mental health - davis

The nurse is documenting care of a patient following the APIE method. Which of the following would you expect to see in the nursing note? Select all that apply.

- pt stated he is 'sad and depressed,' stays in room, not involved in group activities

- impaired social interaction r/t lack of motivation and depressed mood

- developed therapeutic relationship w patient, stayed with p. while he ate dinner, encouraged getting dressed and going to dining room

- pt able to get dressed and eat in dining room

The nurse is following the nursing process to care for a patient with a nursing diagnosis of Risk for suicide. Which activity is the priority?

assess for suicidal ideation

The nurse is documenting the care of a patient with a nursing diagnosis of Risk for suicide. Which of the following is correct documentation for using problem-oriented recording? Select all that apply.

- pt states that he doesn't have anything to live for

- pt crying frequently, stays in room alone, superficial scratch marks on wrist

- initiated therapeutic relationship, spent time w pt, provided positive feedback for discussing feelings

- pt attended group, reported decreased thoughts of suicide. has no current plan

The nurse is following the nursing process to care for a patient with a nursing diagnosis of Hopelessness. Which of the following actions is appropriate for the outcomes identification step?

pt will verbalize a measure of hope and acceptance of life and situations over where there is no control

A patient has been given a nursing diagnosis of Hopelessness. Which of the following actions is appropriate for the planning step?

interventions based on assessment

Arrange the steps of the nursing process in order according to the standards of practice for psychiatric mental health nursing set by the American Nurses Association.

assess, diagnosis, outcomes ID, plan, implement, evaluation

The estimated length of a hospital stay for a client experiencing alcohol withdrawal symptoms is 7 days. What is the expected dose of chlordiazepoxide administered to the client on the first day of admission in the hospital?

200 mg in divided doses

The nurse observes that the client with schizophrenia has an inability to trust others. Which problem would the client's treatment team determine the client exhibits?

paranoid delusions

How is subjective data about a client obtained for use within the subjective, objective, assessment, plan, implementation, and evaluation (SOAPIE) format?

from verbal reports of the client, family, or other sources

Which standard of psychiatric mental health clinical nursing practice includes milieu therapy?

implementation

The nurse is caring for a client with schizophrenia in a psychiatric unit. Which outcome in the client indicates effective treatment?

perofrm activities of daily living independently by the time of discharge

Which core capability of the electronic documentation system improves workflow by eliminating ambiguities caused by illegible handwriting?

order entry/order management

While reviewing the mental history of a client with psychiatric illness, the nurse finds that the client expresses incoherent neologisms and has slurred speech. Which would the nurse infer from these findings?

the pt has impaired communication patterns

Which information would the nurse find under the section of general information in the mental history form? Select all that apply.

pt's name, sex, height or weight

To assess attention and immediate recall, which questions would the nurse ask the client? Select all that apply.

- remember these words and i will ask you to repeat them in a few minutes

- repeat these words now: dog, orange, house

Which statement made by a new nurse regarding the disadvantages of paper records requires correction?

paper records are nonportable and are often illegible

Which symptoms may occur in a client suffering from alcohol withdrawal? Select all that apply.

nausea and vomiting, insomnia, seizures

A client with schizophrenia who is experiencing auditory hallucinations, paranoid delusions, social withdrawal, and developmental regression is admitted to the psychiatric unit. Which symptom of the client requires priority of treatment?

auditory hallucinations

Which signs and symptoms indicate that the client has disturbed thought processes? Select all that apply.

- suspicious

-delusional thinking

Which core capability of electronic documentation helps access various types of test reports of the client at the same time without any delay?

result management

The nurse is caring for a client who is complaining about her treatment in an aggressive tone of voice. Which statement made by the nurse would encourage the client to continue what she is saying?

Yes I understand. Please go on.

The nurse manager suspects that a nurse may have crossed professional boundaries. Which situation would confirm this suspicion?

The nurse spends free time outside of work with a particular client.

A client who lost a spouse in an accident tells the nurse, "Leave me alone. I can't talk to you." How would the nurse respond to this client using therapeutic communication techniques?

Do you feel that no one understand your feelings?

A client who separated from his or her spouse tells the nurse, "I don't know why I am living. There is nothing to live for." Which statement made by the nurse serves as the best nontherapeutic communication technique?

You appear to be upset. Can you tell me how you're feeling?

The nurse is counseling a group of clients on a one-to-one basis to obtain information regarding their current health situation. Which type of distance would the nurse maintain while communicating with the clients?

personal

A client in a psychiatric unit tells the nurse, "I think I don't want to continue with the treatment. Maybe I should just self-medicate." Which is the best response the nurse could give in this situation using a nontherapeutic communication technique?

I will try to answer your question and clarify issues regarding the treatment.

Which therapeutic communication technique is often used with clients experiencing delusional thinking?

Voicing doubt

The nurse is in the first phase of relationship development with a client who has a problem with alcohol abuse. Which statement is accurate regarding the goal of the nurse during this phase?

exploring self-perceptions

The nurse patted a client's back while providing care. The client felt offended by the nurse's gesture. Which boundary is in jeopardy in this situation?

personal boundary

The client says, "All men are messy and untidy." Which type of belief does the client have?

Stereotype

The nurse is assessing a client's condition by asking some questions. Which facial expression indicates that the client is surprised?

raised eyebrows

The nurse is caring for a client with chronic low self-esteem. Which statement made by the nurse indicates an accepting attitude?

I understand what you're saying

The nurse is caring for a client with situational low self-esteem. Which statement made by the nurse helps the client recognize his or her life experiences?

how did you respond when this happened in the past?

The client is upset and wants to the nurse to stay by his or her side because he or she feels safe and comforted by the nurse. According to Peplau, in which role would the nurse be performing?

Surrogate

Which actions of the nurse convey an attitude of respect toward the client? Select all that apply.

- being honest while interacting w the patient

- calling the pt by name

- spending time with the pt

-promoting an atmosphere during therapeutic interaction

The nurse has received report on Jade, a 23-year-old transgender female who has recently been admitted for Major Depressive Disorder with a suicide attempt. The nurse uses the SOLER technique to begin her assessment with the patient.What is the main purpose of the SOLER technique?

active listening

Mel is a 49-year-old male who has just been transferred to a mandated outpatient program for continuing treatment of his Substance Use Disorder. The nurse asks Mel how he would like to be addressed and spends some time with the patient to answer his questions about the program.Which condition of a therapeutic relationship is described in this scenario?

respect

A nurse states to a 13-year-old male patient on the unit, "You seem really angry today."Which therapeutic/nontherapeutic technique is this?

Making observations

Sally, a 55-year-old woman, comes into the community mental health clinic for her appointment. She discloses to the nurse that she has stopped taking her medications. The nurse asks Sally, "Why did you stop taking your medications? Did something happen?"Which therapeutic/nontherapeutic technique is this?

Requesting an explanation

A 21-year-old female patient is crying and upset because she is failing her classes after her boyfriend of 2 years broke up with her. The nurse says, "Tell me more about what is going on in your life right now."Which therapeutic/nontherapeutic technique is this?

Exploring

John, a 33-year-old male patient, is in the day room yelling at someone on the phone. John tells the nurse to go away and leave him alone so he can talk to his friends. The nurse says to John, "I just wanted to make sure you were okay. I am here if you need me."Which therapeutic/nontherapeutic technique is this?

Offering self

Vanessa is a newly admitted patient. On assessment she states, "I just don't even know where to begin, I am not sure I can talk about this." The nurse responds saying, "It must feel really overwhelming to think about sharing what happened. Maybe you think others won't understand what you've been through?"Which condition of a therapeutic relationship is described in this scenario?

empathy

Arianna is an 18-year-old female patient who is getting discharged. The nurse is reviewing the discharge plan with her and Arianna asks what she should do about her abusive boyfriend who is on his way to get her. The nurse responds, "You should leave him. He abuses you and nobody deserves that."Which therapeutic/nontherapeutic technique is this?

giving advice

Robert has been on the inpatient unit for 7 days and is ready to go home. He tells the nurse, "I am ready to leave, but my doctor will not let me go. She says I'm not ready yet. What do you think?" The nurse states, "The doctor knows what she is doing. I trust her judgment."Which therapeutic/nontherapeutic technique is this?

defending

Sharon is talking to the nurse and states, "I just can't leave my husband. I don't know how to survive on my own." The nurse comments, "You're afraid to leave your husband because you don't think you can make it on your own?"Which therapeutic/nontherapeutic technique is this?

restating

There are several conditions that are essential for the nurse in the development of the therapeutic relationship. Select the appropriate conditions from the list below. Select all that apply.

- trust

-genuine

- rapport

-empathy

The nurse is preparing to talk to a patient and wants to use the SOLER technique. Which technique(s) listed are part of SOLER? Select all that apply.

- sit squarely

- open posture

- maintain eye contact

- relax body language

A newly admitted patient has never been on an inpatient psychiatric unit before. The patient asks, "What's the schedule for? I am here to get some rest." The nurse's best response to verbalize the implied is:

it must be overwhelming to be in a place you've never been before.

The patient states to the nurse, "My wife said she was going to leave me if I was admitted one more time and here I am again." The nurse responds, "I am sure your wife only wants you to get better." This is an example of which technique?

defending

Joe just broke up with his girlfriend and tells the nurse he isn't sure he did the right thing. Which therapeutic techniques would be good to use in this example? Select all that apply.

- exploring

- offering self

- reflecting

Which of the following are appropriate assessment questions to elicit suicidal ideation or intent? Select all that apply.

- have you wished you were dead or wished you could go to sleep and not wake up?

- have you ever had any thoughts of killing yourself?

- have you thought about how you would kill yourself?

Potential warning signs of suicide include which of the following? Select all that apply.

- hopelessness

- expression of a suicide plan

- increasing substance abuse

- social isolation

- feeling trapped

Other factors besides impulsivity elevate risk of suicidal ideation to an active risk for attempt. Which factors listed below are part of the three-step trajectory and increases a person's risk? Select all that apply.

- pain

- hopelessness

Presenting symptoms that increase a person's risk for suicidal behavior include which of the following using the IS PATH WARM mnemonic? Select all that apply.

- ideation

-anger

-trapped

Which of the following are suicide risk factors that a nurse should assess for? Select all that apply.

-age

-gender

-ethnicity

-religion