Principles And Practice of Psychiatric Nursing,10th Edition by Gail Wiscarz Stuart -Test Bank

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Principles And Practice of Psychiatric Nursing,10th Edition by Gail Wiscarz Stuart -Test Bank

Chapter 2: Therapeutic Nurse-Patient Relationship

Test Bank

 

MULTIPLE CHOICE

 

  1. A novice nurse states, “Psychiatric nursing can’t be very difficult. After all, I believe in showing care and in mutual exchange with my friends.” The experienced nurse’s understanding of the difference between a social and a therapeutic relationship is primarily based on the:
a. kind of information given.
b. amount of emotion invested.
c. degree of satisfaction obtained.
d. type of responsibility involved.

 

 

ANS:  D

Social and therapeutic relationships both involve the giving of information, emotional investment, and personal satisfaction. These aspects all have differences, but they are minor in comparison with the difference in responsibility that exists between social and therapeutic relationships. In the therapeutic relationship the nurse has both ethical and legal responsibilities to the patient; these responsibilities do not exist in the social relationship.

 

DIF:    Cognitive Level: Comprehension   REF:   Text Page: 13

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Psychosocial Integrity

 

The diagram above is a Johari window that a nurse thinks is accurately self-representative. If the nurse wishes to be more successful in psychiatric nursing, the nurse should make an initial goal to increase the size of quadrant:

a. 1.
b. 2.
c. 3.
d. 4.

 

 

ANS:  A

Quadrant 1 is the open quadrant; it includes the behaviors, feelings, and thoughts known to the individual and others. The smaller an individual’s quadrant 1, the poorer the communication of that individual. The goal of increasing self-awareness is to enlarge the area of quadrant 1 and reduce the size of the other three quadrants.

 

DIF:    Cognitive Level: Application          REF:   Text Page: 15

TOP:   Nursing Process: Planning              MSC:  NCLEX: Psychosocial Integrity

 

  1. Which strategy can the nursing student use to foster authenticity in therapeutic relationships with patients?
a. Reading and discussing textbook assignments with a study group
b. Modeling behaviors with patients on the behaviors of a clinically competent staff nurse
c. Attending patient-centered clinical conferences on the assigned psychiatric inpatient unit
d. Analyzing feelings associated with psychiatric clinical experience with the help of instructors and peers

 

 

ANS:  D

Nursing students have many new experiences that provide opportunities for self-learning. Nurses should focus on and discuss the feelings related to these experiences. Instructors and peers can help students by facilitating self-awareness during these discussions; self-awareness contributes to authenticity.

 

DIF:    Cognitive Level: Application          REF:   Text Page: 15

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Psychosocial Integrity

 

  1. A person who has always wished to care for “special children” adopts a biracial child and another child who has spina bifida. What is the highest step of the value clarification process that this person has achieved?
a. Doing something with the choice in a pattern of life
b. Choosing freely from alternatives
c. Being happy with the choice
d. Affirming the choice publicly

 

 

ANS:  A

The highest level of value clarification is acting in a pattern. Adopting two “special children” is affirmation of a pattern. Acting follows choosing and prizing in the sequence of value clarification.

 

DIF:    Cognitive Level: Comprehension   REF:   Text Page: 16

TOP:   Nursing Process: N/A                     MSC:  NCLEX: Psychosocial Integrity

 

  1. A nurse makes observations that a depressed patient is more energetic and is smiling much more. Still, the nurse shares with the unit manager that when thinking about the patient a sense of hopelessness surfaces. The nurse manager replies:
a. “Sometimes it’s best to disregard subjective perceptions like that and focus on the objective signs.”
b. “Pay attention to your feelings. They can provide valuable clues about the patient’s feelings.”
c. “You should share your perceptions with the patient and seek an explanation.”
d. “Confrontation can be a useful tool in situations like this.”

 

 

ANS:  B

The feelings that nurses have serve an important purpose. They are valuable clues about the patient’s problems, and they are barometers for feedback about the nurses themselves and their relationships with others.

 

DIF:    Cognitive Level: Application          REF:   Text Page: 17

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Psychosocial Integrity

 

  1. A new nurse has the following thoughts: “How will I handle things if my patient walks away from me? How will I react if the patient is sexually provocative? How will I cope with a patient who cries?” These thoughts indicate that the nurse is engaged in:
a. role modeling.
b. self-exploration.
c. altruistic thinking.
d. value clarification.

 

 

ANS:  B

Self-exploration leads to the development of self-awareness, and it is essential that the nurse be self-aware to learn to deal with anxiety, anger, sadness, and joy in helping patients through the health-illness continuum.

 

DIF:    Cognitive Level: Application          REF:   Text Pages: 17-18

TOP:   Nursing Process: Assessment          MSC:  NCLEX: Psychosocial Integrity

 

  1. A nurse’s most appropriate initial action during the preinteraction phase of a relationship with a homosexual patient should be to:
a. examine personal feelings about homosexuality.
b. review the literature that pertains to the human sexual response.
c. attempt to identify the underlying reasons for the patient’s values.
d. focus on a method to assist the patient with changing personal sexual values.

 

 

ANS:  A

Self-examination is a task of the preinteraction phase of a relationship. This is especially important if the value systems of the nurse and patient are known to be different.

 

DIF:    Cognitive Level: Application          REF:   Text Page: 18

TOP:   Nursing Process: Planning              MSC:  NCLEX: Psychosocial Integrity

 

  1. A nurse engaged in the preinteraction phase of the nurse-patient relationship will:
a. consider what he or she has to offer the patient.
b. form a workable but detailed contract.
c. review the general goals of a therapeutic relationship.
d. plan for the first interaction with the patient.
e. identify existing stressors affecting the relationship.

 

 

ANS:  D

In the preinteraction phase the nurse and the patient have not yet met. The nurse prepares for the initial contact by performing self-assessment, gathering available data about the patient, reviewing the goals of a therapeutic relationship, and considering what he or she has to offer the patient. Contract creation is addressed in the orientation phase while the identification of stress factors occurs in the working phase.

 

DIF:    Cognitive Level: Application          REF:   Text Pages: 18-19

TOP:   Nursing Process: Planning              MSC:  NCLEX: Psychosocial Integrity

 

  1. When asked to contrast social superficiality with therapeutic intimacy, an experienced nurse mentor explains to a new nurse that the termination component in therapeutic intimacy is:
a. unknown.
b. open-ended.
c. specified and agreed to.
d. closed to negotiation or agreement.

 

 

ANS:  C

Conditions for termination are part of the nurse-patient contract negotiated during the introductory/orientation phase of the relationship. In a social relationship, termination is open-ended.

 

DIF:    Cognitive Level: Comprehension   REF:   Text Pages: 19-20

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Psychosocial Integrity

 

  1. Which task would be most appropriate to focus on during the introductory phase of work with a teenage patient with low self-esteem?
a. Mutual formulation of a contract
b. Nurse’s self-analysis of strengths
c. Promotion of patient use of constructive coping mechanisms
d. Review of progress of therapy and goal attainment with patient

 

 

ANS:  A

The tasks of the introductory phase of the nurse-patient partnership include establishing a climate of trust, understanding, acceptance, and open communication and formulating a contract with the patient.

 

DIF:    Cognitive Level: Analysis               REF:   Text Pages: 19-20

TOP:   Nursing Process: Planning              MSC:  NCLEX: Psychosocial Integrity

 

  1. A patient admitted with a diagnosis of schizophrenia, paranoid type, coldly tells a nurse during the admission interview, “I am here because my family brought me here and locked me up.” The nurse’s best response would be:
a. “How has hospitalization affected your life?”
b. “Do you feel angry or resentful about being hospitalized?”
c. “I see you are angry about being here. I hope that after we talk you will feel differently.”
d. “We are here to protect you and see that you do not harm yourself or others in your anger.”

 

 

ANS:  C

It is appropriate to acknowledge the angry or otherwise negative feelings of a patient who has not voluntarily sought treatment. Feeling understood by the nurse paves the way for a therapeutic relationship.

 

DIF:    Cognitive Level: Application          REF:   Text Page: 21

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Psychosocial Integrity

 

  1. A patient is admitted to the unit and complains of being depressed. The patient says, “I want to feel like my old self again.” Which nursing response will be most therapeutic?
a. “How long have you felt this way?”
b. “We’re all here to help you get better.”
c. “What do you think the hospital can do for you?”
d. “Tell me more so that I can better understand.”

 

 

ANS:  D

When a patient initially offers psychiatric symptoms as the reason for admission, the nurse will want to ask for clarification and elaboration to better understand the life experiences of the patient. Understanding fosters empathy, empathic remarks lead the patient to feel understood, and this understanding paves the way for the therapeutic nurse-patient partnership.

 

DIF:    Cognitive Level: Application          REF:   Text Pages: 19-21

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Psychosocial Integrity

 

  1. In the initial sessions a patient frequently asks the nurse for money and expresses doubt about the nurse’s ability to help. Which principle provides guidance for the nurse in this situation?
a. This behavior is typical of transference reactions.
b. All patients have feelings of insecurity and low self-esteem.
c. Manipulative behavior is part of this patient’s psychopathology.
d. Testing behavior is common during the introductory phase of a relationship.

 

 

ANS:  D

Testing behavior serves the purpose of exploring the nurse’s consistency and intent.

 

DIF:    Cognitive Level: Application          REF:   Text Page: 20

TOP:   Nursing Process: Planning              MSC:  NCLEX: Psychosocial Integrity

 

  1. A young adult has been receiving treatment for an anxiety disorder. Which statement by the patient confirms that the nurse and patient are most likely entering the terminal phase of the therapeutic relationship?
a. “My anxiety seems to be a result of having so much to get done.”
b. “I don’t know whether I’ll be able to handle things alone.”
c. “I can’t seem to be able to manage going to school and working.”
d. “I need to find a way that can help me manage my anxiety.”

 

 

ANS:  B

Establishing the reality of separation is difficult for both the nurse and patient. Patients often respond to impending termination with increased anxiety; they may experience negative feelings associated with earlier terminations, and they may regress to previous, less adaptive behaviors in the hope of postponing termination. The expression of the cause of the anxiety is reflective of the working phase while a general statement of the problem is appropriate for the introduction phase. Expressing a need for help is seen in the preinteraction phase.

 

DIF:    Cognitive Level: Application          REF:   Text Page: 21

TOP:   Nursing Process: Planning              MSC:  NCLEX: Psychosocial Integrity

 

  1. A psychiatric nurse will recognize which action as demonstration of resistance behavior?
a. Regularly referring to himself as a “loser”
b. Becoming tearful during every therapy session about abuse
c. Asking to postpone a therapy session until after visiting hours
d. Consistently describing his drug use as starting “a little while ago”

 

 

ANS:  D

Resistance is the patient’s reluctance or avoidance of verbalizing or experiencing troubling aspects of himself or herself. This is often caused by the patient’s unwillingness to change when the need for change is recognized. The remaining options lack the needed reluctance to open communication seen with resistant behaviors.

 

DIF:    Cognitive Level: Application          REF:   Text Page: 39

TOP:   Nursing Process: Assessment          MSC:  NCLEX: Psychosocial Integrity

 

  1. During the working phase of the relationship, the nurse assesses that the patient may be demonstrating resistance. The most appropriate way to deal with this would be to:
a. assist the patient in exploring his or her past for uncovered issues and conflicts.
b. clarify, share observations, and reflect content and feelings with the patient.
c. confront the patient with the behavior and state, “You will be expected to work harder.”
d. avoid mentioning the therapeutic barrier and wait until the patient again indicates readiness.

 

 

ANS:  B

The relationship can become stalled if the nurse is not prepared to deal with the impasse. The nurse may use clarification by saying something such as, “I sense that you’re struggling with yourself and wanting to explore your relationship with your parents, but that you don’t yet want to experience the pain it may bring.”

 

DIF:    Cognitive Level: Application          REF:   Text Page: 40

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Psychosocial Integrity

 

  1. A patient reports seeing a “frightening” face on the wall of the dayroom. A nurse attempts to calm her by providing an explanation for the flawed perception of what she saw. The nurse would implement this strategy by stating:
a. “Let’s see if anyone else has seen those frightening faces on the walls of the dayroom.”
b. “The shadows of the tree outside the window make strange shapes on the dayroom walls.”
c. “Have you ever seen frightening faces like that on the dayroom walls before today?”
d. “Did someone in the dayroom tell you there were frightening faces on the walls?”

 

 

ANS:  B

Perception is the identification and interpretation of a stimulus based on information received through the senses. In this instance the patient has incorrectly interpreted the shadows as a face on the wall. The remaining options do not relate to a misinterpretation of what the patient actually saw.

 

DIF:    Cognitive Level: Application          REF:   Text Page: 26

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Psychosocial Integrity

 

  1. A patient says to a nurse, “My spouse and I get along just fine. We usually agree on everything.” The nurse observes nonverbal communication that disagrees with what the patient has verbally communicated. Which of the patient’s actions is incongruent with her statement?
a. Getting up from her chair while making the statement
b. Walking toward the nurse while talking about her spouse
c. Staring down at her shoes during the conversation
d. Smiling while talking with the nurse

 

 

ANS:  C

Incongruent communication occurs when the verbal content and the nonverbal level of communication are not in agreement. Avoiding eye contact during the statement would demonstrate such a disagreement. The remaining options are not in disagreement and so are not incongruent.

 

DIF:    Cognitive Level: Application          REF:   Text Page: 25

TOP:   Nursing Process: Assessment          MSC:  NCLEX: Psychosocial Integrity

 

  1. A nurse tells a patient who is feeling guilty about an infidelity to call the spouse and beg for forgiveness. According to the transactional model of communication, the nurse’s response originated from which state?
a. Adult
b. Child
c. Parent
d. Complementary

 

 

ANS:  C

The nurse’s statement can be construed as critical. The parent ego state consists of all the nurturing, critical, and prejudicial attitudes, behaviors, and experiences learned from other people, especially from parents and teachers.

 

DIF:    Cognitive Level: Comprehension   REF:   Text Page: 26

TOP:   Nursing Process: Evaluation           MSC:  NCLEX: Psychosocial Integrity

 

  1. According to transactional analysis theory, when a patient finally recognizes the importance of being medication-compliant, which type of transaction has occurred?
a. Ulterior
b. Crossed
c. Incongruent
d. Complementary

 

 

ANS:  D

In this interaction the two parties are communicating from adult ego state to adult ego state. Communication flows smoothly between the sender and the receiver. The remaining options do not demonstrate such effective communication.

 

DIF:    Cognitive Level: Application          REF:   Text Page: 26

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Psychosocial Integrity

 

  1. When the nurse suggests the patient communicate to her employer how overwhelmed she is by the workload, the patient responds, “Yes but I’ll get fired if I do that.” According to transactional analysis theory, this is an example of a(n) _____ transaction.
a. ulterior
b. crossed
c. congruous
d. complementary

 

 

ANS:  A

This is an example of the “Why don’t you? Yes, but…” game. On the surface the game involves two adults solving problems; in reality, one person is using the child ego state to show what a bad parent the other person is.

 

DIF:    Cognitive Level: Application          REF:   Text Page: 27

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Psychosocial Integrity

 

  1. A patient who is currently in an abusive marriage shares, “Some days I think it’s just not worth it. I’d be better off if we separated.” The nurse uses restating as a therapeutic communication technique when responding:
a. “Are you sure you are ready to be on your own?”
b. “Can I help you work on a safe, realistic plan to leave?”
c. “You think you would be better off without your spouse?”
d. “How much thought have you given to leaving the marriage?”

 

 

ANS:  C

Clarification involves the nurse attempting to put into words the vague ideas or thoughts that are implicit or explicit in the patient’s conversation.

 

DIF:    Cognitive Level: Application          REF:   Text Page: 27 | Text Page: 29 | Text Page: 32

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Psychosocial Integrity

 

  1. When a patient is late for three consecutive therapy sessions, the nurse implements perception sharing as a communication technique when stating:
a. “You say how important therapy is to you, but you can’t seem to get here on time.”
b. “Do you think it’s polite being late for therapy sessions like this?”
c. “Do you have really good reasons for being late so often?”
d. “I feel that you aren’t ready to work on your problems.”

 

 

ANS:  D

Sharing perceptions involves asking the patient to verify the nurse’s understanding of what the patient is thinking or feeling. The nurse can provide information and then ask for feedback. The other options do not focus on clarification.

 

DIF:    Cognitive Level: Application          REF:   Text Page: 29 | Text Page: 32

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Psychosocial Integrity

 

  1. The therapeutic communication technique of suggesting is appropriate to use when it:
a. meets the patient’s unmet dependency needs.
b. shifts responsibility from the patient to the health care professional.
c. is used during the working stage to present alternative coping strategies.
d. is used early in the nurse-patient relationship to provide sound, everyday advice.

 

 

ANS:  C

Suggesting is the presentation of alternative ideas. It is useful in the working phase of the relationship, when the patient has analyzed the problem and is exploring alternative coping mechanisms. At that time, nurse suggestions will increase the patient’s perceived options.

 

DIF:    Cognitive Level: Comprehension   REF:   Text Pages: 30-32

TOP:   Nursing Process: Planning              MSC:  NCLEX: Psychosocial Integrity

 

  1. A teenager being treated for oppositional defiance behavior states: “I wish my parents would stop treating me like an irresponsible child.” The nurse implements confrontation as a therapeutic technique when responding:
a. “How can they treat you like an adult when you are only a teenager?”
b. “You want to be treated like an adult, but is it adult-like when you skip school?”
c. “Your parents have a legal responsibility to care for you until you are eighteen.”
d. “Your parents are worried about giving you more freedom than you can handle.”

 

 

ANS:  B

Confrontation is an expression by the nurse of discrepancies in the patient’s behavior such as being irresponsible and untrustworthy while wanting to be treated like an adult. The remaining options are not confrontational since they are not identifying such discrepancies.

 

DIF:    Cognitive Level: Application          REF:   Text Page: 38

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Psychosocial Integrity

 

  1. Which statement is true of planning the timing for the use of confrontation?
a. Confrontation should never be used during the orientation phase of the relationship.
b. Confrontation is useful during the working phase to focus on specific patient discrepancies.
c. Confront patients with their limitations early in the relationship and with their assets later in therapy.
d. Confront patients when other therapeutic action dimensions have proven ineffective.

 

 

ANS:  B

Confrontation, when posed as an observation of incongruent behavior, can be used infrequently during the orientation phase of the relationship, but it is more useful during the working stage to expand the patient’s awareness and to help him or her move to a higher level of functioning. The remaining options are not true statements.

 

DIF:    Cognitive Level: Application          REF:   Text Pages: 35-36

TOP:   Nursing Process: Planning              MSC:  NCLEX: Psychosocial Integrity

 

  1. The nurse suspects that a client has a problem with the action dimension of immediacy when she states, “You can’t tell people very much about yourself; it gives them too much power over you.” The nurse responds:
a. “It sounds as though people have tried to control you inappropriately in the past.”
b. “It’s reasonable for you to be suspicious of me until I’ve earned your trust.”
c. “Allowing yourself to trust people will be a step toward getting well.”
d. “It appears that you aren’t ready to discuss your problems yet.”

 

 

ANS:  B

Immediacy involves focusing on the current interaction of the nurse and the patient in the relationship. In this situation the client is focusing on past issues of trust and the nurse correctly identifies a reasonable reaction to the client’s need to trust the nurse. The remaining options do not deal with the immediate need for trust on the part of the client.

 

DIF:    Cognitive Level: Application          REF:   Text Page: 36

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Psychosocial Integrity

 

  1. A chronically depressed patient has been diagnosed with having a dependent personality. The nurse suspects that the situation has resulted in dependence transference when the patient shares that:
a. “Leaving the hospital and helpful, caring people like you will be really hard.”
b. “Over the weeks we’ve been meeting I’ve come to feel as though you are a very special person.”
c. “I think of you as being sent from heaven to guide me out of this darkness of the soul.”
d. “I know I can count on you to chart my course back to health. I will do whatever you say.”

 

 

ANS:  D

Dependent reaction transference is characterized by submissive, ingratiating behavior, regarding the nurse as a godlike figure, and overvaluing the nurse’s characteristics and qualities. The remaining options demonstrate gratitude but lack that submissive element.

 

DIF:    Cognitive Level: Application          REF:   Text Pages: 39-40

TOP:   Nursing Process: Evaluation           MSC:  NCLEX: Psychosocial Integrity

 

  1. A nurse tells the unit supervisor, “I’m having a difficult time empathizing with my patient especially since he is so unwilling to change. Talking with him makes me feel both frustrated and depressed.” The supervisor may suspect that the cause of the barrier in this nurse-client relation is the:
a. existence of countertransference on the part of the nurse.
b. patient’s demonstration of resistance to the prescribed plan of care.
c. violation of a therapeutic boundary by either the nurse or the patient.
d. nurse’s ineffective use of therapeutic verbal communication techniques.

 

 

ANS:  A

Countertransference is a therapeutic impasse created by the nurse’s specific emotional response to the qualities of the patient. This response is inappropriate to the content and context of the therapeutic relationship or inappropriate in the degree of intensity of emotion. The remaining options do not relate to inappropriate emotional responses especially by the nurse.

 

DIF:    Cognitive Level: Application          REF:   Text Pages: 40-41

TOP:   Nursing Process: Assessment          MSC:  NCLEX: Psychosocial Integrity

 

Chapter 14: Recovery and Psychiatric Rehabilitation

Test Bank

 

MULTIPLE CHOICE

 

  1. A psychiatric nurse whose area of practice is tertiary prevention of mental illness is asked to describe the focus of this type of practice. The nurse can best describe it as:
a. enriching the understanding of mental illness.
b. preventing mental illness from occurring initially.
c. limiting disability related to an episode of mental illness.
d. increasing community awareness of the symptoms of mental illness.

 

 

ANS:  C

Psychiatric rehabilitation is the process of helping the person return to the highest possible level of functioning by focusing on the limiting of illness-caused disability.

 

DIF:    Cognitive Level: Comprehension   REF:   Text Page: 199

TOP:   Nursing Process: Implementation

MSC:  NCLEX: Safe, Effective Care Environment: Management of Care

 

  1. When asked to explain how psychiatric rehabilitation under the tertiary prevention model differs from the traditional medical model, the nurse’s response should stress that the focus of tertiary prevention is on:
a. disease as opposed to the coping continuum.
b. learning to receive treatment in institutional settings.
c. health and wellness and not just symptoms of disease.
d. proper diagnosis and appropriate medications to treat disorders.

 

 

ANS:  C

In traditional medical rehabilitation, the focus is on disease, illness, and symptoms. Psychiatric rehabilitation focuses on wellness and health, not symptoms.

 

DIF:    Cognitive Level: Comprehension   REF:   Text Page: 200

TOP:   Nursing Process: Planning|Nursing Process: Implementation

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. Under the recovery model, a nurse is more likely to work with a patient with a psychiatric disorder:
a. in a decision-making partnership.
b. by prescribing appropriate treatment.
c. with the assumption the patient is curable.
d. from the position of expecting compliance.

 

 

ANS:  A

The patient-helper relationship in psychiatric rehabilitation is an adult-to-adult relationship that is more egalitarian and promotes choices and empowerment, whereas the traditional medical model uses an expert-to-patient relationship.

 

DIF:    Cognitive Level: Application          REF:   Text Pages: 200-201

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Psychosocial Integrity

 

  1. A patient has been treated for a mental disorder on an outpatient basis. Function has deteriorated and the patient is hospitalized in an inpatient unit; a nurse will now implement the recovery model by:
a. comparing patient deficits to original baseline.
b. identifying and reinforcing patient strengths.
c. reviewing the patient’s former treatment plan for updates.
d. reconsidering expectations when the patient is discharged.

 

 

ANS:  B

Although deficits are assessed, implementation focuses on the reinforcement of identified strengths.

 

DIF:    Cognitive Level: Application          REF:   Text Page: 203

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Psychosocial Integrity

 

  1. A nurse notes that a patient voices shame and socially isolates. The nurse will most likely interpret this behavior as:
a. unrelated to serious mental illness.
b. likely representing learned behaviors.
c. associated with secondary symptoms of serious mental illness.
d. a coincidental response that has little relationship to the illness.

 

 

ANS:  C

Secondary symptoms of mental illness are caused by a person’s response to the illness or its treatment (e.g., loneliness and social isolation).

 

DIF:    Cognitive Level: Application          REF:   Text Page: 201

TOP:   Nursing Process: Assessment          MSC:  NCLEX: Psychosocial Integrity

 

  1. Which statement regarding the self-perception of the mentally ill regarding community acceptance is supported by research?
a. “Many feel stigmatized and alienated.”
b. “Most feel well accepted and supported.”
c. “The majority are intensely angry and hostile.”
d. “Most are more concerned with their primary symptoms.”

 

 

ANS:  A

The Vellenga study identified several themes related to secondary symptoms: stigmatization, alienation, loss of relationships and vocational opportunities, distress caused by the effects of the illness, acceptance of self as having a mental illness, and the need for acceptance by others.

 

DIF:    Cognitive Level: Comprehension   REF:   Text Pages: 201-202

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Psychosocial Integrity

 

  1. At a community meeting, a homeowner states, “I don’t want mentally ill people in the neighborhood. They’re dangerous!” The community mental health nurse should respond:
a. “Former patients need care and concern, not stigmatization.”
b. “I sincerely believe your fears and concerns are really unfounded.”
c. “The way you act toward former patients will determine how they act toward you.”
d. “Our residents are more apt to be withdrawn and timid than aggressive or violent.”

 

 

ANS:  D

The nurse’s response should be aimed at dispelling the myth that mentally ill patients are dangerous and continue to be dangerous after discharge.

 

DIF:    Cognitive Level: Application          REF:   Text Page: 202

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Psychosocial Integrity

 

  1. A psychiatric nurse is assessing the family and home of a patient who is being discharged within the next few days from an inpatient unit. The assessment component with the highest priority is:
a. how the family members will make changes to meet the needs of the patient.
b. the attitudes and feelings of family members toward the mentally ill member.
c. how family members will cope with the responsibility of caring for the patient.
d. who will be responsible for helping the client with his or her activities of daily living (ADLs).

 

 

ANS:  B

The priority assessment is to determine the family’s understanding and acceptance of the patient and the patient’s mental illness. The remaining options are all of lesser priority since they are all based on the family’s ability and willingness to support the patient.

 

DIF:    Cognitive Level: Application          REF:   Text Pages: 204-205

TOP:   Nursing Process: Assessment

MSC:  NCLEX: Safe, Effective Care Environment: Management of Care

 

  1. Which daily stressors would an unemployed 24-year-old diagnosed with chronic depression who lives on a family farm most likely experience?
a. Housing, school, and work problems
b. Money problems, loneliness, and boredom
c. Florid symptoms, odd dress, and bizarre behavior
d. Sexual, anger management, and medication problems

 

 

ANS:  B

Daily hassles are concerns, worries, and events that disrupt daily life and well-being. The hassles of most frequent concern are money, loneliness, boredom, crime, past, present, and future accomplishments, communication problems, and physical health.

 

DIF:    Cognitive Level: Application          REF:   Text Page: 201

TOP:   Nursing Process: Diagnosis|Nursing Process: Analysis

MSC:  NCLEX: Psychosocial Integrity

 

  1. A nurse is assessing the community living skills of a 28-year-old patient. The nurse ascertains that the patient has poor personal hygiene and has never assumed responsibility or management of any aspect of self-care. Based on the data, the nurse makes the assessment that the patient:
a. has low readiness for function in the community.
b. will be too much of a burden to live in a foster setting.
c. is too psychotic to be considered for community placement.
d. requires stabilization to profit from psychiatric rehabilitation.

 

 

ANS:  A

The only conclusion that can be drawn based on the assessment data is that the patient currently has low readiness to function in the community.

 

DIF:    Cognitive Level: Analysis               REF:   Text Page: 203

TOP:   Nursing Process: Diagnosis|Nursing Process: Analysis

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. The family burden associated with having a mentally ill family member is evidenced by:
a. decreased family stress and conflict.
b. family members blaming each other for the illness.
c. increased understanding and acceptance of the illness.
d. too little time, energy, and money given to the ill member.

 

 

ANS:  B

Usual assessment findings are increased family stress and conflict, a tendency of members to blame each other for the illness, difficulty understanding or accepting the illness, tension during family gatherings, and disproportionate family time, energy, or money expended on the ill member.

 

DIF:    Cognitive Level: Comprehension   REF:   Text Page: 204

TOP:   Nursing Process: Assessment

MSC:  NCLEX: Safe, Effective Care Environment: Management of Care

 

  1. To ensure complete data regarding family social support needs, the nurse should consider seeking information relating to which four categories?
a. Anger quotient, resiliency, flexibility, and guilt
b. Financial, dependency, worry, and involvement
c. Emotional, feedback, cognitive, and instrumental
d. Diagnosis, treatment, relapse prediction, and violence potential

 

 

ANS:  C

Norbeck and associates identified four categories of support needs as emotional support, feedback support exemplified by affirmation, cognitive or informational support, and instrumental support exemplified by resources and respite.

 

DIF:    Cognitive Level: Application          REF:   Text Page: 204

TOP:   Nursing Process: Assessment

MSC:  NCLEX: Safe, Effective Care Environment: Management of Care

 

  1. A patient in a psychiatric rehabilitation program says, “I feel so guilty because my family gives me so much and I have so little to give in return.” What is the nurse’s most therapeutic reply?
a. “Your family feels good about giving to you.”
b. “Remember that, and show them you are grateful.”
c. “Following your treatment plan and helping with household tasks are ways you can give back.”
d. “You can help most by keeping your feelings to yourself and not burdening the family when you feel upset.”

 

 

ANS:  C

Patients, too, can contribute to and provide support for their families by helping with household tasks, showing concern for others, thanking the family for their help, sharing positive personal characteristics such as sense of humor, caring for themselves by following the treatment plan, and giving others peace of mind by communicating how they are feeling.

 

DIF:    Cognitive Level: Application          REF:   Text Page: 204

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Health Promotion and Maintenance

 

  1. The most effective way for a nurse working in psychiatric rehabilitation to gain firsthand knowledge about a community agency is to:
a. query patients who have used the services of the agency.
b. go to the agency with someone who is requesting services.
c. read the description in a community social services directory.
d. go to the agency pretending to be someone who needs services.

 

 

ANS:  B

The best knowledge is that which is gained firsthand by observing how the agency responds to a patient in need of services. It would be unethical to pretend to be someone who is in need of services.

 

DIF:    Cognitive Level: Application          REF:   Text Page: 205

TOP:   Nursing Process: Implementation

MSC:  NCLEX: Safe, Effective Care Environment: Management of Care

 

  1. A patient diagnosed with major affective disorder expresses concern to a nurse about how to spend time after discharge. The patient states, “I don’t want to just sit at home alone but I’m a little afraid of how others will respond to me.” The nurse should suggest:
a. “Just try to get out and meet people.”
b. “You should really take it easy when you get home.”
c. “Try taking a course at your local community college.”
d. “Consider going to a consumer-run psychosocial program.”

 

 

ANS:  D

Consumer-run psychosocial programs offer various levels of service, from drop-in socialization centers to a full range of rehabilitative services. The patient will be able to become involved in meaningful social and vocational activities.

 

DIF:    Cognitive Level: Application          REF:   Text Page: 208

TOP:   Nursing Process: Implementation

MSC:  NCLEX: Safe, Effective Care Environment: Management of Care

 

  1. In a recovery treatment program, staff members are assigned to spend time with psychiatric patients who are in crisis in the community rather than hospitalizing the patient. Staff members help patients learn to meet real-world demands. Such a program typifies:
a. respite care.
b. foster home care.
c. halfway housing.
d. training in community living.

 

 

ANS:  D

Training in community living averts hospitalization. It allows for the assessment of patient skills and the establishment of realistic collaborative goals. Staff contact is reduced as patient function improves.

 

DIF:    Cognitive Level: Comprehension   REF:   Text Page: 208

TOP:   Nursing Process: Implementation

MSC:  NCLEX: Safe, Effective Care Environment: Management of Care

 

  1. Effective programs are essential for families of patients with severe mental illness. Which components should be included to enhance a program’s effectiveness?
a. Education and empowerment
b. Political support and education
c. Financial support and a large membership
d. Empowerment and the participation of political figures

 

 

ANS:  A

Effective programs for families of people with serious mental illnesses focus on empowerment and education.

 

DIF:    Cognitive Level: Application          REF:   Text Page: 211

TOP:   Nursing Process: Planning

MSC:  NCLEX: Safe, Effective Care Environment: Management of Care

 

  1. A patient who dropped out of college when diagnosed with schizophrenia repeatedly states, “I want to get a job. I can work.” Which statement made by the nurse would be the most therapeutic in facilitating the patient’s need to be more productive?
a. “If you return to school and get a degree you can graduate from college and get a better job in 5 or 6 years.”
b. “School will be stressful. Let’s just look at the classified ads and find something you are capable of doing right now.”
c. “You could return to school by taking courses where class size is small; this would help your self-esteem and allow you to be more independent.”
d. “Work part-time and go back to school part-time; you’ll get a good job when you finish a degree.”

 

 

ANS:  C

Education that is offered in a supportive environment can increase self-esteem, improve job qualifications, and encourage some people to pursue higher education.

 

DIF:    Cognitive Level: Application          REF:   Text Page: 210

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Psychosocial Integrity

 

  1. A 27-year-old diagnosed with schizophrenia lives at home with both parents. A nurse is helping the family become better prepared to work with their child. Which nursing intervention would be most beneficial?
a. Having the family members remind the patient often about appointments and the schedule of daily activities
b. Helping the family members with scheduling regular daily activities and suggesting the family members allow the patient privacy and personal space
c. Suggesting that family members spend as much time as possible with the patient and continuously reassure the patient that he or she will never be left alone
d. Suggesting that a family member help the patient plan activities of daily living (ADLs) and make sure that all family members understand the need for vigilance with the patient

 

 

ANS:  B

There are several common trouble spots in family life that can be anticipated. Learning ways to handle these troublesome areas empowers the family by giving them a sense of control over their lives. Some of these trouble spots include mechanics of everyday life, including the need for privacy and control over personal space, keeping a regular schedule, television usage, money management, grooming, alcohol and drug use, and a need for relatives to remember to take care of themselves. The remaining options do not support the patient in achieving self-reliance.

 

DIF:    Cognitive Level: Application          REF:   Text Page: 211

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Psychosocial Integrity

 

  1. A nurse is conducting a workshop on family skill building. All participants have a family member with severe mental illness living in their household. Which method should be used to present coping skills to the participants?
a. Have a rehabilitation counselor facilitate the family-centered learning workshop.
b. Present a skill and allow participants to give feedback on the usefulness of the skill for their family member.
c. Arrange for the workshop presenter to be someone who has a family member diagnosed with serious and persistent mental illness.
d. Have someone who has experience with in-home care for the mentally ill present a talk and question-and-answer session at the workshop.

 

 

ANS:  C

Family education has become a primary nursing intervention when providing rehabilitative services to relatives of people with severe mental illness. Nurses have established workshops for family members that have been well received and have helped families cope with the challenges presented by the mental illness. Programming for these workshops can include information and skill-building exercises. The experiences of the more seasoned family members can be particularly helpful because they can share their successes and failures in using various coping strategies and provide needed social support.

 

DIF:    Cognitive Level: Application          REF:   Text Pages: 211-212

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Psychosocial Integrity

 

MULTIPLE RESPONSE

 

  1. In addition to the psychiatric nurse, which professional would be considered a multidisciplinary rehabilitative treatment team member in a community mental health center? (Select all that apply.)
a. Psychologist
b. Pharmacist
c. Social worker
d. Psychiatrist
e. Employment specialist

 

 

ANS:  A, C, D, E

Rehabilitative psychiatric nursing takes place in the context of a multidisciplinary treatment team. Other team members may include psychiatrists, psychologists, social workers, occupational therapists, rehabilitation counselors, case managers, consumer team members, family advocates, employment specialists, and job coaches. Pharmacists are not necessarily focused on rehabilitative services.

 

DIF:    Cognitive Level: Comprehension   REF:   Text Page: 200

TOP:   Nursing Process: N/A

MSC:  NCLEX: Safe, Effective Care Environment: Management of Care

 

  1. To promote positive outcomes, nurses in psychiatric rehabilitation practices should be skilled in: (Select all that apply.)
a. teaching the patient living skills.
b. actively listening to patient complaints.
c. assisting the patient in developing his or her strengths.
d. helping patients accept their own disabilities.
e. accessing the appropriateness of environmental support.

 

 

ANS:  A, C, E

These interventions are the basis of practice in psychiatric nursing rehabilitation. Active listening is not unique to rehabilitation. Acceptance is not the preferred attitude.

 

DIF:    Cognitive Level: Application          REF:   Text Page: 205

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Health Promotion and Maintenance

 

  1. All recovery programs should be evaluated regularly to ensure: (Select all that apply.)
a. accountability.
b. cost effectiveness.
c. relevancy of services.
d. geographical service area.
e. appropriate grant funding.

 

 

ANS:  A, B, C

Program evaluation is conducted to inform administrators about the relevance and cost effectiveness of the services they offer. Program evaluation is evolving as program funders and the public demand greater accountability from service providers.

 

DIF:    Cognitive Level: Comprehension   REF:   Text Pages: 212-213

TOP:   Nursing Process: Evaluation

MSC:  NCLEX: Safe, Effective Care Environment: Management of Care

 

 

 

Chapter 28: Preventing and Managing Aggressive Behavior

Test Bank

 

MULTIPLE CHOICE

 

  1. An adolescent patient says to a nurse, “I’m so glad you’ve come in. The nurse manager ordered me to stay in my room until dinner just because I got into another fight!” An appropriate response from the nurse would be:
a. “You’re not going to split me from the nurse manager. Please go back in your room until your time-out is finished.”
b. “I’m wondering why you’ve left your room, then. Please return to your room until your time-out is completed. I will talk with you after that.”
c. “I’m sorry to hear that you are being punished. Please return to your room immediately. We can talk about this when your time-out is over.”
d. “It sounds as if you haven’t had a very good day. Return to your room, and complete your time-out. I will speak with you after dinner.”

 

 

ANS:  D

Firm but empathetic limit setting is required in this situation. The patient is splitting, and the nurse needs to set limits and support the consequence that has been administered. By reflecting the patient’s psychic distress and providing clear instructions about the behavior that is expected (along with a time limit for that behavior), the nurse is assisting the patient in problem solving more adaptively. In addition, the nurse provides a reward or positive regard when offering a specific time to meet with the patient that occurs after the consequence has been accepted. Although the remaining options also provide similar feedback, they do not provide specific times that the patient can concretely conceptualize. Mutuality and respect for all patients are required from the therapeutic professional nurse, especially for those patients with impulse-control problems; they may try to enter into a regressive struggle with the nurse, who is trying to set limits on behavior.

 

DIF:    Cognitive Level: Analysis               REF:   Text Page: 583

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Psychosocial Integrity

 

  1. A nurse is facilitating a social skills group on the inpatient unit for nursing assistants. Which comment would the nurse identify as assertive?
a. “I enjoy my work. I do all my own work, and so I seldom have time to help others. I would if I had the time.”
b. “I love my work. I try to help others whenever they ask because on our unit it’s certainly a team effort.”
c. “I enjoy my work. I always try to be helpful, but I am careful not to help those who aren’t willing to help others.”
d. “I enjoy my work. I help others after I have spent sufficient time with my patients and feel my assistance is needed.”

 

 

ANS:  D

Assertive behavior involves communicating clearly and directly with others. If the assertive individual is conveying negative feelings, thoughts, or issues of concern, the positive aspects are noted in balance with the negative information, and the individual takes responsibility to state what he or she would like to have done differently or changed. Assertiveness also involves accepting positive and negative input and is used for the purposes of expressing one’s feelings, wishes, or desires, but not necessarily as a means of getting one’s way or winning. Nursing staff members who are unable to demonstrate appropriate assertive behavior and communications will be unsuccessful role models for their patients.

 

DIF:    Cognitive Level: Application          REF:   Text Page: 574

TOP:   Nursing Process: Evaluation           MSC:  NCLEX: Psychosocial Integrity

 

  1. A newly licensed nurse tells a nurse manager, “I’d like you to stop referring to me as ‘the smart new degree nurse.’” The nurse manager replies, “I was only teasing. You are being overly sensitive.” Which statement accurately evaluates the newly licensed nurse’s comment to the nurse manager?
a. The nurse is appropriately assertive, but now the nurse manager will likely belittle the nurse even more.
b. The nurse is behaving aggressively because of the newness of being a graduate licensed nurse and owes the nurse manager an apology.
c. The nurse is assertive, and responding that the nurse does not regard the nurse manager’s comments as “teasing” would be an effective follow-up communication.
d. The nurse is overly sensitive and ought to have ignored the nurse manager’s teasing until it was extinguished. Now the nurse manager will be more sarcastic than ever.

 

 

ANS:  C

In the above communication, a request is made that describes what the newly licensed nurse would like the charge nurse to do (i.e., stop calling the nurse “the smart new degree nurse”). This communication is clear and concise and describes the behavior that the nurse wants to stop. The remaining options fail to demonstrate effective use of appropriate assertiveness.

 

DIF:    Cognitive Level: Application          REF:   Text Page: 574

TOP:   Nursing Process: Evaluation           MSC:  NCLEX: Psychosocial Integrity

 

  1. One morning, the nurse manager asks a nurse to work overtime for the fourth week in a row, saying “I know you’ve done a lot of overtime, but I’m in a bind. Can you help me out?” The nurse had planned to attend a child’s recital that evening. Which would be the most appropriate assertive response the nurse could give?
a. “I cannot work tonight. I’m sure you will agree I’ve worked more than my share of overtime.”
b. “This isn’t a good time for me to help you. It’s my child’s recital and the family has plans.”
c. “Well, my child’s recital is tonight. If I work for you this evening you’d have to give me three weekends off on this schedule.”
d. “For goodness sake! Am I the only one working for you? Get someone else. You are not going to take advantage of me anymore!”

 

 

ANS:  B

The most therapeutic communication is the one that communicates clearly what the nurse is able to do or, in this case, not to do. Assertive people are not afraid to ask for what they want or need.

 

DIF:    Cognitive Level: Application          REF:   Text Page: 574

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Psychosocial Integrity

 

  1. A nurse facilitating a social skills group recognizes that one patient monopolizes the group. After the session the psychologist asks the nurse, “Why did you let that patient monopolize the group?” A response from the nurse using appropriate assertiveness would be:
a. “I didn’t know what I was supposed to do. You could see how much the patient needed to control the meeting. So you don’t think it was appropriate to let it be for today?”
b. “I didn’t let the patient monopolize the group. I wasn’t sure if I ought to stop the behavior or let the patient talk. What could I have said to end the patient’s monopolizing of the group?”
c. “Honestly, I never feel you are satisfied with my work. Why don’t you lead the group next time? That will give me an opportunity to observe you appropriately managing the patient’s need to monopolize the group.”
d. “I felt that the patient needed to express feelings and that the control was a rather tenuous one that required sensitivity and patience. I believe the other patients felt that, too, which is why they let the patient monopolize the group.”

 

 

ANS:  B

The most assertive communication is the one that clarifies any misperceptions and seeks assistance in a direct manner. Rationalization is not professional. Patients will take their cue from the facilitator of the group. Becoming angry because the psychologist has constructively criticized the nurse’s facilitation skills in dynamic supervision is aggressive.

 

DIF:    Cognitive Level: Analysis               REF:   Text Page: 574

TOP:   Nursing Process: Evaluation           MSC:  NCLEX: Psychosocial Integrity

 

  1. A nurse leader facilitating a group of recovering alcoholics observes patients drinking nonalcoholic look-alike beer and wine coolers they have brought with them instead of the available decaffeinated coffee and soda. An appropriate response from the nurse would be:
a. telling the patients that they are behaving inappropriately and instructing them to throw the nonalcoholic beer and wine drinks away.
b. stopping the group and asking the patients who are drinking inappropriately to leave and return next week without the nonalcoholic beverages.
c. ignoring their behavior but firmly stating “If you want me to return next week, all of you will come prepared to appropriately participate in this group.”
d. stating, “I see that some of you are drinking nonalcoholic beverages and wine coolers. What is your understanding of the purpose of this group?”

 

 

ANS:  D

There are many dynamic reasons that might be postulated about why alcohol-troubled patients would bring pseudo-alcoholic beverages to the group. The facilitator needs to be assertive and bring the behavior out to the group for its members to examine. It is time to review the purpose of the group and then to assist the group in reflecting on their behavior and its meaning for their sobriety. The remaining options do not attempt to determine the reason for the inappropriate behavior.

 

DIF:    Cognitive Level: Application          REF:   Text Page: 574

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Psychosocial Integrity

 

  1. A patient who is displaying manic behavior enters the unit’s dayroom and declares in a loud, threatening voice, “I have friends, and if you don’t show me proper respect, you’ll be sorry!” The nurse’s initial response should be to approach the patient, address him formally, and say in a:
a. soft voice, “You will always have proper respect here. Let’s sit over here and talk.”
b. soft voice, “You are really frightening the other patients. Please go to your room.”
c. firm voice, “You are out of control. I expect you to go to your room immediately.”
d. firm voice, “You seem to be escalating again. I’ve brought an injection that will calm you and slow your thinking.”

 

 

ANS:  A

When dealing with a patient who is escalating, the nurse initially assesses the patient’s ability to use self-control and to respond to verbal cues. Speaking in a calm, soft voice and calling the patient by his or her formal title (unless the patient has insisted on being called by a first name), the nurse attempts to deescalate the patient by engaging him or her in a conversation that allows the expression of concerns. The remaining options either appear to threaten the client or have the nurse determine the topic of the conversation rather than focusing on the client’s concerns.

 

DIF:    Cognitive Level: Analysis               REF:   Text Page: 581

TOP:   Nursing Process: Implementation

MSC:  NCLEX: Safe, Effective Care Environment: Management of Care

 

  1. Which medication would a nurse expect to be prescribed to an adolescent patient diagnosed with a conduct disorder who has a history of physically abusing younger siblings?
a. Propranolol (Inderal)
b. Propranolol (Ritalin)
c. Clozapine (Clozaril)
d. Phenytoin (Dilantin)

 

 

ANS:  C

Atypical antipsychotic agents are more effective than stimulants in treating aggression in children and conduct disorders in adolescents. The remaining options are not known to be effective for this condition.

 

DIF:    Cognitive Level: Application          REF:   Text Page: 585

TOP:   Nursing Process: Planning

MSC:  NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies

 

  1. A nurse working in a walk-in clinic is approached by a person with a history of violent behavior. The person states, “I want to go to the hospital for a rest. You better get me in or I’ll do something bad. I can get a gun.” An appropriate response from the nurse would be:
a. “If I get you admitted, will you promise to behave yourself?”
b. “You seem very anxious to be hospitalized. What do you think will happen if you aren’t hospitalized?”
c. “Do you have a gun? I’m not sure I believe you. Are you really threatening to kill yourself or someone else?”
d. “Do you really want to go to the hospital? Would you be satisfied if I were able to find you someplace safe to rest?”

 

 

ANS:  B

The most therapeutic communication is the one in which the nurse assesses the potential for violence by ascertaining the patient’s plan, means, and commitment. The remaining options fail to do that satisfactorily.

 

DIF:    Cognitive Level: Application          REF:   Text Pages: 579-580

TOP:   Nursing Process: Assessment

MSC:  NCLEX: Safe, Effective Care Environment: Management of Care

 

  1. An adolescent patient who just completed a time-out for having slapped another patient complains, “The other patient started it, but I get punished. It’s unfair.” An appropriate response from the nurse would be:
a. “Don’t expect me to take your side in this. You received punishment because you were violent. It doesn’t matter who started it. On this unit, violent behavior will always be punished.”
b. “Let’s talk about that. Do you think you were asked to take a time-out because you ‘started it’ or because your response was both out of control and violent?”
c. “You make a good point. We need to punish both of you in a similar fashion. Since I believe in fair play, I’ll assign the other patient to a time-out as well.”
d. “Sounds to me as if you have really been bullied. I will have to discuss this with the staff. I’m pleased that you accepted the time-out like an adult.”

 

 

ANS:  B

It is important that the patient identify his or her own inappropriate behavior. It is also important that the nurse deliver the time-out as a consequence in a matter-of-fact manner and not as a punishment. Behavior is altered more adaptively if the consequence (e.g., deduction of tokens, time-out to one’s room) is delivered as a support to assist the patient to relearn adaptive ways to behave in problematic situations. The remaining options fail to address the issue of personal responsibility for one’s own actions.

 

DIF:    Cognitive Level: Analysis               REF:   Text Page: 584

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Psychosocial Integrity

 

  1. A crisis team is working to admit a violent patient who has been both medicated and physically restrained. Which statement made to the patient is the best example of team function?
a. The team leader tells the patient “I believe you’re feeling very frightened right now. We can allow you to walk to the unit if you are willing to cooperate.”
b. A team member tells the patient, “Because you have been so violent we had to restrain you.” The team leader adds, “Try to cooperate with us. We really don’t want to hurt you.”
c. A crisis team member says, “I know that you’re feeling very frightened, but we’ll help you feel calmer.” The admitting nurse says, “Do you feel you can do this without being agitated and physically violent?”
d. The admitting nurse states, “You were restrained because you are behaving very violently.” The crisis team leader adds, “Do you want to be carried into the unit, or will you go quietly?”

 

 

ANS:  A

When working in a crisis team, there is one leader who does all the talking. Having several members of the crisis team talk is confusing to the patient.

 

DIF:    Cognitive Level: Analysis               REF:   Text Pages: 585-586

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Psychosocial Integrity

 

  1. A patient’s contract to be taken outside for a fresh air break after meals has been unavoidably postponed. The patient says, “I’ve waited patiently for 2 hours, and now I want to stay outside for an extra 10 minutes!” An appropriate response from the nurse would be:
a. “I’m sorry but you will have to wait. You know that as adults we don’t always get what we want when we want it.”
b. “I’ll arrange to have someone take you after lunch, and you can stay out for as long as you like if you’ll just wait patiently.”
c. “You are quite right. Thank you for being so patient. Someone will come right now and take you outside for your break.”
d. “Please show a little consideration; we’ve been very busy handling other patients’ problems. You would understand if it were you with the problem.”

 

 

ANS:  C

Contracting is a two-way street. According to the situation presented in this question, the nurse already has received time and understanding from the patient. The nurse or another member of the staff needs to stop and provide the patient with the break time that has been contracted. It is not the patient’s fault if the unit is busy, and the nurse who responds with anger or sarcasm is not being self-aware or mutually respectful of the patient.

 

DIF:    Cognitive Level: Application          REF:   Text Pages: 583-584

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Psychosocial Integrity

 

  1. A nurse has just explained to a newly admitted patient that the token economy system is employed on the unit. The patient announces, “I have a PhD, and I’ll be damned if I participate in a barter exchange for my human rights.” An appropriate response from the nurse would be:
a. “Well, according to the unit rules you have just lost four tokens for swearing, and you haven’t even earned any yet. That makes your score a negative four.”
b. “Being a PhD, I’m sure you are familiar with being held responsible for your actions. That’s the policy on this unit, and you now have minus four tokens.”
c. “It seems as if you’re having difficulty being here. Are you saying that you feel you don’t have to abide by the same policies for living on this unit because you are well educated?”
d. “Well-educated individuals usually have no need to swear. You have now lost four tokens. We’ll talk when you are able to be more polite.”

 

 

ANS:  C

The most therapeutic communication is the one in which the nurse expresses empathy for the patient and asks the patient to reflect on his or her thinking. In this way, the nurse seeks to determine whether the patient is able to think critically about his or her situation and response and how it appears to others. This eliminates any countertransference in the nurse’s behavior. Lecturing the patient will only stimulate more angry behavior. The nurse’s goal ought to be to facilitate the patient’s expression of feelings so that the patient can begin to reflect and eventually problem solve effectively.

 

DIF:    Cognitive Level: Analysis               REF:   Text Pages: 578-580

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Psychosocial Integrity

 

  1. A patient attending an aggression management group therapy session disrupts the meeting repeatedly by interrupting the discussion. An appropriate response from the nurse would be:
a. “It sounds as if your thoughts are troubling you. This may not be a good time for you to be meeting with us. I suggest you take a brief time-out.”
b. “What’s happening with you right now? How can you control the effect this may have on your ability to stay calm and focused on our group goals?”
c. “Can you remember what we talked about in the assertiveness training group yesterday? What do you need to do to regain control of your behavior?”
d. “Do any of you want to share your feelings about what is happening? If not, I’ll assume no one is particularly distressed by the disruptive behavior.”

 

 

ANS:  A

The most therapeutic nursing intervention is the one that excuses the patient from the group to protect the patient from being embarrassed once control is regained. In addition, the time-out may provide a reduction in milieu stimulation and provide needed structure and control. In assessing the potential for violent behavior, the nurse measures the patient’s mental status as well as is possible. A patient who is unable to control talking out loud is not a good participant in a group meeting, whether the behavior is one of manipulation or a sign of potential aggression and disintegration.

 

DIF:    Cognitive Level: Analysis               REF:   Text Page: 584

TOP:   Nursing Process: Implementation

MSC:  NCLEX: Safe, Effective Care Environment: Management of Care

 

  1. A unit has experienced several violent outbursts that have resulted in the forcible restraint of patients. On review, each violent event and all crisis management strategies were appropriately followed. To maximize staff efficiency the nurse manager should:
a. determine the institution’s policies regarding the management of crisis situations should be reviewed in mandatory staff education sessions.
b. schedule staff breaks at intervals that allow staff members to leave the unit and relax while discussing the problems in the current milieu.
c. invite a team of experts to evaluate crisis management on the unit for 1 month to determine whether any procedures are being unintentionally omitted.
d. schedule a multidisciplinary team education meeting and invite a distinguished expert who can help staff members understand that they managed each crisis appropriately.

 

 

ANS:  B

Despite the fact that everything that could be done in each violent event was done, the staff members are still experiencing high levels of stress more often. If feasible, the nurse will provide ways to manage the staff’s higher level of stress during this time. The only selection that offers an avenue for immediate stress management is scheduling frequent breaks.

 

DIF:    Cognitive Level: Application          REF:   Text Pages: 589-591

TOP:   Nursing Process: Planning

MSC:  NCLEX: Safe, Effective Care Environment: Management of Care

 

  1. Which rationale for placing a violent patient into seclusion best reflects the philosophy of nursing?
a. It restricts patients to a physical space in order to reduce sensory overload. The goal is to minimize the risk of harm to others while preserving the patient’s personal safety and dignity.
b. It offers safety by removing all potentially harmful objects and allows for the testing of the patient’s interpersonal control by gradually decreasing and/or increasing sensory input.
c. It provides for a carefully protected milieu that offers safety, permeability of sensory input, and only incrementally increased interpersonal relationships.
d. It prevents patients from harming themselves or others, reduces the need for proprioception, and provides a protective milieu at the risk of sensory deprivation.

 

 

ANS:  A

Seclusion is the use of a fully protective environment with close observation by nursing staff for the purpose of safety or behavior management based on a professional nursing philosophy of concern for human dignity and optimal fulfillment of basic human needs. The scientific rationale for the use of seclusion is based on three principles: containment, isolation, and decrease in sensory input.

 

DIF:    Cognitive Level: Analysis               REF:   Text Pages: 586-587

TOP:   Nursing Process: Planning

MSC:  NCLEX: Safe, Effective Care Environment: Management of Care

 

  1. A patient is being restrained after biting himself and members of the nursing staff. An appropriate response from the nurse would be:
a. “You have been restrained because you are violent and the staff is unable to deal with you. Until you regain control, we will do our best to make you comfortable and keep you safe.”
b. “You are being restrained because you have been biting yourself and others. Let the staff know if the restraints are uncomfortable. You will be released when you are able to again control your behavior.”
c. “Your thinking is making you violently uncontrollable, and in addition you’re trying to bite us. We do not like having to restrain you but it is necessary until you are more in control. We hope to release you soon.”
d. “I know this feels terrible to you, but you are so violent that you may hurt yourself, the staff, and other patients. We won’t keep you restrained for long, just long enough for you to regain control of your behavior.”

 

 

ANS:  B

There is no easy way to discuss the use of restraints with a patient who is currently violent. It is important to explain in a nonjudgmental way why restraint is being employed and to open up an avenue of communication so staff members can ensure the patient’s optimal well-being during the period of restraint.

 

DIF:    Cognitive Level: Application          REF:   Text Pages: 586-587

TOP:   Nursing Process: Implementation

MSC:  NCLEX: Safe, Effective Care Environment: Management of Care

 

  1. During staff debriefing after placing a patient with a history of violence into seclusion, a nurse new to the unit says, “I think we acted prematurely. We didn’t spend enough time trying to deescalate the situation.” An appropriate response from the nurse manager would be:
a. “You’re new here. Trust the staff to make decisions based on experience and sound, evidence-based practice.”
b. “We’re a team. We all need to be open to other possibilities, and I expect that we respect each other’s viewpoints.”
c. “I’d like to hear more specifically what you think we could have said or done to talk the patient down and avoid the need for seclusion.”
d. “Professional nurses are familiar with a variety of communication interventions; maybe it’s time we had an in-service to improve our communication skills.”

 

 

ANS:  C

The most therapeutic nursing communication is the one that addresses the new nurse’s concerns more specifically. Often new staff members can offer a new perspective on an issue that will enrich unit operations and provide an expanded approach to effective clinical decision making.

 

DIF:    Cognitive Level: Analysis               REF:   Text Pages: 589-591

TOP:   Nursing Process: Implementation

MSC:  NCLEX: Safe, Effective Care Environment: Management of Care

 

  1. At 7 AM, a patient demands in a loud, tremulous voice, “Where’s my doctor? The doctor promised to see me first thing in the morning. Call the doctor and say that I’m waiting.” An appropriate response from the nurse would be:
a. “Please get ready for breakfast. It’s only 7 AM. Your doctor will be in and I’ll make sure that you’re seen.”
b. “Don’t yell at me like that; it isn’t polite and certainly isn’t necessary. I want to help you, but I will not be verbally abused.”
c. “You seem very angry that your doctor has not come in yet. Your doctor will be in this morning but not until later. The doctor spends time with everyone.”
d. “Your doctor doesn’t come to the unit until after breakfast and morning groups are over. Have your breakfast now so you’ll be ready when your doctor gets here.”

 

 

ANS:  D

The most therapeutic communication is the one that does the following: addresses the patient by name (this assesses the patient’s ability to listen and respond to the nurse) and offers information in a matter-of-fact way (this addresses the well part of the patient’s communication, that is, the part in which the patient asks, “When is my doctor coming?”). The patient’s communication is appropriate and needs to be acknowledged in a respectful manner. The best response promotes structure for the patient by offering a plan that suggests a shower (Maslow’s hierarchy: the patient will feel better physically while waiting for the doctor) and provides breakfast on the unit with the structure of a reduced-stimulus milieu. (The patient may be escalating, so it is better to order a tray on the unit if the patient is usually able to go to breakfast in the cafeteria.)

 

DIF:    Cognitive Level: Application          REF:   Text Pages: 583-584

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Psychosocial Integrity

 

  1. Which response best reflects appropriate assertiveness by a nurse when approached by a patient who demands medications immediately?
a. “I will get your medications as soon as I am finished with what I am doing right now, so please wait for me in your room.”
b. “I will give you your medications as soon as I finish here. It’s not appropriate for you to keep asking me for your medications.”
c. “I’ll check on your medications as soon as I finish with what I am doing. If it is not quite time for your medications I will bring them to you when it is.”
d. “We need to talk about your impatient behavior before I give you your medications. You must understand that you are not the only patient on the unit.”

 

 

ANS:  C

Assertive behavior conveys a sense of self-assurance but also communicates respect for the other person. Acknowledging the patient’s concern and explaining that you will meet needs is considerate and respectful. This response also lets the patient know that you are completing a task and will then meet the needs within a reasonable time.

 

DIF:    Cognitive Level: Application          REF:   Text Page: 574

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Psychosocial Integrity

 

  1. Which statement by a nurse new to the unit best reflects an understanding that staff attitudes and actions have a powerful effect on both patient behavior and milieu management?
a. “I understand that there are going to be days where the unit will be short-staffed or really busy. As new members of the team, how can we contribute to keeping the stress level on the unit from escalating?”
b. “What are the administration’s expectations of us as new employees related to the management of the milieu in general and of individual patient behavior?”
c. “I’m new, so I will learn best by observing while one of the more experienced staff members manages control over the patients.”
d. “How do I best involve the health care providers in the management of the milieu when a patient begins to escalate?”

 

 

ANS:  A

Clinicians may intentionally or inadvertently precipitate an outbreak of violence because staff attitudes and actions have a powerful effect on patient behavior. Inexperienced staff members, provocation by staff, poor milieu management, understaffing, close physical encounters, inconsistent limit setting, and a norm of violence all may negatively affect the inpatient environment.

 

DIF:    Cognitive Level: Analysis               REF:   Text Pages: 580-581

TOP:   Nursing Process: Planning

MSC:  NCLEX: Safe, Effective Care Environment: Management of Care

 

  1. A newly admitted patient diagnosed with bipolar disorder is speaking loudly and demanding attention. A nurse assures the patient that the staff is always willing to listen and will help in any way possible but that the patient will need to speak more slowly and softly in order to be understood. The nurse is demonstrating an example of:
a. necessary aggression with a difficult patient.
b. effective, patient-directed therapeutic use of self.
c. implementing therapeutic patience when providing patient care.
d. patient education regarding effective nurse-patient communication.

 

 

ANS:  B

The most valuable resource of a nurse is the ability to use one’s self to help others. To ensure the most effective use of self, it is important to be aware of personal stress that can interfere with one’s ability to communicate therapeutically with patients.

 

DIF:    Cognitive Level: Application          REF:   Text Page: 580

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Psychosocial Integrity

 

  1. A nurse is caring for a patient who has come into the clinic insisting on seeing a psychiatric nurse practitioner immediately because the patient is in crisis. In order to prevent a possible catastrophic reaction, the nurse will:
a. take the patient to an exam room immediately and begin to assess the situation and needs.
b. ask the patient to please take a seat in the waiting room until the nurse practitioner can be called.
c. ask the patient what psychiatric medications have been prescribed and when the patient last self-administered the drugs.
d. call the clinic manager to assume responsibility for the patient’s care so that the other patients can be attended to effectively.

 

 

ANS:  A

Because it is much less dangerous to prevent a crisis than to respond to one, every effort should be made to carefully monitor patients who are at risk for violent behavior and intervene at the first possible sign of increasing agitation.

 

DIF:    Cognitive Level: Application          REF:   Text Pages: 581-582

TOP:   Nursing Process: Implementation

MSC:  NCLEX: Safe, Effective Care Environment: Management of Care

 

  1. A nurse observes a patient with a history of aggressive behavior toward others pacing in the dayroom while appearing to talk to himself. The nurse will best intervene with this patient therapeutically by:
a. asking him to sit in the dayroom and watch television with the other patients and staff.
b. instructing him to go to his room and remain there until he shows that he can be sociable.
c. asking him if he would like to walk to his room where he and the nurse can sit together quietly to discuss the cause of his behavior.
d. assigning an ancillary staff member the task of walking him around the unit for several minutes and then returning him to his room.

 

 

ANS:  C

Having the patient return to his room to write about his feelings, do deep-breathing or relaxation exercise, or talk about his emotions with a supportive person can help the patient regain control and lower feelings of tension and agitation. The responsibility of patient/milieu management is not one that may be delegated to ancillary staff.

 

DIF:    Cognitive Level: Application          REF:   Text Page: 583

TOP:   Nursing Process: Implementation

MSC:  NCLEX: Safe, Effective Care Environment: Management of Care

 

 

Chapter 40: Psychological Care of Patients with Life-Threatening Illness

Test Bank

 

MULTIPLE CHOICE

 

  1. A nurse is caring for a patient awaiting test results that will indicate whether the patient has cancer. Which communication would be most helpful initially to facilitate a therapeutic nurse-patient relationship?
a. “I’m sure this must be a difficult time. It may be most helpful for you to focus on the development of new drugs and other therapies.”
b. “How sad and frightened you must feel right now. Do you have any family or friends that are good support systems for you that I might call?”
c. “I am trying to imagine how you feel. If you spend this time making sure all your affairs are in order, it will give you more of a sense of control over the situation.”
d. “This is a time of uncertainty for you and your family. I sense that you are quite anxious and in disbelief. I’d like to talk to you about how you’re feeling.”

 

 

ANS:  D

Between the development of symptoms and a definitive diagnosis, patients and their family members or loved ones have to endure a time of uncertainty. Often the best way to begin the intervention is to tell the person the behavior or emotion that you are observing and give it a name (shock, disbelief, fear, or sadness). It is important to validate and seek the person’s agreement with or refinement of this perception. The correct response “offers self,” a therapeutic communication technique.

 

DIF:    Cognitive Level: Application          REF:   Text Page: 764

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Psychosocial Integrity

 

  1. A patient has just been diagnosed with an inoperable brain tumor. Which patient statement about concerns should the nurse expect initially?
a. “I wish I knew what I did to cause this to happen.”
b. “I’m very concerned about becoming a burden to my family.”
c. “If that is the case I would like to look into nursing home placement or hospice care right away.”
d. “Well, all of us have to die someday. I’ll have to see a lawyer about a will, and I’ll need you to tell me more about advance directives.”

 

 

ANS:  B

Patients and families have concerns immediately after receiving a diagnosis of terminal illness. Concerns frequently include how long people live after diagnosis, emotional effect or inconvenience to family or friends, being a burden, financial concerns, suffering pain or disfigurement, feelings of loss of control, feelings of still having much to do in life, and dying alone.

 

DIF:    Cognitive Level: Application          REF:   Text Page: 765

TOP:   Nursing Process: Assessment          MSC:  NCLEX: Psychosocial Integrity

 

  1. A patient with liver failure rings the call bell and tells the nurse, “The lunch is cold, and my sheets are wrinkled. You never seem to have enough help to give me the care I need.” Which intervention should the nurse implement initially?
a. Listen quietly but attentively until the patient has finished speaking.
b. Attempt to correct each problem the patient has identified immediately.
c. Say to the patient, “I’m sorry but please know that the staff is really doing the best they can.”
d. Promise the patient to share all of the concerns with the unit’s nurse manager on day shift.

 

 

ANS:  A

Ways in which the nurse can respond to patient or family concerns include, among others, listening without interrupting or defending, and providing what is requested if possible. For this reason, the nurse should initially listen to the patient before attempting to correct the perceived problems.

 

DIF:    Cognitive Level: Application          REF:   Text Pages: 762-763

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Psychosocial Integrity

 

  1. A patient diagnosed with amyotrophic lateral sclerosis says to the nurse, “I’ve been looking on the Internet to get more information about this disease. Which of the sites has the most reliable information?” Which site would the nurse recommend?
a. National Institutes of Health (NIH)
b. Food and Drug Administration (FDA)
c. Centers for Disease Control and Prevention (CDC)
d. Occupational Safety and Health Administration (OSHA)

 

 

ANS:  A

The NIH is a reputable and accurate website for obtaining health-related information. The CDC is appropriate for information about communicable diseases. OSHA oversees workplace safety, and the FDA oversees food and drug standards.

 

DIF:    Cognitive Level: Application          REF:   Text Page: 764

TOP:   Nursing Process: Implementation

MSC:  NCLEX: Safe, Effective Care Environment: Management of Care

 

  1. A nurse advocating for an anxious patient newly diagnosed with a life-threatening illness would ask the health care provider to prescribe which type of medication?
a. Selective serotonin reuptake inhibitor
b. Monoamine oxidase inhibitor
c. Tricyclic antidepressant
d. Benzodiazepine

 

 

ANS:  D

The patient’s symptoms of anxiety need not meet the criteria for a formal psychiatric diagnosis in order to be treated. Pharmacological treatment with benzodiazepines is common practice, and nurses should initiate requests for a prescription if the patient does not already have one.

 

DIF:    Cognitive Level: Application          REF:   Text Page: 764

TOP:   Nursing Process: Planning

MSC:  NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies

 

  1. A patient underwent surgery for cancer and now needs follow-up chemotherapy. The patient reports anorexia, fatigue, and trouble concentrating and sleeping. A nurse would place highest priority on responding to which statement by the family member?
a. “We are so concerned about him. He hardly eats or sleeps anymore. Can something be done?”
b. “We’re not surprised he’s depressed after all he is going through, but is there some medicine that can help him right now?”
c. “We’re not surprised he’s so depressed. It ought to be expected after all that he’s been through. He’ll be back to normal after the chemotherapy.”
d. “We can’t wait for the chemotherapy to start. He worries about any remaining cancer starting to grow between the surgery and the chemotherapy.”

 

 

ANS:  C

A persistent myth proposes that if a person “has a reason” to be depressed, no treatment is needed because this “functional depression” is a normal response. However, this myth denies that the patient has a need for effective treatment. For this reason, the nurse should first follow up on that response.

 

DIF:    Cognitive Level: Analysis               REF:   Text Page: 764

TOP:   Nursing Process: Planning              MSC:  NCLEX: Psychosocial Integrity

 

  1. A nurse enters the room of a patient newly diagnosed with multiple sclerosis and notes that the patient is crying quietly while lying in bed. Which communication by the nurse would be most appropriate?
a. “You are crying. What are you feeling that’s making you so sad?”
b. “Do you want me to call the health care provider to order some antidepressant medication for you?”
c. “I can understand why you would cry. I imagine most people would feel sad after being given your diagnosis.”
d. “Crying is a normal response to a diagnosis such as yours. You’ll feel better after your plan of care has been fully developed.”

 

 

ANS:  A

The most appropriate statement is the one that attempts to use therapeutic communication to determine whether the patient is depressed. The correct option is the only one that attempts to elicit more information about the patient’s feelings. This would be the most effective means of assessing the patient’s emotional status.

 

DIF:    Cognitive Level: Application          REF:   Text Pages: 764-765

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Psychosocial Integrity

 

  1. The adult child of a critically ill patient has been keeping vigil, remaining at the bedside constantly for 3 days. Which communication from the nurse would be most appropriate when the child becomes demanding and impatient with the staff providing the parent’s care?
a. “I can see that you are feeling short-tempered, which is not unusual under the circumstances. Still, it is not good for your parent to hear you complaining.”
b. “It must be difficult for you to be here day after day. What other family members can stay so that you can get a good night’s sleep at home?”
c. “It would be best for you to go home for a few days and get some sleep and proper nutrition. Do you have the number here so you can call if you feel the need to?”
d. “You have had little sleep in the last few days. Perhaps you should go home for some rest. You can’t be of much help if you are so tired you can’t think properly.”

 

 

ANS:  B

The correct response is one that acknowledges the family member’s situation and then explores an alternative.

 

DIF:    Cognitive Level: Application          REF:   Text Page: 765

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Psychosocial Integrity

 

  1. A nurse working in the pediatric intensive care unit is assigned to pediatric patients who are experiencing pain. The nurse would select the Wong FACES Pain Rating Scale for use in which child?
a. A 6-month-old patient with failure to thrive
b. A 12-month-old patient with a burn injury
c. A 24-month-old patient with injuries after a fall
d. A 38-month-old patient with sickle cell disease

 

 

ANS:  D

The Wong FACES Pain Rating Scale can be used for children ages 3 years (36 months) and above. The patient is asked to point to the face that best describes the pain, from a smiley face to a tearful one.

 

DIF:    Cognitive Level: Application          REF:   Text Pages: 765-766

TOP:   Nursing Process: Assessment

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. A patient receiving palliative care is treated with large doses of narcotic analgesics to control pain. To minimize side effects of this medication the nurse should ensure that there is a prn prescription for which type of medication?
a. Antiemetic
b. Stool softener
c. Bronchodilator
d. Nonopioid analgesic

 

 

ANS:  B

Constipation occurs in as many as two thirds of patients receiving palliative care. Patients taking narcotic pain-control agents regularly should have prophylactic treatment for constipation, which could include stool softeners and laxatives.

 

DIF:    Cognitive Level: Application          REF:   Text Page: 766

TOP:   Nursing Process: Planning

MSC:  NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies

 

  1. A patient undergoing chemotherapy is experiencing anxiety-induced anticipatory nausea and vomiting. A nurse could assist this patient by requesting a prescription for which preferred medication?
a. Lorazepam (Ativan)
b. Hydroxyzine (Vistaril)
c. Promethazine (Phenergan)
d. Chlorpromazine (Thorazine)

 

 

ANS:  A

Because the nausea and vomiting are anxiety-induced, lorazepam (a benzodiazepine) may be used to reduce both the anxiety and the nausea and vomiting. The other medications listed are useful in treatment of nausea and vomiting.

 

DIF:    Cognitive Level: Application          REF:   Text Page: 766

TOP:   Nursing Process: Planning

MSC:  NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies

 

  1. A nurse should use which measure initially to reduce dyspnea in a patient with end-stage chronic obstructive pulmonary disease?
a. Administer a dose of an ordered prn bronchodilator.
b. Encourage the patient to use an incentive spirometer.
c. Assist the patient to cough and deep breathe.
d. Elevate the head of the bed.

 

 

ANS:  D

Dyspnea occurs in many chronic and end-stage diseases and the nurse can assist the patient with shortness of breath by raising the head of the bed to a comfortable position. Bronchodilators may be used as an aid, but positioning is noninvasive and is a first-line intervention. Incentive spirometry, coughing, and deep breathing would prevent atelectasis but would not treat the symptom of dyspnea resulting from the end-stage disease process.

 

DIF:    Cognitive Level: Application          REF:   Text Page: 766

TOP:   Nursing Process: Implementation

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. The adult child of a terminally ill patient tells a nurse, “The doctor recommended considering end-of-life care.” The nurse interprets that this most likely means that the patient will not live more than _____ month(s).
a. 1
b. 3
c. 6
d. 24

 

 

ANS:  C

End of life is generally accepted as the probable last 6 months of life.

 

DIF:    Cognitive Level: Comprehension   REF:   Text Pages: 766-767

TOP:   Nursing Process: Assessment          MSC:  NCLEX: Psychosocial Integrity

 

  1. A patient with metastasized cancer says to the nurse, “I’ve been reading about some of the cancer research, and I am still hoping for a cure in the next few months.” In formulating a response to the patient, which should the nurse consider first?
a. The patient’s religion and/or faith-based beliefs
b. The need for a consultation with a professional grief counselor
c. The purpose that would be served in confronting the patient’s denial
d. The patient’s ability to understand the meaning of this particular research

 

 

ANS:  C

Having “hope against hope” may not mean that the patient is in denial, but rather that he or she is using denial as an adaptive defense mechanism. The nurse should first consider what purpose confrontation would serve at this time.

 

DIF:    Cognitive Level: Analysis               REF:   Text Page: 767 | Text Page: 770

TOP:   Nursing Process: Planning              MSC:  NCLEX: Psychosocial Integrity

 

  1. An older adult patient diagnosed with Parkinson-induced dementia becomes critically ill with severe pneumonia. No family is available. After repeated failed attempts to contact the patient’s agent designated by the Health Care Power of Attorney, which standard should the health care team use as the best method for decision making in planning care for this patient?
a. Informed consent
b. Best interests standard
c. Patient’s Bill of Rights
d. Substituted judgment standard

 

 

ANS:  B

The best interests standard is applied when the patient lacks decisional capacity and no other designated health care proxy is available. This standard is based on what would promote the welfare of the “average” patient.

 

DIF:    Cognitive Level: Application          REF:   Text Page: 767

TOP:   Nursing Process: Planning

MSC:  NCLEX: Safe, Effective Care Environment: Management of Care

 

  1. A patient with end-stage renal disease does not want further aggressive treatment but is reluctant to withdraw life-sustaining treatment. The nurse would help the patient to understand that life-sustaining treatment includes maintaining:
a. full code status.
b. comfort measures only.
c. nutrition, hydration, and dialysis.
d. nutrition and hydration but removal of dialysis.

 

 

ANS:  C

The patient who wants to withhold further aggressive therapy but not withdraw life-sustaining therapy would be informed that nutrition, hydration, and current treatments such as dialysis would be maintained.

 

DIF:    Cognitive Level: Application          REF:   Text Pages: 767-768

TOP:   Nursing Process: Planning

MSC:  NCLEX: Safe, Effective Care Environment: Management of Care

 

  1. When a terminally ill patient is attempting to make the decision to withhold further treatment, the nurse would indicate that which medication would no longer be prescribed if treatment were to be withheld?
a. Antibiotics
b. Antiemetics
c. Opioid analgesics
d. Nonopioid analgesics

 

 

ANS:  A

Antibiotics are used to treat infection and therefore would be withheld in the care of a patient who has designated that life-sustaining treatment should be withheld. The medications in the other options promote comfort and would continue to be administered.

 

DIF:    Cognitive Level: Application          REF:   Text Page: 768

TOP:   Nursing Process: Implementation

MSC:  NCLEX: Safe, Effective Care Environment: Management of Care

 

  1. A nurse explained hospice services to a patient with metastatic cancer. In evaluating the teaching, the nurse determines the need for further information when the patient states that one of the services provided in hospice care is:
a. experimental chemotherapy.
b. symptom management.
c. psychosocial support.
d. nutritional counseling.

 

 

ANS:  A

Hospice care would not include any form of chemotherapy, which is a therapy generally intended to treat or cure cancer. Hospice care does involve pain and symptom management, nutritional counseling, physical/occupational/speech therapies, home health services for personal care, psychosocial and emotional support, grief counseling, and crisis care during medical emergencies.

 

DIF:    Cognitive Level: Application          REF:   Text Pages: 768-769

TOP:   Nursing Process: Evaluation

MSC:  NCLEX: Safe, Effective Care Environment: Management of Care

 

  1. A nurse is working with the family of a terminally ill child with leukemia. The nurse shares with the parents that which sibling will likely have a more factual than emotional response to the sibling’s death?
a. 16-year-old
b. 12-year-old
c. 8-year-old
d. 3-year-old

 

 

ANS:  D

Below the age of 6 years, attitudes toward death are often matter-of-fact rather than emotional.

 

DIF:    Cognitive Level: Comprehension   REF:   Text Page: 769

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Health Promotion and Maintenance

 

  1. When the parents of a terminally ill teenager whose death is imminent are approached and counseled regarding the possibility of organ donation, the parents refuse. The nurse is concerned that they may not have fully considered the positive effect organ donation has on both the surviving family members as well as organ recipients. Which nursing action will have the greatest therapeutic effect regarding the parents’ decision?
a. Ask the chaplain to address the issue with the parents after giving them time to reconsider.
b. Gently share with the parents that they could be making a mistake they will later regret.
c. Say nothing, and support the parents in their decision to the fullest extent possible.
d. Refer the matter to the hospital’s organ procurement agent.

 

 

ANS:  C

Even when a nurse finds it difficult to accept an informed decision a parent has made, professional ethics clearly require that the decision be supported.

 

DIF:    Cognitive Level: Application          REF:   Text Page: 770

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Psychosocial Integrity

 

  1. A 22-year-old nurse is working with a seriously ill 23-year-old patient who is recovering from a motor vehicle accident. The nurse recognizes having difficulty maintaining professional boundaries based on their similar ages. Which action should the nurse take initially?
a. Seek guidance from another experienced nurse or the unit manager.
b. Provide excellent care, but keep conversation and contact to a minimum.
c. Arrange to have ancillary staff complete as much care as possible within their scope of practice.
d. Discuss with the nursing supervisor the possibility of having another nurse assume this patient assignment.

 

 

ANS:  A

It may be challenging for the nurse to maintain professional boundaries when the age of the nurse and patient are near the same. It is advisable for the nurse to discuss the conflict with an experienced nurse or supervisor. Seeking reassignment from that patient is considered only after it becomes apparent that the issue cannot be effectively resolved.

 

DIF:    Cognitive Level: Application          REF:   Text Page: 769

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Psychosocial Integrity

 

  1. A patient who is terminally ill expresses a wish to “hurry up and end it all.” In exploring reasons for this wish, which should the nurse assess first?
a. Guilt and fatigue
b. Pain and depression
c. Self-esteem and hope
d. Competency and pain

 

 

ANS:  B

Studies have shown that when pain and depression are adequately treated, patient requests to hasten death diminish.

 

DIF:    Cognitive Level: Application          REF:   Text Page: 770

TOP:   Nursing Process: Assessment          MSC:  NCLEX: Psychosocial Integrity

 

MULTIPLE RESPONSE

 

  1. Palliative care includes: (Select all that apply.)
a. comfort measures.
b. fluid-volume replacement.
c. range-of-motion exercises.
d. nasogastric tube feedings.
e. pain medication therapies.

 

 

ANS:  A, E

Palliative care includes pain medications, stomach ulcer prevention, skin and mouth care, and other comfort measures. Palliative care does not necessarily include IV hydration (or tube feedings). There is no purpose for doing range-of-motion exercises for this patient.

 

DIF:    Cognitive Level: Comprehension   REF:   Text Pages: 765-766

TOP:   Nursing Process: Implementation

MSC:  NCLEX: Safe, Effective Care Environment: Management of Care

 

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