M3

Question 1

A nurse is assessing a client who is experiencing occasional feelings of sadness because of the recent death of a beloved pet. The client’s appetite, sleep patterns, and daily routine have not changed. How should the nurse interpret the clients behaviors?

1. The client’s behaviors demonstrate mental illness in the form of depression.
2. The client’s behaviors are extensive, which indicates the presence of mental illness.
3. The client’s behaviors are not congruent with cultural norms.
4. The client’s behaviors demonstrate no functional impairment, indicating no mental illness.

Answer 1

4. The client’s behaviors demonstrate no functional impairment, indicating no mental illness.

Rationale: The nurse should assess that the clients daily functioning is not impaired. The client who experiences feelings of sadness after the loss of a pet is responding within normal expectations. Without significant impairment, the clients distress does not indicate a mental illness.

Question 2

At what point should the nurse determine that a client is at risk for developing a mental illness?

1. when thoughts, feelings, behaviors, are not reflective of the DSM-5 criteria
2. When maladaptive responses to stress are coupled with interference in daily functioning.
3. When a client communicates significant distress.
4. When a client uses defense mechanisms as ego protection.

Answer 2

2. When maladaptive responses to stress are coupled with interference in daily functioning.

Rationale: The nurse should determine that the client is at risk for mental illness when responses
to stress are maladaptive and interfere with daily functioning. The DSM-5 indicates that in order
to be diagnosed with a mental illness, daily functioning must be significantly impaired. The
clients ability to communicate distress would be considered a positive attribute

Question 3

A nurse is assessing a set of 15-year-old identical twins who respond very differently to stress. One twin becomes anxious and irritable, while the other withdraws and cries. How should the nurse explain these different responses to stress to the parents?

A. Reactions to stress are relative rather than absolute; individual responses to stress vary.
B. It is abnormal for identical twins to react differently to similar stressors.
C. Identical twins should share the same temperament and respond similarly to stress.
D. Environmental influences to stress weigh more heavily than genetic influences.

Answer 3

A.

Reactions to stress are relative rather than absolute; individual responses to stress vary.

Question 4

Which client should the nurse anticipate to be most receptive to psychiatric treatment?

1. A Jewish, female social worker.
2. A Baptist, homeless male.
3. A Catholic, black male.
4. A Protestant, Swedish business executive.

Answer 4

1. A Jewish, female social worker.

Rationale: The nurse should anticipate that the client of Jewish culture would place a high importance on preventative health care and would consider mental health as equally important as physical health. Women are also more likely to seek treatment for mental health problems than men.

Question 5

A psychiatric nurse intern states, “This client’s use of defense mechanisms should be eliminated.” Which is a correct evaluation of this nurse’s statement?

1. Defense mechanisms can be appropriate responses to stress and need not be eliminated.
2. Defense mechanisms are a maladaptive attempt of the ego to manage anxiety and should always be eliminated.
3. Defense mechanisms, used by individuals with weak ego integrity, should be discouraged and not eliminated.
4. Defense mechanisms cause disintegration of the ego and should be fostered and encouraged.

Answer 5

1. Defense mechanisms can be appropriate responses to stress and need not be eliminated.

Rationale: The nurse should determine that defense mechanisms can be appropriate during times of stress. The client with no defense mechanisms may have a lower tolerance for stress, thus leading to anxiety disorders. Defense mechanisms should be confronted when they impede the client from developing healthy coping skills.

Question 6

During an intake assessment, a nurse asks both physiological and psychosocial questions. The client angrily responds, “I’m here for my heart, not my head problems.” Which is the nurse’s best response?

1. “It’s just a routine part of our assessment. All clients are asked these same questions.”
2. “Why are you concerned about these types of questions?”
3. “Psychological factors, like excessive stress, have been found to affect medical conditions.”
4. “We can skip these questions, if you like. It isn’t imperative that we complete this section.”

Answer 6

3. “Psychological factors, like excessive stress, have been found to affect medical conditions.”

Rationale: The nurse should attempt to educate the client on the negative effects of excessive stress on medical conditions. It is not appropriate to skip physiological and psychosocial questions, as this would lead to an inaccurate assessment.

Question 7

An employee uses the defense mechanism of displacement when the boss openly disagrees with suggestions. What behavior would be expected from this employee?

1. The employee assertively confronts the boss.
2. The employee leaves the staff meeting to work out in the gym.
3. The employee criticizes a coworker.
4. The employee takes the boss out to lunch.

Answer 7

3. The employee criticizes a coworker.

Rationale: The nurse should expect that the client using the defense mechanism displacement would criticize a coworker after being confronted by the boss. Displacement refers to transferring feelings from one target to a neutral or less-threatening target.

Question 8

A fourth-grade boy teases and makes jokes about a cute girl in his class. This behavior should be identified by a nurse as indicative of which defense mechanism?

1. Displacement
2. Projection
3. Reaction formation
4. Sublimation

Answer 8

3. Reaction formation

Rationale: The nurse should identify that the boy is using reaction formation as a defense mechanism. Reaction formation is the attempt to prevent undesirable thoughts from being expressed by expressing opposite thoughts or behaviors. Displacement refers to transferring feelings from one target to another. Rationalization refers to making excuses to justify behavior. Projection refers to the attribution of unacceptable feelings or behaviors to another person. Sublimation refers to channeling unacceptable drives or impulses into more constructive, acceptable activities.

Question 9

Which nursing statement about the concept of neurosis is most accurate?

1. An individual experiencing neurosis is unaware that he or she is experiencing distress.
2. An individual experiencing neurosis feels helpless to change his or her situation.
3. An individual experiencing neurosis is aware of psychological causes of his or her behavior.
4. An individual experiencing neurosis has a loss of contact with reality.

Answer 9

2. An individual experiencing neurosis feels helpless to change his or her situation.

Rationale: The nurse should define the concept of neurosis with the following characteristics: The client feels helpless to change his or her situation, the client is aware that he or she is experiencing distress, the client is aware the behaviors are maladaptive, the client is unaware of the psychological causes of the distress, and the client experiences no loss of contact with reality.

Question 10

Which nursing statement regarding the concept of psychosis is most accurate?

1. Individuals experiencing psychoses are aware that their behaviors are maladaptive.
2. Individuals experiencing psychoses experience little distress.
3. Individuals experiencing psychoses are aware of experiencing psychological problems.
4. Individuals experiencing psychoses are based in reality.

Answer 10

2. Individuals experiencing psychoses experience little distress.

Rationale: The nurse should understand that the client with psychosis experiences little distress owing to his or her lack of awareness of reality. The client with psychosis is unaware that his or her behavior is maladaptive or that he or she has a psychological problem.

Question 11

When under stress, a client routinely uses alcohol to excess. Finding her drunk, her husband yells at the client about her chronic alcohol abuse. Which action alerts the nurse to the client’s use of the defense mechanism of denial?

1. The client hides liquor bottles in a closet.
2. The client yells at her son for slouching in his chair.
3. The client burns dinner on purpose.
4. The client says to the spouse, “I don’t drink too much!”

Answer 11

4. The client says to the spouse, “I don’t drink too much!”

Rationale: The client’s statement “I don’t drink too much!” alerts the nurse to the use of the defense mechanism of denial. The client is refusing to acknowledge the existence of a real situation and the feelings associated with it.

Question 12

Devastated by a divorce from an abusive husband, a wife completes grief counseling. Which statement by the wife should indicate to a nurse that the client is in the acceptance stage of grief?

1. “If only we could have tried again, things might have worked out.”
2. “I am so mad that the children and I had to put up with him as long as we did.”
3. “Yes, it was a difficult relationship, but I think I have learned from the experience.”
4. “I still don’t have any appetite and continue to lose weight.”

Answer 12

3. “Yes, it was a difficult relationship, but I think I have learned from the experience.”

Rationale: The nurse should evaluate that the client is in the acceptance stage of grief because during this stage of the grief process, the client would be able to focus on the reality of the loss and its meaning in relation to life

Question 13

A nurse is performing a mental health assessment on an adult client. According to Maslow’s hierarchy of needs, which client action would demonstrate the highest achievement in terms of mental health?

1. Maintaining a long-term, faithful, intimate relationship.
2. Achieving a sense of self-confidence.
3. Possessing a feeling of self-fulfillment and realizing full potential.
4. Developing a sense of purpose and the ability to direct activities.

Answer 13

3. Possessing a feeling of self-fulfillment and realizing full potential.

Rationale: The nurse should identify that the client who possesses a feeling of self-fulfillment and realizes his or her full potential has achieved self-actualization, the highest level on Maslow’s hierarchy of needs

Question 14

According to Maslow’s hierarchy of needs, which situation on an in-patient psychiatric unit would require priority intervention by a nurse?

1. A client rudely complaining about limited visiting hours.
2. A client exhibiting aggressive behavior toward another client.
3. A client stating that no one cares.
4. A client verbalizing feelings of failure.

Answer 14

2. A client exhibiting aggressive behavior toward another client.

Rationale: The nurse should immediately intervene when a client exhibits aggressive behavior toward another client. Safety and security are considered lower-level needs according to Maslow’s hierarchy of needs and must be fulfilled before other higher-level needs can be met. Clients who complain, have feelings of failure, or state that no one cares are struggling with higher-level needs such as the need for love and belonging or the need for self-esteem.

Question 15

How would a nurse best complete the new DSM-5 definition of a mental disorder? “A health condition characterized by significant dysfunction in an individual’s cognitions, or behaviors that reflects a disturbance in the

1. psychosocial, biological, or developmental process underlying mental functioning.”
2. psychological, cognitive, or developmental process underlying mental functioning.”
3. psychological, biological, or developmental process underlying mental functioning.”
4. psychological, biological, or psychosocial process underlying mental functioning.”

Answer 15

3. psychological, biological, or developmental process underlying mental functioning.”

Rationale: “A health condition characterized by significant dysfunction in an individual’s cognitions, or behaviors that reflects a disturbance in the psychological, biological, or developmental process underlying mental functioning”, is the new DSM 5 definition of a mental disorder.

Question 16

16. A nurse is assessing a client who appears to be experiencing some anxiety during questioning. Which symptoms might the client demonstrate that would indicate anxiety? (Select all that apply.)
17. Fidgeting
18. Laughing inappropriately
19. Palpitations
20. Nail biting
21. Limited attention span

Answer 16

1. Fidgeting
2. Laughing inappropriately
3. Nail biting

Rationale: The nurse should assess that fidgeting, laughing inappropriately, and nail biting are indicative of heightened stress levels. The client would not be diagnosed with mental illness unless there is significant impairment in other areas of daily functioning. Other indicators of more serious anxiety are restlessness, difficulty concentrating, muscle tension, and sleep disturbance.

Question 17

_______________________ is a diffuse apprehension that is vague in nature and is associated with feelings of uncertainty and helplessness.

Answer 17

Anxiety

Rationale: The definition of anxiety is a diffuse apprehension that is vague in nature and is associated with feelings of uncertainty and helplessness. Townsend considers this a core concept.

Question 18

_______________________ is a subjective state of emotional, physical, and social responses to the loss of a valued entity.

Answer 18

Grief

Rationale: The definition of grief is a subjective state of emotional, physical, and social responses to the loss of a valued entity. Townsend considers this a core concept.

Question 19

A depressed client states, “I have a chemical imbalance in my brain. I have no control over my behavior. Medications are my only hope to feel normal again.” Which nursing response is appropriate?

A. “Medications only address biological factors. Environmental and interpersonal factors must also be considered.”
B. “Because biological factors are the sole cause of depression, medications will improve your mood.”
C. “Environmental factors have been shown to exert the most influence in the development of depression.”
D. “Researchers have been unable to demonstrate a link between nature (biology and genetics) and nurture (environment).”

Answer 19

A. “Medications only address biological factors. Environmental and interpersonal factors must also be considered.”

The nurse should advise the client that medications address biological factors, but there are other factors that affect mood. The nurse should educate the client on environmental and interpersonal factors that can lead to depression.

Question 20

A client diagnosed with major depressive disorder asks, “What part of my brain controls my emotions?” Which nursing response is appropriate?

A. “The occipital lobe governs perceptions, judging them as positive or negative.”
B. “The parietal lobe has been linked to depression.”
C. “The medulla regulates key biological and psychological activities.”
D. “The limbic system is largely responsible for one’s emotional state.”

Answer 20

D. “The limbic system is largely responsible for one’s emotional state.”

The nurse should explain to the client that the limbic system is largely responsible for one’s emotional state. This system is often called the “emotional brain” and is associated with feelings, sexuality, and social behavior. The occipital lobes are the area of visual reception and interpretation. Somatosensory input (touch, taste, temperature, etc.) occurs in the parietal lobes. The medulla contains vital centers that regulate heart rate and reflexes.

Question 21

Which part of the nervous system should a nurse identify as playing a major role during stressful situations?

A. Peripheral nervous system
B. Somatic nervous system
C. Sympathetic nervous system
D. Parasympathetic nervous system

Answer 21

C. Sympathetic nervous system

The nurse should identify that the sympathetic nervous system plays a major role during stressful situations. The sympathetic nervous system prepares the body for the fight-or-flight response. The parasympathetic nervous system is dominant when an individual is in a nonstressful state.

Question 22

Which client statement reflects an understanding of the effect of circadian rhythms on psychopathology?

A. “When I dream about my mother’s horrible train accident, I become hysterical.”
B. “I get really irritable during my menstrual cycle.”
C. “I’m a morning person. I get my best work done in the a.m.”
D. “Every February, I tend to experience periods of sadness.”

Answer 22

C. “I’m a morning person. I get my best work done in the a.m.”

By stating, “I am a morning person.” the client demonstrates an understanding that circadian rhythms may influence a variety of regulatory functions, including the sleep-wake cycle, regulation of body temperature, and patterns of activity. Most humans follow a 24-hour cycle that is largely affected by light and darkness.

Question 23

Which types of adoption studies should a nurse recognize as providing useful information for the psychiatric community?

A. Studies in which children with mentally ill biological parents are raised by adoptive parents who were mentally healthy
B. Studies in which children with mentally healthy biological parents are raised by adoptive parents who were mentally ill
C. Studies in which monozygotic twins from mentally ill parents were raised separately by different adoptive parents
D. Studies in which monozygotic twins were raised together by mentally ill biological parents
E. All of the above

Answer 23

E. All of the above

The nurse should determine that all of the studies could possibly benefit the psychiatric community. The studies may reveal research findings relating genetic links to mental illness. Adoption studies allow comparisons to be made of the influences of the environment versus genetics.

Question 24

Six months after her husband and children were killed in a car accident, a client is diagnosed with ulcerative colitis. The nurse should recognize that this situation validates which study perspective?

A. The study of neuroendocrinology
B. The study of psychoimmunology
C. The study of diagnostic technology
D. The study of neurophysiology

Answer 24

B. The study of psychoimmunology

Psychoimmunology is the branch of medicine that studies the effects of social and psychological factors on the functioning of the immune system. Studies of the biological response to stress hypothesize that individuals become more susceptible to physical illness following exposure to stressful stimuli

Question 25

A withdrawn client diagnosed with schizophrenia expresses little emotion and refuses to attend group therapy. What altered component of the nervous system should a nurse recognize as being responsible for this behavior?

A. Dendrites
B. Axons
C. Neurotransmitters
D. Synapses

Answer 25

C. Neurotransmitters

The nurse should recognize that neurotransmitters play an essential function in the role of human emotion and behavior. Neurotransmitters are targeted and affected by many psychotropic medications.

Question 26

An instructor is teaching nursing students about neurotransmitters. Which term best explains the process of how neurotransmitters released into the synaptic cleft may return to the presynaptic neuron?

A. Regeneration
B. Reuptake
C. Recycling
D. Retransmission

Answer 26

B. Reuptake

The nursing instructor should best explain that the process by which neurotransmitters are released into the synaptic cleft and returned to the presynaptic neuron is by reuptake. Reuptake is the process by which neurotransmitters are stored for reuse.

Question 27

A nurse concludes that a restless, agitated client is manifesting a “fight-or-flight” response. The nurse should associate this response with which neurotransmitter?

A. Acetylcholine
B. Dopamine
C. Serotonin
D. Norepinephrine

Answer 27

D. Norepinephrine

The nurse should associate the neurotransmitter norepinephrine with the “fight-or-flight” response. Norepinephrine produces activity in the sympathetic postsynaptic nerve terminal and is associated with the regulation of mood, cognition, perception, locomotion, sleep, and arousal.

Question 28

A client is admitted to a psychiatric unit with the diagnosis of catatonic schizophrenia. Which of the client’s neurotransmitters should a nurse expect to be elevated?

A. Serotonin
B. Dopamine
C. Gamma-aminobutyric acid (GABA)
D. Histamine

Answer 28

B. Dopamine

The nurse should expect that elevated dopamine levels might be an attributing factor to the client’s current level of functioning. Dopamine functions include regulation of movements and coordination, emotions, and voluntary decision-making ability.

Question 29

A client’s wife of 34 years dies unexpectedly. The client cries often and becomes socially isolated. The client’s therapist encourages open discussion of feelings, proper nutrition, and exercise. What is the best rationale for the therapist’s advice?

A. The therapist is using an interpersonal approach.
B. The client has an alteration in neurotransmitters.
C. It is routine practice to remind clients about nutrition, exercise, and rest.
D. The client is susceptible to illness due to effects of stress on the immune system.

Answer 29

D. The client is susceptible to illness due to effects of stress on the immune system.

The therapist’s advice should be based on the knowledge that the client has been exposed to stressful stimuli and is at an increased risk of developing illness due to the effects of stress on the immune system. The study of this branch of medicine is called psychoimmunology.

Question 30

Which mental illness should a nurse identify as being associated with a decrease in prolactin hormone level?

A. Major depression
B. Schizophrenia
C. Anorexia nervosa
D. Alzheimer’s disease

Answer 30

B. Schizophrenia

Although the exact mechanism is unknown, there may be some correlation between decreased levels of the hormone prolactin and the diagnosis of schizophrenia. Some studies have shown an inverse relationship between prolactin concentrations and symptoms of schizophrenia.

Question 31

Which cerebral structure should a nursing instructor describe to students as the “emotional brain”?

A. The cerebellum
B. The limbic system
C. The cortex
D. The left temporal lobe

Answer 31

B. The limbic system

The limbic system is often referred to as the “emotional brain.” The limbic system is largely responsible for one’s emotional state and is associated with feelings, sexuality, and social behavior.

Question 32

A nurse understands that the abnormal secretion of growth hormone may play a role in which illness?

A. Acute mania
B. Schizophrenia
C. Anorexia nervosa
D. Alzheimer’s disease

Answer 32

C. Anorexia nervosa

A nurse should understand that research has found a correlation between abnormal levels of growth hormone and anorexia nervosa. The growth hormone is responsible for growth in children, as well as continued protein synthesis throughout life.

Question 33

A client is admitted to an emergency department experiencing memory deficits and decreased motor function. What alteration in brain chemistry should a nurse correlate with the presentation of these symptoms?

A. Abnormal levels of serotonin
B. Decreased levels of dopamine
C. Increased levels of norepinephrine
D. Decreased levels of acetylcholine

Answer 33

D. Decreased levels of acetylcholine

The nurse should correlate memory deficits and decreased motor function with decreased levels of acetylcholine. Acetylcholine is a major effector chemical of the autonomic nervous system. Functions of acetylcholine include sleep regulation, pain perception, the modulation and coordination of movement, and memory.

Question 34

A nurse should recognize that a decrease in norepinephrine levels would play a significant role in which mental illness?

A. Mania
B. Schizophrenia
C. Anxiety
D. Depression

Answer 34

D. Depression

The nurse should recognize that a decrease in norepinephrine levels would play a significant role in generating the symptoms of depression. The functions of norepinephrine include the regulation of mood, cognition, perception, locomotion, cardiovascular functioning, and sleep and arousal.

Question 35

Which client diagnosis should a nurse associate with a decrease in gamma-aminobutyric acid (GABA)?

A. Alzheimer’s disease
B. Schizophrenia
C. Panic disorder
D. Depression

Answer 35

C. Panic disorder

The nurse should associate a decrease in GABA with panic disorder. Enhancement of the GABA system is the mechanism of action by which benzodiazepines produce a calming effect, thus reducing anxiety. Alterations in the GABA system are also associated with movement disorders and epilepsy.

Question 36

A nurse should expect that an increase in dopamine activity might play a significant role in the development of which mental illness?

A. Schizophrenia
B. Depression
C. Body dysmorphic disorder
D. Parkinson’s disease

Answer 36

A. Schizophrenia

The nurse should expect that an increase in dopamine activity might play a significant role in the development of schizophrenia. Dopamine functions include regulation of emotions, coordination, and voluntary decision-making ability. Increased dopamine activity is also associated with mania.

Question 37

Which of the following information should a nurse include when explaining causes of anorexia nervosa to a client? (Select all that apply.)

A. There is a possible correlation between abnormal secretion of growth hormone and anorexia nervosa.
B. There is a possible correlation between antidiuretic hormone levels and anorexia nervosa.
C. There is a possible correlation between low levels of gonadotropin and anorexia nervosa.
D. There is a possible correlation between increased levels of prolactin and anorexia nervosa.
E. There is a possible correlation between altered levels of oxytocin and anorexia nervosa.

Answer 37

ANS: A, C
The nurse should explain to the client that there is a possible correlation between anorexia nervosa and decreased levels of growth hormones and gonadotropin. Anorexia nervosa has also been correlated with increased cortisol levels.

Question 38

Which of the following symptoms should a nurse associate with increased levels of thyroid-stimulating hormone (TSH) in a newly admitted client? (Select all that apply.)

A. Depression
B. Fatigue
C. Increased libido
D. Mania
E. Hyperexcitability

Answer 38

ANS: A, B
The nurse should associate depression and fatigue with increased levels of TSH. TSH is only increased when thyroid levels are low as in the diagnosis of hypothyroidism. In addition to depression and fatigue, other symptoms such as decreased libido, memory impairment, and suicidal ideation are also associated with chronic hypothyroidism.

Question 39

.___________________________ is the study of the biological foundations of cognitive, emotional, and behavioral processes.

Answer 39

ANS: Psychobiology

Question 40

In response to a student’s question regarding choosing a psychiatric specialty, a charge nurse states, “Mentally ill clients need special care. If I were in that position, I’d want a caring nurse also.” From which ethical framework is the charge nurse operating?

A. Kantianism
B. Christian ethics
C. Ethical egoism
D. Utilitarianism

Answer 40

B. Christian ethics

The charge nurse is operating from a Christian ethics framework. The imperative demand of Christian ethics is to treat others as moral equals by permitting them to act as we do when they occupy a position similar to ours. Kantianism states that decisions should be made based on moral law and that actions are bound by a sense of moral duty. Utilitarianism holds that decisions should be made focusing on the end result being happiness. Ethical egoism promotes the idea that what is right is good for the individual.

Question 41

During a hiring interview, which response by a nursing applicant should indicate that the applicant operates from an ethical egoism framework?

A. “I would want to be treated in a caring manner if I were mentally ill.”
B. “This job will pay the bills, and the workload is light enough for me.”
C. “I will be happy caring for the mentally ill. Working in Med/Surg kills my back.”
D. “It is my duty in life to be a psychiatric nurse. It is the right thing to do.”

Answer 41

B. “This job will pay the bills, and the workload is light enough for me.”

The applicant’s comment reflects an ethical egoism framework. This framework promotes the idea that decisions are made based on what is good for the individual and may not take the needs of others into account.

Question 42

Without authorization, a nurse administers an extra dose of narcotic tranquilizer to an agitated client. The nurse’s coworker observes this action but does nothing for fear of repercussion. What is the ethical interpretation of the coworker’s lack of involvement?

A. Taking no action is still considered an unethical action by the coworker.
B. Taking no action releases the coworker from ethical responsibility.
C. Taking no action is advised when potential adverse consequences are foreseen.
D. Taking no action is acceptable because the coworker is only a bystander.

Answer 42

A. Taking no action is still considered an unethical action by the coworker.

The coworker’s lack of involvement can be interpreted as an unethical action. The coworker is experiencing an ethical dilemma in which a decision needs to be made between two unfavorable alternatives. The coworker has a responsibility to report any observed unethical actions.

Question 43

Group therapy is strongly encouraged, but not mandatory, on an inpatient psychiatric unit. The unit manager’s policy is that clients can make a choice about whether or not to attend group therapy. Which ethical principle does the unit manager’s policy preserve?

A. Justice
B. Autonomy
C. Veracity
D. Beneficence

Answer 43

B. Autonomy

The unit manager’s policy regarding voluntary client participation in group therapy preserves the ethical principle of autonomy. The principle of autonomy presumes that individuals are capable of making independent decisions for themselves and that health-care workers must respect these decisions.

Question 44

Which is an example of an intentional tort?

A. A nurse fails to assess a client’s obvious symptoms of neuroleptic malignant syndrome.
B. A nurse physically places an irritating client in four-point restraints.
C. A nurse makes a medication error and does not report the incident.
D. A nurse gives patient information to an unauthorized person.

Answer 44

B. A nurse physically places an irritating client in four-point restraints.

A tort is a violation of civil law in which an individual has been wronged and can be intentional or unintentional. A nurse who physically places an irritating client in restraints has touched the client without consent and has committed an intentional tort.

Question 45

An involuntarily committed client is verbally abusive to the staff and repeatedly threatening to sue. The client records the full names and phone numbers of the staff. Which nursing action is most appropriate to decrease the possibility of a lawsuit?

A. Verbally redirect the client, and then limit one-on-one interaction.
B. Involve the hospital’s security division as soon as possible.
C. Notify the client that documenting personal staff information is against hospital policy.
D. Continue professional attempts to establish a positive working relationship with the client.

Answer 45

D. Continue professional attempts to establish a positive working relationship with the client.

The most appropriate nursing action is to continue professional attempts to establish a positive working relationship with the client. The involuntarily committed client should be respected and has the right to assert grievances if rights are infringed.

Question 46

Which statement should a nurse identify as correct regarding a client’s right to refuse treatment?

1. Clients can refuse pharmacological but not psychological treatment.
2. Clients can refuse any treatment at any time.
3. Clients can refuse only electroconvulsive therapy (ECT).
4. Professionals can override treatment refusal by an actively suicidal or homicidal client.

Answer 46

ANS: 4
Rationale: The nurse should understand that health-care professionals could override treatment refusal when a client is actively suicidal or homicidal. A suicidal or homicidal client who refuses treatment may be in danger or a danger to others. This situation should be treated as an emergency, and treatment may be performed without informed consent.

Question 47

Which client should a nurse identify as a potential candidate for involuntary commitment?

A. A client living under a bridge in a cardboard box
B. A client threatening to commit suicide
C. A client who never bathes and wears a wool hat in the summer
D. A client who eats waste out of a garbage can

Answer 47

B. A client threatening to commit suicide

The nurse should identify the client threatening to commit suicide as eligible for involuntary commitment. The suicidal client who refuses treatment is a danger to self and requires emergency treatment.

Question 48

Which statement should a nurse identify as correct regarding a clients right to refuse treatment?

1. Clients can refuse pharmacological but not psychological treatment.
2. Clients can refuse any treatment at any time.
3. Clients can refuse only electroconvulsive therapy (ECT).
4. Professionals can override treatment refusal by an actively suicidal or homicidal client.

Answer 48

Which statement should a nurse identify as correct regarding a clients right to refuse treatment?

1. Clients can refuse pharmacological but not psychological treatment.
2. Clients can refuse any treatment at any time.
3. Clients can refuse only electroconvulsive therapy (ECT).
4. Professionals can override treatment refusal by an actively suicidal or homicidal client.

Question 49

A client diagnosed with schizophrenia refuses to take medication, citing the right of autonomy. Under which circumstance would a nurse have the right to medicate the client against the client’s wishes?

A. When the client makes inappropriate sexual innuendos to a staff member
B. When the client constantly demands inappropriate attention from the nurse
C. When the client physically attacks another client after being confronted in group therapy
D. When the client refuses to bathe or perform hygienic activities

Answer 49

C. When the client physically attacks another client after being confronted in group therapy

The nurse would have the right to medicate a client against his or her wishes if the client physically attacks another client. This client poses a significant risk to safety and is incapable of making rational choices. The client’s refusal to accept treatment can be challenged because the client is endangering the safety of others.

Question 50

A psychiatric nurse working on an inpatient unit receives a call asking if an individual has been a client in the facility. Which nursing response reflects appropriate legal and ethical obligations?

A. Refusing to give any information to the caller, citing rules of confidentiality
B. Refusing to give any information to the caller by hanging up
C. Affirming that the person has been seen at the facility but providing no further information
D. Suggesting that the caller speak to the client’s therapist

Answer 50

A. Refusing to give any information to the caller, citing rules of confidentiality

The most appropriate action by the nurse is to refuse to give any information to the caller. Admission to the facility would be considered protected health information (PHI) and should not be disclosed by the nurse without prior client consent.

Question 51

A client requests information on several medications in order to make an informed choice about management of depression. A nurse should provide this information to facilitate which ethical principle?

A. Autonomy
B. Beneficence
C. Nonmaleficence
D. Justice

Answer 51

A. Autonomy

The nurse should provide the information to support the client’s autonomy. A client who is capable of making independent choices should be permitted to do so. In instances when clients are incapable of making informed decisions, a legal guardian or representative would be asked to give consent.

Question 52

An inpatient psychiatric physician refuses to treat clients without insurance and prematurely discharges those whose insurance benefits have expired. Which violation of an ethical principle should a nurse recognize in this situation?

A. Autonomy
B. Beneficence
C. Nonmaleficence
D. Justice

Answer 52

D. Justice

The nurse should determine that the ethical principle of justice has been violated by the physician’s actions. The principle of justice requires that individuals should be treated equally regardless of race, sex, marital status, medical diagnosis, social standing, economic level, or religious belief.

Question 53

Which situation violates the ethical principle of veracity?

A. A nurse provides a client with outpatient resources to benefit recovery.
B. A nurse refuses to give information to a physician who is not responsible for the client’s care.
C. A nurse tricks a client into seclusion by asking the client to carry linen to the seclusion room.
D. A nurse treats all of the clients equally regardless of illness severity.

Answer 53

C. A nurse tricks a client into seclusion by asking the client to carry linen to the seclusion room.

The nurse who tricks a client into seclusion has violated the ethical principle of veracity. The principle of veracity refers to one’s duty to always be truthful and not intentionally deceive or mislead clients.

Question 54

A client who will be receiving electroconvulsive therapy (ECT) must provide informed consent. Which situation should cause a nurse to question the validity of the informed consent?

A. The client is paranoid.
B. The client is 87 years old.
C. The client incorrectly reports his or her spouse’s name, date, and time of day.
D. The client relies on his or her spouse to interpret the information.

Answer 54

C. The client incorrectly reports his or her spouse’s name, date, and time of day.

The nurse should question the validity of informed consent when the client incorrectly reports the spouse’s name, date, and time of day. This indicates that this client is disoriented and may not be competent to make informed choices.

Question 55

A client diagnosed with schizophrenia receives fluphenazine decanoate (Prolixin Decanoate) from a home health nurse. The client refuses medication at one regularly scheduled home visit. Which nursing intervention is ethically appropriate?

A. Allow the client to decline the medication and document.
B. Tell the client that if the medication is refused, hospitalization will occur.
C. Arrange with a relative to add medication to the client’s morning orange juice.
D. Call for help to hold the client down while the injection is administered.

Answer 55

A. Allow the client to decline the medication and document.

It is ethically appropriate for the nurse to allow the client to decline the medication and provide accurate documentation. The client’s right to refuse treatment should be upheld unless the refusal puts the client or others in harm’s way.

Question 56

Which situation exemplifies both assault and battery?

A. The nurse becomes angry, calls the client offensive names, and withholds treatment.
B. The nurse threatens to “tie down” the client and then does so against the client’s wishes.
C. The nurse hides the client’s clothes and medicates the client to prevent elopement.
D. The nurse restrains the client without just cause and communicates this to family.

Answer 56

B. The nurse threatens to “tie down” the client and then does so against the client’s wishes.

The nurse in this situation has committed both assault and battery. Assault refers to an action that results in fear and apprehension that the person will be touched without consent. Battery is the touching of another person without consent.

Question 57

A geriatric client is confused and wandering in and out of every door. Which scenario reflects the least restrictive alternative for this client?

A. The client is placed in seclusion.
B. The client is placed in a geriatric chair with tray.
C. The client is placed in soft Posey restraints.
D. The client is monitored by an ankle bracelet.

Answer 57

D. The client is monitored by an ankle bracelet.

The least restrictive alternative for this client would be monitoring by an ankle bracelet. The client does not pose a direct dangerous threat to self or others, so neither physical restraints nor seclusion would be justified.

Question 58

A brother calls to speak to his sister who has been admitted to the psychiatric unit. The nurse connects him to the community phone and the sister is summoned. Later the nurse realizes that the brother was not on the client’s approved call list. What law has the nurse broken?

A. The National Alliance for the Mentally Ill Act
B. The Tarasoff Ruling
C. The Health Insurance Portability and Accountability Act
D. The Good Samaritan Law

Answer 58

C. The Health Insurance Portability and Accountability Act

The nurse has violated the Health Insurance Portability and Accountability Act (HIPAA) by revealing that the client had been admitted to the psychiatric unit. The nurse should not have provided any information without proper consent from the client.

Question 59

After disturbing the peace, an aggressive, disoriented, unkempt, homeless individual is escorted to an emergency department. The client threatens suicide. Which of the following criteria would enable a physician to consider involuntary commitment? (Select all that apply.)

1. Being dangerous to others
2. Being homeless
3. Being disruptive to the community
4. Being gravely disabled and unable to meet basic needs
5. Being suicidal

Answer 59

ANS: 1, 4, 5
Rationale: The physician could consider involuntary commitment when a client is dangerous to others, gravely disabled, or is suicidal. If the physician determines that the client is mentally incompetent, consent should be obtained from the legal guardian or court-approved guardian or conservator. A hospital administrator may give permission for involuntary commitment when time does not permit court intervention.

Question 60

A valid, legally recognized claim or entitlement, encompassing both freedom from government interference or discriminatory treatment and an entitlement to a benefit or a service is defined as a _______________________.

Answer 60

ANS: right
Rationale: A right is a valid, legally recognized claim or entitlement, encompassing both freedom from government interference or discriminatory treatment and an entitlement to a benefit or a service. A right is absolute when there is no restriction whatsoever on the individual’s entitlement.

Question 61

A branch of philosophy that addresses methods for determining the rightness or wrongness of one’s actions is defined as _______________________.

Answer 61

ANS: ethics
Rationale: Ethics is a branch of philosophy that deals with systematic approaches to distinguishing right from wrong behavior. Bioethics is the term applied to these principles when they refer to concepts within the scope of medicine, nursing, and allied health.

Question 62

An inpatient client, whom the treatment team has determined to be a danger to self, gives notice of intention to leave the hospital. What information should the nurse recognize as having an impact on the treatment team’s next action?

A. State law determines how long a psychiatric facility can hold a client.
B. Federal law determines if the client is competent.
C. The client’s family involvement will determine if discharge is possible.
D. Hospital policies will determine treatment team actions.

Answer 62

A. State law determines how long a psychiatric facility can hold a client.

Most states commonly cite that in an emergency a client who is dangerous to self or others may be involuntarily hospitalized.

Question 63

A client is concerned that information given to the nurse remains confidential. Which is the nurse’s best response?

A. “Your information is confidential. It will be kept just between you and I.”
B. “I will share the information with staff members only with your approval.”
C. “If the information impacts your care, I will need to share it with the treatment team.”
D. “You can make the decision whether your physician needs this information or not.”

Answer 63

C. “If the information impacts your care, I will need to share it with the treatment team.”

Basic to the psychiatric client’s hospitalization is his or her right to confidentiality and privacy. When admitted to an inpatient psychiatric facility, a client gives implied consent for information to be shared with health-care workers specifically involved in the client’s care.

Question 64

The nursing staff is discussing the concept of competency. Which information about competency should a nurse recognize as true?

A. Competency is determined with a client’s compliance with treatment.
B. Refusal of medication can initiate an incompetency hearing leading to forced medications.
C. A competent client has the ability to make reasonable judgments and decisions.
D. Competency is a medical determination made by the client’s physician.

Answer 64

C. A competent client has the ability to make reasonable judgments and decisions.

A competent individual’s cognition is not impaired to an extent that would interfere with decision making.

Question 65

A nursing instructor is presenting content on the provisions of the nurse practice act as it relates to their state. Which student statement indicates a need for further instruction?

A. “The nurse practice act provides a list of definitions of important terms including the definition of nursing.”
B. “The nurse practice act lists education requirements for licensure and reciprocity.”
C. “The nurse practice act contains detailed statements that describe the scope of practice for registered nurses (RNs).”
D. “The nurse practice act lists the general authority and powers of the state board of nursing.”

Answer 65

C. “The nurse practice act contains detailed statements that describe the scope of practice for registered nurses (RNs).”

The nurse practice act contains broad, not detailed, statements that describe the scope of practice for various levels of nursing (APN, RN, LPN), not just for the RN. This student statement indicates a need for further instruction.

Question 66

Which is an accurate description of a common law?

A. A common law would be invoked to deal with a nurse who, without justification, threatens a client with restraints.
B. A common law would be invoked to deal with a nurse who touches a client without the client’s consent.
C. A common law would be invoked to deal with a hospital employee who steals drugs, hospital equipment, or both.
D. A common law would be invoked to deal with a nurse’s refusal to provide care for a specific client.

Answer 66

D. A common law would be invoked to deal with a nurse’s refusal to provide care for a specific client.

Common laws apply to a body of principles that evolve from court decisions resolving various controversies. Common law may vary from state to state. Assault (threats) and battery (touch) are governed by civil law. Stealing is governed by criminal law.

Question 67

The experience of being physically restrained can be traumatic. Which nursing intervention would best help the client deal with this experience?

A. Administering a tranquilizing medication before applying the restraints
B. Talking to the client at brief but regular intervals while the client is restrained
C. Decreasing stimuli by leaving the client alone most of the time
D. Checking on the client infrequently, in order to meet documentation requirements

Answer 67

B. Talking to the client at brief but regular intervals while the client is restrained

Restraints are never to be used as punishment or for the convenience of the staff. Connecting with the client by maintaining communication during the period of restraint will help the client recognize this intervention as a therapeutic treatment versus a punishment.

Question 68

What is the most essential task for a nurse to accomplish prior to forming a therapeutic relationship with a client?

A. To clarify personal attitudes, values, and beliefs
B. To obtain thorough assessment data
C. To determine the client’s length of stay
D. To establish personal goals for the interaction

Answer 68

A. To clarify personal attitudes, values, and beliefs

Question 69

If a client demonstrates transference toward a nurse, how should the nurse respond?

1. Promote safety and immediately terminate the relationship with the client.
2. Encourage the client to ignore these thoughts and feelings.
3. Immediately reassign the client to another staff member.
4. Help the client to clarify the meaning of the relationship, based on the present situation.

Answer 69

4. Help the client to clarify the meaning of the relationship, based on the present situation.

Question 70

What should be the priority nursing action during the orientation (introductory) phase of the nurse-client relationship?

A. Acknowledge the client’s actions and generate alternative behaviors.
B. Establish rapport and develop treatment goals.
C. Attempt to find alternative placement.
D. Explore how thoughts and feelings about this client may adversely impact care.

Answer 70

B. Establish rapport and develop treatment goals.

The priority nursing action during the orientation phase of the nurse-client relationship should be to establish rapport and develop treatment goals. Rapport implies feelings on the part of both the nurse and the client based on respect, acceptance, a sense of trust, and a nonjudgmental attitude. It is the essential foundation of the nurse-client relationship.

Question 71

Which client response should a nurse expect during the working phase of the nurse-client relationship?

A. The client gains insight and incorporates alternative behaviors.
B. The client and nurse establish rapport and mutually develop treatment goals.
C. The client explores feelings related to reentering the community.
D. The client explores personal strengths and weaknesses that impact behaviors.

Answer 71

A. The client gains insight and incorporates alternative behaviors.

The nurse should expect that the client would gain insight and incorporate alternative behaviors during the working phase of the nurse-client relationship. The client may also overcome resistance, problem-solve, and continually evaluate progress toward goals.

Question 72

Which client statement should a nurse identify as a typical response to stress most often experienced in the working phase of the nurse-client relationship?

A. “I can’t bear the thought of leaving here and failing.”
B. “I might have a hard time working with you. You remind me of my mother.”
C. “I can’t tell my husband how I feel; he wouldn’t listen anyway.”
D. “I’m not sure that I can count on you to protect my confidentiality.”

Answer 72

C. “I can’t tell my husband how I feel; he wouldn’t listen anyway.”

OR

“I really dont want to talk anymore about my childhood abuse

The nurse should identify that the client statement “I can’t tell my husband how I feel; he wouldn’t listen anyway” reflects resistance to change, which is a common behavior in the working phase of the nurse-client relationship. The working phase includes overcoming resistant behaviors on the part of the client as the level of anxiety rises in response to discussion of painful issues.

Question 73

A mother who has learned that her child was killed in a tragic car accident states, “I can’t bear to go on with my life.” Which nursing statement conveys empathy?
A. “This situation is very sad, but time is a great healer.”

B. “You are sad, but you must be strong for your other children.”
C. “Once you cry it all out, things will seem so much better.”
D. “It must be horrible to lose a child; I’ll stay with you until your husband arrives.”

Answer 73

D. “It must be horrible to lose a child; I’ll stay with you until your husband arrives.”

The nurse’s response, “It must be horrible to lose a child; I’ll stay with you until your husband arrives,” conveys empathy to the client. Empathy is the ability to see the situation from the client’s point of view. Empathy is considered to be one of the most important characteristics of the therapeutic relationship.

Question 74

If an individual is “two-faced,” which characteristic essential to the development of a therapeutic relationship should a nurse identify as missing?

A. Respect
B. Genuineness
C. Sympathy
D. Rapport

Answer 74

B. Genuineness

The nurse should identify that genuineness is missing in the relationship. Genuineness refers to an individual’s ability to be open and honest and maintain congruence between what is felt and what is communicated. Genuineness is essential to establishing trust in a relationship.

Question 75

On which task should a nurse place priority during the working phase of relationship development?

A. Establishing a contract for intervention
B. Examining feelings about working with a particular client
C. Establishing a plan for continuing aftercare
D. Promoting the client’s insight and perception of reality

Answer 75

D. Promoting the client’s insight and perception of reality

The nurse should place priority on promoting the client’s insight and perception of reality during the working phase of relationship development. Establishing a contract for intervention would occur in the orientation phase. Examining feelings about working with a client should occur in the preinteraction phase. Establishing a plan for aftercare would occur in the termination phase.

Question 76

Which therapeutic communication technique is being used in this nurse-client interaction?
Client: “My father spanked me often.”
Nurse: “Your father was a harsh disciplinarian.”
A. Restatement
B. Offering general leads
C. Focusing
D. Accepting

Answer 76

ANS: A. Restatement
The nurse is using the therapeutic communication technique of restatement. Restatement involves repeating the main idea of what the client has said. The nurse uses this technique to communicate that the client’s statement has been heard and understood.

Question 77

Which therapeutic communication technique is being used in this nurse-client interaction?
Client: “When I am anxious, the only thing that calms me down is alcohol.” Nurse: “Other than drinking, what alternatives have you explored to decrease anxiety?

A. Reflecting
B. Making observations
C. Formulating a plan of action
D. Giving recognition

Answer 77

C. Formulating a plan of action

The nurse is using the therapeutic communication technique of formulating a plan of action to help the client explore alternatives to drinking alcohol. The use of this technique, rather than direct confrontation regarding the client’s poor coping choice, may serve to prevent anger or anxiety from escalating.

Question 78

The nurse is interviewing a newly admitted psychiatric client. Which nursing statement is an example of offering a “general lead”?
A. “Do you know why you are here?”
B. “Are you feeling depressed or anxious?”
C. “Yes, I see. Go on.”
D. “Can you chronologically order the events that led to your admission?”

Answer 78

ANS: C “Yes, I see. Go on”
The nurse’s statement, “Yes, I see. Go on,” is an example of the therapeutic communication technique of a general lead. Offering a general lead encourages the client to continue sharing information.

KEY: Cognitive Level: Application | Integrated Process: Nursing Process: Implementation | Client Need: Psychosocial Integrity

Question 79

A client diagnosed with post-traumatic stress disorder is admitted to an inpatient psychiatric unit for evaluation and medication stabilization. Which therapeutic communication technique used by the nurse is an example of a broad opening?
A. “What occurred prior to the rape, and when did you go to the emergency department?”
B. “What would you like to talk about?”
C. “I notice you seem uncomfortable discussing this.”
D. “How can we help you feel safe during your stay here?”

Answer 79

ANS: B
The nurse’s statement, “What would you like to talk about?” is an example of the therapeutic communication technique of giving broad openings. Using a broad opening allows the client to take the initiative in introducing the topic and emphasizes the importance of the client’s role in the interaction.

Question 80

A nurse maintains an uncrossed arm and leg posture. This nonverbal behavior is reflective of which letter of the SOLER acronym for active listening? 
A. S
B. O
C. L
D. E
E. R

Answer 80

ANS: B. O
The nurse should identify that maintaining an uncrossed arm and leg posture is nonverbal behavior that reflects the “O” in the active-listening acronym SOLER. The acronym SOLER includes sitting squarely facing the client (S), open posture when interacting with the client (O), leaning forward toward the client (L), establishing eye contact (E), and relaxing (R).

Question 81

An instructor is correcting a nursing student’s clinical worksheet. Which instructor statementis the best example of effective feedback?

1. “Why did you use the client’s name on your clinical worksheet?”
2. “You were very careless to refer to your client by name on your clinical worksheet.”
3. “Surely you didn’t do this deliberately, but you breeched confidentiality by using names.”
4. “It is disappointing that after being told you’re still using client names on your worksheet.

Answer 81

ANS: 3

Rationale: The instructor’s statement, “Surely you didn’t do this deliberately, but you breechedconfidentiality by using names,” is an example of effective feedback. Feedback is method ofcommunication for helping others consider a modification of behavior. Feedback should bedescriptive, specific, and directed toward a behavior that the person has the capacity to modifyand should impart information rather than offer advice.

Question 82

A client exhibiting dependent behaviors says, “Do you think I should move from my parent’s house and get a job?” Which nursing response is most appropriate?

1. “It would be best to do that in order to increase independence.”
2. “Why would you want to leave a secure home?”
3. “Let’s discuss and explore all of your options.”
4. “I’m afraid you would feel very guilty leaving your parents.”

Answer 82

3. “Let’s discuss and explore all of your options.”

Rationale: The most appropriate response by the nurse is, “Let’s discuss and explore all of your options.” In this example, the nurse is encouraging the client to formulate ideas and decide independently the appropriate course of action.

Question 83

A mother rescues two of her four children from a house fire. In an emergency department, she cries, “I should have gone back in to get them. I should have died, not them.” What is the nurse’s best response?

1. “The smoke was too thick. You couldn’t have gone back in.”
2. “You’re experiencing feelings of guilt, because you weren’t able to save your children.”
3. “Focus on the fact that you could have lost all four of your children.”
4. “It’s best if you try not to think about what happened. Try to move on.”

Answer 83

2. “You’re experiencing feelings of guilt, because you weren’t able to save your children.”

Rationale: The best response by the nurse is, “You’re experiencing feelings of guilt, because you weren’t able to save your children.” This response uses the therapeutic communication technique of restating what the client has said. This lets the client know whether an expressed statement has been understood or if clarification is necessary.

Question 84

A newly admitted client, diagnosed with obsessive-compulsive disorder (OCD), washes his hands continually. This behavior prevents unit activity attendance. Which nursing statement best addresses this situation?

1. “Everyone diagnosed with OCD needs to control their ritualistic behaviors.”
2. “It is important for you to discontinue these ritualistic behaviors.”
3. “Why are you asking for help, if you won’t participate in unit therapy?”
4. “Let’s figure out a way for you to attend unit activities and still wash your hands.”

Answer 84

4. “Let’s figure out a way for you to attend unit activities and still wash your hands.”

Rationale: The most appropriate statement by the nurse is, “Let’s figure out a way for you to attend unit activities and still wash your hands.” This statement reflects the therapeutic communication technique of formulating a plan of action. The nurse attempts to work with the client to develop a plan without damaging the therapeutic relationship.

Question 85

Which of the following characteristics should be included in a therapeutic nurse-client relationship? (Select all that apply.)

1. Meeting the psychological needs of the nurse and the client
2. Ensuring therapeutic termination
3. Promoting client insight into problematic behavior
4. Collaborating to set appropriate goals
5. Meeting both the physical and psychological needs of the client

Answer 85

2. Ensuring therapeutic termination
3. Promoting client insight into problematic behavior
4. Collaborating to set appropriate goals
5. Meeting both the physical and psychological needs of the client

Rationale: The nurse-client therapeutic relationship should include promoting client insight into problematic behavior, collaboration to set appropriate goals, meeting the physical and psychological needs of the client, and ensuring therapeutic termination. Meeting the nurse’s psychological needs should never be addressed within the nurse-client relationship.

Question 86

Which of the following individuals are communicating a message? Select all that apply.

A. A mother spanking her son for playing with matches
B. A teenage boy isolating himself and playing loud music
C. A biker sporting an eagle tattoo on his biceps
D. A teenage girl writing, No one understands me
E. A father checking for new e-mail on a regular basis

Answer 86

A. A mother spanking her son for playing with matches
B. A teenage boy isolating himself and playing loud music
C. A biker sporting an eagle tattoo on his biceps
D. A teenage girl writing, No one understands me

Question 87

The term ________________________ implies special feelings on the part of both the client and the nurse, based on acceptance, warmth, friendliness, common interest, a sense of trust, and a nonjudgmental attitude.

Answer 87

Rapport

Rationale: Rapport implies special feelings on the part of both the client and the nurse, based on acceptance, warmth, friendliness, common interest, a sense of trust, and a nonjudgmental attitude. Establishing rapport may be accomplished by discussing non-health-related topics.

Question 88

___________________ refers to a nurse’s behavioral and emotional response to a client. These responses may be related to unresolved feelings toward significant others from the nurse’s past.

Answer 88

Countertransference

Rationale: Countertransference refers to a nurse’s behavioral and emotional response to a client. These responses may be related to unresolved feelings toward significant others from the nurse’s past or they may be generated in response to transference feelings on the part of the client.

Question 89

1. Which statement is most accurate regarding the assessment of clients diagnosed with psychiatric problems?
2. Medical history is of little significance and can be eliminated from the nursing assessment.
3. Assessment provides a holistic view of the client, including biopsychosocial aspects.
4. Comprehensive assessments can be performed only by advanced practice nurses.
5. Psychosocial evaluations are gained by subjective reports rather than objective observations.

Answer 89

ANS: 2

Question 90

Which statement regarding nursing interventions should a nurse identify as accurate?

1. Nursing interventions are independent from the treatment teams goals.
2. Nursing interventions are solely directed by written physician orders.
3. Nursing interventions occur independently but in concert with overall treatment team goals.
4. Nursing interventions are standardized by policies and procedures.

Answer 90

3. Nursing interventions occur independently but in concert with overall treatment team goals.

Rationale: The nurse should understand that nursing interventions occur independently but in concert with overall treatment goals. Nursing interventions should be developed and implemented in collaboration with other health-care professionals involved in the client’s care.

Question 91

Within the nurse’s scope of practice, which function is exclusive to the advanced practice psychiatric nurse?

1. Teaching about the side effects of neuroleptic medications
2. Using psychotherapy to improve mental health status
3. Using milieu therapy to structure a therapeutic environment
4. Providing case management to coordinate continuity of health services

Answer 91

2. Using psychotherapy to improve mental health status

Rationale: The advanced practice psychiatric nurse is authorized to use psychotherapy to improve mental health. This includes individual, couples, group, and family psychotherapy. Education, case management, and milieu therapy can be provided by registered psychiatric mental health nurses.

Question 92

The nurse should recognize which acronym as representing problem-oriented charting?

1. SOAPIE
2. APIE
3. DAR
4. PQRST

Answer 92

1. SOAPIE

Rationale: The acronym SOAPIE represents problem-oriented charting, which reflects the subjective, objective, assessment, plan, implementation, and evaluation format. Used in nursing, nursing diagnoses (problems) are identified on a written plan of care, with appropriate nursing interventions described for each.

Question 93

Which tool would be appropriate for a nurse to use when assessing mental acuity prior to and immediately following electroconvulsive therapy (ECT)?

1. CIWA scale
2. GGT
3. MMSE
4. CAPS scale

Answer 93

3. MMSE

Rationale: The MMSE, or mini mental status exam, would be the appropriate tool to use to assess the mental acuity of a client prior to and immediately following ECT. The CIWA scale, or clinical institute withdrawal assessment scale, would be used to assess withdraw from substances such as alcohol. The CAPS refers to the clinician-administered PTSD scale and would be used to assess signs and symptoms of PTSD. The GGT test is a blood test used to assess gamma-glutamyl transferase levels, which may be an indication of alcoholism.

Question 94

What is being assessed when a nurse asks a client to identify name, date, residential address, and situation?

1. Mood
2. Perception
3. Orientation
4. Affect

Answer 94

3. Orientation

Rationale: The nurse should ask the client to identify name, date, residential address, and situation to assess the clients orientation. Assessment of the clients orientation to reality is part of a mental status evaluation.

Question 95

What is the purpose when a nurse gathers client information?

A. It enables the nurse to modify client behaviors related to personality disorders.
B. It enables the nurse to make sound clinical judgments and plan appropriate client care.
C. It enables the nurse to prescribe the appropriate medications.
D. It enables the nurse to assign the appropriate Axis I diagnosis.

Answer 95

B. It enables the nurse to make sound clinical judgments and plan appropriate client care.

Question 96

A nurse on an inpatient psychiatric unit implements care by scheduling client activities, interacting with clients, and maintaining a safe therapeutic environment. These actions reflect which role of the nurse? 
A. Health teacher
B. Case manager
C. Milieu manager
D. Psychotherapist

Answer 96

C. Milieu manager

Question 97

The following outcome was developed for a client: “Client will list five personal strengths by the end of day 1.” Which correctly written nursing diagnostic statement most likely generated the development of this outcome?

A. Altered self-esteem R/T years of emotional abuse AEB self-deprecating statements
B. Self-care deficit R/T altered thought processes
C. Disturbed body image R/T major depressive disorder AEB mood rating of 2/10
D. Risk for disturbed self-concept R/T hopelessness AEB suicide attempt

Answer 97

A. Altered self-esteem R/T years of emotional abuse AEB self-deprecating statements

Question 98

How should a nurse prioritize nursing diagnoses?

A. By the established goal of care
B. By the life-threatening potential
C. By the physician’s priority of care
D. By the client’s preference

Answer 98

B. By the life-threatening potential

Question 99

A client has a nursing diagnosis of Insomnia R/T paranoid thinking AEB midnight awakenings, difficulty falling asleep, and daytime napping. Which is a correctly written and appropriate outcome for this client’s problem?

A. The client will avoid daytime napping and attend all groups.
B. The client will exercise, as needed, before bedtime.
C. The client will sleep 7 uninterrupted hours by day four of hospitalization.
D. The client’s sleep habits will improve during hospitalization.

Answer 99

C. The client will sleep 7 uninterrupted hours by day four of hospitalization.

Question 100

The following North American Nursing Diagnosis Association (NANDA) nursing diagnostic stem was developed for a client on an inpatient unit: Risk for injury. What assessment data most likely led to the development of this problem statement?
A. The client is receiving electroconvulsive therapy (ECT) and is diagnosed with Parkinsonism.
B. The client has a history of four suicide attempts in adolescence.
C. The client expresses hopelessness and helplessness and isolates self.
D. The client has disorganized thought processes and delusional thinking

Answer 100

A. The client is receiving electroconvulsive therapy (ECT) and is diagnosed with Parkinsonism.

Question 101

.A client diagnosed with schizophrenia is exhibiting nonverbal behaviors indicating that the client is hearing things that others do not. Which nursing diagnosis, which was recently removed from the NANDA-I list, still accurately reflects this clients problem?

A. Altered thought processes
B. Altered (Disturbed) sensory perception
C. Anxiety
D. Chronic confusion

Answer 101

ANS: 2
Rationale: The nursing diagnosis disturbed sensory perception accurately reflects the clients symptoms of hearing things that others do not. The nursing diagnosis describes the clients condition and facilitates the prescription of interventions.

Question 102

Which of the following nursing interventions fall within the standards of psychiatric-mental health clinical nursing practice for a nurse generalist? Select all that apply.

A. Assist clients to perform activities of daily living.
B. Act as a consultant with other clinicians to provide services for clients and effect system change
C. Encourage clients to discuss triggers for relapse
D. Use prescriptive authority in accordance with state and federal laws
E. Educate families about signs and symptoms of alcohol dependence and withdrawal

Answer 102

A. Assist clients to perform activities of daily living
C. Encourage clients to discuss triggers for relapse
E. Educate families about signs and symptoms of alcohol dependence and withdrawal

Question 103

Which of the following characteristics of accurately developed client outcomes should a nurse identify? (Select all that apply.)

A. Client outcomes are formulated by nurses independent from other team members.
B. Client outcomes are not restricted by time frames.
C. Client outcomes are specific and measurable.
D. Client outcomes are realistically based on client capability.
E. Client outcomes are formally approved by the psychiatrist.

Answer 103

C. Client outcomes are specific and measurable.

D. Client outcomes are realistically based on client capability.

Question 104

Number the following nursing interventions as they would proceed through the steps of the nursing process.
________ Determine if an antianxiety medication is decreasing a clients stress.
________ Measure a clients vital signs and review past history.
________ Encourage deep breathing and teach relaxation techniques.
________ Aim, with client collaboration, for a seven-hour nights sleep.
________ Recognize and document the clients problem.

Answer 104

ANS: The correct order is 5, 1, 4, 3, 2
Rationale:
1. Measuring a clients vital signs and reviewing past history is a nursing intervention that occurs in the assessment step of the nursing process.
2. Recognizing and documenting the clients problem occurs in the nursing diagnosis step.
3. Setting a goal with client collaboration, for a seven-hour nights sleep occurs in the planning step.
4. Encouraging deep breathing and teaching relaxation techniques occur in the implementation step.
5. Determining if an antianxiety medication is decreasing a clients stress occurs in the evaluation step.

Question 105

A _________________ __________________ provides the basis for selection of nursing interventions to achieve outcomes for which the nurse has accountability.

Answer 105

ANS: nursing diagnosis
Rationale: Nursing diagnoses are clinical judgments about individual, family, or community experiences/responses to actual or potential health problems/life processes. A nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse has accountability.

Question 106

An angry client on an inpatient unit approaches a nurse stating, “Someone took my lunch! People need to respect others, and you need to do something about this now!” The nurse’s response should be guided by which basic assumption of milieu therapy?

A. Conflict should be avoided at all costs on inpatient psychiatric units.
B. Conflict should be resolved by the nursing staff.
C. Every interaction is an opportunity for therapeutic intervention.
D. Conflict resolution should only be addressed during group therapy.

Answer 106

ANS: C (on inpatient units) Every interaction is an opportunity for therapeutic intervention

The nurse’s response should be guided by the basic assumption that every interaction is an opportunity for therapeutic intervention. The nurse can utilize milieu therapy to effect behavioral change and improve psychological health and functioning.

Question 107

A client on an inpatient unit angrily states to a nurse, “Peter is not cleaning up after himself in the community bathroom. You need to address this problem.” Which is the appropriate nursing response?

A. “I’ll talk to Peter and present your concerns.”
B. “Why are you overreacting to this issue?”
C. “You should bring this to the attention of your treatment team.”
D. “I can see that you are angry. Let’s discuss ways to approach Peter with your concerns.”

Answer 107

ANS: D
The most appropriate nursing response involves restating the client’s feeling and developing a plan with the client to solve the problem. According to Skinner, every interaction in the therapeutic milieu is an opportunity for therapeutic intervention to improve communication and relationship-development skills.

Question 108

A newly admitted client asks, “Why do we need a unit schedule? I’m not going to these groups. I’m here to get some rest.” Which is the most appropriate nursing reply?

A. “( the purpose of) Group therapy (is) opportunity to learn and practice new coping skills.”
B. “Group therapy is mandatory. All clients must attend.”
C. “Group therapy is optional. You can go if you find the topic helpful and interesting.”
D. “Group therapy is an economical way of providing therapy to many clients concurrently.”

Answer 108

A. “( the purpose of) Group therapy (is) opportunity to learn and practice new coping skills.”

Question 109

A client diagnosed with schizophrenia functions well and is bright, spontaneous, and interactive during hospitalization but then decompensates after discharge. What does the milieu provide that may be missing in the home environment?

A. Peer pressure
B. Structured programming
C. Visitor restrictions
D. Mandated activities

Answer 109

B. Structured programming

Question 110

To promote self-reliance, how should a psychiatric nurse best conduct medication administration?

A. Encourage clients to request their medications at the appropriate times.
B. Refuse to administer medications unless clients request them at the appropriate times.
C. Allow the clients to determine appropriate medication times.
D. Take medications to the clients’ bedside at the appropriate times.

Answer 110

ANS: A
The psychiatric nurse promoting self-reliance would encourage clients to request their medications at the appropriate times. Nurses are responsible for the management of medication administration on inpatient psychiatric units; however, nurses must work with clients to foster independence and provide experiences that would foster increased self-esteem.

Question 111

A nurse working on an inpatient psychiatric unit is assigned to conduct a 45-minute education group. What should the nurse identify as an appropriate group topic?

A. Dream analysis
B. Creative cooking
C. Paint by number
D. Stress management

Answer 111

ANS: D
The nurse should identify that teaching clients about stress management is an appropriate education group topic. Nurses should be able to perform the role of client teacher in the psychiatric area. Nurses need to be able to assess a client’s learning readiness. Other topics for education groups include medical diagnoses, side effects of medications, and the importance of medication compliance.

Question 112

What is the best rationale for including the client’s family in therapy within the inpatient milieu?

A. To structure a program of social and work-related activities
B. To facilitate discharge from the hospital
C. To provide a concrete demonstration of caring
D. To encourage the family to model positive behaviors

Answer 112

B. To facilitate discharge from the hospital(ization)

Question 113

How does a democratic form of self-government in the milieu contribute to client therapy?

A. By setting punishments for clients who violate the community rules
B. By dealing with inappropriate behaviors as they occur
C. By setting community expectations wherein all clients are treated on an equal basis
D. By interacting with professional staff members to learn about therapeutic interventions

Answer 113

C. By setting [community] expectations wherein all clients are treated on an equal basis

Question 114

.A client is to undergo psychological testing. Which member of the interdisciplinary team should a nurse consult for this purpose?

A. The psychiatrist
B. The psychiatric social worker
C. The clinical psychologist
D. The clinical nurse specialist

Answer 114

D. The clinical nurse specialist

Question 115

In the role of milieu manager, which activity should the nurse prioritize?

A. Setting the schedule for the daily unit activities
B. Evaluating clients for medication effectiveness
C. Conducting therapeutic group sessions
D. Searching newly admitted clients for hazardous objects

Answer 115

ANS: D
The milieu manager should search newly admitted clients for hazardous objects. Safety of the client and others is the priority. Nurses are responsible for ensuring that the client’s safety and physiological needs are met within the milieu.

Question 116

A nurse attends an interdisciplinary team meeting on an inpatient unit. Which of the following individuals are typically included as members of the interdisciplinary treatment team in psychiatry? (Select all that apply.)

A. Respiratory therapist and psychiatrist
B. Occupational therapist and psychologist
C. Recreational therapist and art therapist
D. Social worker and hospital volunteer
E. Mental health technician and chaplain

Answer 116

ANS: B, C, E
The interdisciplinary treatment team in a psychiatric inpatient setting consists of a psychologist, occupational therapist, recreational therapist, art therapist, mental health technician, and chaplain. In addition, a psychiatrist, psychiatric nurse, psychiatric social worker, music therapist, psychodramatist, and dietician participate in the interdisciplinary treatment team.

Question 117

Which of the following are accurate descriptors of a therapeutic community? (Select all that apply.)

A. The unit schedule includes unlimited free time for personal reflection.
B. Unit responsibilities are assigned according to client capabilities.
C. A flexible schedule is determined by client needs.
D. The individual is the sole focus of therapy.
E. A democratic form of government exists.

Answer 117

ANS: B, E
In a therapeutic community, the unit responsibilities are assigned according to client capability and a democratic form of government exists. Therapeutic communities are structured and provide therapeutic interventions that focus on communication and relationship-development skills.

Question 118

A scientific structuring of the environment in order to effect behavioral changes and to improve the psychological health and functioning of the individual is defined as ________________________ therapy.

Answer 118

ANS: milieu

Question 119

During a therapeutic group, which nursing action demonstrates a laissez-faire leadership style?

1. The nurse mandates that all group members reveal an embarrassing personal situation.
2. The nurse asks for a show of hands to determine group topic preference.
3. The nurse sits silently as the group members stray from the assigned topic.
4. The nurse shuffles through papers to determine the facility policy on length of group.

Answer 119

ANS: 3
Rationale: The nurse leader who sits silently and allows group members to stray from the assigned topic is demonstrating a laissez-faire leadership style. This style allows group members to do as they please with no direction from the leader. Group members often become frustrated and confused in reaction to a laissez-faire leadership style.

Question 120

During a community meeting, a nurse encourages clients to present unit problems and discuss possible solutions. Which type of leadership style is the nurse demonstrating?

1. Democratic
2. Autocratic
3. Laissez-faire
4. Bureaucratic

Answer 120

ANS: 1
Rationale: The nurse who encourages clients to present problems and discuss solutions is demonstrating a democratic leadership style. Democratic leaders share information with group members and promote decision-making by the members of the group. The leader provides guidance and expertise as needed.

Question 121

Which situation should a nurse identify as an example of an autocratic leadership style?

1. The president of Sigma Theta Tau assigns members to committees to research problems.
2. Without faculty input, the dean mandates that all course content be delivered via the Internet.
3. During a community meeting, a nurse listens as clients generate solutions.
4. The student nurses’ association advertises for candidates for president.

Answer 121

ANS: 2
Rationale: The nurse should identify that mandating decisions without consulting the group is considered an autocratic leadership style. Autocratic leadership increases productivity but often reduces morale and motivation owing to lack of member input and creativity.

Question 122

A single, pregnant teenager in a parenting class discloses her ambivalence toward the pregnancy and the subsequent guilt that these thoughts generate. A mother of three admits to having felt that way herself. Which of Yalom’s curative group factors does this illustrate?

1. Imparting of information
2. Instillation of hope
3. Altruism
4. Universality

Answer 122

ANS: 4
Rationale: The scenario is an example of the curative group factor of universality. Universality occurs when individuals realize that they are not alone in the problems, thoughts, and feelings they are experiencing. This realization reduces anxiety by the support and understanding of others.

Question 123

A client diagnosed with alcohol use disorder experiences a first relapse. During an AA meeting, another group member states, “I relapsed three times, but now have been sober for 15 years.” Which of Yalom’s curative group factors does this illustrate?

1. Imparting of information
2. Instillation of hope
3. Catharsis
4. Universality

Answer 123

ANS: 2
Rationale: This scenario is an example of the curative group factor instillation of hope. This occurs when members observe the progress of others in the group with similar problems and begin to believe that personal problems can also be resolved.

Question 124

During a group discussion, members freely interact with each other. Which member statement is an example of Yalom’s curative group factor of imparting information?

1. “I found a Web site explaining the different types of brain tumors and their treatment.”
2. “My brother also had a brain tumor and now is completely cured.”
3. “I understand your fear and will be by your side during this time.”
4. “My mother was also diagnosed with cancer of the brain.”

Answer 124

ANS: 1
Rationale: Yalom’s curative group factor of imparting information involves group members sharing knowledge gained through formal instruction as well as advice and suggestions.

Question 125

Prayer group members at a local Baptist church are meeting with a poor, homeless family whom they are supporting. Which member statement is an example of Yalom’s curative group factor of altruism?
1. “I’ll give you the name of a friend that rents inexpensive rooms.”

2. “The last time we helped a family, they got back on their feet and prospered.”
3. “I can give you all of my baby clothes for your little one.”
4. “I can appreciate your situation. I had to declare bankruptcy last year.”

Answer 125

3. “I can give you all of my baby clothes for your little one.”

Yalom’s curative group factor of altruism occurs when group members provide assistance and support to each other that creates a positive self-image and promotes self-growth. Individuals gain self-esteem through mutual caring and concern.

Question 126

During an inpatient educational group, a client shouts out, “This information is worthless. Nothing you have said can help me.” These statements indicate to a nurse leader that the client is assuming which group role?

1. The group role of aggressor
2. The group role of initiator
3. The group role of gatekeeper
4. The group role of blocker.

Answer 126

1. The group role of aggressor

Rationale: The nurse should identify that the client is assuming the group role of the aggressor. The aggressor expresses negativism and hostility toward others in the group or to the group leader and may use sarcasm in an effort to degrade the status of others.

Question 127

During a group session, which client statement demonstrates that the group has progressed to the middle, or working, phase of group development?

1. “It’s hard for me to tell my story when I’m not sure about the reactions of others.”
2. “I think Joe’s Antabuse suggestion is a good one and might work for me.”
3. “My situation is very complex, and I need professional, not peer, advice.”
4. “I am really upset that you expect me to solve my own problems.”

Answer 127

2. “I think Joe’s Antabuse suggestion is a good one and might work for me.”

Rationale: The nurse should recognize that group members have progressed to the working phase of group development when members begin to look to each other instead of to the leader for guidance. Group members in the working phase begin to accept criticism from each other and use it constructively to create change.

Question 128

Which group leader activity should a nurse identify as being most effective in the final, or termination, phase of group development?

1. The group leader establishes the rules that will govern the group after discharge.
2. The group leader encourages members to rely on each other for problem solving.
3. The group leader presents and discusses the concept of group termination.
4. The group leader helps the members to process feelings of loss.

Answer 128

4. The group leader helps the members to process feelings of loss.

Rationale: The most effective intervention in the final, or termination, phase of group development would be for the group leader to help the members to process feelings of loss. The leader should encourage the members to review the goals and discuss outcomes, reminisce about what has occurred, and encourage members to provide feedback to each other about progress.

Question 129

A nursing instructor is teaching students about self-help groups like Alcoholics Anonymous (AA). Which student statement indicates that learning has occurred?

1. “There is little research to support AA’s effectiveness.”
2. “Self-help groups used to be the treatment of choice, but their popularity is waning.”
3. “These groups have no external regulation, so clients need to be cautious.”
4. “Members themselves run the group, with leadership usually rotating among the members.”

Answer 129

ANS: 4
Rationale: The student indicates an understanding of self-help groups when stating, “Members themselves run the group, with leadership usually rotating among the members.” Nurses may or may not be involved in self-help groups. These groups allow members to talk about feelings and reduce feelings of isolation, while receiving support from others undergoing similar experiences.

Question 130

When planning group therapy, a nurse should identify which configuration as most optimal for a therapeutic group?

1. Open-ended membership; circle of chairs; group size of 5 to 10 members
2. Open-ended membership; chairs around a table; group size of 10 to 15 members
3. Closed membership; circle of chairs; group size of 5 to 10 members
4. Closed membership; chairs around a table; group size of 10 to 15 members

Answer 130

ANS: 3
Rationale: The nurse should identify that the most optimal conditions for a therapeutic group is one in which the membership is closed and in which the group size is between 5 and 10 members, who are arranged in a circle of chairs. The focus of therapeutic groups is directed to relations within the group and the interactions among group members.

Question 131

During the sixth week of a 10-week parenting skills group, a nurse observes as several members get into a heated dispute about spanking. As a group, they decide to create a pros-and-cons poster on the use of physical discipline. At this time, what is the role of the group leader?

1. The leader should referee the debate.
2. The leader should adamantly oppose physical disciplining measures.
3. The leader should redirect the group to a less-controversial topic.
4. The leader should encourage the group to solve the problem collectively

Answer 131

ANS: 4
Rationale: The role of the group leader is to encourage the group to solve the problem collectively. A democratic leadership style supports members in their participation and problem-solving. Members are encouraged to solve issues that relate to the group cooperatively.

Question 132

A 10-week, prenuptial counseling group composed of five couples is terminating. At the last group meeting, a nurse notices that the two most faithful and participative couples are absent. When considering concepts of group development, what might explain this behavior?

1. They are experiencing problems with termination, leading to feelings of abandonment.
2. They did not think any new material would be covered at the last session.
3. They were angry with the leader for not extending the length of the group.
4. They were bored with the material covered in the group.

Answer 132

ANS: 1
Rationale: The nurse should determine that the clients’ absence from the final group meeting may indicate that they are experiencing problems with termination. The termination phase of group development may elicit feelings of abandonment and anger. Successful termination may help members develop skills to cope with future unrelated losses.

Question 133

An experienced psychiatric registered nurse has taken a new position leading groups in a day treatment program. Which group is this nurse most qualified to lead?

1. A psychodrama group
2. A psychotherapy group
3. A parenting group
4. A family therapy group

Answer 133

ANS: 3
Rationale: A psychiatric registered nurse is qualified to lead a parenting group. A parenting group can be classified as either a teaching group or therapeutic group. Psychodrama, psychotherapy, and family therapy are forms of group therapy and must be lead by qualified leaders who generally have advanced degrees in psychology, social work, nursing, or medicine.

Question 134

A nursing instructor is teaching about psychodrama, a specialized type of therapeutic group. Which student statement indicates that further teaching is necessary?

1. “Psychodrama provides a safe setting in which to discuss painful issues.”
2. “In psychodrama, the client is the protagonist.”
3. “In psychodrama, the client observes actor interactions from the audience.”
4. “Psychodrama facilitates resolution of interpersonal conflicts.”

Answer 134

ANS: 2
Rationale: The nurse should educate the student that in psychodrama the client plays the role of him or herself in a life-situation scenario and is called the protagonist. During psychodrama, the client does not observe interactions from the audience. Other group members perform the role of the audience and discuss the situation they have observed, offer feedback, and express their feelings. Leaders of psychodrama must have specialized training to become a psychodramatist.

Question 135

Which of the following behavioral skills should a nurse implement when leading a group that is functioning in the orientation phase of group development? Select all that apply)

A. Encouraging members to provide feedback to each other about individual progress
B. Ensuring that rules established by the group do not interfere with goal fulfillment
C. Working with group members to establish rules that will govern the group
D. Emphasizing the need for and importance of confidentiality within the group

Answer 135

B. Ensuring that rules established by the group do not interfere with goal fulfillment
C. Working with group members to establish rules that will govern the group

D. Emphasizing the need for and importance of confidentiality within the group

Question 136

Order the following leadership expectations that occur in the three phases of the group development process.

_____The leader encourages members to provide feedback to each other about individual progress and to review goals and discuss outcomes.
_____The leader promotes an environment of trust and ensures that rules established by the group do not interfere with fulfillment of the goals.
_____The leader helps to resolve conflict and fosters cohesiveness, while ensuring that members do not deviate from the intended task.

Answer 136

The correct order is 3, 1, 2

Question 137

While conducting the brief mental status evaluation in a client, the nurse evaluates various areas of mental function such as orientation to time, ability to concentrate, and abstract thinking by questioning the client. Which questions posed by the nurse will enable the nurse to evaluate these areas of mental function? Select all that apply.

1. “What year is it?”
2. “Where are you now?”
3. “What does this mean: ‘No use crying over spilled milk’?”
4. “Name the months of the year in reverse, starting with December.”
5. “Repeat these words now: bell, book, and candle.”

Answer 137

1.
“What year is it?”

3. “What does this mean: ‘No use crying over spilled milk’?”
4. “Name the months of the year in reverse, starting with December.”

Question 138

A ______________________ is a collection of individuals whose association is founded on shared commonalities of interest, values, norms, or purpose.

Answer 138

ANS: group