Test Bank For Varcarolis' Essentials Of Psychiatric Mental Health Nursing, 5th Edition By, Exams of Nursing

Download Test Bank For Varcarolis' Essentials Of Psychiatric Mental Health Nursing, 5th Edition By and more Exams Nursing in PDF only on Docsity! Test Bank For Varcarolis' Essentials Of Psychiatric Mental Health Nursing, 5th Edition By Chyllia D Fosbre Which outcome, focused on recovery, would be expected in the plan of care for a patient living in the community and diagnosed with serious and persistent mental illness? Within 3 months, the patient will: - ANSWER ✔️ report a sense of well-being. In the shift-change report, an off-going nurse criticizes a patient who wears heavy makeup. Which comment by the nurse who receives the report best demonstrates advocacy? - ANSWER ✔️ "Our patients need our help to learn behaviors that will help them get along in society." An 86-year-old, previously healthy and independent, falls after an episode of vertigo. Which behavior by this patient best demonstrates resilience? The patient: - ANSWER ✔️ says, "Maybe some physical therapy will help me with my balance." Which organization actively seeks to reduce the stigma associated with mental illness through public presentations such as "In Our Own Voice" (IOOV)? - ANSWER ✔️ National Alliance on Mental Illness (NAMI) A patient is admitted to the psychiatric hospital. Which assessment finding best indicates that the patient has a mental illness? The patient: - ANSWER ✔️ describes mood as consistently sad, discouraged, and hopeless. The goal for a patient is to increase resiliency. Which outcome should a nurse add to the plan of care? Within 3 days, the patient will: - ANSWER ✔️ identify healthy coping behaviors in response to stressful events. A 26-month-old child displays negative behaviors. The parent says, "My child refuses toilet training and shouts, 'No!' when given direction. What do you think is wrong?" Select the nurse's best reply. - ANSWER ✔️ "This is normal for your child's age. The child is striving for independence." A 26-month-old child displays negative behavior, refuses toilet training, and often shouts, "No!" when given directions. Using Freud's stages of psychosexual development, a nurse would assess the child's behavior is based on which stage? - ANSWER ✔️ Anal A 26-month-old child displays negative behavior, refuses toilet training, and often shouts, "No!" when given direction. The nurse's counseling with the parent should be based on the premise that the child is engaged in which of Erikson's psychosocial crises? - ANSWER ✔️ Autonomy versus Shame and Doubt A 4-year-old child grabs toys from siblings, saying, "I want that toy now!" The siblings cry, and the child's parent becomes upset with the behavior. Using the Freudian theory, a nurse can interpret the child's behavior as a product of impulses originating in the: - ANSWER ✔️ id. The parent of a 4-year-old rewards and praises the child for helping a younger sibling, being polite, and using good manners. A nurse supports the use of praise because, according to the Freudian theory, these qualities will likely be internalized and become part of the child's: - ANSWER ✔️ superego. Which patient statement would lead a nurse to suspect that the developmental task of infancy was not successfully completed? - ANSWER ✔️ "I'm afraid to let anyone really get to know me." A nurse assesses that a patient is suspicious and frequently manipulates others. Using the Freudian theory, these traits are related to which psychosexual stage? - ANSWER ✔️ Oral An adult expresses the wish to be taken care of and often behaves in a helpless fashion. This adult has needs related to which of Freud's stages of psychosexual development? - ANSWER ✔️ Oral A nurse listens to a group of recent retirees. One says, "I volunteer with Meals on Wheels, coach teen sports, and do church visitation." Another laughs and says, "I'm too busy taking care of myself to volunteer. I don't language very well." The patient will: - ANSWER ✔️ select and participate in one group activity per day. Nursing behaviors associated with the implementation phase of the nursing process are concerned with: - ANSWER ✔️ carrying out interventions and coordinating care. Which statement made by a patient during an initial assessment interview should serve as the priority focus for the plan of care? - ANSWER ✔️ "I hear evil voices that tell me to do bad things." Which entry in the medical record best meets the requirement for problem- oriented charting? - ANSWER ✔️ "S: States, 'I feel like I'm ready to blow up.' O: Pacing hall, mumbling to self. A: Auditory hallucinations. P: Offer haloperidol (Haldol) 2 mg. I: (Haldol) 2 mg at 0900. E: Returned to lounge at 0930 and quietly watched TV." A nurse assesses an older adult patient brought to the emergency department by a family member. The patient was wandering outside, saying, "I can't find my way home." The patient is confused and unable to ANSWER ✔️ questions. Select the nurse's best action. - ANSWER ✔️ Document the patient's mental status. Obtain other assessment data from the family member. A nurse asks a patient, "If you had fever and vomiting for 3 days, what would you do?" Which aspect of the mental status examination is the nurse assessing? - ANSWER ✔️ Cognition An adolescent asks a nurse conducting an assessment interview, "Why should I tell you anything? You'll just tell my parents whatever you find out." Select the nurse's best reply. - ANSWER ✔️ "What you say about feelings is private, but some things, like suicidal thinking, must be reported to the treatment team." A nurse assessing a new patient asks, "What is meant by the saying, 'You can't judge a book by its cover'?" Which aspect of cognition is the nurse assessing? - ANSWER ✔️ Abstraction When a nurse assesses an older adult patient, the patient's ANSWER ✔️s seem vague or unrelated to the questions. The patient also leans forward and frowns, listening intently to the nurse. An appropriate question for the nurse to ask would be: - ANSWER ✔️ "Are you having difficulty hearing when I speak?" At one point in an assessment interview a nurse asks, "How does your faith help you in stressful situations?" This question would be asked during the assessment of: - ANSWER ✔️ coping strategies. . When a new patient is hospitalized, a nurse takes the patient on a tour, explains the rules of the unit, and discusses the daily schedule. The nurse is engaged in: - ANSWER ✔️ milieu management. After formulating the nursing diagnoses for a new patient, what is the next action a nurse should take? - ANSWER ✔️ Determine the goals and outcome criteria. Select the most appropriate label to complete this nursing diagnosis: ___________, related to feelings of shyness and poorly developed social skills as evidenced by watching television alone at home every evening. - ANSWER ✔️ Social isolation The acronym QSEN refers to: - ANSWER ✔️ Quality and Safety Education for Nurses. A nurse documents: "Patient is mute, despite repeated efforts to elicit speech. Makes no eye contact. Is inattentive to staff. Gazes off to the side or looks upward rather than at the speaker." Which nursing diagnosis should be considered? - ANSWER ✔️ Impaired verbal communication A nurse assesses a patient who reluctantly participates in activities, ANSWER ✔️s questions with minimal responses, and rarely makes eye contact. What information should be included when documenting the assessment? Select all that apply. - ANSWER ✔️ b. Patient's subjective responses d. Description of the patient's behavior during the interview A nurse performing an assessment interview for a patient with a substance abuse disorder decides to use a standardized rating scale. Which scales are appropriate? Select all that apply. - ANSWER ✔️ a. Addiction Severity Index (ASI) b. Brief Drug Abuse Screen Test (B-DAST) e. Recovery Attitude and Treatment Evaluator (RAATE) What information is conveyed by nursing diagnoses? Select all that apply. - ANSWER ✔️ c. Unmet patient needs currently presentd. d. Supporting data that validate the diagnosese. e. Probable causes that will be targets for nursing interventions A patient is very suspicious and states, "The FBI has me under surveillance." Which strategies should a nurse use when gathering initial assessment data about this patient? Select all that apply. - ANSWER ✔️ b. Ask the patient, "Tell me about the problem as you see it." c. Seek information about when the problem began. e. Reassure the patient, "You are safe here." A patient says to the nurse, "I dreamed I was stoned. When I woke up, I felt emotionally drained, as though I hadn't rested well." Which comment would be appropriate if the nurse seeks clarification? - ANSWER ✔️ "Can you give me an example of what you mean by 'stoned'?" A patient diagnosed with schizophrenia tells the nurse, "The CIA is monitoring us through the fluorescent lights in this room. Be careful what you say." Which response by the nurse would be most therapeutic? - ANSWER ✔️ "It sounds like you're concerned about your privacy." The patient says, "My marriage is just great. My spouse and I usually agree on everything." The nurse observes the patient's foot moving continuously as the patient twirls a shirt button. What conclusion can the nurse draw? The patient's communication is: - ANSWER ✔️ mixed. A nurse interacts with a newly hospitalized patient. Select the nurse's comment that applies the communication technique of "offering self." - ANSWER ✔️ "I'd like to sit with you for a while to help you get comfortable talking to me." A patient cries as the nurse explores the patient's relationship with a deceased parent. The patient says, "I shouldn't be crying like this. It happened a long time ago." Which responses by the nurse will facilitate communication? Select all that apply. - ANSWER ✔️ b. "I can see that you feel sad about this situation." c. "The loss of your parent is very painful for you." d. "Crying is a way of expressing the hurt you're experiencing." Which benefits are most associated with the use of telehealth? Select all that apply. - ANSWER ✔️ a. Cost savings for patients b. Maximization of care management c. Access to services for patients in rural areas A nurse assesses a confused older adult. The nurse experiences sadness and reflects, "The patient is like one of my grandparents . . . so helpless." What feelings does the nurse describe? - ANSWER ✔️ Countertransference Which statement shows a nurse has empathy for a patient who made a suicide attempt? - ANSWER ✔️ "You must have been very upset when you tried to hurt yourself." After several therapeutic encounters with a patient who recently attempted suicide, which occurrence should cause the nurse to consider the possibility of countertransference? - ANSWER ✔️ The nurse feels unusually happy when the patient's mood begins to lift. A patient says, "Please don't share information about me with the other people." How should the nurse respond? - ANSWER ✔️ "I won't share information with others without your permission, but I will share information about you with other staff members." A nurse is talking with a patient, and 5 minutes remain in the session. The patient has been silent for most of the session. Another patient comes to the door of the room, interrupts, and says to the nurse, "I really need to talk to you right now." The nurse should: - ANSWER ✔️ tell the patient who interrupted, "This session is 5 more minutes; then, I will talk with you." Termination of a therapeutic nurse-patient relationship with a patient has been successful when the nurse: - ANSWER ✔️ discusses with the patient changes that have happened during the relationship and evaluates the outcomes. What is the desirable outcome for the orientation stage of a nurse-patient relationship? The patient will demonstrate behaviors that indicate: - ANSWER ✔️ rapport and trust with the nurse. During which phase of the nurse-patient relationship can the nurse anticipate that identified patient issues will be explored and resolved? - ANSWER ✔️ Working At what point in the nurse-patient relationship should a nurse plan to first address termination? - ANSWER ✔️ In the orientation phase A nurse should introduce the matter of a contract during the first session with a new patient because contracts: - ANSWER ✔️ spell out the participation and responsibilities of each party. As a nurse escorts a patient being discharged after treatment for major depressive disorder, the patient gives the nurse a gold necklace with a heart pendant and says, "Thank you for helping mend my broken heart." Which is the nurse's best response? - ANSWER ✔️ "I'm glad I could help you, but I can't accept the gift. My reward is seeing you with a renewed sense of hope." Which remark by a patient indicates passage from the orientation phase to the working phase of a nurse-patient relationship? - ANSWER ✔️ "I want to find a way to deal with my anger without becoming violent." A nurse explains to the family of a patient who is mentally ill how the nurse- patient relationship differs from social relationships. Which is the best explanation? - ANSWER ✔️ "The focus is on the patient. Problems are discussed by the nurse and patient, but solutions are implemented by the patient." A nurse wants to demonstrate genuineness with a patient diagnosed with schizophrenia. The nurse should: - ANSWER ✔️ use congruent communication strategies. A nurse caring for a withdrawn, suspicious patient recognizes the development of feelings of anger toward the patient. The nurse should: - ANSWER ✔️ discuss the anger with a clinician during a supervisory session. A nurse wants to enhance the growth of a patient by showing positive regard. The action consistent with this wish is: - ANSWER ✔️ staying with a tearful patient. A patient says, "I've done a lot of cheating and manipulating in my relationships." Select a nonjudgmental response by the nurse. - ANSWER ✔️ "How do you feel about that?" A patient says, "People should be allowed to commit suicide without interference from others." A nurse replies, "You're wrong. Nothing is bad enough to justify death." What is the best analysis of this interchange? - ANSWER ✔️ Differing values are reflected in the two statements. Which issues should a nurse address during the first interview with a patient diagnosed with a psychiatric disorder? - ANSWER ✔️ Relationship parameters, the contract, confidentiality, and termination During the first interview, a nurse notices that the patient does not make eye contact. The nurse can correctly analyze that: - ANSWER ✔️ more information is needed to draw a conclusion. Which behavior shows that a nurse values autonomy? The nurse: - ANSWER ✔️ discusses available alternatives and helps the patient weigh the consequences. As a nurse discharges a patient, the patient gives the nurse a card of appreciation made in an arts and crafts group. What is the nurse's best action? - ANSWER ✔️ Recognize the effectiveness of the relationship and patient's thoughtfulness. Accept the card. On the basis of current knowledge of neurotransmitter effects, a nurse anticipates that the treatment plan for a patient with memory difficulties may include medications designed to: - ANSWER ✔️ prevent destruction of acetylcholine. A patient has disorganized thinking associated with schizophrenia. Neuroimaging would most likely show dysfunction in which part of the brain? - ANSWER ✔️ Prefrontal cortex A nurse should assess a patient taking a medication with anticholinergic properties for inhibited function of the: - ANSWER ✔️ parasympathetic nervous system. The therapeutic action of monoamine oxidase inhibitors (MAOIs) blocks neurotransmitter reuptake, causing: - ANSWER ✔️ increased concentration of neurotransmitters in the synaptic gap. A patient taking medication for mental illness develops restlessness and an uncontrollable need to be in motion. A nurse can correctly analyze that these symptoms are related to which drug action? - ANSWER ✔️ Dopamine-blocking effects A patient has anxiety, increased heart rate, and fear. The nurse would suspect the presence of a high concentration of which neurotransmitter? - ANSWER ✔️ Norepinephrine A patient has symptoms of acute anxiety related to the death of a parent in an automobile accident 2 hours earlier. The nurse should anticipate administering a medication from which group? - ANSWER ✔️ Benzodiazepines A patient is hospitalized for major depressive disorder. Of the medications listed, a nurse can expect to provide the patient with teaching about: - ANSWER ✔️ fluoxetine (Prozac). A patient hospitalized with a mood disorder has aggression, agitation, talkativeness, and irritability. A nurse begins the care plan based on the expectation that the health care provider is most likely to prescribe a medication classified as a(n): - ANSWER ✔️ mood stabilizer. A drug causes muscarinic-receptor blockade. A nurse will assess the patient for: - ANSWER ✔️ dry mouth. A patient begins therapy with a phenothiazine medication. What teaching should a nurse provide related to the drug's strong dopaminergic effect? - ANSWER ✔️ Report muscle stiffness. A nurse can anticipate anticholinergic side effects are likely to occur when a patient is taking: - ANSWER ✔️ fluphenazine (Prolixin). Priority teaching for a patient taking clozapine (Clozaril) should include which instruction? - ANSWER ✔️ Report sore throat and fever immediately. A nurse cares for patients taking various medications, including buspirone (BuSpar), haloperidol (Haldol), trazodone (Desyrel), and phenelzine (Nardil). The nurse will order a special diet for the patient taking: - ANSWER ✔️ phenelzine. A nurse caring for a patient taking a serotonin reuptake inhibitor (SSRI) will develop outcome criteria related to: - ANSWER ✔️ mood improvement. A patient's spouse, who is a chemist, asks a nurse how serotonin reuptake inhibitors (SSRIs) lift depression. The nurse should explain that SSRIs: - ANSWER ✔️ make more serotonin available at the synaptic gap. A patient has taken many conventional antipsychotic drugs over years. The health care provider, who is concerned about early signs of tardive dyskinesia, prescribes risperidone (Risperdal). A nurse planning care for this patient understands that atypical antipsychotics: - ANSWER ✔️ produce fewer motor side effects. The laboratory report for a patient taking clozapine (Clozaril) shows a white blood cell count of 3000 mm3 and a granulocyte count of 1500 mm3. The nurse should: - ANSWER ✔️ report the laboratory results to the health care provider. A nurse administering psychotropic medications should be prepared to intervene when giving a drug that blocks the attachment of norepinephrine to alpha1 receptors because the patient may experience: - ANSWER ✔️ orthostatic hypotension. A nurse prepares to administer an antipsychotic medication to a patient diagnosed with schizophrenia. Additional monitoring of the medication's effects and side effects will be most important if the patient is also diagnosed with which health problem? Select all that apply. - ANSWER ✔️ a. Parkinson disease d. Epilepsye. e. Diabetes The spouse of a patient diagnosed with schizophrenia asks, "Which neurotransmitters are more active when a person has schizophrenia?" The nurse should state, "The current thinking is that the thought disturbances are related to increased activity of: (Select all that apply.) - ANSWER ✔️ d. dopamine." e. norepinephrine." An individual is experiencing problems associated with memory. Which cerebral structures are most likely to be involved in this deficit? Select all that apply. - ANSWER ✔️ a. Prefrontal cortex c. Temporal lobed. e. Parietal lobe Planning for patients with mental illness is facilitated by understanding that inpatient hospitalization is generally reserved for patients who: - ANSWER ✔️ present a clear danger to self or others. A patient is hospitalized for a reaction to a psychotropic medication and then is closely monitored for 24 hours. During a predischarge visit, the case manager learns the patient received a notice of eviction on the day of admission. The most appropriate intervention for the case manager is to: - ANSWER ✔️ arrange a temporary place for the patient to stay until new housing can be arranged. nurse's most appropriate intervention. - ANSWER ✔️ Investigate the possibility of once-daily dosing of the antidepressant. A community psychiatric nurse assesses that a patient diagnosed with a mood disorder is more depressed than on the previous visit a month ago; however, the patient says, "I feel the same." Which intervention supports the nurse's assessment while preserving the patient's autonomy? - ANSWER ✔️ Schedule weekly clinic appointments. A patient hurriedly tells the community mental health nurse, "Everything's a disaster! I can't concentrate. My disability check didn't come. My roommate moved out, and I can't afford the rent. My therapist is moving away. I feel like I'm coming apart." Which nursing diagnosis applies? - ANSWER ✔️ Anxiety, related to changes perceived as threatening to psychological equilibrium Which patient would a nurse refer to partial hospitalization? An individual who - ANSWER ✔️ states, "I'm not sure I can avoid using alcohol when my spouse goes to work every morning." A nurse can best address factors of critical importance to successful community treatment for persons with mental illness by including assessments related to which of the following? Select all that apply. - ANSWER ✔️ a. Housing adequacy and stability b. Income adequacy and stability c. Family and other support systems e. Substance abuse history and current use A community member asks a nurse, "People diagnosed with mental illnesses used to go to a state hospital. Why has that changed?" Select the nurse's accurate responses. Select all that apply. - ANSWER ✔️ a. "Science has made significant improvements in drugs for mental illness, so now many people may live in their communities." b. "A better selection of less restrictive settings is now available in communities to care for individuals with mental illness." e. "Federal legislation and payment for treatment of mental illness have shifted the focus to community rather than institutional settings." A psychiatric nurse best implements the ethical principle of autonomy when he or she: - ANSWER ✔️ explores alternative solutions with a patient, who then makes a choice. Which action by a psychiatric nurse best supports a patient's right to be treated with dignity and respect? - ANSWER ✔️ Consistently addressing a patient by title and surname. Two hospitalized patients fight when they are in the same room. During a team meeting, a nurse asserts that safety is of paramount importance and therefore the treatment plans should call for both patients to be secluded to prevent them from injuring each other. This assertion: - ANSWER ✔️ violates the civil rights of the two patients. In a team meeting a nurse says, "I'm concerned whether we are behaving ethically by using restraint to prevent one patient from self-mutilation while the care plan for another patient who has also self-mutilated calls for one- on-one supervision." Which ethical principle most clearly applies to this situation? - ANSWER ✔️ Justice Which scenario is an example of a tort? - ANSWER ✔️ A nurse gives an as-needed dose of an antipsychotic drug to a patient to prevent violence because a unit is short staffed. A nurse's neighbor asks, "Why aren't people with mental illness kept in state institutions anymore?" What is the nurse's best response? - ANSWER ✔️ "Less restrictive settings are now available to care for individuals with mental illness." Which nursing intervention demonstrates false imprisonment? - ANSWER ✔️ A patient has been irritating, seeking the attention of nurses most of the day. Now a nurse escorts the patient down the hall, saying, "Stay in your room or you'll be put in seclusion." A patient should be considered for involuntary commitment for psychiatric care when he or she: - ANSWER ✔️ fraudulently files for bankruptcy. A nurse at the mental health center prepares to administer a scheduled injection of haloperidol decanoate (Haldol depot) to a patient with schizophrenia. As the nurse swabs the site, the patient shouts, "Stop! I don't want to take that medicine anymore. I hate the side effects." Select the nurse's best initial action. - ANSWER ✔️ Stop the medication administration procedure and say to the patient, "Tell me more about the side effects you've been having." Several nurses are concerned that agency policies related to restraint and seclusion are inadequate. Which statement about the relationship of substandard institutional policies and individual nursing practice should guide nursing practice? - ANSWER ✔️ The policies do not absolve an individual nurse of the responsibility to practice according to the professional standards of nursing care. A newly admitted patient who is acutely psychotic is a private patient of the senior psychiatrist. To whom does the psychiatric nurse who is assigned to this patient owe the duty of care? - ANSWER ✔️ Patient An example of a breach of a patient's right to privacy occurs when a nurse: - ANSWER ✔️ releases information to the patient's employer without consent. An adolescent hospitalized after a violent physical outburst tells the nurse, "I'm going to kill my father, but you can't tell anyone." Select the nurse's best response. - ANSWER ✔️ "I am required to share information with the treatment team." A voluntarily hospitalized patient tells the nurse, "Get me the forms for discharge against medical advice so I can leave now." What is the nurse's best initial response? - ANSWER ✔️ "I will get them for you, but let's talk about your decision to leave treatment." The family of a patient whose insurance will not pay for continuing hospitalization considers transferring the patient to a public psychiatric hospital. The family expresses concern that the patient will "never get any treatment." Which reply by the nurse would be most helpful? - ANSWER ✔️ "Under the law, treatment must be provided. Hospitalization without treatment violates patients' rights." A nurse wishes to teach alternative coping strategies to a patient experiencing severe anxiety. The nurse will first need to: - ANSWER ✔️ Lower the patient's current anxiety level. An adult seeks counseling after the spouse is murdered. The adult angrily says, "I hate the beast that did this. It has ruined my life. During the trial, I don't know what I'll do if the jury doesn't return a guilty verdict." What is the nurse's highest priority question?a. "Would you like to talk to a psychiatrist about some medication to help you cope during the trial?" - ANSWER ✔️ "Are you having thoughts of hurting yourself or others?" A patient visiting the crisis clinic for the first time asks, "How long will I be coming here?" The nurse's reply should consider that the usual duration of crisis intervention is _______ weeks. - ANSWER ✔️ 4 to 6 After celebrating a 40th birthday, an individual becomes concerned with the loss of youthful appearance. What type of crisis has occurred? - ANSWER ✔️ Maturational An adolescent comes to the crisis clinic and reports sexual abuse by an uncle. The patient told the parents about the uncle's behavior, but the parents did not believe the adolescent. What type of crisis exists? - ANSWER ✔️ Situational A woman says, "I can't take anymore! Last year my husband had an affair and now we don't communicate. Three months ago, I found a lump in my breast. Yesterday my daughter said she's quitting college." What type of crisis is this person experiencing? - ANSWER ✔️ Situational After celebrating a 40th birthday, an individual becomes concerned with the loss of youthful appearance. What type of crisis has occurred? - ANSWER ✔️ Maturational Which health care worker should be referred to critical incident stress debriefing? - ANSWER ✔️ Emergency medical technician (EMT) who treated victims of a car bombing at a department A patient tells the nurse, "My husband is abusive most often when he drinks too much. His family was like that when he was growing up. He always apologizes and regrets hurting me." What risk factor was most predictive for the husband to become abusive? - ANSWER ✔️ History of family violence Which family scenario presents the greatest risk for family violence? - ANSWER ✔️ An unemployed husband with low self-esteem, a wife who loses her job, and a developmentally delayed 3-year-old child A nurse assists a victim of intimate partner violence to create a plan for escape if it becomes necessary. The plan should include which components? Select all that apply.a. Keep a cell phone fully charged. - ANSWER ✔️ a. Keep a cell phone fully charged. c. Have the telephone number for the nearest shelter. e. Secure a supply of current medications for self and children. f. Determine a code word to signal children that it is time to leave. g. Assemble birth certificates, Social Security cards, and licenses. A depressed patient says, "Nothing matters anymore." What is the most appropriate response by the nurse? - ANSWER ✔️ "Are you having thoughts of suicide?" A patient with suicidal impulses is on the highest level of suicide precautions. Which measures should the nurse incorporate into the patient's plan of care? Select all that apply. - ANSWER ✔️ a. Allow no glass or metal on meal trays. b. Remove all potentially harmful objects from the patient's possession. c. Maintain arm's length, one-on-one nursing observation around the clock. Which changes in brain biochemical function is most associated with suicidal behavior? - ANSWER ✔️ Serotonin deficiency A nurse uses the SAD PERSONS scale to interview a patient. This tool provides data relevant to: - ANSWER ✔️ suicide potential. A person attempts suicide by overdose, is treated in the emergency department, and then hospitalized. What is the best initial outcome? The patient will: - ANSWER ✔️ exercise suicide self-restraint by refraining from gestures or attempts to kill self for 24 hours. A patient's fiancé died in an automobile accident several days ago. The patient reports crying and experiencing feelings of guilt and anger. This behavior is characteristic of which stage of acute grief? - ANSWER ✔️ Development of awareness A nurse works with a person who was raped four years ago. This person says, "It took a long time for me to recover from that horrible experience." Which term should the nurse use when referring to this person? - ANSWER ✔️ Survivor A person was abducted and raped at gunpoint. The nurse observes this person is confused, talks rapidly in disconnected phrases, and is unable to concentrate or make simple decisions. What is the person's level of anxiety? - ANSWER ✔️ Severe A person was abducted and raped at gunpoint by an unknown assailant. Which assessment finding best indicates the person is in the acute phase of rape trauma syndrome? - ANSWER ✔️ Confusion and disbelief A nurse interviews a person abducted and raped at gunpoint by an unknown assailant. The person says, "I can't talk about it. Nothing happened. I have to forget!" What is the person's present coping strategy? - ANSWER ✔️ Denial A child was abducted and raped. Which personal reaction by the nurse could interfere with the child's care? - ANSWER ✔️ Anger A nurse working in the county jail interviews a man who recently committed a violent sexual assault against a woman. Which comment from this perpetrator is most likely? - ANSWER ✔️ "I gave her what she wanted." A rape victim asks an emergency department nurse, "Maybe I did something to cause this attack. Was it my fault?" Which response by the nurse is the most therapeutic? - ANSWER ✔️ Support the victim to separate issues of vulnerability from blame. A person was abducted and raped at gunpoint by an unknown assailant. Which interventions should the nurse use while caring for this person in the emergency department? Select all that apply. - ANSWER ✔️ a. Allow the person to talk at a comfortable pace. b. Pose questions in nonjudgmental, empathic ways. c. Place the person in a private room with a caregiver. Which activities are in the scope of practice of a sexual assault nurse examiner? Select all that apply. - ANSWER ✔️ b. Collecting and preserving evidence d. Obtaining signed consents for photographs and examinations e. Providing pregnancy and sexually transmitted disease prophylaxis After assessing a victim of sexual assault, which terms could the nurse use in the documentation? Select all that apply. - ANSWER ✔️ b. Reported c. Penetration f. Declined Which changes in brain biochemical function is most associated with suicidal behavior? - ANSWER ✔️ Serotonin deficiency A college student failed two tests. Afterward, the student cried for hours and then tried to telephone a parent but got no ANSWER ✔️. The student then gave several expensive sweaters to a roommate. Which behavior provides the strongest clue of an impending suicide attempt? - ANSWER ✔️ Giving away sweaters A nurse uses the SAD PERSONS scale to interview a patient. This tool provides data relevant to: - ANSWER ✔️ suicide potential. A person intentionally overdoses on antidepressant drugs. Which nursing diagnosis has the highest priority? - ANSWER ✔️ Risk for suicide A person attempts suicide by overdose, is treated in the emergency department, and then hospitalized. What is the best initial outcome? The patient will: - ANSWER ✔️ exercise suicide self-restraint by refraining from gestures or attempts to kill self for 24 hours. A college student who attempted suicide by overdose is hospitalized. When the parents are contacted, they respond, "There must be a mistake. This could not have happened. We've given our child everything." The parents' reaction reflects: - ANSWER ✔️ denial. An adolescent tells the school nurse, "My friend threatened to take an overdose of pills." The nurse talks to the friend who verbalized the suicide threat. The most critical question for the nurse to ask would be: - ANSWER ✔️ "Do you have access to medications?" An adult attempts suicide after declaring bankruptcy. The patient is hospitalized and takes an antidepressant medication for five days. The patient is now more talkative and shows increased energy. Select the highest priority nursing intervention. - ANSWER ✔️ Supervise the patient 24 hours a day. A nurse and patient construct a no-suicide contract. Select the preferable wording for the contract. - ANSWER ✔️ "For the next 24 hours, I will not kill or harm myself in any way." A tearful, anxious patient at the outpatient clinic reports, "I should be dead." The initial task of the nurse conducting the assessment interview is to: - ANSWER ✔️ establish a rapport with the patient. Select the most helpful response for a nurse to make when a patient being treated as an outpatient states, "I am considering suicide." - ANSWER ✔️ "Bringing this up is a very positive action on your part." Which intervention should a nurse recommend for the distressed family and friends of someone who has committed suicide? - ANSWER ✔️ Attending a self-help group for survivors Which statement provides the best rationale for why a nurse should closely monitor a severely depressed patient during antidepressant medication therapy? - ANSWER ✔️ As depression lifts, physical energy becomes available to carry out suicide. A nurse assesses a patient who reports a 3-week history of depression and crying spells. The patient says, "My business is bankrupt, and I was served with divorce papers." Which subsequent statement by the patient alerts the nurse to a concealed suicidal message? - ANSWER ✔️ "I have a plan that will fix everything." A depressed patient says, "Nothing matters anymore." What is the most appropriate response by the nurse? - ANSWER ✔️ "Are you having thoughts of suicide?" A nurse counsels a patient with recent suicidal ideation. Which is the nurse's most therapeutic comment? - ANSWER ✔️ "Let's consider which problems are most important and which are less important." When assessing a patient's plan for suicide, what aspect has priority? - ANSWER ✔️ Availability of means and lethality of method Which understanding about individuals who attempt suicide will help a nurse plan the care for a suicidal patient? Every suicidal person should be considered: - ANSWER ✔️ experiencing hopelessness. Which statement by a patient during an assessment interview should alert the nurse to the patient's need for immediate, active intervention? - ANSWER ✔️ "I have no one for help or support." The feeling experienced by a patient that should be assessed by the nurse as most predictive of elevated suicide risk is: - ANSWER ✔️ hopelessness. Four individuals have given information about their suicide plans. Which plan evidences the highest suicide risk? - ANSWER ✔️ Jumping from a 100-foot-high railroad bridge located in a deserted area late at night Which individual in the emergency department should be considered at the highest risk for completing suicide? - ANSWER ✔️ A 79-year-old single white man with cancer of the prostate gland A nurse ANSWER ✔️s a suicide crisis line. A caller says, "I live alone in a home several miles from my nearest neighbors. I have been considering