic break. Her parents feel very guilty. What is your best nursing response? A. No one really knows the cause of schizophrenia. It is not your fault and is not due to anything you did in the past. It is important to understand this, to support your daughter, and to find support for yourselves. B. Does anyone in your family have schizophrenia, as this disease is known to be genetic? C. You may feel bad now, but there are so many other bad things out there, such as cancer and paralysis. D. Let me share with you some websites to help you deal with your guilt. - correct answer A. No one really knows the cause of schizophrenia. It is not your fault and is not due to anything you did in the past. It is important to understand this, to support your daughter, and to find support for yourselves.

Reason: Schizophrenia has a multifocal origin and its cause may include a genetic component. Support is needed for both patients and caregivers. A physical indicator of possible abuse in a battered woman would be a fracture of the distal bones, such as the skull, face, or extremities. A. TRUE B. FALSE - correct answer A. TRUE Reason: Musculoskeletal fractures and sprains, especially of distal versus proximal bones, are indications of battering. Also assess for dislocated shoulders and old fractures. Which of the following statements indicates that your patient, who has schizophrenia, is ready to manage a relapse? A. I will think of a plan of action before I get these racing thoughts again. B. I will not drink alcohol and will exercise daily. This will help me stay well. C. If I start feeling badly and don't sleep very much, then I will tell my friend Sandy and talk to her. She or I will call my therapist. D. When I feel stressed, I will sit near my bed and wait to feel better. - correct answer C. If I start feeling badly and don't sleep very much, then I will tell my friend Sandy and talk to her. She or I will call my therapist. Reason: Managing a relapse includes a plan of action, involvement of a friend or family member, and, after identification of signs, notification of a therapist. Your patient has a diagnosis of schizophrenia and believes that his thoughts are broadcast from his head. What is the most appropriate nursing diagnosis? A. Risk for self-directed violence. B. Disturbed sensory perception. C. Impaired verbal communication. D. Disturbed thought processes. - correct answer D. Disturbed thought processes.

Reason: Thought broadcasting and thought withdrawal are disturbed thought processes. As a nurse, you wish to reinforce functional behavior in your schizophrenic patient. Which intervention will accomplish reinforcement? A. Praise the patient for reality-based perceptions and cessation of acting-out behaviors. B. Educate the patient about the symptoms of schizophrenia. C. Facilitate learning about the importance of medication compliance using written materials for reinforcing medication use. D. Focus on the feelings of delusion to reinforce reality and decrease false beliefs by talking to the patient. - correct answer A. Praise the patient for reality-based perceptions and cessation of acting-out behaviors. Reason: Reinforcement by praise increases functional behavior. Your patient is preoccupied with perfection and control, has difficulty relaxing, exhibits rule-conscious behavior, and cannot discard anything. What type of personality disorder does this behavior reflect? A. Antisocial personality. B. Obsessive-compulsive personality. C. Manic behavior. D. Anxiety disorder. - correct answer B. Obsessive-compulsive personality. Reason: Obsessive-compulsive disorder is a personality disorder that includes perfection, control, procrastination, excessive devotion to work, difficulty relaxing, rule-conscious behavior, and inability to discard anything. Which of the following questions is appropriate to assess for disturbances in a patient's relationships? A. What are your main worries? B. Have you ever used alcohol or illegal drugs? C. How has your appetite been in the past month? D. What do you talk about with friends? - correct answer D. What do you talk about with friends?

Reason: Asking what the patient talks about with family or friends and what types of activities he or she engages in can help assess relationships. Which type of therapy helps patients with personality disorders explore ways to enjoy themselves and increase their socialization skills? A. Occupational therapy. B. Recreational therapy. C. Music therapy. D. Medication therapy. - correct answer B. Recreational therapy. Reason: Recreational therapy helps patients explore ways to enjoy themselves without using alcohol or drugs and strengthens social skills. Which of the following symptoms of alcohol detoxification would you be most concerned about? A. Vitamin and mineral depletion. B. Diaphoresis. C. Increased heart rate. D. Hallucinations and delusions. - correct answer D. Hallucinations and delusions. Reason: Hallucinations and delusions can result in problems with safety and possibly lead to suicide. What is the priority nursing intervention to help orient a patient who has Alzheimer's disease? A. Post a schedule in the dining room of daily activities. B. Use an overhead loudspeaker to announce upcoming events. C. Provide a daily routine and easy-to-read clocks. D. Have the patient live alone in a private room. - correct answer C. Provide a daily routine and easy-to-read clocks. Reason: Daily routines and large clocks help patients' functional status.

You are caring for a patient and pour out his evening risperidone (Risperdal) 2 mg tablet. The pill falls on the countertop. What is your next intervention? A. Pick the pill up from the counter and place it in a cup. B. Wash the pill off with alcohol and place it in a cup. C. Discard the pill and repour the medication. D. Call the patient up to the pill line to receive his medication. - correct answer C. Discard the pill and repour the medication. Reason: The pill is contaminated once dropped, so for infection control purposes you discard it and repour the medication. Your patient has just shown you some fresh, self-inflicted, superficial cuts-eight of them going up and down his right arm. What is your initial intervention based on infection control principles? A. Send the patient back to his room as part of behavioral modification. B. Suture the cuts using a large-bore needle and nondissolving sutures. C. Cleanse the wounds with soap and water. D. Administer tetanus toxoid injection intramuscularly. - correct answer C. Cleanse the wounds with soap and water. Reason: Cleansing the wound with soap and water is the initial intervention. A hypomanic patient tells you that she has been 'picking up energy from my car engine and car CD player' while driving and has received five speeding tickets in the past 6 months. What would be one effective intervention to avoid fast driving? A. Make a contract not to drive more than 55 miles per hour and drive with the CD played turned off. B. Call the local police and alert them to the patient's car license plate number and the make and model of her car. C. Ask the patient to "hand over the keys" to you, and tell her that now she must use a cab or other public transportation until your next session. D. Share with the patient that she cannot drink and drive. - correct answer A. Make a contract not to drive more than 55 miles per hour and drive with the CD played turned off.

Reason: Contracts can see a patient through period of hypomanic agitation. Patients who require close surveillance due to the potential for safety hazards give up the right of A. Continued confusion. B. Decision making. C. Social contact. D. Privacy. - correct answer D. Privacy. Reason: Privacy and autonomy are often given up for the sake of safety. patient is extremely agitated and is throwing body fluids at anyone who comes near him. What is the best way to protect yourself as you and others physically restrain the patient? A. Wash your clothes within 30 minutes of becoming soiled with body fluids. B. Wear protective eyewear and a face shield. C. Check that your tetanus and hepatitis B titers are within normal limits. D. Wear a gown over your clothes and shoe covers. - correct answer B. Wear protective eyewear and a face shield. Reason: Protective gear helps prevent infections that may gain entry through openings in the skin, the eyes, or the mouth. A patient who is psychotic has a formed bowel movement on the floor of his room. How should you clean up this excrement? A. Use a thick diaper or pad. B. Wear gloves and use some paper towels or toilet paper. C. Wear gloves, use toilet paper, and wash the area with a 1:10 bleach solution. D. Wear a gown, shoe covers, mask, and chemotherapy-impervious gloves, and wash the area with an ammonia with bleach 1:1 solution. - correct answer C. Wear gloves, use toilet paper, and wash the area with a 1:10 bleach solution.

Reason: Clean all body fluids with an appropriate disinfectant such as 1:10 bleach solution, using universal precautions. Your patient is scheduled for a one-on-one therapy session. Upon his entry into your office, you note that the patient has a cough, is sweating, is coughing up a small amount of blood, and has a fever. What is your initial intervention regarding infection control? A. Wash all of the patient's sheets and clothes. B. Place a mask on the patient and yourself. C. Take the patient's temperature. D. Place resuscitation equipment in the patient's room. - correct answer B. Place a mask on the patient and yourself. Reason: The patient might have tuberculosis, so wear a mask, especially given that the patient is coughing. You have just given your patient an intramuscular injection of fluphenazine (Prolixin) with a syringe that does not have a safety lock. What is your next step? A. Recap the needle. B. Snap the needle off and place it in the needle box. C. Immediately place the syringe in a nearby impermeable container. D. Clip the needle off with a syringe needle cutter (SNC). - correct answer C. Immediately place the syringe in a nearby impermeable container. Reason: Place the syringe in a nearby container specific for needles. Do not recap, bend, clip, or manipulate the needle in any way. In an inpatient acute psychiatric unit, it is important to shut and lock the unit door behind you. A. TRUE B. FALSE - correct answer A. TRUE Reason: This behavior enhances safety.

You drive up to the house of your patient, who is known to have schizophrenia with manic episodes. This is your fifth visit. On this occasion, the patient is sitting on his front porch in a rocking chair with a shotgun in his arms. What should your next intervention be? A. Beep your car horn to get your patient's attention. B. Yell your patient's name out your car window and wave at him to say hello. C. Keep driving in a path that is going away from the patient's house. D. Stop the car in the patient's driveway and call your boss on your cell phone. - correct answer C. Keep driving in a path that is going away from the patient's house. Reason: Safety includes not placing yourself in vulnerable situations. Your patient, who is in a community psychiatric program, shows up at your home peeping through your kitchen window. You also noticed the patient yesterday when you went to the grocery story and the hairdresser. You believe he is stalking you. What should you do? A. Call the local police and report your suspicion of stalking. B. Call the patient's spouse and discuss his behavior. C. Invite the patient to have a cup of coffee with you at a local café to discuss his behavior. D. Wait until the patient's next group meeting to discuss his stalking behavior. - correct answer A. Call the local police and report your suspicion of stalking. Reason: Stalking behavior needs to be dealt with by the police for your safety. Your patient's auditory, visual, and tactile hallucinations are controlled with bimonthly injections of haloperidol (Haldol) that the community health nurse administers during home visits. You are the new nurse on this case; the previous nurse has retired. The previous nurse has stated in her care plan that the patient will let the nurse in the house only if the nurse carries a public health-issued blue bag and wears black pants. You are scheduled to visit this patient tomorrow. What should you do? A. Call the patient and tell her that you are a new nurse and will be wearing white pants. B. Show up as scheduled carrying only a stethoscope, vial, alcohol wipe, and medication syringe. C. Show up as scheduled with a police officer. D. Telephone the patient, introduce yourself, and show up carrying a blue bag and wearing black pants. - correct answer D. Telephone the patient, introduce yourself, and show up carrying a blue bag and wearing black pants.

Reason: The patient needs her medication, and following the care plan is the optimal course of action. Your patient has an admitting diagnosis of alcohol withdrawal syndrome. You receive a phone call at the nurses' station from a person who says he is the patient's minister and wants to know if the patient 'fell off the wagon again' and when visitation hours are. What is your best response? A. Yes, the patient drank too much, but he should be fine in a few days. Visiting hours are 9 A.M. to 6 P.M. B. We do not give out any information. Visitation hours in the hospital are from 9 A.M. to 6 P.M. daily. C. Please pray for the patient; he is in bad shape. You can visit him anytime between 9 A.M. and 6 P.M. daily. D. Please contact the hospital's chief executive officer, who can give you the information you are requesting. - correct answer B. We do not give out any information. Visitation hours in the hospital are from 9 A.M. to 6 P.M. daily. Reason: Patient confidentiality is required, and there is no way to verify the identity of the person calling. Your patient has been hospitalized for acute alcohol withdrawal. It is the fifth day, and he is having visual hallucinations followed by a seizure. What is the most likely source of the patient's problem? A. Autonomic dysreflexia (AD). B. A brain tumor. C. Sleep deprivation. D. Delirium tremens (DTs). - correct answer D. Delirium tremens (DTs). Reason: Delirium tremens occurs as acute alcohol withdrawal progresses. It includes symptoms such as clouding of sensorium, hallucinations, seizures, and autonomic hyperactivity. Which of the following assessments is used to confirm alcohol intake? A. Pupil dilation. B. Serum sample. C. Hair shaft analysis.

D. Sputum sample. - correct answer B. Serum sample. Reason: Urine and serum samples are toxicology specimens used to assess and monitor alcohol withdrawal. Which of the following questions is most appropriate to ask in screening for a potential problem of high alcohol intake? A. Have you felt you should cut down on your alcohol consumption? B. Do you enjoy getting smashed? C. Have you ever thought about killing someone? D. In the last week, have you had a glass of wine? - correct answer A. Have you felt you should cut down on your alcohol consumption? Reason: Screening requires questions associated with cutting down, feelings of guilt about drinking, and having a first drink in the morning. Your patient in the Emergency Department has a diagnosis of acute alcohol withdrawal syndrome (AWS). He is acting euphoric, yet shy. The APN has prescribed the following care: CAGE questionnaire, serum for toxicology, IV of D5 1/2 NS and 1 amp multivitamin (MVI) at 75 mL/h, neuro check q 1 h. What is your first priority? A. Administer the CAGE questionnaire. B. Start the IV. C. Do the neuro check. D. Obtain a serum blood sample. - correct answer D. Obtain a serum blood sample. Reason: Obtain a toxicology sample, as the patient is too euphoric to answer the CAGE questionnaire. The IV and neuro checks can wait. Your patient sees you at a preplanned postoperative visit 4 weeks after being hospitalized for acute alcohol withdrawal. Upon questioning, she states that her husband is abusive, so she drinks to 'drown out his yelling.' The patient also complains of depression and severe pain in the epigastric region that radiates to her back and has been constant since yesterday. She has vomited twice in the past 12 hours. What is your first priority?

A. Refer her immediately for treatment of depression. B. Call social services and report spousal abuse. C. Assess her for pancreatitis. D. Administer a test or scale that assesses alcohol withdrawal. - correct answer C. Assess her for pancreatitis. Reason: Approximately 65% of cases of pancreatitis are related to alcohol. This patient is exhibiting the classic symptoms of this disease. Prolonged alcohol ingestion can cause disorders of the liver such as A. Pancreatitis. B. Hypomagnesemia. C. Cirrhosis. D. Colitis - correct answer D. Colitis Reason: Cirrhosis is a liver disorder that can result from prolonged ingestion of alcohol. Adolescent suicide has increased over the past and is among the top five causes of death in U.S. adolescents. A. TRUE B. FALSE - correct answer A. TRUE Reason: Adolescent suicides have quadrupled since 1950 and are the third leading cause of death in U.S. adolescents. Alcohol tolerance develops as a result of the central nervous system's adaptive mechanisms. A. TRUE B. FALSE - correct answer A. TRUE

Reason: The central nervous system adapts, so more alcohol is needed to obtain the initial effects of alcohol ingestion, especially euphoria. Your patient experienced alcohol withdrawal syndrome and now admits he 'needs help.' Which of the following is the most appropriate resource to which you should direct the patient? A. Reach to Recovery. B. Alcoholics Anonymous. C. Depression support group. D. Suicide support group. - correct answer B. Alcoholics Anonymous. Reason: Alcoholics Anonymous is the most appropriate resource for alcoholism, although depression may or may not be involved in this case. Which of the following is a common symptom of a major depressive episode? A. Loss of hearing. B. Increased energy. C. Hopelessness. D. Recurrent thoughts of well-being. - correct answer C. Hopelessness. Reason: Hopelessness, loss of pleasure, and a profound sense of sadness are symptoms of a major depressive episode. Which of the following statements would indicate a depressed mood? A. I can't wait to go to the ballgame today; it should be fun. B. I feel sad today, just like yesterday. C. I feel like going to the gym for a workout today, then maybe to a movie. D. Since it's raining outside, how about a game of chess? - correct answer B. I feel sad today, just like yesterday. Reason: A subjective report of feeling sad or empty is a sign of depression.

Which of the following medical conditions has similar signs and symptoms as those seen in a major depressive episode? A. Pancreatitis. B. Cholecystitis. C. Tuberculosis. D. Hypothyroidism. - correct answer D. Hypothyroidism. Reason: Signs and symptoms of hypothyroidism include changes in weight, sleep disturbances, decreased energy, and difficulty in thinking—just like in depression. Once a patient is diagnosed with a major depressive episode, the primary nursing intervention should be associated with A. Safety. B. Pharmacology. C. Administration of gastric lavage. D. Hemodialysis. - correct answer A. Safety. Reason: Safety is the primary focus for an intervention, as 25% to 30% of depressed patients are at risk for suicide. A 35-year-old male patient has been brought to your hospital unit after making a suicide attempt at his workplace. Which of the following interventions can you legally implement? A. Call the patient's girlfriend and inform her of his admission and visiting hours. B. Physically search the patient for weapons and harmful materials. C. Call the patient's boss at work and report him as in need of extended medical leave. D. Place the patient in four-point restraints and begin an IV for sedation. - correct answer B. Physically search the patient for weapons and harmful materials. Reason: A suicide attempt is a serious and self-destructive behavior that demands searching for weapons and harmful materials to increase safety.

Your patient has just received his sixth electroconvulsant therapy outpatient treatment. He tells you that he plans to drive himself home because his wife is working at her part-time job today. What is your best response? A. Be careful and drive slowly. B. You need to wait 30 minutes and then you will be safe to drive. C. Let me take your vital signs; if they are stable, then you can drive. D. You cannot drive. I can call you a cab, or would you prefer to call your wife or someone for a ride home? - correct answer D. You cannot drive. I can call you a cab, or would you prefer to call your wife or someone for a ride home? Reason: Patients cannot drive after ECT, as its effects can include disorientation, muscle pain, central nervous system depression, and cardiac dysrhythmias. Which of the following patients is at risk for depression? A. A patient with history of diabetes mellitus. B. A patient with a depressive genetic predisposition. C. A patient who recently bought a puppy. D. A patient who had only 6 hours of sleep last night due to watching a TV movie. - correct answer B. A patient with a depressive genetic predisposition. Reason: Risk factors include genetic predisposition, a recent loss or trauma, and a feeling of sadness or hopelessness. A patient has been admitted to your unit with a drug overdose, and you need to assess for acidosis and hypoxemia. Which test should you perform? A. Complete blood count (CBC). B. Serum electrolytes. C. Partial thromboplastin time (PTT). D. Arterial blood gases (ABG). - correct answer D. Arterial blood gases (ABG). Reason: ABGs assess for acidosis [pH, bicarbonate, and hypoxemia (pO2)].

Which of the following is an example of a bite/sting that can cause a poison exposure? A. Butterfly. B. Grass seed. C. Jellyfish. D. Fly. - correct answer C. Jellyfish. Reason: A jellyfish sting can cause a poison exposure. When a patient shares with a psychiatrist that he plans to harm a specific person and includes the person's name, the health professional must notify the intended identified victim. What is this rule called? A. Seclusion and restraints rule. B. Voluntary commitment rule. C. Right to treatment rule. D. Duty to warn rule. - correct answer D. Duty to warn rule. Reason: Duty to warn is a protective privilege and ends where public peril begins, so an intended, identifiable victim needs to be notified. When documenting the behavior of a patient with a mental health diagnosis, which chart entry includes the patient's action and responses? A. The patient is less expressive today in group therapy. B. The patient appears to drift in and out of reality. C. The patient is wearing shorts and a sleeveless top even though it's January and wintertime. When asked about her clothing choices, she states, "The devil told me what to wear. To make things different, I need an exorcism." D. The patient is wearing pants and a long-sleeved shirt, is appropriately dressed for group therapy, and refrains from sleeping as she did in last group sessions. - correct answer C. The patient is wearing shorts and a sleeveless top even though it's January and wintertime. When asked about her clothing choices, she states, "The devil told me what to wear. To make things different, I need an exorcism."

Reason: Action and responses include what one does and says. During a group session, one patient states that he will be released soon because he is superior to his therapist, who is a female. This is an example of which bias or prejudice? A. Racism. B. Sexism. C. Ageism. D. Neonatalism. - correct answer B. Sexism. Reason: Sexism is the belief that members of one sex are superior to members of the other sex.