Chapter 5: Settings for Psychiatric Care
Test Bank
MULTIPLE CHOICE
- Planning for patients with mental illness is facilitated by understanding that inpatient hospitalization is generally reserved for patients who:
| a. | present a clear danger to self or others. |
| b. | are noncompliant with medications at home. |
| c. | have no support systems in the community. |
| d. | develop new symptoms during the course of an illness. |
ANS: A
Hospitalization is justified when the patient is a danger to self or others, has dangerously decompensated, or needs intensive medical treatment. The incorrect options do not necessarily describe patients who require inpatient treatment.
DIF: Cognitive Level: Comprehension REF: Pages: 72-74 TOP: Nursing Process: Planning
MSC: NCLEX: Safe, Effective Care Environment
- A patient is hospitalized for a reaction to a psychotropic medication and then is closely monitored for 24 hours. During a predischarge visit, the case manager learns the patient received a notice of eviction on the day of admission. The most appropriate intervention for the case manager is to:
| a. | cancel the patient’s discharge from the hospital. |
| b. | contact the landlord who evicted the patient to further discuss the situation. |
| c. | arrange a temporary place for the patient to stay until new housing can be arranged. |
| d. | document that the adverse medication reaction was feigned because the patient had nowhere to live. |
ANS: C
The case manager should intervene by arranging temporary shelter for the patient until suitable housing can be found. This is part of the coordination and delivery of services that falls under the case manager role. The other options are not viable alternatives.
DIF: Cognitive Level: Application REF: Page: 73
TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment
- A multidisciplinary health care team meets 12 hours after an adolescent is hospitalized after a suicide attempt. Members of the team report their assessments. What outcome can be expected from this meeting?
| a. | A treatment plan will be determined. |
| b. | The health care provider will order neuroimaging studies. |
| c. | The team will request a court-appointed advocate for the patient. |
| d. | Assessment of the patient’s need for placement outside the home will be undertaken. |
ANS: A
Treatment plans are formulated early in the course of treatment to streamline the treatment process and reduce costs. It is too early to determine the need for alternative postdischarge living arrangements. Neuroimaging is not indicated for this scenario.
DIF: Cognitive Level: Application REF: Pages: 72-74
TOP: Nursing Process: Outcomes Identification
MSC: NCLEX: Safe, Effective Care Environment
- The relapse of a patient with schizophrenia is related to medication noncompliance. The patient is hospitalized for 5 days, medication is restarted, and the patient’s thoughts are now more organized. The patient’s family members are upset and say, “It’s too soon about the patient being scheduled for discharge. Hospitalization is needed for at least a month.” The nurse should:
| a. | call the psychiatrist to come explain the discharge rationale. |
| b. | explain that health insurance will not pay for a longer stay for the patient. |
| c. | call security to handle the disturbance and escort the family off the unit. |
| d. | explain that the patient will continue to improve if medication is taken regularly. |
ANS: D
Patients no longer stay in the hospital until every vestige of a symptom disappears. The nurse must assume responsibility to advocate for the patient’s right to the least restrictive setting as soon as the symptoms are under control and for the right of citizens to control health care costs. The health care provider will use the same rationale. Shifting blame will not change the discharge. Calling security is unnecessary. The nurse can handle this matter.
DIF: Cognitive Level: Application REF: Pages: 74-75
TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment
- A nurse assesses an inpatient psychiatric unit, noting that exits are free from obstruction, no one is smoking, the janitor’s closet is locked, and all sharp objects are being used under staff supervision. These observations relate to:
| a. | management of milieu safety |
| b. | coordinating care of patients |
| c. | management of the interpersonal climate |
| d. | use of therapeutic intervention strategies |
ANS: A
Members of the nursing staff are responsible for all aspects of milieu management. The observations mentioned in this question directly relate to the safety of the unit. The other options, although part of the nurse’s concerns, are unrelated to the observations cited.
DIF: Cognitive Level: Application REF: Pages: 72-74
TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment
- The following patients are seen in the emergency department. The psychiatric unit has one bed available. Which patient should the admitting officer recommend for admission to the hospital? The patient who:
| a. | experiencing dry mouth and tremor related to side effects of haloperidol (Haldol). |
| b. | experiencing anxiety and a sad mood after a separation from a spouse of 10 years. |
| c. | who self-inflicted a superficial cut on the forearm after a family argument. |
| d. | who is a single parent and hears voices saying, “Smother your infant.” |
ANS: D
Admission to the hospital would be justified by the risk of patient danger to self or others. The other patients have issues that can be handled with less restrictive alternatives than hospitalization.
DIF: Cognitive Level: Analysis REF: Pages: 72-74
TOP: Nursing Process: Analysis| Nursing Process: Diagnosis
MSC: NCLEX: Safe, Effective Care Environment
- A student nurse prepares to administer oral medications to a patient with major depression, but the patient refuses the medication. The student nurse should:
| a. | tell the patient, “I’ll get an unsatisfactory grade if I don’t give you the medication.” |
| b. | tell the patient, “Refusing your medication is not permitted. You are required to take it.” |
| c. | explore the patient’s concerns about the medication, and report to the staff nurse. |
| d. | document the patient’s refusal of the medication without further comment. |
ANS: C
The patient has the right to refuse medication in most cases. The patient’s reason for refusing should be ascertained, and the refusal should be reported to a unit nurse. Sometimes refusals are based on unpleasant side effects that can be ameliorated. Threats and manipulation are inappropriate. Medication refusal should be reported to permit appropriate intervention.
DIF: Cognitive Level: Application REF: Page: 74
TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment
- A nurse surveys the medical records for violations of patients’ rights. Which finding signals a violation?
| a. | No treatment plan is present in record. |
| b. | Patient belongings are searched at admission. |
| c. | Physical restraint is used to prevent harm to self. |
| d. | Patient is placed on one-to-one continuous observation. |
ANS: A
The patient has the right to have a treatment plan. Inspecting a patient’s belongings is a safety measure. Patients have the right to a safe environment, including the right to be protected against impulses to harm self that occur as a result of a mental disorder.
DIF: Cognitive Level: Application REF: Page: 74 TOP: Nursing Process: Evaluation
MSC: NCLEX: Safe, Effective Care Environment
- Which principle takes priority for the psychiatric inpatient staff when addressing behavioral crises?
| a. | Resolve behavioral crises with the least restrictive intervention possible. |
| b. | Rights of the majority of patients supersede the rights of individual patients. |
| c. | Swift intervention is justified to maintain the integrity of the therapeutic milieu. |
| d. | Allow patients the opportunities to regain control without intervention if the safety of other patients is not compromised. |
ANS: A
The rule of using the least restrictive treatment or intervention possible to achieve the desired outcome is the patient’s legal right. Planned interventions are nearly always preferable. Intervention may be necessary when the patient threatens harm to self.
DIF: Cognitive Level: Application REF: Page: 74
TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment
- To provide comprehensive care to patients, which competency is more important for a nurse who works in a community mental health center than a psychiatric nurse who works in an inpatient unit?
| a. | Problem-solving skills |
| b. | Calm external manner |
| c. | Ability to cross service systems |
| d. | Knowledge of psychopharmacology |
ANS: C
A community mental health nurse must be able to work with schools, corrections facilities, shelters, health care providers, and employers. The mental health nurse working in an inpatient unit needs only to be able to work within the single setting. Problem-solving skills are needed by all nurses. Nurses in both settings must have knowledge of psychopharmacology.
DIF: Cognitive Level: Analysis REF: Pages: 71-72
TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment
- A suspicious and socially isolated patient lives alone, eats one meal a day at a nearby shelter, and spends the remaining daily food allowance on cigarettes. Select the community psychiatric nurse’s best initial action.
| a. | Report the situation to the manager of the shelter. |
| b. | Tell the patient, “You must stop smoking to save money.” |
| c. | Assess the patient’s weight; determine the foods and amounts eaten. |
| d. | Seek hospitalization for the patient while a new plan is being formulated. |
ANS: C
Assessment of biopsychosocial needs and general ability to live in the community is called for before any action is taken. Both nutritional status and income adequacy are critical assessment parameters. A patient may be able to maintain adequate nutrition while eating only one meal a day. Nurses assess before taking action. Hospitalization may not be necessary.
DIF: Cognitive Level: Application REF: Pages: 71-72
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
- A patient with schizophrenia has been stable in the community. Today, the spouse reports the patient is delusional and explosive. The patient says, “I’m willing to take my medicine, but I forgot to get my prescription refilled.” Which outcome should the nurse add to the plan of care?
| a. | Nurse will obtain prescription refills every 90 days and deliver them to the patient. |
| b. | Patient’s spouse will mark dates for prescription refills on the family calendar. |
| c. | Patient will report to the hospital for medication follow-up every week. |
| d. | Patient will call the nurse weekly to discuss medication-related issues. |
ANS: B
The nurse should use the patient’s support system to meet patient needs whenever possible. Delivery of medication by the nurse should be unnecessary for the nurse to do if the patient or a significant other can be responsible. The patient may not need more intensive follow-up as long as he or she continues to take the medications as prescribed. No patient issues except failure to obtain medication refills were identified.
DIF: Cognitive Level: Application REF: Pages: 71-72 TOP: Nursing Process: Planning
MSC: NCLEX: Safe, Effective Care Environment
- A community mental health nurse has worked for 6 months to establish a relationship with a delusional, suspicious patient. The patient recently lost employment and stopped taking medications because of inadequate money. The patient says, “Only a traitor would make me go to the hospital.” Which solution is best?
| a. | Arrange a bed in a local homeless shelter with nightly onsite supervision. |
| b. | Negotiate a way to provide medication so the patient can remain at home. |
| c. | Hospitalize the patient until the symptoms have stabilized. |
| d. | Seek inpatient hospitalization for up to 1 week. |
ANS: B
Hospitalization may damage the nurse-patient relationship even if it provides an opportunity for rapid stabilization. If medication can be obtained and restarted, the patient can possibly be stabilized in the home setting, even if it takes a little longer. A homeless shelter is inappropriate and unnecessary. Hospitalization may be necessary later, but a less restrictive solution should be tried first because the patient is not dangerous.
DIF: Cognitive Level: Analysis REF: Pages: 71-72 TOP: Nursing Process: Planning
MSC: NCLEX: Safe, Effective Care Environment
- A community psychiatric nurse facilitates medication compliance for a patient by having the health care provider prescribe depot medications by injection every 3 weeks at the clinic. For this plan to be successful, which factor will be of critical importance?
| a. | Attitude of significant others toward the patient |
| b. | Nutritional services in the patient’s neighborhood |
| c. | Level of trust between the patient and the nurse |
| d. | Availability of transportation to the clinic |
ANS: D
The ability of the patient to get to the clinic is of paramount importance to the success of the plan. The depot medication relieves the patient of the necessity to take medication daily, but if he or she does not receive the injection at 3-week intervals, noncompliance will again be the issue. Attitude toward the patient, trusting relationships, and nutrition are important but not fundamental to this particular problem.
DIF: Cognitive Level: Analysis REF: Pages: 71-72
TOP: Nursing Process: Assessment MSC: NCLEX: Safe, Effective Care Environment
- Which assessment finding for a patient in the community requires priority intervention by the nurse? The patient:
| a. | receives Social Security disability income plus a small check from a trust fund. |
| b. | lives in an apartment with two patients who attend day hospital programs. |
| c. | has a sibling who is interested and active in care planning. |
| d. | purchases and uses marijuana on a frequent basis. |
ANS: D
Patients who regularly buy illegal substances often become medication noncompliant. Medication noncompliance, along with the disorganizing influence of illegal drugs on cellular brain function, promotes relapse. The remaining options do not suggest problems.
DIF: Cognitive Level: Analysis REF: Page: 71|Page: 76
TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity
- A patient tells the nurse at the clinic, “I haven’t been taking my antidepressant medication as directed. I leave out the midday dose. I have lunch with friends and don’t want them to ask me about the pills.” Select the nurse’s most appropriate intervention.
| a. | Investigate the possibility of once-daily dosing of the antidepressant. |
| b. | Suggest to the patient to take the medication when no one is watching. |
| c. | Explain how taking each dose of medication on time relates to health maintenance. |
| d. | Add the nursing diagnosis—Ineffective therapeutic regimen management, related to lack of knowledge—to the plan of care. |
ANS: A
Investigating the possibility of once-daily dosing of the antidepressant has the highest potential for helping the patient achieve compliance. Many antidepressants can be administered by once-daily dosing, a plan that increases compliance. Explaining how taking each dose of medication on time relates to health maintenance is reasonable but would not achieve the goal; it does not address the issue of stigma. The self-conscious patient would not be comfortable doing this. A better etiologic statement would be related to social stigma. The question asks for an intervention, not analysis.
DIF: Cognitive Level: Application REF: Pages: 71-72
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
- A community psychiatric nurse assesses that a patient with a mood disorder is more depressed than on the previous visit a month ago; however, the patient says, “I feel the same.” Which intervention supports the nurse’s assessment while preserving the patient’s autonomy?
| a. | Arrange for a short hospitalization. |
| b. | Schedule weekly clinic appointments. |
| c. | Refer the patient to the crisis intervention clinic. |
| d. | Call the family and ask them to observe the patient closely. |
ANS: B
Scheduling clinic appointments at shorter intervals will give the opportunity for more frequent assessment of symptoms and allow the nurse to use early intervention. If the patient does not admit to having a crisis or problem, this referral would be useless. The remaining options may produce unreliable information, violate the patient’s privacy, and waste scarce resources.
DIF: Cognitive Level: Analysis REF: Pages: 71-72
TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment
- A patient hurriedly tells the community mental health nurse, “Everything’s a disaster! I can’t concentrate. My disability check didn’t come. My roommate moved out, and I can’t afford the rent. My therapist is moving away. I feel like I’m coming apart.” Which nursing diagnosis applies?
| a. | Decisional conflict, related to challenges to personal values |
| b. | Spiritual distress, related to ethical implications of treatment regimen |
| c. | Anxiety, related to changes perceived as threatening to psychological equilibrium |
| d. | Impaired environmental interpretation syndrome, related to solving multiple problems affecting security needs |
ANS: C
Subjective and objective data obtained by the nurse suggest the patient is experiencing anxiety caused by multiple threats to security needs. Data are not present to suggest Decisional conflict, ethical conflicts around treatment causing Spiritual distress, or Impaired environmental interpretation syndrome.
DIF: Cognitive Level: Analysis REF: Pages: 71-72
TOP: Nursing Process: Diagnosis| Nursing Process: Analysis
MSC: NCLEX: Psychosocial Integrity
- Which patient would a nurse refer to partial hospitalization? An individual who:
| a. | spent yesterday in the 24-hour supervised crisis care center and continues to be actively suicidal. |
| b. | because of agoraphobia and panic episodes needs psychoeducation for relaxation therapy |
| c. | has a therapeutic lithium level and reports regularly for blood tests and clinic follow-up. |
| d. | states, “I’m not sure I can avoid using alcohol when my spouse goes to work every morning.” |
ANS: D
This patient could profit from the structure and supervision provided by spending the day at the partial hospitalization program. During the evening, at night, and on weekends, the spouse could assume supervision responsibilities. The patient who is actively suicidal needs inpatient hospitalization. The patient in need of psychoeducation can be referred to home care. The patient who reports regularly for blood tests and clinical follow-up can continue on the same plan.
DIF: Cognitive Level: Analysis REF: Pages: 71-72 TOP: Nursing Process: Planning
MSC: NCLEX: Safe, Effective Care Environment
- Which employer’s health plan is required to include parity provisions related to mental illnesses?
| a. | Employer with more than 50 employees |
| b. | Cancer thrift shop staffed by volunteers |
| c. | Daycare center that employs 7 teachers |
| d. | Church that employs 15 people |
ANS: A
Under federal parity laws, companies with more than 50 employees may not limit annual or lifetime mental health benefits unless they also limit benefits for physical illnesses.
DIF: Cognitive Level: Comprehension REF: Pages: 76-77
TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment
MULTIPLE RESPONSE
- A nurse can best address factors of critical importance to successful community treatment for persons with mental illness by including assessments related to which of the following? Select all that apply.
| a. | housing adequacy and stability |
| b. | income adequacy and stability |
| c. | family and other support systems |
| d. | early psychosocial development |
| e. | substance abuse history and current use |
ANS: A, B, C, E
Early psychosocial developmental history is less relevant to successful outcomes in the community than the assessments listed in the other options. If a patient is homeless or fears homelessness, focusing on other treatment issues is impossible. Sufficient income for basic needs and medication is necessary. Adequate support is a requisite to community placement. Substance abuse undermines medication effectiveness and interferes with community adjustment.
DIF: Cognitive Level: Application REF: Pages: 71-72
TOP: Nursing Process: Assessment MSC: NCLEX: Safe, Effective Care Environment
- A community member asks a nurse, “People with mental illnesses used to go to a state hospital. Why has that changed?” Select the nurse’s accurate responses. Select all that apply.
| a. | “Science has made significant improvements in drugs for mental illness, so now many people may live in their communities.” |
| b. | “A better selection of less restrictive settings is now available in communities to care for individuals with mental illness.” |
| c. | “National rates of mental illness have declined significantly. The need for state institutions is actually no longer present.” |
| d. | “Most psychiatric institutions were closed because of serious violations of patients’ rights and unsafe conditions.” |
| e. | “Federal legislation and payment for treatment of mental illness have shifted the focus to community rather than institutional settings.” |
ANS: A, B, E
The community is a less restrictive alternative than hospitals for the treatment of people with mental illness. Funding for treatment of mental illness remains largely inadequate but now focuses on community rather than institutional care. Antipsychotic medications improve more symptoms of mental illness; hence, management of psychiatric disorders has improved. Rates of mental illness have increased, not decreased. Hospitals were closed because funding shifted to the community. Conditions in institutions have
improved.
DIF: Cognitive Level: Analysis REF: Pages: 69-70
TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment
Chapter 7: Nursing Process and QSEN: The Foundation for Safe and Effective Care
Test Bank
MULTIPLE CHOICE
- A new staff nurse completes orientation to the psychiatric unit. This nurse will expect to ask an advanced practice nurse to perform which action for patients?
| a. | Perform mental health assessment interviews. |
| b. | Establish therapeutic relationships. |
| c. | Prescribe psychotropic medications. |
| d. | Individualize nursing care plans. |
ANS: C
Prescriptive privileges are granted to Master’s-prepared nurse practitioners who have taken special courses on prescribing medications. The nurse prepared at the basic level performs mental health assessments, establishes relationships, and provides individualized care planning.
DIF: Cognitive Level: Comprehension REF: Page: 109
TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment
- A newly admitted patient with major depression has lost 20 pounds over the past month and has suicidal ideation. The patient has taken an antidepressant medication for 1 week without remission of symptoms. Select the priority nursing diagnosis.
| a. | Imbalanced nutrition: Less than body requirements |
| b. | Chronic low self-esteem |
| c. | Risk for suicide |
| d. | Hopelessness |
ANS: C
Risk for suicide is the priority diagnosis when the patient has both suicidal ideation and a plan to carry out the suicidal intent. Imbalanced nutrition, Hopelessness, and Chronic low self-esteem may be applicable nursing diagnoses, but these problems do not affect patient safety as urgently as a suicide attempt.
DIF: Cognitive Level: Application REF: Page: 105
TOP: Nursing Process: Diagnosis| Nursing Process: Analysis
MSC: NCLEX: Psychosocial Integrity
- A patient with major depression has lost 20 pounds in one month has chronic low self-esteem and a plan for suicide. The patient has taken an antidepressant medication for 1 week. Which nursing intervention is most directly related to this outcome: “Patient will refrain from gestures and attempts to harm self”?
| a. | Implement suicide precautions. |
| b. | Frequently offer high-calorie snacks and fluids. |
| c. | Assist the patient to identify three personal strengths. |
| d. | Observe patient for therapeutic effects of antidepressant medication. |
ANS: A
Implementing suicide precautions is the only option related to patient safety. The other options, related to nutrition, self-esteem, and medication therapy, are important but are not priorities.
DIF: Cognitive Level: Application REF: Pages: 105-106
TOP: Nursing Process: Planning MSC: NCLEX: Safe, Effective Care Environment
- A patient’s nursing diagnosis is Insomnia. The desired outcome is: “Patient will sleep for a minimum of 5 hours nightly by October 31.” On November 1, a review of the sleep data shows the patient sleeps an average of 4 hours nightly and takes a 2-hour afternoon nap. Which evaluation should be documented?
| a. | Consistently demonstrated |
| b. | Often demonstrated |
| c. | Sometimes demonstrated |
| d. | Never demonstrated |
ANS: D
Although the patient is sleeping 6 hours daily, the total is not in one uninterrupted session at night. Therefore the outcome must be evaluated as never demonstrated.
DIF: Cognitive Level: Application REF: Page: 110 TOP: Nursing Process: Evaluation
MSC: NCLEX: Physiological Integrity
- A patient’s nursing diagnosis is Insomnia. The desired outcome is: “Patient will sleep for a minimum of 5 hours nightly by October 31.” On November 1, a review of the sleep data shows the patient sleeps an average of 4 hours nightly and takes a 2-hour afternoon nap. What is the nurse’s next action?
| a. | Continue the current plan without changes. |
| b. | Remove this nursing diagnosis from the plan of care. |
| c. | Write a new nursing diagnosis that better reflects the problem. |
| d. | Revise the target date for outcome attainment and examine interventions. |
ANS: D
Sleeping a total of 5 hours at night remains a reasonable outcome. Extending the time frame for attaining the outcome is appropriate. Examining interventions might result in planning an activity during the afternoon rather than permitting a nap. Continuing the current plan without changes is inappropriate. At the very least, the time in which the outcome is to be attained must be extended. Removing this nursing diagnosis from the plan of care could be used when the outcome goal has been met and the problem resolved. Writing a new nursing diagnosis is inappropriate because no other nursing diagnosis relates to the problem.
DIF: Cognitive Level: Application REF: Page: 110 TOP: Nursing Process: Evaluation
MSC: NCLEX: Physiological Integrity
- A patient begins a new program to assist with building social skills. In which part of the plan of care should a nurse record the item “Encourage patient to attend one psychoeducational group daily”?
| a. | Assessment |
| b. | Analysis |
| c. | Planning |
| d. | Implementation |
| e. | Evaluation |
ANS: D
Interventions are the nursing prescriptions to achieve the outcomes. Interventions should be specific.
DIF: Cognitive Level: Application REF: Page: 109
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity
- Before assessing a new patient, a nurse is told by another health care worker, “I know that patient. No matter how hard we work, there isn’t much improvement by the time of discharge.” The nurse’s responsibility is to:
| a. | document the other worker’s assessment of the patient. |
| b. | assess the patient based on data collected from all sources. |
| c. | validate the worker’s impression by contacting the patient’s significant other. |
| d. | discuss the worker’s impression with the patient during the assessment interview. |
ANS: B
Assessment should include data obtained from both the primary and reliable secondary sources. Biased assessments by others should be evaluated as objectively as possible by the nurse, keeping in mind the possible effects of counter-transference.
DIF: Cognitive Level: Application REF: Pages: 98-99|Pages: 103-105
TOP: Nursing Process: Assessment MSC: NCLEX: Safe, Effective Care Environment
- A nurse works with a patient to establish outcomes. The nurse believes that one outcome suggested by the patient is not in the patient’s best interest. What is the nurse’s best action?
| a. | Remain silent. |
| b. | Educate the patient that the outcome is not realistic. |
| c. | Explore with the patient possible consequences of the outcome. |
| d. | Formulate an appropriate outcome without the patient’s input. |
ANS: C
The nurse should not impose outcomes on the patient; however, the nurse has a responsibility to help the patient evaluate what is in his or her best interest. Exploring possible consequences is an acceptable approach.
DIF: Cognitive Level: Application REF: Pages: 105-108
TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment
- A patient states, “I’m not worth anything. I have negative thoughts about myself. I feel anxious and shaky all the time. Sometimes I feel so sad that I want to go to sleep and never wake up.” Which nursing intervention should have the highest priority?
| a. | Self-esteem–building activities |
| b. | Anxiety self-control measures |
| c. | Sleep enhancement activities |
| d. | Suicide precautions |
ANS: D
The nurse should place priority on monitoring and reinforcing suicide self-restraint because it relates directly and immediately to patient safety. Patient safety is always a priority concern. The nurse should monitor and reinforce all patient attempts to control anxiety, improve sleep patterns, and develop self-esteem while giving priority attention to suicide self-restraint.
DIF: Cognitive Level: Analysis REF: Pages: 108-109
TOP: Nursing Process: Planning MSC: NCLEX: Safe, Effective Care Environment
- Select the best outcome for a patient with the nursing diagnosis: Impaired social interaction, related to sociocultural dissonance as evidenced by stating, “Although I’d like to, I don’t join in because I don’t speak the language very well.” The patient will:
| a. | demonstrate improved social skills. |
| b. | express a desire to interact with others. |
| c. | become more independent in decision making. |
| d. | select and participate in one group activity per day. |
ANS: D
The outcome describes social involvement on the part of the patient. Neither cooperation nor independence has been an issue. The patient has already expressed a desire to interact with others. Outcomes must be measurable. Two of the distracters are not measurable.
DIF: Cognitive Level: Analysis REF: Pages: 105-106
TOP: Nursing Process: Outcomes Identification
MSC: NCLEX: Psychosocial Integrity
- Nursing behaviors associated with the implementation phase of the nursing process are concerned with:
| a. | participating in the mutual identification of patient outcomes. |
| b. | gathering accurate and sufficient patient-centered data. |
| c. | comparing patient responses and expected outcomes. |
| d. | carrying out interventions and coordinating care. |
ANS: D
Nursing behaviors relating to implementation include using available resources, performing interventions, finding alternatives when necessary, and coordinating care with other team members.
DIF: Cognitive Level: Comprehension REF: Page: 109
TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment
- Which statement made by a patient during an initial assessment interview should serve as the priority focus for the plan of care?
| a. | “I can always trust my family.” |
| b. | “It seems like I always have bad luck.” |
| c. | “You never know who will turn against you.” |
| d. | “I hear evil voices that tell me to do bad things.” |
ANS: D
The statement regarding evil voices tells the nurse that the patient is experiencing auditory hallucinations. The other statements are vague and do not clearly identify the patient’s chief symptom.
DIF: Cognitive Level: Analysis REF: Pages: 101-103
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
- Which entry in the medical record best meets the requirement for problem-oriented charting?
| a. | “A: Pacing and muttering to self. P: Sensory perceptual alteration, related to internal auditory stimulation. I: Given fluphenazine (Prolixin) 2.5 mg at 0900, and went to room to lie down. E: Calmer by 0930. Returned to lounge to watch TV.” |
| b. | “S: States, ‘I feel like I’m ready to blow up.’ O: Pacing hall, mumbling to self. A: Auditory hallucinations. P: Offer haloperidol (Haldol) 2 mg . I: (Haldol) 2 mg at 0900. E: Returned to lounge at 0930 and quietly watched TV.” |
| c. | “Agitated behavior. D: Patient muttering to self as though answering an unseen person. A: Given haloperidol (Haldol) 2 mg and went to room to lie down. E: Patient calmer. Returned to lounge to watch TV.” |
| d. | “Pacing hall and muttering to self as though answering an unseen person. haloperidol (Haldol) 2 mg administered at 0900 with calming effect in 30 minutes. Stated, ‘I’m no longer bothered by the voices.’” |
ANS: B
Problem-oriented documentation uses the first letter of key words to organize data: S for subjective data, O for objective data, A for assessment, P for plan, I for intervention, and E for evaluation. The distracters offer examples of PIE charting, focus documentation, and narrative documentation.
DIF: Cognitive Level: Analysis REF: Page: 111
TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment
- A nurse assesses an older adult patient brought to the emergency department by a family member. The patient was wandering outside, saying, “I can’t find my way home.” The patient is confused and unable to answer questions. Select the nurse’s best action.
| a. | Document the patient’s mental status. Obtain other assessment data from the family member. |
| b. | Record the patient’s answers to questions on the nursing assessment form. |
| c. | Ask an advanced practice nurse to perform the assessment interview. |
| d. | Call for a mental health advocate to maintain the patient’s rights. |
ANS: A
When the patient (primary source) is unable to provide information, secondary sources should be used, in this case the family member. Later, more data may be obtained from other relatives or neighbors who are familiar with the patient. An advanced practice nurse is not needed for this assessment; it is within the scope of practice of the staff nurse. Calling a mental health advocate is unnecessary.
DIF: Cognitive Level: Application REF: Pages: 98-101
TOP: Nursing Process: Assessment MSC: NCLEX: Safe, Effective Care Environment
- A nurse asks a patient, “If you had fever and vomiting for 3 days, what would you do?” Which aspect of the mental status examination is the nurse assessing?
| a. | Behavior |
| b. | Cognition |
| c. | Affect and mood |
| d. | Perceptual disturbances |
ANS: B
Assessing cognition involves determining a patient’s judgment and decision-making capabilities. In this case, the nurse expects a response of, “Call my doctor” if the patient’s cognition and judgment are intact. If the patient responds, “I would stop eating” or “I would just wait and see what happened,” the nurse would conclude that judgment is impaired. The other options refer to other aspects of the examination.
DIF: Cognitive Level: Application REF: Pages: 101-103
TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity
- An adolescent asks a nurse conducting an assessment interview, “Why should I tell you anything? You’ll just tell my parents whatever you find out.” Select the nurse’s best reply.
| a. | “That isn’t true. What you tell us is private and held in strict confidence. Your parents have no right to know.” |
| b. | “Yes, your parents may find out what you say, but it is important that they know about your problems.” |
| c. | “What you say about feelings is private, but some things, like suicidal thinking, must be reported to the treatment team.” |
| d. | “It sounds as though you are not really ready to work on your problems and make changes.” |
ANS: C
The patient has a right to know that most information will be held in confidence but that certain material must be reported or shared with the treatment team, such as threats of suicide, homicide, use of illegal drugs, or issues of abuse. The first response is not strictly true. The second response will not inspire the confidence of the patient. The fourth response is confrontational.
DIF: Cognitive Level: Application REF: Pages: 100-101
TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment
- A nurse assessing a new patient asks, “What is meant by the saying, ‘You can’t judge a book by its cover’?” Which aspect of cognition is the nurse assessing?
| a. | Mood |
| b. | Attention |
| c. | Orientation |
| d. | Abstraction |
ANS: D
Patient interpretation of proverbial statements gives assessment information regarding the patient’s ability to abstract, which is an aspect of cognition. Mood, orientation, and attention span are assessed in other ways.
DIF: Cognitive Level: Application REF: Pages: 101-103
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity
- When a nurse assesses an older adult patient, answers seem vague or unrelated to the questions. The patient also leans forward and frowns, listening intently to the nurse. An appropriate question for the nurse to ask would be:
| a. | “Are you having difficulty hearing when I speak?” |
| b. | “How can I make this assessment interview easier for you?” |
| c. | “I notice you are frowning. Are you feeling annoyed with me?” |
| d. | “You’re having trouble focusing on what I’m saying. What is distracting you?” |
ANS: A
The patient’s behaviors may indicate difficulty hearing. Identifying any physical need the patient may have at the onset of the interview and making accommodations are important considerations. By asking if the patient is annoyed, the nurse is jumping to conclusions. Asking how to make the interview easier for the patient may not elicit a concrete answer. Asking about distractions is a way of asking about auditory hallucinations, which is not appropriate because the nurse has observed that the patient seems to be listening intently.
DIF: Cognitive Level: Application REF: Pages: 100-101
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
- At what point in an assessment interview would a nurse ask, “How does your faith help you in stressful situations?” During the assessment of:
| a. | childhood growth and development. |
| b. | substance use and abuse. |
| c. | educational background. |
| d. | coping strategies. |
ANS: D
When discussing coping strategies, the nurse might ask what the patient does when upset, what usually relieves stress, and to whom the patient goes to talk about problems. The question regarding whether the patient’s faith helps deal with stress fits well here. It would seem out of place if introduced during exploration of the other topics.
DIF: Cognitive Level: Application REF: Pages: 101-104
TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity
- When a new patient is hospitalized, a nurse takes the patient on a tour, explains the rules of the unit, and discusses the daily schedule. The nurse is engaged in:
| a. | counseling. |
| b. | health teaching. |
| c. | milieu management. |
| d. | psychobiologic intervention. |
ANS: C
Milieu management provides a therapeutic environment in which the patient can feel comfortable and safe while engaging in activities that meet the patient’s physical and mental health needs. Counseling refers to activities designed to promote problem solving and enhanced coping and includes interviewing, crisis intervention, stress management, and conflict resolution. Health teaching involves identifying health educational needs and giving information about these needs. Psychobiologic interventions involve medication administration and monitoring response to medications.
DIF: Cognitive Level: Comprehension REF: Page: 109
TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment
- After formulating the nursing diagnoses for a new patient, what is the next action a nurse should take?
| a. | Design interventions to include in the plan of care. |
| b. | Determine the goals and outcome criteria. |
| c. | Implement the nursing plan of care. |
| d. | Complete the spiritual assessment. |
ANS: B
The third step of the nursing process is planning and outcome identification. Outcomes cannot be determined until the nursing assessment is complete and the nursing diagnoses have been formulated.
DIF: Cognitive Level: Comprehension REF: Pages: 105-106
TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment
- Select the most appropriate label to complete this nursing diagnosis: ___________, related to feelings of shyness and poorly developed social skills as evidenced by watching television alone at home every evening.
| a. | Deficient knowledge |
| b. | Ineffective coping |
| c. | Powerlessness |
| d. | Social isolation |
ANS: D
Nursing diagnoses are selected on the basis of the etiologic factors and assessment findings or evidence. In this instance, the evidence shows social isolation that is caused by shyness and poorly developed social skills.
DIF: Cognitive Level: Application REF: Pages: 105-106
TOP: Nursing Process: Diagnosis| Nursing Process: Analysis
MSC: NCLEX: Psychosocial Integrity
- The acronym QSEN refers to:
| a. | Qualitative Standardized Excellence in Nursing. |
| b. | Quality and Safety Education for Nurses. |
| c. | Quantitative Effectiveness in Nursing. |
| d. | Quick Standards Essential for Nurses. |
ANS: B
QSEN represents national initiatives centered on patient safety and quality. The primary goal of QSEN is to prepare future nurses with the knowledge, skills, and attitudes to increase the quality, care, and safety in the health care setting in which they work.
DIF: Cognitive Level: Knowledge REF: Pages: 97-98 TOP: Nursing Process: N/A
MSC: NCLEX: Safe, Effective Care Environment
- A nurse documents: “Patient is mute, despite repeated efforts to elicit speech. Makes no eye contact. Is inattentive to staff. Gazes off to the side or looks upward rather than at the speaker.” Which nursing diagnosis should be considered?
| a. | Defensive coping |
| b. | Decisional conflict |
| c. | Risk for other-directed violence |
| d. | Impaired verbal communication |
ANS: D
The defining characteristics are more related to the nursing diagnosis of Impaired verbal communication than to the other nursing diagnoses.
DIF: Cognitive Level: Application REF: Pages: 105-106
TOP: Nursing Process: Diagnosis| Nursing Process: Analysis
MSC: NCLEX: Psychosocial Integrity
MULTIPLE RESPONSE
- A nurse assesses a patient who reluctantly participates in activities, answers questions with minimal responses, and rarely makes eye contact. What information should be included when documenting the assessment? Select all that apply.
| a. | Uncooperative patient |
| b. | Patient’s subjective responses |
| c. | Only data obtained from the patient’s verbal responses |
| d. | Description of the patient’s behavior during the interview |
| e. | Analysis of why the patient is unresponsive during the interview |
ANS: B, D
Both the content and process of the interview should be documented. Providing only the patient’s verbal responses creates a skewed picture of the patient. Writing that the patient is uncooperative is subjectively worded. An objective description of patient behavior is preferable. Analysis of the reasons for the patient’s behavior is speculation, which is inappropriate.
DIF: Cognitive Level: Application REF: Pages: 98-99|Page: 110
TOP: Nursing Process: Assessment MSC: NCLEX: Safe, Effective Care Environment
- A nurse performing an assessment interview for a patient with a substance use disorder decides to use a standardized rating scale. Which scales are appropriate? Select all that apply.
| a. | Addiction Severity Index (ASI) |
| b. | Brief Drug Abuse Screen Test (B-DAST) |
| c. | Abnormal Involuntary Movement Scale (AIMS) |
| d. | Cognitive Capacity Screening Examination (CCSE) |
| e. | Recovery Attitude and Treatment Evaluator (RAATE) |
ANS: A, B, E
Standardized scales are useful for obtaining data concerning substance use disorders. The ASI, B-DAST, and RAATE are scales related to substance abuse. The AIMS assesses involuntary movements associated with antipsychotic medications. The CCSE assesses cognitive function.
DIF: Cognitive Level: Application REF: Page: 106
TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity
- What information is conveyed by nursing diagnoses? Select all that apply.
| a. | Medical judgments about the disorder |
| b. | Goals and outcomes for the plan of care |
| c. | Unmet patient needs currently present |
| d. | Supporting data that validate the diagnoses |
| e. | Probable causes that will be targets for nursing interventions |
ANS: C, D, E
Nursing diagnoses focus on phenomena of concern to nurses rather than on medical diagnoses.
DIF: Cognitive Level: Comprehension REF: Pages: 105-106
TOP: Nursing Process: Diagnosis| Nursing Process: Analysis
MSC: NCLEX: Safe, Effective Care Environment
- A patient is very suspicious and states, “The FBI has me under surveillance.” Which strategies should a nurse use when gathering initial assessment data about this patient? Select all that apply.
| a. | Tell the patient that medication will help this type of thinking. |
| b. | Ask the patient, “Tell me about the problem as you see it.” |
| c. | Seek information about when the problem began. |
| d. | Tell the patient, “Your ideas are not realistic.” |
| e. | Reassure the patient, “You are safe here.” |
ANS: B, C, E
During the assessment interview, the nurse should listen attentively and accept the patient’s statements in a nonjudgmental way. Because the patient is suspicious and fearful, reassuring safety may be helpful, although trust is unlikely so early in the relationship. Saying that medication will help or telling the patient that the ideas are not realistic will undermine the development of trust between the nurse and patient.
DIF: Cognitive Level: Application REF: Pages: 98-99|Pages: 103-105
TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity
Chapter 11: Anxiety, Anxiety Disorders, and Obsessive-Compulsive Disorders
Test Bank
MULTIPLE CHOICE
- A nurse wishes to teach alternative coping strategies to a patient who is experiencing severe anxiety. The nurse will first need to:
| a. | Lower the patient’s current anxiety level. |
| b. | Verify the patient’s learning style. |
| c. | Create outcomes and a teaching plan. |
| d. | Assess how the patient uses defense mechanisms. |
ANS: A
A patient experiencing severe anxiety has a significantly narrowed perceptual field and difficulty attending to events in the environment. A patient experiencing severe anxiety will not learn readily. Determining preferred modes of learning, devising outcomes, and constructing teaching plans are relevant to the task but are not the priority measure. The nurse has already assessed the patient’s anxiety level. Using defense mechanisms does not apply.
DIF: Cognitive Level: Analysis REF: Pages: 167-168
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
- A patient approaches the nurse and impatiently blurts out, “You’ve got to help me! Something terrible is happening. My heart is pounding.” The nurse responds, “It’s almost time for visiting hours. Let’s get your hair combed.” Which approach has the nurse used?
| a. | Distracting technique to lower anxiety |
| b. | Bringing up an irrelevant topic |
| c. | Responding to physical needs |
| d. | Addressing false cognitions |
ANS: B
The nurse has closed off patient-centered communication. The introduction of an irrelevant topic makes the nurse feel better. The nurse is uncomfortable dealing with the patient’s severe anxiety.
DIF: Cognitive Level: Application REF: Page: 167
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity
- A patient who is experiencing moderate anxiety says, “I feel undone.” An appropriate response for the nurse would be:
| a. | “Why do you suppose you are feeling anxious?” |
| b. | “What would you like me to do to help you?” |
| c. | “I’m not sure I understand. Give me an example.” |
| d. | “You must get your feelings under control before we can continue.” |
ANS: C
Increased anxiety results in scattered thoughts and an inability to articulate clearly. Clarification helps the patient identify his or her thoughts and feelings. Asking the patient why he or she feels anxious is nontherapeutic, and the patient will not likely have an answer. The patient may be unable to determine what he or she would like the nurse to do to help. Telling the patient to get his or her feelings under control is a directive the patient is probably unable to accomplish.
DIF: Cognitive Level: Application REF: Page: 167
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity
- A patient with a high level of motor activity runs from chair to chair and cries, “They’re coming! They’re coming!” The patient does not follow the staff’s directions or respond to verbal interventions. The initial nursing intervention of highest priority is to:
| a. | provide for patient safety. |
| b. | increase environmental stimuli. |
| c. | respect the patient’s personal space. |
| d. | encourage the clarification of feelings. |
ANS: A
Safety is of highest priority; the patient who is experiencing panic is at high risk for self-injury related to an increase in non–goal-directed motor activity, distorted perceptions, and disordered thoughts. The goal should be to decrease the environmental stimuli. Respecting the patient’s personal space is a lower priority than safety. The clarification of feelings cannot take place until the level of anxiety is lowered.
DIF: Cognitive Level: Analysis REF: Pages: 167-168
TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment
- A patient with a high level of motor activity runs from chair to chair and cries, “They’re coming! They’re coming!” The patient is unable to follow staff direction or respond to verbal interventions. Which nursing diagnosis has the highest priority?
| a. | Risk for injury |
| b. | Self-care deficit |
| c. | Disturbed energy field |
| d. | Disturbed thought processes |
ANS: A
A patient who is experiencing panic-level anxiety is at high risk for injury, related to an increase in non–goal-directed motor activity, distorted perceptions, and disordered thoughts. Existing data do not support the nursing diagnoses of Self-care deficit or Disturbed energy field. This patient has disturbed thought processes, but the risk for injury has a higher priority.
DIF: Cognitive Level: Analysis REF: Page: 179
TOP: Nursing Process: Diagnosis| Nursing Process: Analysis
MSC: NCLEX: Safe, Effective Care Environment
- A supervisor assigns a worker a new project. The worker initially agrees but feels resentful. The next day when asked about the project, the worker says, “I’ve been working on other things.” When asked 4 hours later, the worker says, “Someone else was using the copier, so I couldn’t finish it.” The worker’s behavior demonstrates:
| a. | acting out. |
| b. | projection. |
| c. | rationalization. |
| d. | passive aggression. |
ANS: D
A passive-aggressive person deals with emotional conflict by indirectly expressing aggression toward others. Compliance on the surface masks covert resistance. Resistance is expressed through procrastination, inefficiency, and stubbornness in response to assigned tasks.
DIF: Cognitive Level: Application REF: Pages: 170-171
TOP: Nursing Process: Assessment MSC: NCLEX: Safe, Effective Care Environment
- A patient is undergoing diagnostic tests. The patient says, “Nothing is wrong with me except a stubborn chest cold.” The spouse reports that the patient smokes, coughs daily, has lost 15 pounds, and is easily fatigued. Which defense mechanism is the patient using?
| a. | Displacement |
| b. | Regression |
| c. | Projection |
| d. | Denial |
ANS: D
Denial is an unconscious blocking of threatening or painful information or feelings. Regression involves using behaviors appropriate at an earlier stage of psychosexual development. Displacement shifts feelings to a more neutral person or object. Projection attributes one’s own unacceptable thoughts or feelings to another.
DIF: Cognitive Level: Application REF: Pages: 171-172
TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity
- A patient with a mass in the left upper lobe of the lung is scheduled for a biopsy. The patient has difficulty understanding the nurse’s comments and asks, “What do you mean? What are they going to do?” Assessment findings include a tremulous voice, respirations at 28 breaths per minute, and a pulse rate at 110 beats per minute. What is the patient’s level of anxiety?
| a. | Mild |
| b. | Moderate |
| c. | Severe |
| d. | Panic |
ANS: B
Moderate anxiety causes the individual to grasp less information and reduces his or her problem-solving ability to a less-than-optimal level. Mild anxiety heightens attention and enhances problem-solving abilities. Severe anxiety causes great reduction in the perceptual field. Panic-level anxiety results in disorganized behavior.
DIF: Cognitive Level: Application REF: Pages: 165-167
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
- A patient who is preparing for surgery has moderate anxiety and is unable to understand preoperative information. Which nursing intervention is appropriate?
| a. | Reassure the patient that all nurses are skilled in providing postoperative care. |
| b. | Describe the procedure again in a calm manner using simple language. |
| c. | Tell the patient that the staff is prepared to promote recovery. |
| d. | Encourage the patient to express feelings to his or her family. |
ANS: B
Providing information in a calm, simple manner helps the patient grasp the important facts. Introducing extraneous topics as described in the remaining options will further scatter the patient’s attention.
DIF: Cognitive Level: Application REF: Pages: 167-168|Pages: 178-179
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity
- A nurse encourages an anxious patient to talk about feelings and concerns. What is the rationale for this intervention?
| a. | Offering hope allays and defuses the patient’s anxiety. |
| b. | Concerns stated aloud become less overwhelming and help problem solving to begin. |
| c. | Anxiety is reduced by focusing on and validating what is occurring in the environment. |
| d. | Encouraging patients to explore alternatives increases the sense of control and lessens anxiety. |
ANS: B
All principles listed are valid, but the only rationale directly related to the intervention of assisting the patient to talk about feelings and concerns is the one that states that concerns spoken aloud become less overwhelming and help problem solving to begin.
DIF: Cognitive Level: Application REF: Page: 168
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity
- Which assessment question would be most appropriate to ask a patient who has possible generalized anxiety disorder?
| a. | “Have you been a victim of a crime or seen someone badly injured or killed?” |
| b. | “Do you feel especially uncomfortable in social situations involving people?” |
| c. | “Do you repeatedly do certain things over and over again?” |
| d. | “Do you find it difficult to control your worrying?” |
ANS: D
Patients with generalized anxiety disorder frequently engage in excessive worrying. They are less likely to engage in ritualistic behavior, fear social situations, or have been involved in a highly traumatic event.
DIF: Cognitive Level: Analysis REF: Pages: 176-177|Pages: 182-183
TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity
- A patient in the emergency department exhibits disorganized behavior and incoherence after a friend suggested a homosexual encounter. In which room should the nurse place the patient?
| a. | Interview room furnished with a desk and two chairs |
| b. | Small, empty storage room with no windows or furniture |
| c. | Room with an examining table, instrument cabinets, desk, and chair |
| d. | Nurse’s office, furnished with chairs, files, magazines, and bookcases |
ANS: A
Individuals who are experiencing a severe-to-panic level of anxiety require a safe environment that is quiet, nonstimulating, structured, and simple. A room with a desk and two chairs provides simplicity, few objects with which the patient could cause self-harm, and a small floor space around which the patient can move. A small, empty storage room without windows or furniture would be like a jail cell. The nurse’s office or a room with an examining table and instrument cabinets may be overstimulating and unsafe.
DIF: Cognitive Level: Application REF: Page: 169
TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment
- A person has minor physical injuries after an automobile accident. The person is unable to focus and says, “I feel like something awful is going to happen.” This person has nausea, dizziness, tachycardia, and hyperventilation. What is this person’s level of anxiety?
| a. | Mild |
| b. | Moderate |
| c. | Severe |
| d. | Panic |
ANS: C
The person whose anxiety is severe is unable to solve problems and may have a poor grasp of what is happening in the environment. Somatic symptoms such as those described are usually present. The individual with mild anxiety is only mildly uncomfortable and may even find his or her performance enhanced. The individual with moderate anxiety grasps less information about a situation and has some difficulty with problem solving. The individual in a panic level of anxiety demonstrates significantly disturbed behavior and may lose touch with reality.
DIF: Cognitive Level: Application REF: Pages: 166-167
TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity
- Two staff nurses applied for a charge nurse position. After the promotion was announced, the nurse who was not promoted said, “The nurse manager had a headache the day I was interviewed.” Which defense mechanism is evident?
| a. | Introjection |
| b. | Conversion |
| c. | Projection |
| d. | Splitting |
ANS: C
Projection is the hallmark of blaming, scapegoating, thinking prejudicially, and stigmatizing others. Conversion involves the unconscious transformation of anxiety into a physical symptom. Introjection involves intense, unconscious identification with another person. Splitting is the inability to integrate the positive and negative qualities of oneself or others into a cohesive image.
DIF: Cognitive Level: Application REF: Pages: 171-172
TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity
- A patient tells a nurse, “My new friend is the most perfect person one could imagine—kind, considerate, and good looking. I can’t find a single flaw.” This patient is demonstrating:
| a. | denial. |
| b. | projection. |
| c. | idealization. |
| d. | compensation. |
ANS: C
Idealization is an unconscious process that occurs when an individual attributes exaggerated positive qualities to another. Denial is an unconscious process that calls for the nurse to ignore the existence of the situation. Projection operates unconsciously and results in blaming behavior. Compensation results in the nurse unconsciously attempting to make up for a perceived weakness by emphasizing a strong point.
DIF: Cognitive Level: Application REF: Pages: 171-172
TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity
- A patient experiences an episode of severe anxiety. Of these medications in the patient’s medical record, which is most appropriate to administer as an as-needed (prn) anxiolytic medication?
| a. | buspirone (BuSpar) |
| b. | lorazepam (Ativan) |
| c. | amitriptyline (Elavil) |
| d. | desipramine (Norpramin) |
ANS: B
Lorazepam is a benzodiazepine medication used to treat anxiety; it may be administered as needed. Buspirone is long acting and not useful as an as-needed drug. Amitriptyline and desipramine are tricyclic antidepressants and considered second- or third-line agents.
DIF: Cognitive Level: Application REF: Pages: 184-185
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
- Two staff nurses applied for promotion to nurse manager. The nurse not promoted initially had feelings of loss but then became supportive of the new manager by helping make the transition smooth and encouraging others. Which term best describes the nurse’s response?
| a. | Altruism |
| b. | Sublimation |
| c. | Suppression |
| d. | Passive aggression |
ANS: A
Altruism is the mechanism by which an individual deals with emotional conflict by meeting the needs of others and vicariously receiving gratification from the responses of others. The nurse’s reaction is conscious, not unconscious. No evidence of aggression is exhibited, and no evidence of conscious denial of the situation exists. Passive aggression occurs when an individual deals with emotional conflict by indirectly and unassertively expressing aggression toward others.
DIF: Cognitive Level: Application REF: Pages: 168-169
TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity
- A person who feels unattractive repeatedly says, “Although I’m not beautiful, I am smart.” This is an example of:
| a. | Repression |
| b. | Devaluation |
| c. | Identification |
| d. | Compensation |
ANS: D
Compensation is an unconscious process that allows an individual to make up for deficits in one area by excelling in another area to raise self-esteem. Repression unconsciously puts an idea, event, or feeling out of awareness. Identification is an unconscious mechanism calling for an imitation of the mannerisms or behaviors of another. Devaluation occurs when the individual attributes negative qualities to self or to others.
DIF: Cognitive Level: Application REF: Page: 172
TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity
- A person who is speaking about a rival for a significant other’s affection says in a gushy, syrupy voice, “What a lovely person. That’s someone I simply adore.” The individual is demonstrating:
| a. | Reaction formation |
| b. | Repression |
| c. | Projection |
| d. | Denial |
ANS: A
Reaction formation is an unconscious mechanism that keeps unacceptable feelings out of awareness by using the opposite behavior. Instead of expressing hatred for the other person, the individual gives praise. Denial operates unconsciously to allow an anxiety-producing idea, feeling, or situation to be ignored. Projection involves unconsciously disowning an unacceptable idea, feeling, or behavior by attributing it to another. Repression involves unconsciously placing an idea, feeling, or event out of awareness.
DIF: Cognitive Level: Application REF: Pages: 169-170|Page: 172|Page: 176
TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity
- An individual experiences sexual dysfunction and blames it on a partner by calling the person unattractive and unromantic. Which defense mechanism is evident?
| a. | Rationalization |
| b. | Compensation |
| c. | Introjection |
| d. | Regression |
ANS: A
Rationalization involves unconsciously making excuses for one’s behavior, inadequacies, or feelings. Regression involves the unconscious use of a behavior from an earlier stage of emotional development. Compensation involves making up for deficits in one area by excelling in another area. Introjection is an unconscious, intense identification with another person.
DIF: Cognitive Level: Application REF: Pages: 170-172
TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity
- A student says, “Before taking a test, I feel a heightened sense of awareness and restlessness.” The nurse can correctly assess the student’s experience as:
| a. | Culturally influenced |
| b. | Displacement |
| c. | Trait anxiety |
| d. | Mild anxiety |
ANS: D
Mild anxiety is rarely obstructive to the task at hand. It may be helpful to the patient because it promotes study and increases awareness of the nuances of questions. The incorrect responses have different symptoms.
DIF: Cognitive Level: Application REF: Pages: 165-166
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
- A student says, “Before taking a test, I feel a heightened sense of awareness and restlessness.” The nursing intervention most suitable for assisting the student is to:
| a. | Explain that the symptoms are the result of mild anxiety, and discuss the helpful aspects. |
| b. | Advise the student to discuss this experience with a health care provider. |
| c. | Encourage the student to begin antioxidant vitamin supplements. |
| d. | Listen without comment. |
ANS: A
Teaching about the symptoms of anxiety, their relation to precipitating stressors, and, in this case, the positive effects of anxiety serves to reassure the patient. Advising the patient to discuss the experience with a health care provider implies that the patient has a serious problem. Listening without comment will do no harm but deprives the patient of health teaching. Antioxidant vitamin supplements are not useful in this scenario.
DIF: Cognitive Level: Application REF: Pages: 165-168
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity
- If a cruel and abusive person rationalizes this behavior, which comment is most characteristic of this person?
| a. | “I don’t know why it happens.” |
| b. | “I have poor impulse control.” |
| c. | “That person shouldn’t have provoked me.” |
| d. | “I’m really a coward who is afraid of being hurt.” |
ANS: C
Rationalization consists of justifying one’s unacceptable behavior by developing explanations that satisfy the teller and attempt to satisfy the listener. The abuser is suggesting that the abuse is not his or her fault; it would not have occurred except for the provocation by the other person.
DIF: Cognitive Level: Application REF: Pages: 170-172
TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity
- A patient with severe anxiety suddenly begins running and shouting, “I’m going to explode!” The nurse should:
| a. | Ask, “I’m not sure what you mean. Give me an example.” |
| b. | Chase after the patient, and give instructions to stop running. |
| c. | Capture the patient in a basket-hold to increase feelings of control. |
| d. | Assemble several staff members and state, “We will help you regain control.” |
ANS: D
The safety needs of the patient and other patients are a priority. The patient is less likely to cause self-harm or hurt others when several staff members take responsibility for providing limits. The explanation given to the patient should be simple and neutral. Simply being told that others can help provide the control that has been lost may be sufficient to help the patient regain control. Running after the patient will increase the patient’s anxiety. More than one staff member is needed to provide physical limits if they become necessary. Asking the patient to give an example is futile; a patient in panic processes information poorly.
DIF: Cognitive Level: Application REF: Pages: 167-169
TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment
- A person who has been unable to leave home for more than a week because of severe anxiety says, “I know it does not make sense, but I just can’t bring myself to leave my apartment alone.” Which nursing intervention is appropriate?
| a. | Teach the person to use positive self-talk. |
| b. | Assist the person to apply for disability benefits. |
| c. | Ask the person to explain why the fear is so disabling. |
| d. | Advise the person to accept the situation and use a companion. |
ANS: A
This intervention, a form of cognitive restructuring, replaces negative thoughts such as “I can’t leave my apartment” with positive thoughts such as “I can control my anxiety.” This technique helps the patient gain mastery over the symptoms. The other options reinforce the sick role.
DIF: Cognitive Level: Application REF: Page: 183
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity
- Which comment by a person who is experiencing severe anxiety indicates the possibility of obsessive-compulsive disorder?
| a. | “I check where my car keys are eight times.” |
| b. | “My legs often feel weak and spastic.” |
| c. | “I’m embarrassed to go out in public.” |
| d. | “I keep reliving the car accident.” |
ANS: A
Recurring doubt (obsessive thinking) and the need to check (compulsive behavior) suggest obsessive-compulsive disorder. The repetitive behavior is designed to decrease anxiety but fails and must be repeated. The statement, “My legs feel weak most of the time,” is more in keeping with a somatoform disorder. Being embarrassed to go out in public is associated with an avoidant personality disorder. Reliving a traumatic event is associated with posttraumatic stress disorder.
DIF: Cognitive Level: Application REF: Pages: 176-177
TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity
- When alprazolam (Xanax) is prescribed for acute anxiety, health teaching should include instructions to:
| a. | Report drowsiness. |
| b. | Eat a tyramine-free diet. |
| c. | Avoid alcoholic beverages. |
| d. | Adjust dose and frequency based on anxiety level. |
ANS: C
Drinking alcohol or taking other anxiolytic medications along with the prescribed benzodiazepine should be avoided because depressant effects of both drugs will be potentiated. Tyramine-free diets are necessary only with monoamine oxidase inhibitors (MAOIs). Drowsiness is an expected effect and needs to be reported only if it is excessive. Patients should be taught not to deviate from the prescribed dose and schedule for administration.
DIF: Cognitive Level: Application REF: Page: 187 TOP: Nursing Process: Planning
MSC: NCLEX: Physiological Integrity
- Which statement is mostly likely to be made by a patient with agoraphobia?
| a. | “Being afraid to go out seems ridiculous, but I can’t go out the door.” |
| b. | “I’m sure I’ll get over not wanting to leave home soon. It takes time.” |
| c. | “When I have a good incentive to go out, I can do it.” |
| d. | “My family says they like it now that I stay home.” |
ANS: A
Individuals who are agoraphobic generally acknowledge that the behavior is not constructive and that they do not really like it. Patients state they are unable to change the behavior. Patients with agoraphobia are not optimistic about change. Most families are dissatisfied when family members refuse to leave the house.
DIF: Cognitive Level: Analysis REF: Pages: 175-176
TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity
- A patient has the nursing diagnosis: Anxiety, related to __________, as evidenced by an inability to control compulsive cleaning. Which phrase correctly completes the etiologic portion of the diagnosis?
| a. | Ensuring the health of household members |
| b. | Attempting to avoid interactions with others |
| c. | Having persistent thoughts about bacteria, germs, and dirt |
| d. | Needing approval for cleanliness from friends and family |
ANS: C
Many compulsive rituals accompany obsessive thoughts. The patient uses these rituals to relief anxiety. Unfortunately, the anxiety relief is short lived, and the patient must frequently repeat the ritual. The other options are unrelated to the dynamics of compulsive behavior.
DIF: Cognitive Level: Analysis REF: Pages: 176-177
TOP: Nursing Process: Diagnosis| Nursing Process: Analysis
MSC: NCLEX: Psychosocial Integrity
- A patient performs ritualistic hand washing. What should the nurse do to help the patient develop more effective coping strategies?
| a. | Allow the patient to set a hand-washing schedule. |
| b. | Encourage the patient to participate in social activities. |
| c. | Encourage the patient to discuss hand-washing routines. |
| d. | Focus on the patient’s symptoms rather than on the patient. |
ANS: B
Because patients with obsessive-compulsive disorder become overly involved in rituals, promoting involvement with other people and activities is necessary to improve the patient’s coping strategies. Daily activities prevent the constant focus on anxiety and its symptoms. The other interventions focus on the compulsive symptom.
DIF: Cognitive Level: Analysis REF: Pages: 176-177
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity
- For a patient experiencing panic, which nursing intervention should be first?
| a. | Teach relaxation techniques. |
| b. | Administer an anxiolytic medication. |
| c. | Provide calm, brief, directive communication. |
| d. | Gather a show of force in preparation for gaining physical control. |
ANS: C
Calm, brief, directive verbal interaction can help the patient gain control of the overwhelming feelings and impulses related to anxiety. Patients experiencing panic-level anxiety are unable to focus on reality; thus learning relaxation techniques is virtually impossible. Administering an anxiolytic medication should be considered if providing calm, brief, directive communication is ineffective. Although the patient is disorganized, violence may not be imminent, ruling out the intervention of preparing for physical control until other less-restrictive measures are proven ineffective.
DIF: Cognitive Level: Application REF: Page: 169
TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment
- Which finding indicates that a patient with moderate-to-severe anxiety has successfully lowered the anxiety level to mild? The patient:
| a. | Asks, “What’s the matter with me?” |
| b. | Stays in a room alone and paces rapidly. |
| c. | Can concentrate on what the nurse is saying. |
| d. | States, “I don’t want anything to eat. My stomach is upset.” |
ANS: C
The ability to concentrate and attend to reality is increased slightly in mild anxiety and decreased in moderate-, severe-, and panic-level anxiety. Patients with high levels of anxiety often ask, “What’s the matter with me?” Staying in a room alone and pacing suggest moderate anxiety. Expressing a lack of hunger is not necessarily a criterion for evaluating anxiety.
DIF: Cognitive Level: Application REF: Page: 166 TOP: Nursing Process: Evaluation
MSC: NCLEX: Physiological Integrity
- A patient tells the nurse, “I don’t go to restaurants because people might laugh at the way I eat or I could spill food and be laughed at.” The nurse assesses this behavior as consistent with:
| a. | Acrophobia |
| b. | Agoraphobia |
| c. | Social phobia |
| d. | Posttraumatic stress disorder |
ANS: C
The fear of a potentially embarrassing situation represents a social phobia. Acrophobia is the fear of heights. Agoraphobia is the fear of a place in the environment. Posttraumatic stress disorder is associated with a major traumatic event.
DIF: Cognitive Level: Application REF: Page: 175
TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity
- A patient checks and rechecks electrical cords related to an obsessive thought that the house may burn down. The nurse and patient explore the likelihood of an actual fire. The patient states that a house fire is not likely. This counseling demonstrates the principles of:
| a. | Flooding |
| b. | Desensitization |
| c. | Relaxation technique |
| d. | Cognitive restructuring |
ANS: D
Cognitive restructuring involves the patient in testing automatic thoughts and drawing new conclusions. Desensitization involves a graduated exposure to a feared object. Relaxation training teaches the patient to produce the opposite of the stress response. Flooding exposes the patient to a large amount of undesirable stimuli in an effort to extinguish the anxiety response.
DIF: Cognitive Level: Application REF: Page: 186
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity
- A patient has a fear of public speaking. The nurse should be aware that social phobias are often treated with which type of medication?
| a. | (beta)-blockers. |
| b. | Antipsychotic medications. |
| c. | Tricyclic antidepressant agents. |
| d. | Monoamine oxidase inhibitors. |
ANS: A
Beta-blockers, such as propranolol, are often effective in preventing symptoms of anxiety associated with social phobias. Neuroleptic medications are major tranquilizers and not useful in treating social phobias. Tricyclic antidepressants are rarely used because of their side effect profile. MAOIs are administered for depression and only by individuals who can observe the special diet required.
DIF: Cognitive Level: Comprehension REF: Pages: 173-175|Page: 186
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
- A patient tells the nurse, “I wanted my health care provider to prescribe diazepam (Valium) for my anxiety disorder, but buspirone (BuSpar) was prescribed instead. Why?” The nurse’s reply should be based on the knowledge that buspirone:
| a. | Does not produce blood dyscrasias. |
| b. | Does not cause dependence. |
| c. | Can be administered as needed. |
| d. | Is faster acting than diazepam. |
ANS: B
Buspirone is considered effective in the long-term management of anxiety because it is not habituating. Because it is long acting, buspirone is not valuable as an as-needed or as a fast-acting medication. The fact that buspirone does not produce blood dyscrasias is less relevant in the decision to prescribe buspirone.
DIF: Cognitive Level: Comprehension REF: Page: 185
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
MULTIPLE RESPONSE
- A child is placed in a foster home after being removed from parental contact because of abuse. The child is apprehensive and overreacts to environmental stimuli. The foster parents ask the nurse how to help the child. What should the nurse recommend? Select all that apply.
| a. | Use a calm manner and low voice. |
| b. | Maintain simplicity in the environment. |
| c. | Avoid repetition in what is said to the child. |
| d. | Minimize opportunities for exercise and play. |
| e. | Explain and reinforce reality to avoid distortions. |
ANS: A, B, E
The child can be hypothesized to have moderate-to-severe trait (chronic) anxiety. A calm manner calms the child. A simple, structured, predictable environment is less anxiety provoking and reduces overreaction to stimuli. Calm, simple explanations that reinforce reality validate the environment. Repetition is often needed when the child is unable to concentrate because of elevated levels of anxiety. Opportunities for play and exercise should be provided as avenues to reduce anxiety. Physical movement helps channel and lower anxiety. Play also helps by allowing the child to act out concerns.
DIF: Cognitive Level: Application REF: Page: 168|Pages: 179-183
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity
- A nurse plans health teaching for a patient with generalized anxiety disorder who takes lorazepam (Ativan). What information should be included? Select all that apply.
| a. | Use caution when operating machinery. |
| b. | Allowed tyramine-free foods in diet. |
| c. | Understand the importance of caffeine restriction. |
| d. | Avoid alcohol and other sedatives. |
| e. | Take the medication on an empty stomach. |
ANS: A, C, D
Caffeine is a central nervous system stimulant that acts as an antagonist to the benzodiazepine lorazepam. Daily caffeine intake should be reduced to the amount contained in one cup of coffee. Benzodiazepines are sedatives, thus the importance of exercising caution when driving or using machinery and the importance of not using other central nervous system depressants such as alcohol or sedatives to avoid potentiation. Benzodiazepines do not require a special diet. Food will reduce gastric irritation from the medication.
DIF: Cognitive Level: Application REF: Page: 187 TOP: Nursing Process: Planning
MSC: NCLEX: Physiological Integrity
- Which assessment questions are most appropriate to ask a patient with possible obsessive-compulsive disorder? Select all that apply.
| a. | “Have you been a victim of a crime or seen someone badly injured or killed?” |
| b. | “Are there certain social situations that cause you to feel especially uncomfortable?” |
| c. | “Do you have to do things in a certain way to feel comfortable?” |
| d. | “Is it difficult to keep certain thoughts out of awareness?” |
| e. | “Do you do certain things over and over again?” |
ANS: C, D, E
The correct questions refer to obsessive thinking and compulsive behaviors. The incorrect responses are more pertinent to a patient with suspected posttraumatic stress disorder or with suspected social phobia.
DIF: Cognitive Level: Analysis REF: Pages: 176-177
TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity
