Exam 1 - Psychiatric/Mental Health Nursing practice questions

A patient says to the nurse, "I dreamed I was stoned. When I woke up, I felt emotionally drained, as though I hadn't rested well." Which response should the nurse use to clarify the patient's comment?

a. "It sounds as though you were uncomfortable with the content of your dream."

b. "I understand what you're saying. Bad dreams leave me feeling tired, too."

c. "So you feel as though you did not get enough quality sleep last night?"

d. "Can you give me an example of what you mean by 'stoned'?"

ANS: D

The technique of clarification is therapeutic and helps the nurse examine the meaning of the patient's statement. Asking for a definition of "stoned" directly asks for clarification. Restating that the patient is uncomfortable with the dream's content is parroting, a non-therapeutic technique. The other responses fail to clarify the meaning of the patient's comment.

A patient diagnosed with schizophrenia tells the nurse, "The CIA is monitoring us through the fluorescent lights in this room. Be careful what you say." Which response by the nurse would be most therapeutic?

a. "Let's talk about something other than the CIA."

b. "It sounds like you're concerned about your privacy."

c. "The CIA is prohibited from operating in health care facilities."

d. "You have lost touch with reality, which is a symptom of your illness."

ANS: B

It is important not to challenge the patient's beliefs, even if they are unrealistic. Challenging undermines the patient's trust in the nurse. The nurse should try to understand the underlying feelings or thoughts the patient's message conveys. The correct response uses the therapeutic technique of reflection. The other comments are non-therapeutic. Asking to talk about something other than the concern at hand is changing the subject. Saying that the CIA is prohibited from operating in health care facilities gives false reassurance. Stating that the patient has lost touch with reality is truthful, but uncompassionate.

The patient says, "My marriage is just great. My spouse and I always agree." The nurse observes the patient's foot moving continuously as the patient twirls a shirt button. The conclusion the nurse can draw is that the patient's communication is:

a. clear.

b. mixed.

c. precise.

d. inadequate.

ANS: B

Mixed messages involve the transmission of conflicting or incongruent messages by the speaker. The patient's verbal message that all was well in the relationship was modified by the nonverbal behaviors denoting anxiety. Data are not present to support the choice of the verbal message being clear, explicit, or inadequate.

A nurse interacts with a newly hospitalized patient. Select the nurse's comment that applies the communication technique of "offering self."

a. "I've also had traumatic life experiences. Maybe it would help if I told you about them."

b. "Why do you think you had so much difficulty adjusting to this change in your life?"

c. "I hope you will feel better after getting accustomed to how this unit operates."

d. "I'd like to sit with you for a while to help you get comfortable talking to me."

ANS: D

"Offering self" is a technique that should be used in the orientation phase of the nurse-patient relationship. Sitting with the patient, an example of "offering self," helps to build trust and convey that the nurse cares about the patient. Two incorrect responses are ineffective and non-therapeutic. The other incorrect response is therapeutic but is an example of "offering hope."

Which technique will best communicate to a patient that the nurse is interested in listening?

a. Restating a feeling or thought the patient has expressed.

b. Asking a direct question, such as "Did you feel angry?"

c. Making a judgment about the patient's problem.

d. Saying, "I understand what you're saying."

ANS: A

Restating allows the patient to validate the nurse's understanding of what has been communicated. Restating is an active listening technique. Judgments should be suspended in a nurse-patient relationship. Close-ended questions such as "Did you feel angry?" ask for specific information rather than showing understanding. When the nurse simply states that he or she understands the patient's words, the patient has no way of measuring the understanding.

A patient discloses several concerns and associated feelings. If the nurse wants to seek clarification, which comment would be appropriate?

a. "What are the common elements here?"

b. "Tell me again about your experiences."

c. "Am I correct in understanding that . . ."

d. "Tell me everything from the beginning."

ANS: C

Asking, "Am I correct in understanding that..." permits clarification to ensure that both the nurse and patient share mutual understanding of the communication. Asking about common elements encourages comparison rather than clarification. The remaining responses are implied questions that suggest the nurse was not listening.

A patient tells the nurse, "I don't think I'll ever get out of here." Select the nurse's most therapeutic response.

a. "Don't talk that way. Of course you will leave here!"

b. "Keep up the good work, and you certainly will."

c. "You don't think you're making progress?"

d. "Everyone feels that way sometimes."

ANS: C

By asking if the patient does not believe that progress has been made, the nurse is reflecting by putting into words what the patient is hinting. By making communication more explicit, issues are easier to identify and resolve. The remaining options are non-therapeutic techniques. Telling the patient not to "talk that way" is disapproving. Saying that everyone feels that way at times minimizes feelings. Telling the patient that good work will always result in success is falsely reassuring.

Documentation in a patient's chart shows, "Throughout a 5-minute interaction, patient fidgeted and tapped left foot, periodically covered face with hands, and looked under chair while stating, 'I enjoy spending time with you.'" Which analysis is most accurate?

a. The patient is giving positive feedback about the nurse's communication techniques.

b. The nurse is viewing the patient's behavior through a cultural filter.

c. The patient's verbal and nonverbal messages are incongruent.

d. The patient is demonstrating psychotic behaviors.

ANS: C

When a verbal message is not reinforced with nonverbal behavior, the message is confusing and incongruent. Some clinicians call it a "mixed message." It is inaccurate to say that the patient is giving positive feedback about the nurse's communication techniques. The concept of a cultural filter is not relevant to the situation because a cultural filter determines what we will pay attention to and what we will ignore. Data are insufficient to draw the conclusion that the patient is demonstrating psychotic behaviors.

While talking with a patient diagnosed with major depression, a nurse notices the patient is unable to maintain eye contact. The patient's chin lowers to the chest, while the patient looks at the floor. Which aspect of communication has the nurse assessed?

a. Nonverbal communication

b. A message filter

c. A cultural barrier

d. Social skills

ANS: A

Eye contact and body movements are considered nonverbal communication. There are insufficient data to determine the level of the patient's social skills or whether a cultural barrier exists.

During the first interview with a parent whose child died in a car accident, the nurse feels empathic and reaches out to take the patient's hand. Select the correct analysis of the nurse's behavior.

a. It shows empathy and compassion. It will encourage the patient to continue to express feelings.

b. The gesture is premature. The patient's cultural and individual interpretation of touch is unknown.

c. The patient will perceive the gesture as intrusive and overstepping boundaries.

d. The action is inappropriate. Psychiatric patients should not be touched.

ANS: B

Touch has various cultural and individual interpretations. Nurses should refrain from using touch until an assessment can be made regarding the way in which the patient will perceive touch. The other options present prematurely drawn conclusions.

During a one-on-one interaction with the nurse, a patient frequently looks nervously at the door. Select the best comment by the nurse regarding this nonverbal communication.

a. "I notice you keep looking toward the door."

b. "This is our time together. No one is going to interrupt us."

c. "It looks as if you are eager to end our discussion for today."

d. "If you are uncomfortable in this room, we can move someplace else."

ANS: A

Making observations and encouraging the patient to describe perceptions are useful therapeutic communication techniques for this situation. The other responses are assumptions made by the nurse.

A black patient says to a white nurse, "There's no sense talking. You wouldn't understand because you live in a white world." The nurse's best action would be to:

a. explain, "Yes, I do understand. Everyone goes through the same experiences."

b. say, "Please give an example of something you think I wouldn't understand."

c. reassure the patient that nurses interact with people from all cultures.

d. change the subject to one that is less emotionally disturbing.

ANS: B

Having the patient speak in specifics rather than globally will help the nurse understand the patient's perspective. This approach will help the nurse engage the patient. Reassurance and changing the subject are not therapeutic techniques.

A Filipino American patient had a nursing diagnosis of situational low self-esteem related to poor social skills as evidenced by lack of eye contact. Interventions were used to raise the patient's self-esteem, but after 3 weeks, the patient's eye contact did not improve. What is the most accurate analysis of this scenario?

a. The patient's eye contact should have been directly addressed by role-playing to increase comfort with eye contact.

b. The nurse should not have independently embarked on assessment, diagnosis, and planning for this patient.

c. The patient's poor eye contact is indicative of anger and hostility that were unaddressed.

d. The nurse should have assessed the patient's culture before making this diagnosis and plan.

ANS: D

The amount of eye contact a person engages in is often culturally determined. In some cultures, eye contact is considered insolent, whereas in others eye contact is expected. Asian Americans, including persons from the Philippines, often prefer not to engage in direct eye contact.

When a female Mexican American patient and a female nurse sit together, the patient often holds the nurse's hand. The patient also links arms with the nurse when they walk. The nurse is uncomfortable with this behavior. Which analysis is most accurate?

a. The patient is accustomed to touch during conversation, as are members of many Hispanic subcultures.

b. The patient understands that touch makes the nurse uncomfortable and controls the relationship based on that factor.

c. The patient is afraid of being alone. When touching the nurse, the patient is reassured and comforted.

d. The patient is trying to manipulate the nurse using nonverbal techniques.

ANS: A

The most likely answer is that the patient's behavior is culturally influenced. Hispanic women frequently touch women they consider to be their friends. Although the other options are possible, they are less likely.

A Puerto Rican American patient uses dramatic body language when describing emotional discomfort. Which analysis most likely explains the patient's behavior? The patient:

a. has a histrionic personality disorder.

b. believes dramatic body language is sexually appealing.

c. wishes to impress staff with the degree of emotional pain.

d. belongs to a culture in which dramatic body language is the norm.

ANS: D

Members of Hispanic American subcultures tend to use high affect and dramatic body language as they communicate. The other options are more remote possibilities.

During an interview, a patient attempts to shift the focus from self to the nurse by asking personal questions. The nurse should respond by saying:

a. "Why do you keep asking about me?"

b. "Nurses direct the interviews with patients."

c. "Do not ask questions about my personal life."

d. "The time we spend together is to discuss your concerns."

ANS: D

When a patient tries to focus on the nurse, the nurse should refocus the discussion back onto the patient. Telling the patient that interview time should be used to discuss patient concerns refocuses discussion in a neutral way. Telling patients not to ask about the nurse's personal life shows indignation. Saying that nurses prefer to direct the interview reflects superiority. "Why" questions are probing and non-therapeutic.

Which principle should guide the nurse in determining the extent of silence to use during patient interview sessions?

a. A nurse is responsible for breaking silences.

b. Patients withdraw if silences are prolonged.

c. Silence can provide meaningful moments for reflection.

d. Silence helps patients know that what they said was understood.

ANS: C

Silence can be helpful to both participants by giving each an opportunity to contemplate what has transpired, weigh alternatives, and formulate ideas. A nurse breaking silences is not a principle related to silences. It is inaccurate to say that patients withdraw during long silences or that silence helps patients know that they are understood. Feedback helps patients know they have been understood.

A patient is having difficulty making a decision. The nurse has mixed feelings about whether to provide advice. Which principle usually applies? Giving advice:

a. is rarely helpful.

b. fosters independence.

c. lifts the burden of personal decision making.

d. helps the patient develop feelings of personal adequacy.

ANS: A

Giving advice fosters dependence on the nurse and interferes with the patient's right to make personal decisions. It robs patients of the opportunity to weigh alternatives and develop problem-solving skills. Furthermore, it contributes to patient feelings of personal inadequacy. It also keeps the nurse in control and feeling powerful.

A school age child tells the school nurse, "Other kids call me mean names and will not sit with me at lunch. Nobody likes me." Select the nurse's most therapeutic response.

a. "Just ignore them and they will leave you alone."

b. "You should make friends with other children."

c. "Call them names if they do that to you."

d. "Tell me more about how you feel."

ANS: D

The correct response uses exploring, a therapeutic technique. The distracters give advice, a non-therapeutic technique.

A patient with acute depression states, "God is punishing me for my past sins." What is the nurse's most therapeutic response?

a. "You sound very upset about this."

b. "God always forgives us for our sins."

c. "Why do you think you are being punished?"

d. "If you feel this way, you should talk to your minister."

ANS: A

The nurse reflects the patient's comment, a therapeutic technique to encourage sharing for perceptions and feelings. The incorrect responses reflect probing, closed-ended comments, and giving advice, all of which are non-therapeutic.

Select all that apply.

A patient cries as the nurse explores the patient's feelings about the death of a close friend. The patient sobs, "I shouldn't be crying like this. It happened a long time ago." Which responses by the nurse facilitate communication?

a. "Why do you think you are so upset?"

b. "I can see that you feel sad about this situation."

c. "The loss of a close friend is very painful for you."

d. "Crying is a way of expressing the hurt you are experiencing."

e. "Let's talk about something else because this subject is upsetting you."

ANS: B, C, D

Reflecting ("I can see that you feel sad," "This is very painful for you") and giving information ("Crying is a way of expressing hurt") are therapeutic techniques. "Why" questions often imply criticism or seem intrusive or judgmental. They are difficult to answer. Changing the subject is a barrier to communication.

Select all that apply.

Which benefits are most associated with use of telehealth technologies?

a. Cost savings for patients

b. Maximize care management

c. Access to services for patients in rural areas

d. Prompt reimbursement by third party payers

e. Rapid development of trusting relationships with patients

ANS: A, B, C

Telehealth has shown it can maximize health and improve disease management skills and confidence with the disease process. Many rural parents have felt disconnected from services; telehealth technologies can solve those problems. Although telehealth's improved health outcomes regularly show cost savings for payers, one significant barrier is the current lack of reimbursement for remote patient monitoring by third party payers. Telehealth technologies have not shown rapid development of trusting relationships.

Select all that apply.

Which comments by a nurse demonstrate use of therapeutic communication techniques?

a. "Why do you think these events have happened to you?"

b. "There are people with problems much worse than yours."

c. "I'm glad you were able to tell me how you felt about your loss."

d. "I noticed your hands trembling when you told me about your accident."

e. "You look very nice today. I'm proud you took more time with your appearance."

ANS: C, D

The correct responses demonstrate use of the therapeutic techniques making an observation and showing empathy. The incorrect responses demonstrate minimizing feelings, probing, and giving approval, which are non-therapeutic techniques.

Select all that apply.

A nurse is interacting with patients in a psychiatric unit. Which statements reflect use of therapeutic communication?

a. "Tell me more about that situation."

b. "Let's talk about something else."

c. "I notice you are pacing a lot."

d. "I'll stay with you a while."

e. "Why did you do that?"

ANS: A, C, D

The correct responses demonstrate use of the therapeutic techniques making an observation and showing empathy. The incorrect responses demonstrate changing the subject and probing, which are non-therapeutic techniques.

A nurse assesses a confused older adult. The nurse experiences sadness and reflects, "The patient is like one of my grandparents...so helpless." Which response is the nurse demonstrating?

a. Transference

b. Countertransference

c. Catastrophic reaction

d. Defensive coping reaction

ANS: B

Countertransference is the nurse's transference or response to a patient that is based on the nurse's unconscious needs, conflicts, problems, or view of the world. See relationship to audience response question.

Which statement shows a nurse has empathy for a patient who made a suicide attempt?

a. "You must have been very upset when you tried to hurt yourself."

b. "It makes me sad to see you going through such a difficult experience."

c. "If you tell me what is troubling you, I can help you solve your problems."

d. "Suicide is a drastic solution to a problem that may not be such a serious matter."

ANS: A

Empathy permits the nurse to see an event from the patient's perspective, understand the patient's feelings, and communicate this to the patient. The incorrect responses are nurse- centered (focusing on the nurse's feelings rather than the patient's), belittling, and sympathetic.

After several therapeutic encounters with a patient who recently attempted suicide, which occurrence should cause the nurse to consider the possibility of countertransference?

a. The patient's reactions toward the nurse seem realistic and appropriate.

b. The patient states, "Talking to you feels like talking to my parents."

c. The nurse feels unusually happy when the patient's mood begins to lift.

d. The nurse develops a trusting relationship with the patient.

ANS: C

Strong positive or negative reactions toward a patient or over-identification with the patient indicate possible countertransference. Nurses must carefully monitor their own feelings and reactions to detect countertransference and then seek supervision. Realistic and appropriate reactions from a patient toward a nurse are desirable. One incorrect response suggests transference. A trusting relationship with the patient is desirable. See relationship to audience response question.

A patient says, "Please don't share information about me with the other people." How should the nurse respond?

a. "I will not share information with your family or friends without your permission, but I share information about you with other staff."

b. "A therapeutic relationship is just between the nurse and the patient. It is up to you to tell others what you want them to know."

c. "It depends on what you choose to tell me. I will be glad to disclose at the end of each session what I will report to others."

d. "I cannot tell anyone about you. It will be as though I am talking about my own problems, and we can help each other by keeping it between us."

ANS: A

A patient has the right to know with whom the nurse will share information and that confidentiality will be protected. Although the relationship is primarily between the nurse and patient, other staff needs to know pertinent data. The other incorrect responses promote incomplete disclosure on the part of the patient, require daily renegotiation of an issue that should be resolved as the nurse-patient contract is established, and suggest mutual problem solving. The relationship must be patient centered. See relationship to audience response question.

A nurse is talking with a patient, and 5 minutes remain in the session. The patient has been silent most of the session. Another patient comes to the door of the room, interrupts, and says to the nurse, "I really need to talk to you." The nurse should:

a. invite the interrupting patient to join in the session with the current patient.

b. say to the interrupting patient, "I am not available to talk with you at the present time."

c. end the unproductive session with the current patient and spend time with the interrupting patient.

d. tell the interrupting patient, "This session is 5 more minutes; then I will talk with you."

ANS: D

When a specific duration for sessions has been set, the nurse must adhere to the schedule. Leaving the first patient would be equivalent to abandonment and would destroy any trust the patient had in the nurse. Adhering to the contract demonstrates that the nurse can be trusted and that the patient and the sessions are important. The incorrect responses preserve the nurse-patient relationship with the silent patient but may seem abrupt to the interrupting patient, abandon the silent patient, or fail to observe the contract with the silent patient.

Termination of a therapeutic nurse-patient relationship has been successful when the nurse:

a. avoids upsetting the patient by shifting focus to other patients before the discharge.

b. gives the patient a personal telephone number and permission to call after discharge.

c. discusses with the patient changes that happened during the relationship and evaluates outcomes.

d. offers to meet the patient for coffee and conversation three times a week after discharge.

ANS: C

Summarizing and evaluating progress help validate the experience for the patient and the nurse and facilitate closure. Termination must be discussed; avoiding discussion by spending little time with the patient promotes feelings of abandonment. Successful termination requires that the relationship be brought to closure without the possibility of dependency-producing ongoing contact.

What is the desirable outcome for the orientation stage of a nurse-patient relationship? The patient will demonstrate behaviors that indicate:

a. self-responsibility and autonomy.

b. a greater sense of independence.

c. rapport and trust with the nurse.

d. resolved transference.

ANS: C

Development of rapport and trust is necessary before the relationship can progress to the working phase. Behaviors indicating a greater sense of independence, self-responsibility, and resolved transference occur in the working phase.

During which phase of the nurse-patient relationship can the nurse anticipate that identified patient issues will be explored and resolved?

a. Preorientation

b. Orientation

c. Working

d. Termination

ANS: C

During the working phase, the nurse strives to assist the patient in making connections among dysfunctional behaviors, thinking, and emotions and offers support while alternative coping behaviors are tried.

At what point in the nurse-patient relationship should a nurse plan to first address termination?

a. During the orientation phase

b. At the end of the working phase

c. Near the beginning of the termination phase

d. When the patient initially brings up the topic

ANS: A

The patient has a right to know the conditions of the nurse-patient relationship. If the relationship is to be time-limited, the patient should be informed of the number of sessions. If it is open-ended, the termination date will not be known at the outset, and the patient should know that the issue will be negotiated at a later date. The nurse is responsible for bringing up the topic of termination early in the relationship, usually during the orientation phase.

A nurse introduces the matter of a contract during the first session with a new patient because contracts:

a. specify what the nurse will do for the patient.

b. spell out the participation and responsibilities of each party.

c. indicate the feeling tone established between the participants.

d. are binding and prevent either party from prematurely ending the relationship.

ANS: B

A contract emphasizes that the nurse works with the patient rather than doing something for the patient. "Working with" is a process that suggests each party is expected to participate and share responsibility for outcomes. Contracts do not, however, stipulate roles or feeling tone, and premature termination is forbidden.

As a nurse escorts a patient being discharged after treatment for major depression, the patient gives the nurse a necklace with a heart pendant and says, "Thank you for helping mend my broken heart." Which is the nurse's best response?

a. "Accepting gifts violates the policies and procedures of the facility."

b. "I'm glad you feel so much better now. Thank you for the beautiful necklace."

c. "I'm glad I could help you, but I can't accept the gift. My reward is seeing you with a renewed sense of hope."

d. "Helping people is what nursing is all about. It's rewarding to me when patients recognize how hard we work."

ANS: C

Accepting a gift creates a social rather than therapeutic relationship with the patient and blurs the boundaries of the relationship. A caring nurse will acknowledge the patient's gesture of appreciation, but the gift should not be accepted. See relationship to audience response question.

Which remark by a patient indicates passage from orientation to the working phase of a nurse-patient relationship?

a. "I don't have any problems."

b. "It is so difficult for me to talk about problems."

c. "I don't know how it will help to talk to you about my problems."

d. "I want to find a way to deal with my anger without becoming violent."

ANS: D

Thinking about a more constructive approach to dealing with anger indicates a readiness to make a behavioral change. Behavioral change is associated with the working phase of the relationship. Denial is often seen in the orientation phase. It is common early in the relationship, before rapport and trust are firmly established, for a patient to express difficulty in talking about problems. Stating skepticism about the effectiveness of the nurse-patient relationship is more typically a reaction during the orientation phase.

A nurse explains to the family of a mentally ill patient how a nurse-patient relationship differs from social relationships. Which is the best explanation?

a. "The focus is on the patient. Problems are discussed by the nurse and patient, but solutions are implemented by the patient."

b. "The focus shifts from nurse to patient as the relationship develops. Advice is given by both, and solutions are implemented."

c. "The focus of the relationship is socialization. Mutual needs are met, and feelings are shared openly."

d. "The focus is creation of a partnership in which each member is concerned with growth and satisfaction of the other."

ANS: A

Only the correct response describes elements of a therapeutic relationship. The remaining responses describe events that occur in social or intimate relationships.

A nurse wants to demonstrate genuineness with a patient diagnosed with schizophrenia. The nurse should:

a. restate what the patient says.

b. use congruent communication strategies.

c. use self-revelation in patient interactions.

d. consistently interpret the patient's behaviors.

ANS: B

Genuineness is a desirable characteristic involving awareness of one's own feelings as they arise and the ability to communicate them when appropriate. The incorrect options are undesirable in a therapeutic relationship.

A nurse caring for a withdrawn, suspicious patient recognizes development of feelings of anger toward the patient. The nurse should:

a. suppress the angry feelings.

b. express the anger openly and directly with the patient.

c. tell the nurse manager to assign the patient to another nurse.

d. discuss the anger with a clinician during a supervisory session.

ANS: D

The nurse is accountable for the relationship. Objectivity is threatened by strong positive or negative feelings toward a patient. Supervision is necessary to work through countertransference feelings.

A nurse wants to enhance growth of a patient by showing positive regard. The nurse's action most likely to achieve this goal is:

a. making rounds daily.

b. staying with a tearful patient.

c. administering medication as prescribed.

d. examining personal feelings about a patient.

ANS: B

Staying with a crying patient offers support and shows positive regard. Administering daily medication and making rounds are tasks that could be part of an assignment and do not necessarily reflect positive regard. Examining feelings regarding a patient addresses the nurse's ability to be therapeutic.

A patient says, "I've done a lot of cheating and manipulating in my relationships." Select a nonjudgmental response by the nurse.

a. "How do you feel about that?"

b. "I am glad that you realize this."

c. "That's not a good way to behave."

d. "Have you outgrown that type of behavior?"

ANS: A

Asking a patient to reflect on feelings about his or her actions does not imply any judgment about those actions, and it encourages the patient to explore feelings and values. The remaining options offer negative judgments.

A patient says, "People should be allowed to commit suicide without interference from others." A nurse replies, "You're wrong. Nothing is bad enough to justify death." What is the best analysis of this interchange?

a. The patient is correct.

b. The nurse is correct.

c. Neither person is correct.

d. Differing values are reflected in the two statements.

ANS: D

Values guide beliefs and actions. The individuals stating their positions place different values on life and autonomy. Nurses must be aware of their own values and be sensitive to the values of others.

Which issues should a nurse address during the first interview with a patient with a psychiatric disorder?

a. Trust, congruence, attitudes, and boundaries

b. Goals, resistance, unconscious motivations, and diversion

c. Relationship parameters, the contract, confidentiality, and termination

d. Transference, countertransference, intimacy, and developing resources

ANS: C

Relationship parameters, the contract, confidentiality, and termination are issues that should be considered during the orientation phase of the relationship. The remaining options are issues that are dealt with later.

An advanced practice nurse observes a novice nurse expressing irritability regarding a patient with a long history of alcoholism and suspects the new nurse is experiencing countertransference. Which comment by the new nurse confirms this suspicion?

a. "This patient continues to deny problems resulting from drinking."

b. "My parents were alcoholics and often neglected our family."

c. "The patient cannot identify any goals for improvement."

d. "The patient said I have many traits like her mother."

ANS: B

Countertransference occurs when the nurse unconsciously and inappropriately displaces onto the patient feelings and behaviors related to significant figures in the nurse's past. In this instance, the new nurse's irritability stems from relationships with parents. The distracters indicate transference or accurate analysis of the patient's behavior.

Which behavior shows that a nurse values autonomy? The nurse:

a. suggests one-on-one supervision for a patient who has suicidal thoughts.

b. informs a patient that the spouse will not be in during visiting hours.

c. discusses options and helps the patient weigh the consequences.

d. sets limits on a patient's romantic overtures toward the nurse.

ANS: C

A high level of valuing is acting on one's belief. Autonomy is supported when the nurse helps a patient weigh alternatives and their consequences before the patient makes a decision. Autonomy or self-determination is not the issue in any of the other behaviors.

As a nurse discharges a patient, the patient gives the nurse a card of appreciation made in an arts and crafts group. What is the nurse's best action?

a. Recognize the effectiveness of the relationship and patient's thoughtfulness. Accept the card.

b. Inform the patient that accepting gifts violates policies of the facility. Decline the card.

c. Acknowledge the patient's transition through the termination phase but decline the card.

d. Accept the card and invite the patient to return to participate in other arts and crafts groups.

ANS: A

The nurse must consider the meaning, timing, and value of the gift. In this instance, the nurse should accept the patient's expression of gratitude. See relationship to audience response question.

A patient says, "I'm still on restriction, but I want to attend some off-unit activities. Would you ask the doctor to change my privileges?" What is the nurse's best response?

a. "Why are you asking me when you're able to speak for yourself?"

b. "I will be glad to address it when I see your doctor later today."

c. "That's a good topic for you to discuss with your doctor."

d. "Do you think you can't speak to a doctor?"

ANS: C

Nurses should encourage patients to work at their optimal level of functioning. A nurse does not act for the patient unless it is necessary. Acting for a patient increases feelings of helplessness and dependency.

A community mental health nurse has worked with a patient for 3 years but is moving out of the city and terminates the relationship. When a novice nurse begins work with this patient, what is the starting point for the relationship?

a. Begin at the orientation phase.

b. Resume the working relationship.

c. Initially establish a social relationship.

d. Return to the emotional catharsis phase.

ANS: A

After termination of a long-term relationship, the patient and new nurse usually have to begin at ground zero, the orientation phase, to build a new relationship. If termination is successfully completed, the orientation phase sometimes progresses quickly to the working phase. Other times, even after successful termination, the orientation phase may be prolonged.

As a patient diagnosed with a mental illness is being discharged from a facility, a nurse invites the patient to the annual staff picnic. What is the best analysis of this scenario?

a. The invitation facilitates dependency on the nurse.

b. The nurse's action blurs the boundaries of the therapeutic relationship.

c. The invitation is therapeutic for the patient's diversional activity deficit.

d. The nurse's action assists the patient's integration into community living.

ANS: B

The invitation creates a social relationship rather than a therapeutic relationship.

A nurse says, "I am the only one who truly understands this patient. Other staff members are too critical." The nurse's statement indicates:

a. boundary blurring.

b. sexual harassment.

c. positive regard.

d. advocacy.

ANS: A

When the role of the nurse and the role of the patient shift, boundary blurring may arise. In this situation the nurse is becoming over-involved with the patient as a probable result of unrecognized countertransference. When boundary issues occur, the need for supervision exists. The situation does not describe sexual harassment. Data are not present to suggest positive regard or advocacy.

Select all that apply.

Which descriptors exemplify consistency regarding nurse-patient relationships?

a. Encouraging a patient to share initial impressions of staff

b. Having the same nurse care for a patient on a daily basis

c. Providing a schedule of daily activities to a patient

d. Setting a time for regular sessions with a patient

e. Offering solutions to a patient's problems

ANS: B, C, D

Consistency implies predictability. Having the same nurse see the patient daily and provide a daily schedule of patient activities and a set time for regular sessions will help a patient predict what will happen during each day and develop a greater degree of security and comfort. Encouraging a patient to share initial impressions of staff and giving advice are not related to consistency and would not be considered a therapeutic intervention.

Select all that apply.

A nurse ends a relationship with a patient. Which actions by the nurse should be included in the termination phase?

a. Focus dialogues with the patient on problems that may occur in the future.

b. Help the patient express feelings about the relationship with the nurse.

c. Help the patient prioritize and modify socially unacceptable behaviors.

d. Reinforce expectations regarding the parameters of the relationship.

e. Help the patient to identify strengths, limitations, and problems.

ANS: A, B

The correct actions are part of the termination phase. The other actions would be used in the working and orientation phases.

Select all that apply.

A novice psychiatric nurse has a parent with bipolar disorder. This nurse angrily recalls feelings of embarrassment about the parent's behavior in the community. Select the best ways for this nurse to cope with these feelings.

a. Seek ways to use the understanding gained from childhood to help patients cope with their own illnesses.

b. Recognize that these feelings are unhealthy. The nurse should try to suppress them when working with patients.

c. Recognize that psychiatric nursing is not an appropriate career choice. Explore other nursing specialties.

d. The nurse should begin new patient relationships by saying, "My own parent had mental illness, so I accept it without stigma."

e. Recognize that the feelings may add sensitivity to the nurse's practice, but supervision is important.

ANS: A, E

The nurse needs support to explore these feelings. An experienced psychiatric nurse is a resource that may be helpful. The knowledge and experience gained from the nurse's relationship with a mentally ill parent may contribute sensitivity to compassionate practice. Self-disclosure and suppression are not adaptive coping strategies. The nurse should not give up on this area of practice without first seeking ways to cope with the memories.

Select all that apply.

A novice nurse tells a mentor, "I want to convey to my patients that I am interested in them and that I want to listen to what they have to say." Which behaviors will be helpful in meeting the nurse's goal?

a. Sitting behind a desk, facing the patient

b. Introducing self to a patient and identifying own role

c. Maintaining control of discussions by asking direct questions

d. Using facial expressions to convey interest and encouragement

e. Assuming an open body posture and sometimes mirror imaging

ANS: B, D, E

Trust is fostered when the nurse gives an introduction and identifies his or her role. Facial expressions that convey interest and encouragement support the nurse's verbal statements to that effect and strengthen the message. An open body posture conveys openness to listening to what the patient has to say. Mirror imaging enhances patient comfort. A desk would place a physical barrier between the nurse and patient. A face-to-face stance should be avoided when possible and a less intense 90- or 120-degree angle used to permit either party to look away without discomfort.

Inpatient hospitalization for persons with mental illness is generally reserved for patients who:

a. present a clear danger to self or others.

b. are noncompliant with medication at home.

c. have limited 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 distracters do not necessarily describe patients who require inpatient treatment.

A patient was hospitalized for 24 hours after a reaction to a psychotropic medication. While planning discharge, the case manager learned that the patient received a notice of eviction immediately prior to admission. Select the case manager's most appropriate action.

a. Postpone 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. Determine whether the adverse medication reaction was genuine because the patient had nowhere to live.

ANS: C

The case manager should intervene by arranging temporary shelter for the patient until an apartment can be found. This activity is part of the coordination and delivery of services that falls under the case manager role. None of the other options is a viable alternative.

Select the example of tertiary prevention.

a. Helping a person diagnosed with a serious mental illness learn to manage money

b. Restraining an agitated patient who has become aggressive and assaultive

c. Teaching school-age children about the dangers of drugs and alcohol

d. Genetic counseling with a young couple expecting their first child

ANS: A

Tertiary prevention involves services that address residual impairments, with a goal of improved independent functioning. Restraint is a secondary prevention. Genetic counseling and teaching school-age children about substance abuse and dependence are examples of primary prevention.

A patient diagnosed with schizophrenia had an exacerbation related to medication noncompliance and was hospitalized for 5 days. The patient's thoughts are now more organized, and discharge is planned. The patient's family says, "It's too soon for discharge. We will just go through all this again." The nurse should:

a. ask the case manager to arrange a transfer to a long-term care facility.

b. notify hospital security to handle the disturbance and escort the family off the unit.

c. explain that the patient will continue to improve if the medication is taken regularly.

d. contact the health care provider to meet with the family and explain the discharge rationale.

ANS: C

Patients do not stay in a hospital until every 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. Security is unnecessary. The nurse can handle this matter.

A nurse inspects an inpatient psychiatric unit and finds that exits are free of obstructions, no one is smoking, and the janitor's closet is locked. These observations relate to:

a. coordinating care of patients.

b. management of milieu safety.

c. management of the interpersonal climate.

d. use of therapeutic intervention strategies.

ANS: B

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.

The patients below were evaluated in the emergency department. The psychiatric unit has one bed available. Which patient should be admitted? The patient:

a. feeling anxiety and a sad mood after separation from a spouse of 10 years.

b. who self-inflicted a superficial cut on the forearm after a family argument.

c. experiencing dry mouth and tremor related to taking haloperidol (Haldol).

d. who is a new parent and hears voices saying, "Smother your baby."

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.

A suspicious, socially isolated patient lives alone, eats one meal a day at a local shelter, and spends the remaining daily food allowance on cigarettes. Select a community psychiatric nurse's best initial action.

a. Explore ways to help the patient stop smoking.

b. Report the situation to the manager of the shelter.

c. Assess the patient's weight; determine foods and amounts eaten.

d. Arrange hospitalization for the patient in order to formulate a new treatment plan.

ANS: C

Assessment of biopsychosocial needs and general ability to live in the community is called for before any other 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. The rule is to assess before taking action. Hospitalization may not be necessary. Smoking cessation strategies can be pursued later.

A nurse surveys medical records. Which finding signals a violation of patients' rights?

a. A patient was not allowed to have visitors.

b. A patient's belongings were searched at admission.

c. A patient with suicidal ideation was placed on continuous observation.

d. Physical restraint was used after a patient was assaultive toward a staff member.

ANS: A

The patient has the right to have visitors. Inspecting patients' belongings is a safety measure. Patients have the right to a safe environment, including the right to be protected against impulses to harm self.

Which principle has the highest priority when addressing a behavioral crisis in an inpatient setting?

a. Resolve the crisis with the least restrictive intervention possible.

b. Swift intervention is justified to maintain the integrity of a therapeutic milieu.

c. Rights of an individual patient are superseded by the rights of the majority of patients.

d. Patients should have opportunities to regain control without intervention if the safety of others 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.

Clinical pathways are used in managed care settings to:

a. stabilize aggressive patients.

b. identify obstacles to effective care.

c. relieve nurses of planning responsibilities.

d. streamline the care process and reduce costs.

ANS: D

Clinical pathways provide guidelines for assessments, interventions, treatments, and outcomes as well as a designated timeline for accomplishment. Deviations from the timeline must be reported and investigated. Clinical pathways streamline the care process and save money. Care pathways do not identify obstacles or stabilize aggressive patients. Staff are responsible for the necessary interventions. Care pathways do not relieve nurses of the responsibility of planning; pathways may, however, make the task easier.

A nurse receives these three phone calls regarding a newly admitted patient.

• The psychiatrist wants to complete an initial assessment.

• An internist wants to perform a physical examination.

• The patient's attorney wants an appointment with the patient.

The nurse schedules the activities for the patient. Which role has the nurse fulfilled?

a. Advocate

b. Case manager

c. Milieu manager

d. Provider of care

ANS: B

Nurses on psychiatric units routinely coordinate patient services, serving as case managers as described in this scenario. The role of advocate would require the nurse to speak out on the patient's behalf. The role of milieu manager refers to maintaining a therapeutic environment. Provider of care refers to giving direct care to the patient.

Which aspect of direct care is an experienced, inpatient psychiatric nurse most likely to provide for a patient?

a. Hygiene assistance

b. Diversional activities

c. Assistance with job hunting

d. Building assertiveness skills

ANS: D

Assertiveness training relies on the counseling and psychoeducational skills of the nurse. Assistance with personal hygiene would usually be accomplished by a psychiatric technician or nursing assistant. Diversional activities are usually the province of recreational therapists. The patient would probably be assisted in job hunting by a social worker or vocational therapist.

Which characteristic would be more applicable to a community mental health nurse than to a nurse working in an operating room?

a. Kindness

b. Autonomy

c. Compassion

d. Professionalism

ANS: B

A community mental health nurse often works autonomously. Kindness, compassion, and professionalism apply to both nurses.

Which patient would be most appropriate to refer for assertive community treatment (ACT)? A patient diagnosed with:

a. a phobic fear of crowded places.

b. a single episode of major depression.

c. a catastrophic reaction to a tornado in the community.

d. schizophrenia and four hospitalizations in the past year.

ANS: D

Assertive community treatment (ACT) provides intensive case management for persons with serious persistent mental illness who live in the community. Repeated hospitalization is a frequent reason for this intervention. The distracters identify mental health problems of a more episodic nature.

The unit secretary receives a phone call from the health insurer for a hospitalized patient. The caller seeks information about the patient's projected length of stay. How should the nurse instruct the unit secretary to handle the request?

a. Obtain the information from the patient's medical record and relay it to the caller.

b. Inform the caller that all information about patients is confidential.

c. Refer the request for information to the patient's case manager.

d. Refer the request to the health care provider.

ANS: C

The case manager usually confers with insurers and provides the treatment team with information about available resources. The unit secretary should be mindful of patient confidentiality and should neither confirm that the patient is an inpatient nor disclose other information.

Select the example of primary prevention.

a. Assisting a person diagnosed with a serious mental illness to fill a pill-minder

b. Helping school-age children identify and describe normal emotions

c. Leading a psychoeducational group in a community care home

d. Medicating an acutely ill patient who assaulted a staff person

ANS: B

Primary preventions are directed at healthy populations with a goal of preventing health problems from occurring. Helping school-age children describe normal emotions people experience promotes coping, a skill that is needed throughout life. Assisting a person with serious and persistent mental illness to fill a pill-minder is an example of tertiary prevention. Medicating an acutely ill patient who assaulted a staff person is a secondary prevention. Leading a psychoeducational group in a community care home is an example of tertiary prevention.

Which level of prevention activities would a nurse in an emergency department employ most often?

a. Primary

b. Secondary

c. Tertiary

ANS: B

An emergency department nurse would generally see patients in crisis or with acute illness, so secondary prevention is used. Primary prevention involves preventing a health problem from developing, and tertiary prevention applies to rehabilitative activities.

The nurse assigned to assertive community treatment (ACT) should explain the program's treatment goal as:

a. assisting patients to maintain abstinence from alcohol and other substances of abuse.

b. providing structure and a therapeutic milieu for mentally ill patients whose symptoms require stabilization.

c. maintaining medications and stable psychiatric status for incarcerated inmates who have a history of mental illness.

d. providing services for mentally ill individuals who require intensive treatment to continue to live in the community.

ANS: D

An assertive community treatment (ACT) program provides intensive community services to persons with serious, persistent mental illness who live in the community but require aggressive services to prevent repeated hospitalizations.

Which scenario best depicts a behavioral crisis? A patient is:

a. waving fists, cursing, and shouting threats at a nurse.

b. curled up in a corner of the bathroom, wrapped in a towel.

c. crying hysterically after receiving a phone call from a family member.

d. performing push-ups in the middle of the hall, forcing others to walk around.

ANS: A

This behavior constitutes a behavioral crisis because the patient is threatening harm to another individual. Intervention is called for to defuse the situation. The other options speak of behaviors that may require intervention of a less urgent nature because the patients in question are not threatening harm to self or others.

The case manager plans to discuss the treatment plan with a patient's family. Select the case manager's first action.

a. Determine an appropriate location for the conference.

b. Support the discussion with examples of the patient's behavior.

c. Obtain the patient's permission for the exchange of information.

d. Determine which family members should participate in the conference.

ANS: C

The case manager must respect the patient's right to privacy, which extends to discussions with family. Talking to family members is part of the case manager's role. Actions identified in the distracters occur after the patient has given permission.

A patient usually watches television all day, seldom going out in the community or socializing with others. The patient says, "I don't know what to do with my free time." Which member of the treatment team would be most helpful to this patient?

a. Psychologist

b. Social worker

c. Recreational therapist

d. Occupational therapist

ANS: C

Recreational therapists help patients use leisure time to benefit their mental health. Occupational therapists assist with a broad range of skills, including those for employment. Psychologists conduct testing and provide other patient services. Social workers focus on the patient's support system.

A patient diagnosed with schizophrenia has been stable for 2 months. Today the patient's spouse calls the nurse to report the patient has not taken prescribed medication and is having disorganized thinking. The patient forgot to refill the prescription. The nurse arranges a refill. Select the best outcome to add to the plan of care.

a. The patient's spouse will mark dates for prescription refills on the family calendar.

b. The nurse will obtain prescription refills every 90 days and deliver to the patient.

c. The patient will call the nurse weekly to discuss medication-related issues.

d. The patient will report to the clinic for medication follow-up every week.

ANS: A

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 patient or a significant other can be responsible. The patient may not need more intensive follow-up as long as medication is taken as prescribed.

A community mental health nurse has worked for months to establish a relationship with a delusional, suspicious patient. The patient recently lost employment and could no longer afford prescribed medications. The patient says, "Only a traitor would make me go to the hospital." Select the nurse's best initial intervention.

a. With the patient's consent, contact resources to provide medications without charge temporarily.

b. Arrange a bed in a local homeless shelter with nightly on-site supervision.

c. Hospitalize the patient until the symptoms have stabilized.

d. Ask the patient, "Do you feel like I am a traitor?"

ANS: A

Hospitalization may damage the nurse-patient relationship, even if it provides an opportunity for rapid stabilization. If medication is restarted, the patient may possibly be stabilized in the home setting, even if it takes a little longer. Programs are available to help patients who are unable to afford their medications. A homeless shelter is inappropriate and unnecessary. Hospitalization may be necessary later, but a less restrictive solution should be tried first, since the patient is not dangerous. A yes/no question is non-therapeutic communication.

Which activity is appropriate for a nurse engaged exclusively in community-based primary prevention?

a. Medication follow-up

b. Teaching parenting skills

c. Substance abuse counseling

d. Making a referral for family therapy

ANS: B

Primary prevention activities are directed to healthy populations to provide information for developing skills that promote mental health. The distracters represent secondary or tertiary prevention activities.

A health care provider prescribed depot injections every 3 weeks at the clinic for a patient with a history of medication noncompliance. For this plan to be successful, which factor will be of critical importance?

a. The attitude of significant others toward the patient

b. Nutrition services in the patient's neighborhood

c. The level of trust between the patient and nurse

d. The 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, non-adherence will again be the issue. Attitude toward the patient, trusting relationships, and nutrition are important but not fundamental to this particular problem.

Which assessment finding for a patient in the community deserves priority intervention by the psychiatric nurse? The patient:

a. receives Social Security disability income plus a small check from a trust fund every month.

b. was absent from two of six planned Alcoholics Anonymous meetings in the past 2 weeks.

c. lives in an apartment with two patients who attend partial hospitalization programs.

d. has a sibling who was recently diagnosed with a mental illness.

ANS: B

Patients who use alcohol or illegal substances often become medication noncompliant. Medication noncompliance, along with the disorganizing influence of substances on cellular brain function, promotes relapse. The distracters do not suggest problems.

The nurse should refer which of the following patients to a partial hospitalization program? A patient who:

a. has a therapeutic lithium level and reports regularly for blood tests and clinic follow-up.

b. needs psychoeducation for relaxation therapy related to agoraphobia and panic episodes.

c. spent yesterday in a supervised crisis care center and continues to have active suicidal ideation.

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 responsibility for supervision. A suicidal patient needs inpatient hospitalization. The other patients can be served in the community or with individual visits.

A Category V tornado hits a community, destroying many homes and businesses. Which nursing intervention would best demonstrate compassion and caring?

a. Encouraging persons to describe their memories and feelings about the event

b. Arranging transportation to the local community mental health center

c. Referring a local resident to a community food bank

d. Coordinating psychiatric home care services

ANS: A

Disaster victims benefit from telling their story. Nurses show compassion by listening and offering hope. The distracters identify other aspects of psychological first aid and services on the mental health continuum.

A nurse makes an initial visit to a homebound patient diagnosed with a serious mental illness. A family member offers the nurse a cup of coffee. Select the nurse's best response.

a. "Thank you. I would enjoy having a cup of coffee with you."

b. "Thank you, but I would prefer to proceed with the assessment."

c. "No, but thank you. I never accept drinks from patients or families."

d. "Our agency policy prohibits me from eating or drinking in patients' homes."

ANS: A

Accepting refreshments or chatting informally with the patient and family represent therapeutic use of self and help to establish rapport. The distracters fail to help establish rapport.

A nurse performed these actions while caring for patients in an inpatient psychiatric setting. Which action violated patients' rights?

a. Prohibited a patient from using the telephone

b. In patient's presence, opened a package mailed to patient

c. Remained within arm's length of patient with homicidal ideation

d. Permitted a patient with psychosis to refuse oral psychotropic medication

ANS: A

The patient has a right to use the telephone. The patient should be protected against possible harm to self or others. Patients have rights to send and receive mail and be present during package inspection. Patients have rights to refuse treatment.

Select all that apply.

A nurse can best address factors of critical importance to successful community treatment by including making assessments relative to:

a. housing adequacy.

b. family and support systems.

c. income adequacy and stability.

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.

Select all that apply.

The health care team at an inpatient psychiatric facility drafts these criteria for admission. Which criteria should be included in the final version of the admission policy?

a. Clear risk of danger to self or others

b. Adjustment needed for doses of psychotropic medication

c. Detoxification from long-term heavy alcohol consumption needed

d. Respite for caregivers of persons with serious and persistent mental illness

e. Failure of community-based treatment, demonstrating need for intensive treatment

ANS: A, C, E

Medication doses can be adjusted on an outpatient basis. The goal of caregiver respite can be accomplished without hospitalizing the patient. The other options are acceptable, evidence-based criteria for admission of a patient to an inpatient service.

Select all that apply.

A psychiatric nurse discusses rules of the therapeutic milieu and patients' rights with a newly admitted patient. Which rights should be included? The right to:

a. have visitors

b. confidentiality

c. a private room

d. complain about inadequate care

e. select the nurse assigned to their care

ANS: A, B, D

Patients' rights should be discussed shortly after admission. Patients have rights related to receiving/refusing visitors, privacy, filing complaints about inadequate care, and accepting/refusing treatments (including medications). Patients do not have a right to a private room or selecting which nurse will provide care.

Select all that apply.

Which statements by patients diagnosed with a serious mental illness best demonstrate that the case manager has established an effective long-term relationship? "My case manager:

a. talks in language I can understand."

b. helps me keep track of my medication."

c. gives me little gifts from time to time."

d. looks at me as a whole person with many needs."

e. lets me do whatever I choose without interfering."

ANS: A, B, D

Each correct answer is an example of appropriate nursing foci: communicating at a level understandable to the patient, providing medication supervision, and using holistic principles to guide care. The distracters violate relationship boundaries or suggest a laissez faire attitude on the part of the nurse.

Select all that apply.

Which statements most clearly reflect the stigma of mental illness?

a. "Many mental illnesses are hereditary."

b. "Mental illness can be evidence of a brain disorder."

c. "People claim mental illness so they can get disability checks."

d. "Mental illness results from the breakdown of American families."

e. "If people with mental illness went to church, their symptoms would vanish."

ANS: C, D, E

Stigma is represented by judgmental remarks that discount the reality and validity of mental illness. Many mental illnesses are genetically transmitted. Neuroimaging can show changes associated with some mental illnesses.

Select all that apply.

A person in the community asks, "People with mental illnesses went to state hospitals in earlier times. Why has that changed?" Select the nurse's accurate responses.

a. "Science has made significant improvements in drugs for mental illness, so now many persons may live in their communities."

b. "There's now a better selection of less restrictive treatment options available in communities to care for people with mental illness."

c. "National rates of mental illness have declined significantly. There actually is not a need for state institutions anymore."

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 has shifted the focus to community rather than institutional settings."

ANS: A, B, E

The community is a less restrictive alternative than hospitals for treatment of persons 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.

Select all that apply.

A patient diagnosed with schizophrenia lives in the community. On a home visit, the community psychiatric nurse case manager learns that the patient:

• wants to attend an activity group at the mental health outreach center.

• is worried about being able to pay for the therapy.

• does not know how to get from home to the outreach center.

• has an appointment to have blood work at the same time an activity group meets.

• wants to attend services at a church that is a half-mile from the patient's home.

Which tasks are part of the role of a community mental health nurse?

a. Rearranging conflicting care appointments

b. Negotiating the cost of therapy for the patient

c. Arranging transportation to the outreach center

d. Accompanying the patient to church services weekly

e. Monitoring to ensure the patient's basic needs are met

ANS: A, C, E

The correct answers reflect the coordinating role of the community psychiatric nurse case manager. Negotiating the cost of therapy and accompanying the patient to church services are interventions the nurse would not be expected to undertake. The patient can walk to the church services; the nurse can provide encouragement.

A parent says, "My 2-year-old child refuses toilet training and shouts 'No!' when given directions. What do you think is wrong?" Select the nurse's best reply.

a. "Your child needs firmer control. It is important to set limits now."

b. "This is normal for your child's age. The child is striving for independence."

c. "There may be developmental problems. Most children are toilet trained by age 2."

d. "Some undesirable attitudes are developing. A child psychologist can help you develop a plan."

ANS: B

This behavior is typical of a child around the age of 2 years, whose developmental task is to develop autonomy. The distracters indicate the child's behavior is abnormal.

A 26-month-old displays negative behavior, refuses toilet training, and often says, "No!" Which stage of psychosexual development is evident?

a. Oral

b. Anal

c. Phallic

d. Genital

ANS: B

The anal stage occurs from age 1 to 3 years and has as its focus toilet training and learning to delay immediate gratification. The oral stage occurs between birth and 1 year. The phallic stage occurs between 3 and 5 years, and the genital stage occurs between age 13 and 20 years.

A 26-month-old displays negative behavior, refuses toilet training, and often says, "No!" Which psychosocial crisis is evident?

a. Trust versus mistrust

b. Initiative versus guilt

c. Industry versus inferiority

d. Autonomy versus shame and doubt

ANS: D

The crisis of autonomy versus shame and doubt relates to the developmental task of gaining control of self and environment, as exemplified by toilet training. This psychosocial crisis occurs during the period of early childhood. Trust versus mistrust is the crisis of the infant. Initiative versus guilt is the crisis of the preschool and early-school-aged child. Industry versus inferiority is the crisis of the 6- to 12-year-old child.

A 4-year-old grabs toys from siblings and says, "I want that now!" The siblings cry, and the child's parent becomes upset with the behavior. According to Freudian theory, this behavior is a product of impulses originating in which system of the personality?

a. Id

b. Ego

c. Superego

d. Preconscious

ANS: A

The id operates on the pleasure principle, seeking immediate gratification of impulses. The ego acts as a mediator of behavior and weighs the consequences of the action, perhaps determining that taking the toy is not worth the mother's wrath. The superego would oppose the impulsive behavior as "not nice." The preconscious is a level of awareness. This item relates to an audience response question.

The parent of a 4-year-old rewards and praises the child for helping a younger sibling, being polite, and using good manners. The nurse supports this use of praise related to these behaviors. These qualities are likely to be internalized and become part of which system of the personality?

a. Id

b. Ego

c. Superego

d. Preconscious

ANS: C

The superego contains the "thou shalts," or moral standards internalized from interactions with significant others. Praise fosters internalization of desirable behaviors. The id is the center of basic instinctual drives, and the ego is the mediator. The ego is the problem-solving and reality-testing portion of the personality that negotiates solutions with the outside world. The preconscious is a level of awareness from which material can be retrieved easily with conscious effort. This item relates to an audience response question.

A nurse supports a parent for praising a child behaving in a helpful way. When this child behaves with politeness and helpfulness in adulthood, which feeling will most likely result?

a. Guilt

b. Anxiety

c. Humility

d. Self-esteem

ANS: D

The individual will be living up to the ego ideal, which will result in positive feelings about self. The other options are incorrect because each represents a negative feeling.

An adult says, "I never know the answers," and "My opinion doesn't count." Which psychosocial crisis was unsuccessfully resolved for this adult?

a. Initiative versus guilt

b. Trust versus mistrust

c. Autonomy versus shame and doubt

d. Generativity versus self-absorption

ANS: C

These statements show severe self-doubt, indicating that the crisis of gaining control over the environment was not met successfully. Unsuccessful resolution of the crisis of initiative versus guilt results in feelings of guilt. Unsuccessful resolution of the crisis of trust versus mistrust results in poor interpersonal relationships and suspicion of others. Unsuccessful resolution of the crisis of generativity versus self-absorption results in self-absorption that limits the ability to grow as a person.

Which patient statement would lead the nurse to suspect unsuccessful completion of the developmental task of infancy?

a. "I have very warm and close friendships."

b. "I'm afraid to allow anyone to really get to know me."

c. "I'm always absolutely right, so don't bother saying more."

d. "I'm ashamed that I didn't do things correctly in the first place."

ANS: B

According to Erikson, the developmental task of infancy is the development of trust. The correct response is the only statement clearly showing lack of ability to trust others. Warm, close relationships suggest the developmental task of infancy was successfully completed; rigidity and self-absorption are reflected in the belief one is always right; and shame for past actions suggests failure to resolve the crisis of initiative versus guilt.

A patient is suspicious and frequently manipulates others. To which psychosexual stage do these traits relate?

a. Oral

b. Anal

c. Phallic

d. Genital

ANS: A

The behaviors in the stem develop as the result of attitudes formed during the oral stage, when an infant first learns to relate to the environment. Anal-stage traits include stinginess, stubbornness, orderliness, or their opposites. Phallic-stage traits include flirtatiousness, pride, vanity, difficulty with authority figures, and difficulties with sexual identity. Genital-stage traits include the ability to form satisfying sexual and emotional relationships with members of the opposite sex, emancipation from parents, a strong sense of personal identity, or the opposites of these traits.