Flashcards in Psych Deck (35)
bipolar p. states "I no longer take my meds bc I like to feel manic." RN response?
a. You may feel good now but what about when you get depressed
b. what do you like about being manic?
c. you feel better when you don't take your meds?
d. you really should follow your HCP's orders if you want to be well
c. You feel better when you don't take your meds? - this open-ended response uses the tool of validation or clarification of the p's feelings and allows further exploration. the response in A. uses the nontherapeutic communication block of devaluing the p's feelings. The response in B. asks for an explanation (never ask why?). The response in D. gives advice (which you should never do either).
A RN should recognize that MRI procedures are generally CI for p's who have a fear of wotf?
a. closed spaces
b. dark places
a. closed spaces (claustrophobia).
Spouse of chronic alcoholic p states "I told my husband I would leave if he did not get into txmt. Now that he is here, I feel differently. What can I do to help him?" Response?
a. you should attend an Al-anon. The grp can teach you how best to help him stay sober
b. you have already done a great deal by getting him here. Now it is up to him
c. are you feeling responsible for his drinking?
d. tell me more about the kind of help you feel you are able to provide at this time
d. The wife is the p in this question. This response will help her to clarify what assistance she can give w/out sacrificing her own needs. A. is giving advice (never do). B. is nontherapeutic and overlooks the wife's need for help in dealing with her husband. Option C. is a closed ended response.
Pt. admitted for depression 1 wk ago who started on Paroxetine (Paxil) at the time of admission. P. states, "My family would be better off without me." Response?
a. I do not feel that you really believe that.
b. everyone feels this way when depressed
c. you sound upset. Are you thinking of hurting yourself?
d. youll feel better once your meds start working
c. This response shows empathy and is the priority to determine if the p. has suicidal ideation. A. expresses disbelief of the p's feelings which is a communication block. B. uses a cliché/overgeneralization and takes the focus away from the p's feelings. D. gives false reassurance, there is no guarantee that the p will feel better once meds reach TE.
P in psych unit w/ bip. d/o. At 3am, p. runs to nrs station and demands to see the therapist immediately. RN response?
a. you are being unreasonable and I will not call your therapist at 3am
b. why do you need to see you therapist tonight?
c. calm down, go back to your room, and Ill try to get in touch with your therapist right away
d. you must be very upset about something to want to see your therapist in the middle of the night.
d. This response shows empathy and gives the p an opportunity to clarify the situation. In A. the RN is showing disapproval- a comm. block. In B., "why" question may be difficult for p to answer= comm. block. In C. the RN does not address the p's feelings and gives the p complex directives (may be difficult for p to follow complex directives)
FM p. seen in ER for ecchymosis on trunk and face, hit by husband. When offered info for a shelter the p. declines stating she wouldn't leave bc of her children. RN response?
a. Aren't you worried about the safety of your children
b. Can you identify the situations that provoke your husband?
c. I am concerned about your safety
d. I wouldn't put up with that if I were you
c. This is an open ended response that allows the p to respond and promotes further dialogue. Option A may make the p defensive about her abilities to protect her children. Option B may insinuate that the p is somehow to blame for the abuse. Option D shows disapproval of the p., who may become defensive
A Rn on a mental health unit is providing care for a p w/ schizophrenia who is experiencing delusional thinking. Wotf defense mechanisms is p using when making delusional statements?
a. w/ projection, the p. attributes emotions and qualities to others which is delusional thinking.
b. dissociation is detaching emotional or behavioral processes from usual conscious behavior patterns or identity. (amnesia)
c. displacement is redirecting an emotion from the original object to a more acceptable substitute.
d. Regression- p returns to less mature behaviors which helps them tolerate anxiety and conflict.
P w/ hallucinations is admitted to the psych unit. In the initial phase of establishing a therapeutic nurse/pt. relationship, it would be appropriate for the RN to explore wotf?
a. perception of the presenting problem
b. description of hallucinations
c. feelings about hospitalization
d. relationship w/ the family
a. In the initial orientation phase, the RN should gather date from secondary sources,, establish rapport w/ the p and assess the p's beliefs about the reason for therapy.
b. and c. are appropriate for the assessment phase of the nurse/p relationship
d. this is appropriate for the working phase of the nurse-pt. relationship.
P. c/o waking up with butterflies, a sense of restlessness, urine freq., and difficulty concentrating while driving to hosp. What lvl of anxiety is he having?
a. moderate- combination of physical symptoms and difficulty concentrating.
b. mild- pt. is alert and able to concentrate closely on the task at hand
c. severe- p. would only be able to focus on small details and would have a great deal of discomfort (this p. was able to drive to hospital)
d. panic- p would be disorganized and may appear paralyzed or hyperactive/agitated.
Short term goal for nurse to plan w/ a suicidal p.?
a. develop more adaptive family relationships
b. sign a contract pledging not to act on suicide plans
c. explore the motivating factors for suicide
d. no longer verbalize thoughts or feelings as they r/t suicide.
b. Physical safety = greatest priority for these ps and the priority goal is to prevent suicide.
a. the goal should focus on the p
c. this can be a later goal for the p.
d. the rn would want to encourage the p to verbalize thoughts and feelings not to suppress them.
Widow brought to clinic by son. She said she could not go on alone. Family amazed by how unaffected she acted after her husband died 6 mths earlier. She exhibited which defense mechanism?
a. denial, a component of the grief process that delays the emotional response to death.
b. repression- the p. would have involuntarily forgotten or banished the husband's death into her unconscious mind.
c. introjection- the pt. did not adopt characteristics of a loved one (her husband).
d. sublimation- the p did not convert unacceptable drives/behaviors into socially acceptable activities
P. receives news from doctor that he has colon cancer after undergoing a colonoscopy. Rn enters room and pt. states "I have received lousy care here and no one cares about me." Defense mechanism?
b. displacement - (act of redirecting thoughts/feelings from an object that provokes anxiety to a safer, alternative object). the p is redirecting his anxiety r/t his dx towards his care at the hosp.
a. denial- p. is not acting like his diagnosis isn't real
c. regression- p is not exhibiting immature behaviors
d. projection - (blaming others for unacceptable thoughts/feelings) p. is not blaming others for his diagnosis
Depressed p. has not come to breakfast and is still in bed. P. states, "I'm too sick to bother, leave me alone and go help someone who is worth your time." RN response?
a. Everyone feels that way when they first start txmt
b. You sound very discouraged and hopeless today.
c. you'll feel so much better once you get up and into your clothes.
d. Why do you say that you are too sick to bother?
b. This is therapeutic, the Rn restates the p's feelings which offers further clarification and communication.
c- false reassurance
d- "why" question
College student receives low grade in a course and spends entire counseling session blaming teacher and complaining about the lack of help seminars. Defense mech?
b. displacement - the p. is shifting feelings from being a inept student toward the teacher and lack of seminars.
depressed pt. comes to breakfast after bathing, combing, and putting on clean clothes. RN response?
a. you must be getting better, you look great!
b. Let's go put some make-up on to make you look even better
c. Why did you get all dressed up today? Is it a special occasion?
d. You look nice after you bath and shampoo.
d. this acknowledges and affirms the p's behavior. (positive reinforcement)
a- false reassurance, often suicidal p's appear improved after having made the decision to commit suicide
b- devalues the p's actions
c- requests an explanation for the p's actions
Pt. w/schizophrenia is relaxed at first when talking to RN but then becomes restless/tense. RN response?
a. Did I say something wrong that made you feel tense?
b. Do you often feel tense when you are talking to a HCP?
c. What were we discussing when you began to feel uncomfortable?
d. I sometimes feel tense too when I'm talking to a stranger.
c. This statement seeks clarification and is open-ended
a- close ended questions that focuses on nurse
b- closed-ended q, assumes that p. is tense bc of talking
d- this response is also focused on the nurse. Responses should always be focused on the p's feelings
Schizophrenic says, "They lied about me and are trying to poison my food." RN response?
a. Tell me who would do such things to you
b. you are mistaken .Nobody has told lies about you or tried to poison you
c. tell me more about your concerns r/t being poisoned
d. youre having very frightening thoughts
d. fear of being poisoned is a common delusion for schizophrenics. The rn is responding to the p's feelings and shifting the focus from the p's beliefs (which are not real), to the p's fear (which is real).
a- this supports the p's delusional thinking (non-therap.)
b- this directly confronts the p's delusion (non-therap.)
c.- this supports the p's delusional thinking
Alcoholic P. in detox center develops hand tremors and asks about them?
a. They are permanent changes bc your nerves are destroyed
b. They will persist for a few days now that you stopped drinking
c. this is unusual. We will notify your HCP
d. These are very typical of the seizures r/t alcohol w/drawal
b. Alcohol w/drawal leads to tremors, vomiting, restlessness, insomnia, tachy-c, transient hallucinations/illusions, anxiety, htn, tachypnea, fever and tonic-clonic seizures. These effects start w/in 4-12 hr after stopping, peak after 24-48 hrs, and then disappear. Chlordiazepoxide (Librium), an antianxiety agent, will help the p w/ these manifestations in the initial stages of w/drawal
P. w/ BPD has become attached to one of the RNs who calls in sick one day. P becomes angry and cuts himself. Therapeutic RN action?
a. permit the p to remain alone
b. ignore the p's behavior
c. telephone the p's favorite nurse to talk w/ him
d. help the p verbalize his feelings and reasons for the acting-out behavior.
d. The most therapeutic action is to help the p. verbalize feelings. The nurse must do this to determine the p's suicide potential and to help the p learn to control impulsive behavior.
c- non-therapeutic, reinforces dependency on p's favorite nurse
P. w/ schizophrenia is tense and rapidly pacing, tells approaching nurse to back off and leave her alone. RN response?
a. I can't leave you alone when you are this upset. Sit down, and try to relax
b. Lets go to your room and you can tell me what is really bothering you
c. I will give you space as long as you control yourself. I'd like to know what is causing you to feel so tense.
d. I will leave you alone for a few minutes while you try to compose yourself.
c. this is correct, 1st concern is to ensure safety. To avoid escalating the p's behavior the RN should stay at a comfortable distance and remain calm while stressing the importance of maintaining control. Verbal intervention is the least restrictive form of action. If verbal intervention is ineffective, then more restrictive measures may have to be used.
a- nontherap. response- p is anxious and out of control
b- shouldn't be alone w/ p. unless p. provides assurance of maintaining self-control
d- shouldn't leave potentially violent p alone
P. admitted to psych unit following intentional OD. During admit axmt, p states, "Why would you want to waste your time on a worthless person like me?" RN response?
a. let's discuss your feelings after we finish your admission
b. I don't think talking to you is a waste of time
c. why do you feel the way you do?
d. I think you are worthwhile and I want to talk to you
d. This uses the technique of offering one's self and addresses the p's feelings of worthlessness.
a- minimizes p's feelings by putting them on hold
b- doesn't address p's feelings
c- requests explanation
Wotf statements made by depressed ps indicates the highest potential for suicide?
a. At breakfast today everyone was talking about me. They were all staring
b. I don't feel like going to grp therapy today. I don't want to be with other ppl
c. I have it all figured out. Everything is going to be okay now.
d. I don't feel like showering or eating. I'd rather just stay in bed
c. A sudden lifting of spirits, when there have been other previous indications of depression and/or suicidal ideation, may point to a decision to end the pain of life through suicide. This p. may now have the energy to plan or carry out a suicidal act.
a- this is paranoid/delusional thinking
b and d- this p is showing signs of severe depression and prob does not have energy to plan/carry out suicide
P. states to RN, "I cannot make a safety contract bc I can't promise that I will not harm myself." In the POC, wotf initial actions is best to ensure the p's safety?
a. lock the doors to the unit and secure the windows.
b. remove belts, glass objects, and sharp instruments from the p's environment
c. have a staff member stay w/ the p. at all times.
d. provide a relaxed and accepting environment to develop trust
c. high suicidal risk ps require constant supervision to ensure safety
a- this is appropriate, but not best option
b-not the best option
d- " " " "
P. exhibiting mild anxiety when?
a. the p is extremely alert
b. the p c/o a stomach ache
c. the p paces in the day room
d. the p. has dilated pupils
a. mild anxiety- alertness, increased awareness
b- severe anxiety yields physical symptoms like stomach ache, confusion and hyperventilation
c- moderate anxiety= pacing, difficulty concentrating and tachy-c
d- panic level anxiety= dilated pupils, cool/clammy skin and immobility
RN receives call on a crisis intervention hotline from p who threatens to commit suicide. Most important question for the RN to ask?
a. Have you attempted suicide before?
b. What happened to make you so desperate?
c. How will you carry out your plan?
d. What will you accomplish by taking your life?
c. asking about the p's plan may give the RN important data like the p's location and method of self-harm.
Primary goal for a p experiencing panic level anxiety?
a. identify the cause of the anxiety
b. reduce the p's immediate anxiety
c. investigate the situation that preceded the attack
d. explain the physical manifestations of anxiety to the p
b. goal is to reduce anxiety to a more manageable state
In a, c, and d, the pt would be expected to think about other things or understand knowledge given- both of which are not possible
P. taking a TCA. WOTF SEs report promptly to HCP?
a. fine hand tremor
d. urinary retention
d. urine retention is a potentially serious SE that can lead to bladder infection and loss of bladder tone. RN should mon 4 bladder distention and I&O.
Pt. w/ OCD and recurring thoughts r/t mouth odors. P has mouth care rituals that take up a lot of time and causes him to lose his job. These represent wotf?
a. method to reduce anxiety
b. form of manipulation to avoid work
c. strategy to get attention
d. rationalization for avoiding social contact
a. Ritualistic behaviors r/t OCD are performed to control anxiety.
Maslow's hierarchy, prioritizing care
Ps w/ basic physiologic needs would come first (sleep, food), then p's w/ safety needs (security), then those w/ love and belonging needs, then self-esteem needs, then self-actualization needs