Essentials Of Psychiatric Mental Health Nursing

DisDisturbed body image is the nursing diagnosis for a patient with an eating disorder. Which outcome indicator is most appropriate to monitor?

• Weight, muscle, and fat congruence with height, frame, age, and sex

• Calorie intake within required parameters of treatment plan

• Weight at established normal range for the patient

• Patient satisfaction with body appearance

A patient referred to the eating disorders clinic has lost 35 pounds during one summer. To assess the patient’s eating patterns, the nurse should ask:

• “Do you often feel fat?”

• “Who plans the family meals?”

• “What do you eat in a typical day?”

• “What do you think about your present weight?”

A patient is diagnosed with anorexia nervosa. The history reveals the patient virtually stopped eating 5 months ago and lost 25% of body weight. A nurse tells the patient, “Describe what you think about your present weight and how you think you look.” Which response would be most consistent with the diagnosis?  

• “I’m fat and ugly.”

• “What I think about myself is my business.”

• “I’m grossly underweight, but thin is interesting.”

• “I’m a few pounds overweight, but I can live with it.”

A psychiatric clinical nurse specialist uses cognitive therapy techniques with a patient with anorexia nervosa. Which statement by the nurse supports this type of therapy?  

• “What are your feelings about not eating the food that you prepare?”

• “You seem to feel much better about yourself when you eat something.”

• “It must be difficult to talk about private matters to someone you just met.”

• “Being thin doesn’t seem to solve your problems. You’re thin now but still unhappy.”

A student transferred from a hometown community college to a university 100 miles from home. She was slow to make new friends at the university. The history shows a close relationship with her mother and sister and that she broke up with her boyfriend of 2 years. She began to eat large quantities when she felt sad, and then induce vomiting. These cycles continued until they interfered with her schoolwork. She sought help from the university health clinic. During the initial interview, what other priority issue should a nurse address?

• Sleep patterns

• School activities

• Losses

• Menstrual flow

One bed is available on the inpatient eating disorders unit. Which patient should be admitted? The patient whose weight dropped from:

• 150 to 100 pounds over a 4-month period. Vital signs: temperature, 35.9° C; pulse, 38 beats/min; blood pressure 60/40 mm Hg

• 120 to 90 pounds over a 3-month period. Vital signs: temperature, 36° C; pulse, 50 beats/min; blood pressure 70/50 mm Hg

• 110 to 70 pounds over a 4-month period. Vital signs: temperature 36.5° C; pulse, 60 beats/min; blood pressure 80/66 mm Hg

• 90 to 78 pounds over a 5-month period. Vital signs: temperature, 36.7° C; pulse, 62 beats/min; blood pressure 74/48 mm Hg

A patient with an eating disorder has been under significant stress and works long hours. At home, the patient watches television and eats until going to bed. The patient is too tired to exercise and has gained 25 pounds in 1 month. The patient is 5 feet tall and weighs 175 pounds. A desired outcome for the patient is to recognize the anxiety that precedes binge eating and reduce it with a constructive strategy. Which intervention addresses the outcome?  

• Teach stress reduction techniques such as relaxation and imagery.

• Explore the patient’s need to single-handedly make up for a staff shortage.

• Explore ways in which the patient may feel in control of the environment.

• Encourage the patient to attend a support group such as Overeaters Anonymous.

A patient being admitted to the eating disorders unit has a yellow cast to the skin, has hair that is limp and dry, and has fine, downy hair covering the body. The patient weighs 70 pounds; height is 5 feet 4 inches. The patient is quiet and sullen during the physical assessment saying only, “I don’t intend to eat until I lose enough weight to look thin.” What is the best initial nursing diagnosis?  

• Disturbed body image related to weight loss

• Anxiety related to fear of weight gain

• Ineffective coping related to lack of conflict resolution skills

• Imbalanced nutrition: less than body requirements related to self-starvation

Nursing physical assessment of a patient with bulimia often reveals:

• Prominent parotid glands.

• Peripheral edema.

• Thin, brittle hair.

• Amenorrhea.

When a nurse finds a patient with anorexia nervosa vigorously exercising before gaining the agreed upon weekly weight, the nurse should state:

• “It bothers me to see you exercising. You’ll lose more weight.”

• “You and I will have to sit down and discuss this problem.”

• “According to our agreement, no exercising is permitted until you have gained a specific amount of weight.”

• “Let’s discuss the relationship between exercise and weight loss and how that affects your body.”

A patient referred to the eating disorders clinic has lost 35 pounds during the summer and developed amenorrhea. For which physical manifestations of anorexia nervosa should a nurse assess? (More than one answer is correct.)

• Peripheral edema

• Parotid swelling

• Constipation

• Hypotension

• Dental caries

• Lanugo

When a patient with anorexia is admitted for treatment, what should the milieu provide? (More than one answer is correct.)

• Flexible mealtimes

• Adherence to a selected menu

• Observation during and after meals

• Unscheduled weight checks

• Monitoring during bathroom trips

• Privileges correlated with affective display

An alcohol-dependent patient was hospitalized at 0200 today. When would the nurse expect withdrawal symptoms to peak?  

• Between 0800 and 1000 today (6 to 8 hours after drinking stopped)

• Between 0200 tomorrow and hospital day 2 (24 to 48 hours after drinking stopped)

• About 0200 on hospital day 3 (72 hours after drinking stopped)

• About 0200 on hospital day 4 (96 hours after drinking stopped)

A nurse reviews vital signs for a patient admitted last night with an injury sustained while intoxicated. The medical record shows the following blood pressure and pulse readings: Admission, 0200—122/80 mm Hg and 72 beats/min; 0400—126/78 mm Hg and 76 beats/min; 0600—124/80 mm Hg and 72 beats/min; 0800—132/88 mm Hg and 80 beats/min; 1000—148/88 mm Hg and 96 beats/min. What is the nurse’s priority action?

• Encourage the patient to drink plenty of liquids.

• Obtain a clean-catch urine sample.

• Place the patient in a vest-type restraint.

• Consult the health care provider.

A patient admitted for injuries sustained while intoxicated has been hospitalized for 48 hours. The patient is shaky, irritable, anxious, and diaphoretic, and reports nightmares. The pulse rate is 130 beats/min. The patient shouts, “Bugs are crawling on my bed. I’ve got to get out of here,” and begins to thrash about. The most accurate assessment of the situation would be that the patient:  

• Is attempting to obtain attention by manipulating staff.

• May have sustained a head injury before admission.

• Is having a recurrence of an acute psychosis.

• Has symptoms of alcohol withdrawal delirium.

A patient admitted yesterday for injuries sustained in a fall while intoxicated believes the window blinds are snakes trying to get in the room. The patient is anxious, agitated, and diaphoretic. Which medication can the nurse anticipate the health care provider will prescribe?

• A benzodiazepine, such as lorazepam (Ativan) or chlordiazepoxide (Librium)

• A phenothiazine, such as chlorpromazine (Thorazine) or thioridazine (Mellaril)

• A monoamine oxidase inhibitor, such as phenelzine (Nardil)

• A narcotic analgesic, such as codeine

A hospitalized patient, injured in a fall while intoxicated, believes spiders are spinning entrapping webs in the room. The patient is anxious, agitated, and diaphoretic. Which nursing intervention should be instituted?  

• Check the patient every 15 minutes.

• Provide one-on-one supervision.

• Keep the room dimly lit.

• Rigorously encourage fluid intake.

A patient experienced alcohol withdrawal delirium, but now has a clear sensorium. The patient says, “Drinking helps me cope with being a single parent.” Which response by the nurse would help the patient conceptualize the drinking more objectively?

• “Sooner or later, alcohol will kill you. Then what will happen to your children?”

• “I hear a lot of defensiveness in your voice. Do you really believe this?”

• “If you were coping so well, why were you hospitalized again?”

• “Tell me what happened the last time you drank.”

During the third week of treatment, the spouse of a patient in an alcoholism rehabilitation program says, “After discharge, I’m sure everything will be just fine.” Which remark by the nurse will be most helpful to the spouse?  

• “It is good that you’re supportive of your spouse’s sobriety and want to help maintain it.”

• “Although sobriety solves some problems, new ones may emerge as one adjusts to living without alcohol.”

• “It will be important for you to structure life to avoid as much stress as possible. You will need to provide social protection.”

• “Remember that alcoholism is a disease of self-destruction. You will need to observe your spouse’s behavior carefully.”

In the emergency department, a patient’s vital signs are: BP 66/40 mm Hg; pulse 140 beats/min; respirations 8 breaths/min and shallow. Naloxone (Narcan) is administered. The nursing diagnosis is “ineffective breathing pattern related to depression of respiratory center secondary to narcotic overdose.” Select the desired outcome.

• Within 8 hours, vital signs will stabilize as evidenced by BP greater than 90/60 mm Hg, pulse less than 100 beats/min, and respirations at or above12 breaths/min.

• The patient will be able to describe a plan for home care and achieving a drug-free state before release from the emergency department.

• The patient will demonstrate effective coping skills within 1 week of hospitalization.

• The patient will identify two community resources for treatment of substance abuse by discharge.

A nurse worked at a community hospital for several months, resigned, then took a position at another hospital. In the new position, the nurse volunteered or switched with others to be the medication nurse. After a year, several serious medication errors occurred in rapid succession. During the investigation, it was learned that the nurse was allowed to resign from the community hospital after diverting patient narcotics for self-use. The nurse manager could retrospectively identify which early indicator of the nurse’s drug use?  

• Accepting responsibility for medication errors.

• High sociability with peers.

• Seeking to be assigned as medication nurse.

• Presenting a neat physical appearance.

A nurse with a history of narcotic abuse is found unconscious in the hospital locker room after overdosing. The nurse is transferred from the emergency department to the inpatient psychiatric unit. Which attitudes or behaviors on the part of nursing staff may be enabling behaviors?

• Conveying understanding that pressures experienced in nursing underlie substance use.

• Pointing out that work problems are the result, but not the cause, of substance abuse.

• Empathizing when the nurse discusses fears of disciplinary action by the state board of nursing.

• Providing health teaching about stress management.

A nurse manager tells the staff nurse, “We anticipate this patient will have symptoms of withdrawal from sedative-hypnotics, so close observation is needed.” For which symptoms should the staff nurse assess the patient?  

• Dilated pupils, tachycardia, elevated blood pressure, elation

• Mood lability, incoordination, fever, drowsiness

• Nausea, vomiting, diaphoresis, anxiety, tremors

• Excessive eating, constipation, headache

A patient has smoked two packs of cigarettes daily for many years. When the patient does not smoke or tries to cut back, anxiety, craving, poor concentration, and headache result. What does this scenario describe?

• Substance abuse

• Substance intoxication

• Substance dependence

• Recreational use of a social drug

In what significant way should the therapeutic environment differ for a patient who ingested LSD from that for a patient who ingested PCP?

• For LSD ingestion, have one person stay with the patient and provide verbal support. For PCP ingestion, maintain a regimen of limited contact with one staff member accompanied by two or more staff.

• For PCP ingestion, place patient on one-on-one intensive supervision. For LSD ingestion, maintain a regimen of limited interaction and minimal verbal stimulation.

• For LSD ingestion, provide continual moderate sensory stimulation involving as many senses as possible. For PCP ingestion, provide continual high-level stimulation.

• For LSD ingestion, place the patient in restraints. For PCP ingestion, place the patient on seizure precautions.

A patient in an alcohol rehabilitation program says, “I have been a loser all my life. I’m so ashamed of what I put my family through. Now I’m not even sure I can succeed at staying sober.” Which nursing diagnosis applies?

• Chronic low self-esteem

• Situational low self-esteem

• Ineffective health maintenance

• Disturbed personal identity

A patient undergoing alcohol rehabilitation decides to accept disulfiram (Antabuse) therapy to avoid impulsively responding to drinking cues. Which needs should be included in discharge teaching for the patient? (More than one answer is correct.)

• Read labels of all liquid medications.

• Avoid aged cheeses.

• Avoid alcohol-based skin products.

• Wear sunscreen and avoid bright sunlight.

• Maintain an adequate dietary intake of sodium.

• Refrain from eating foods prepared with alcohol.

• Avoid breathing fumes of paints, stains, and stripping compounds.

A nurse can assist a patient and family in which aspects of substance abuse relapse prevention? (More than one answer is correct.)  

• Advising the patient to accept residential treatment if relapse occurs

• Assisting the patient to identify life skills needed for effective coping

• Rehearsing techniques to handle anticipated stressful situations

• Isolating self from significant others and social situations until sobriety is established

• Education about physical changes to expect as the body adapts to functioning without substances

After a methamphetamine overdose, on which tasks will priority nursing and medical measures focus? (More than one answer is correct.)

• Administration of naloxone (Narcan)

• Vitamin B12 and folate supplements

• Restoring nutritional integrity

• Reduction of fever

• Prevention of seizures

A community health nurse makes a home visit to a family with four children. The father behaves angrily, finds fault with a child, and asks twice, “Why are you such a stupid kid?” The wife says, “I have difficulty disciplining the children. It’s so frustrating.” The nurse seeks to gather more assessment data. Which comments by the nurse will facilitate communication? (More than one answer is correct.)  

• “Tell me how you punish your children.”

• “How do you stop your baby’s crying?”

• “Caring for four small children must be difficult.”

• “Do you or your husband ever beat the children?”

• “Calling children stupid injures their self-esteem.”

A nurse assists a victim of spousal abuse to create a plan for escape if it becomes necessary. The plan should include which components? (More than one answer is correct.)  

• Keeping a cell phone fully charged

• Hiding money with which to buy new clothes

• Having the phone number for the nearest shelter

• Taking enough toys to amuse the children for 2 days

• Securing a supply of current medications for self and children

• Determining a code word to signal children it is time to leave

• Assembling birth certificates, Social Security cards, and licenses

A community health nurse visits the home of a child, age 11, to investigate frequent school absences. The nurse finds the child caring for three siblings, all younger than age 4. Both parents are at work. The child says, “I want to go to school regularly, but when my mother has to work, I watch the kids. We can’t afford a babysitter. It doesn’t matter anyway. I’m too dumb to learn much. I don’t have friends at school, probably because I don’t deserve any.” What preliminary assessment can be made?

• Insufficient data are present to make an assessment.

• The child and siblings are experiencing neglect.

• The children are at high risk for sexual abuse.

• The children are experiencing physical abuse

What is a nurse’s legal responsibility if child abuse or neglect is suspected?

• Discuss the findings with the child’s teacher, principal, and school psychologist.

• Report the suspected abuse or neglect according to state regulations.

• Document the observations and speculations in the medical record.

• Continue the assessment.

An 11-year-old stays home from school to care for siblings while the parents work. When asked about the parents, the child reluctantly says, “My parents don’t like me. They call me stupid and say I never do anything right.” The level of prevention for work with this family will be:

• Primary.

• Secondary.

• Tertiary.

• Prevention is not possible.

An 11-year-old stays home from school to care for siblings while the parents work. The child says, “My parents don’t like me. They call me stupid and say I never do anything right.” The child also says, “It doesn’t matter anyway. I’m too dumb to learn much. I don’t have friends at school and probably don’t deserve any.” Which nursing diagnosis applies to this child?

• Chronic low self-esteem related to negative feedback about self from parents

• Deficient knowledge related to interpersonal skills with parents

• Noncompliance: school attendance related to parental rules

• Disturbed personal identity related to negative self-evaluation

A person tells the nurse, “My spouse abuses me most often when intoxicated. The drinking has increased lately, but I always receive an apology afterward and a box of chocolates. I’ve considered leaving home but haven’t been able to bring myself to actually leave.” Which phase in the cycle of violence prevents the patient from leaving?  

• Tension-building

• Acute battering

• Honeymoon

• Recovery

A victim of domestic abuse is treated for a detached retina. The patient tells the nurse, “My partner only abuses me when intoxicated. I’ve considered going to a safe house, but I was brought up to believe you stay together, no matter what happens. I always receive an apology and I can tell my spouse feels bad after hitting me.” Which nursing diagnosis has priority?

• Social isolation related to lack of community support system

• Risk for injury related to spouse’s physical abuse when intoxicated

• Deficient knowledge related to resources for escape from the abusive relationship

• Disabled family coping related to uneven distribution of power within the marital relationship

A victim of physical abuse by the domestic partner is treated for a broken wrist. The patient has considered going to a safe house, but cites being brought up to believe “you stay together, no matter what happens.” The patient says the partner is always apologetic and remorseful after an incident. Which outcome should be met before the patient leaves the emergency department? The patient will:

• Name two community resources that can be contacted.

• Demonstrate insight into the abusive relationship.

• Limit contact with the perpetrator by a restraining order.

• Facilitate counseling for the perpetrator.

An older adult with Alzheimer’s disease lives with family and goes to day care on weekdays. The nurse at the center observed an unkempt appearance and multiple bruises. The nurse discussed these observations with the daughter, who became defensive and said, “My mother is so difficult to manage. She wanders all night. Last night she fell down the stairs. Sometimes I just can’t bear to care for her.” Which nursing diagnosis has priority?  

• Risk for injury related to poor judgment, cognitive impairment, and lack of caregiver supervision

• Noncompliance related to confusion and disorientation as evidenced by lack of cooperation

• Insomnia related to cognitive impairment as evidenced by wandering at night

• Impaired verbal communication related to brain impairment as evidenced by the confusion

Which family scenario presents the greatest risk for family violence?

• An unemployed husband with low self-esteem, a wife who loses her job, and a developmentally delayed 3-year-old child

• A husband who finds employment 2 weeks after losing his previous job, a wife with stable employment, and a child doing well in school

• A single mother with an executive position, a talented child, and a widowed grandmother living in the home to provide child care

• A single homosexual male parent, an adolescent son who has just begun

A child stays home from school to care for siblings while the parents work because the family cannot afford a babysitter. The home is cluttered and dirty. The child reveals, “My father doesn’t like me very much. He calls me stupid all the time.” The wife mentions that the father is easily frustrated and has trouble disciplining the children. In planning interventions to stabilize the home situation, the community health nurse should consider which resources? (More than one answer is correct.)

• Anger management counseling for the father

• Placing the children in a children’s shelter

• Continuing home visits to give support

• Group sessions to teach childrearing practices

• A safety plan for the wife and children

A nurse in the emergency department explains to a victim of domestic violence that the psychosocial history, statements about battering, body map, and photos will be placed in the medical record. The victim says, “Oh, no, what if my spouse finds out?” What information regarding the medical record can the nurse give the patient to help with acceptance of the documentation? (More than one answer is correct.)

• It is not available to the perpetrator or perpetrator’s legal counsel.

• It will be valuable to the patient if legal action is pursued later.

• It makes pertinent information available to other care providers.

• It will provide evidence to law enforcement if another incident occurs.

• It can be a resource to providers of treatment to the perpetrator or the victim.

A community health nurse makes a home visit to a family with four children. The father behaves angrily, finds fault with a child, and asks twice, “Why are you such a stupid kid?” The wife says, “I have difficulty disciplining the children. It’s so frustrating.” The nurse seeks to gather more assessment data. Which comments by the nurse will facilitate communication? (More than one answer is correct.)  

• “Tell me how you punish your children.”

• “How do you stop your baby’s crying?”

• “Caring for four small children must be difficult.”

• “Do you or your husband ever beat the children?”

• “Calling children stupid injures their self-esteem.”

A nurse interviews a patient abducted and raped at gunpoint by an unknown assailant. The patient says, “I can’t talk about it. Nothing happened. I have to forget!” What is the patient’s present coping strategy?

• Somatic reaction

• Denial

• Repression

• Projection

A child with a congenital heart defect is ordered 200 mcg of Digoxin IV QD. The medication is available in a vial of 100 mcg/ml and needs to be diluted with 3 ml of NS. After diluting the medication the concentration available is 25mcg/ml. How much mls is needed for your dose of 200 mcg?

A child with an acute infection has an order of Ancef 300 mg IV every 12 hours. The pharmacy prepares this medication for you in a syringe of 300mg/15ml and suggests that it be administered over 30 minutes. Using the rate suggested by pharmacy, what will be the rate set on your syringe pump in ml/hour?

A child with cellulitis is ordered Rocephin 1000 mg IV every 12 hours. The pharmacy prepares this medication for you in a syringe of 1000mg/25ml. The pharmacy suggests the medication be administered over 30 minutes. Using the pharmacy's suggested rate, what will you program your rate in your syringe pump in ml/hour?

A newborn with sepsis is ordered Vancomycin 40mg IV every 12 hours. The pharmacy prepares and delivers a syringe of 40mg/8ml to be administered in 90 minutes. What is your rate that you will set on your syringe pump? (Round to Whole Number)