Essentials Of Psychiatric Mental Health Nursing

The doctor orders Tobramycin 100 mg IV q 8 hours for a child admitted with an acute infection. The child weighs 44 lbs. The therapeutic range for Tobramycin is 6-7.5 mg/kg/day divided into 3 doses. Is this a therapeutic dose for this child? (Answer only yes or no)

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.

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

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

A paA patient is referred to the mental health center by the family health care provider. Over the past year, the patient has cooked gourmet meals for family members, but eats only tiny portions of the food. The patient wears layers of loose clothing, saying, “It’s just my style.” The patient’s weight has dropped from 130 to 95 pounds. The patient has amenorrhea. The history and symptoms are most consistent with which medical diagnosis?

• Anorexia nervosa

• Bulimia nervosa

• Binge eating

• Eating disorder not otherwise specified

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

The parent of a 4-year-old says that the child is in constant motion. The parent tries to interest the child in toys, but the child is easily distracted, doesn’t listen, and talks constantly. The child gets out of bed earlier than the parent every morning and has caused damage to expensive family possessions. The child was enrolled in preschool, but the teacher could not handle the behavior. The child’s problem is most consistent with the DSM-IV-TR criteria for:

• Pervasive developmental disorder.

• Mental retardation.

• Oppositional defiant disorder.

• Attention deficit hyperactivity disorder.

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 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.

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.

Which child shows behaviors indicative of mental illness?  

• A 3-month-old who cries after feeding until burped and sucks a thumb

• A 6-month-old who does not eat vegetables well and likes to be rocked

• A 3-year-old who is mute, passive toward adults, and twirls while walking

• A 4-year-old who lisps and became enuretic after the birth of a sibling

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.”

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

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.

The parent of a child with Tourette’s disorder says to the nurse, “I think my child is faking the tics because they come and go.” Which response by the nurse is accurate?

• “Perhaps your child was misdiagnosed.”

• “Your observation indicates the medication is effective.”

• “Tics often change frequency or severity. That doesn’t mean they aren’t real.”

• “This finding indicates a worsening of the condition. Let’s review how you’ve been administering the child’s medication.”

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 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 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.

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

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 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

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 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 child with ADHD will begin medication therapy. The nurse should prepare a plan to teach the family about which classification of medications?

• Central nervous system stimulants

• Monoamine oxidase inhibitors (MAOIs)

• Antipsychotic medications

• Anxiolytic medications

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 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 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 5-year-old with ADHD bounces out of a chair in the waiting room, runs across the room, and begins to slap another child. What is the nurse’s best action?

• Call for emergency assistance from other staff.

• Direct the child to stop, and then comfort the other child.

• Instruct the parents to take the child home immediately.

• Take the child to another room with toys to act out feelings.

A young adolescent is suspected to have Asperger’s syndrome. Which assessment finding would support this diagnosis?

• Absence of verbal language

• Presence of tics and twitching

• Severe developmental delays

• Limited social skills and empathy

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.

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 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

The doctor orders Vancomycin 10mg/kg every 12 hours IV for a newborn with sepsis. The newborn weighs 4000 grams. The medication is supplied in a vial of 500mg/5ml. How much volume should the infant receive per dose?

A 44 lb child must receive streptomycin sulfate, 30mg/kg/day in divided doses every 12 hours. The drug is available in 1 gram vials that can be diluted to a concentration of 1 gram/ml. What volume of the drug should the nurse administer at each dose? (Answer to the first decimal point).

An 11-year-old diagnosed with oppositional defiant disorder becomes angry and defiant over the rules at a residential treatment program and begins shouting at the nurse. What might be the best method to defuse the situation?

• Suggest the child go to the gym and shoot baskets.

• Place the child in a basket-hold.

• Call staff to seclude the child.

• Administer an anxiolytic medication.

An infant has just been born with a myelomeningocele. The infant has been admitted to the neonatal intensive care unit. Upon noticing the nursing tech preparing an open crib for this infant, the nurse should:

• Not say anything; the tech is doing an appropriate action.

• Stop the tech and ask her to prepare a warmer for this infant.

• Remind the tech to include adequate warm blankets in the crib.

• Ask the tech to place a hat and warm gown for the infant in the crib.

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.”

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 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 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?

Which is an important nursing intervention when caring for an infant with a myelomeningocele in the preop stage? 

• Place infant supine to decrease pressure on the sac.

• Apply a heat lamp to facilitate drying and toughening of the sac.

• Measure head circumference daily to identify developing hydrocephalus

• Apply a diaper to prevent contamination of the sac.

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 child with ADHD has the nursing diagnosis Delayed growth and development related to altered brain executive function as evidenced by hyperactivity, distractibility, and impaired play. The plan of care includes administration of methylphenidate (Concerta). The desired goal for which the nurse should monitor is:

• Increased expressiveness in communication with others.

• Improved ability to participate in play with other children.

• Ability to identify anxiety and implement self-control strategies.

• Improved socialization skills with other children and authority figures.

Shortly after a 15-year-old’s parents announced that they were divorcing, the adolescent stopped participating in sports, sat alone at lunch, avoided former friends, and  stayed in a bedroom while at home. The adolescent told the school nurse, “All the other kids have families. If my parents loved me, they would work out their problems.” What nursing diagnosis is most applicable?

• Decisional conflict

• Social isolation

• Chronic low self-esteem

• Disturbed personal identity

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)

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.