Mental Health Hardest Test! Trivia Quiz
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A patient with the diagnosis of schizophrenia, disorganized type, approaches the nurse and says, “It’s beat, it’s eaten. No room for doom.” The nurse can correctly assess this verbalization as:
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Neologisms
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Clanging
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Ideas of reference.
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Associative looseness.
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Challenge your understanding of psychiatric nursing with the 'Mental Health Hardest Test! Trivia Quiz'. Explore roles, interventions, advocacy, and perceptions in mental health care, assessing complex communication skills and critical thinking in real-world scenarios.
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- 2.
Which of these statements about suicide is accurate?
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The majority of persons who attempt suicide have given overt or covert indications of their intentions to others.
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A background in health care has a protective effect, leading to a lower rate of suicide among physicians and nurses than in the general public.
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Most persons with previous suicide attempts survived because they did not truly intend to die; they are at lower risk than those making their first attempt.
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Use of a low-lethality means or likelihood of being discovered in time to prevent death are merely suicide gestures, not genuine attempts.
Correct Answer
A. The majority of persons who attempt suicide have given overt or covert indications of their intentions to others.Explanation
The answer states that the majority of persons who attempt suicide have given overt or covert indications of their intentions to others. This means that most individuals who attempt suicide have shown signs or communicated their intentions to someone else, either directly or indirectly. This information is important because it emphasizes the importance of recognizing and responding to these indications in order to prevent suicide attempts and provide appropriate support and intervention.Rate this question:
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- 3.
A woman with a history of several suicide attempts by overdose is found to have recurrent major depression. Given this patient’s history and diagnosis, which of the following antidepressant medications would the nurse expect to be ordered?
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Amitriptyline (Elavil), a sedating tricyclic medication
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Desipramine (Norpramin), a stimulating tricyclic medication
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Fluoxetine (Prozac), a selective serotonin reuptake inhibitor
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Tranylcypromine sulfate (Parnate), a monoamine oxidase inhibitor
Correct Answer
A. Fluoxetine (Prozac), a selective serotonin reuptake inhibitorExplanation
The nurse would expect fluoxetine (Prozac), a selective serotonin reuptake inhibitor (SSRI), to be ordered for a patient with a history of several suicide attempts by overdose and recurrent major depression. SSRIs are commonly prescribed for major depression as they work by increasing the levels of serotonin in the brain, which can help improve mood and reduce the risk of suicide. Additionally, fluoxetine is a commonly prescribed SSRI due to its effectiveness and tolerability.Rate this question:
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- 4.
A patient has not come out of her room for breakfast. The nurse finds the patient moving restlessly about her room in a disorganized manner. The patient is talking to herself, and her verbal responses to the nurse are nonsensical and suggest disorientation. The nurse notices that the patient’s skin is hot and dry, and her pupils are somewhat dilated. All these symptoms are significant departures from the patient’s recent presentation. The patient is likely experiencing ________ , and the nurse should ___________.
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Agranulocytosis…hold her antipsychotic and draw blood for a complete blood count
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Anticholinergic toxicity…check vital signs and prepare to use a cooling blanket stat
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Relapse of her psychosis…administer PRN antipsychotic drugs and notify her physician
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Neuroleptic malignant syndrome…contact her physician for a transfer to intensive care
Correct Answer
A. Anticholinergic toxicity…check vital signs and prepare to use a cooling blanket statExplanation
The patient is likely experiencing anticholinergic toxicity, as indicated by her disorganized behavior, nonsensical verbal responses, hot and dry skin, and dilated pupils. Anticholinergic toxicity can occur as a result of taking medications with anticholinergic effects, such as certain antipsychotic drugs. Checking vital signs is necessary to monitor the patient's condition, and preparing to use a cooling blanket is important to help lower her body temperature, as anticholinergic toxicity can cause hyperthermia.Rate this question:
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- 5.
A student has committed suicide. Which statement(s) about those left behind after suicide is accurate?
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A suicide makes survivors more conscious of risk factors and more motivated to reduce risk in themselves and others, leading to a reduced risk of suicide in survivor groups.
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The first few weeks after a suicide are the most difficult and are when survivors are at highest risk; the risk then returns quickly to its pre-suicide level as time passes.
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All survivors are at increased risk, should be assessed for risk at intervals after their loss, and would benefit from ongoing support primary intervention to reduce their risk.
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Speaking of the dead increases the discomfort of surviving loved ones and should generally be avoided in their presence.
Correct Answer
A. All survivors are at increased risk, should be assessed for risk at intervals after their loss, and would benefit from ongoing support primary intervention to reduce their risk.Explanation
The answer states that all survivors of suicide are at increased risk and should be assessed for risk at intervals after their loss. This is accurate because suicide can have a profound impact on the mental health and well-being of those left behind. Assessing their risk and providing ongoing support and intervention can help reduce the risk of suicide among survivors. It is important to recognize the potential vulnerability of survivors and provide the necessary support to help them cope with their loss and prevent further harm.Rate this question:
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- 6.
A patient receiving risperidone (Risperdal) reports severe muscle stiffness midmorning. During lunch, he has difficulty swallowing food and speaking, and when vital signs are taken 30 minutes later, he is noted to be stuporous and diaphoretic, with a temperature of 38.8° C, the pulse of 110 beats/min, and blood pressure of 150/90 mm Hg. The nurse should suspect _________ and should ______________.
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Neuroleptic malignant syndrome…place him in a cooling blanket and transfer to ICU
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Anticholinergic toxicity…check vital signs and prepare to use a cooling blanket stat
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Relapse of his psychosis…administer PRN antipsychotic drugs and notify his physician
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Agranulocytosis…hold his antipsychotic and draw blood for a complete blood count
Correct Answer
A. Neuroleptic malignant syndrome…place him in a cooling blanket and transfer to ICUExplanation
The symptoms described in the scenario, such as severe muscle stiffness, difficulty swallowing, stupor, diaphoresis, elevated temperature, tachycardia, and increased blood pressure, are indicative of neuroleptic malignant syndrome (NMS). NMS is a potentially life-threatening condition that can occur as a side effect of antipsychotic medications like risperidone. The appropriate nursing intervention for NMS includes placing the patient in a cooling blanket to reduce body temperature and transferring them to the intensive care unit (ICU) for further management and monitoring.Rate this question:
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- 7.
A patient who has attempted suicide by taking a handful of ibuprofen (Motrin) is admitted to the mental health unit. She had attempted suicide three times previously, each by overdose on over-the-counter medications, and in each case was found by family or peers in time to prevent her death, eventually being admitted to this mental health unit each time. Which of the following nursing responses would be most appropriate?
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Search her and her belongings for pills and other dangerous objects, then minimize the attention given to her by staff in order to reduce secondary gains.
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When medically stable, confront her with her pattern of maladaptive coping, noting that the low lethality of her attempts suggests she is seeking attention.
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Discuss with her family ways that they can reduce her attention-seeking suicide gestures by keeping all medications locked and not responding to histrionic behavior.
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Place her on one-to-one observation because her history of previous attempts suggests she is at high risk of suicide; once medically stable, begin intensive psychiatric treatment.
Correct Answer
A. Search her and her belongings for pills and other dangerous objects, then minimize the attention given to her by staff in order to reduce secondary gains.Explanation
The most appropriate nursing response in this situation is to search the patient and her belongings for pills and other dangerous objects, and then minimize the attention given to her by staff in order to reduce secondary gains. This response is appropriate because the patient has a history of previous suicide attempts and is at high risk of further attempts. By searching for dangerous objects, the staff can ensure the patient's safety. Minimizing attention can help reduce the reinforcement the patient may receive from her attempts, discouraging future attempts and promoting healthier coping mechanisms.Rate this question:
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- 8.
An adolescent who attempted suicide and was admitted to an inpatient mental health unit had been assessed as being at high risk of self-harm, but he has shown improvement. His doctor is now considering discharge and asks the nurse’s opinion. Which of the following observations most reliably indicates that he may be ready for discharge to outpatient care?
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He denies that suicide ideation and intent are present.
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His family agrees to observe him closely at home.
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His SAD PERSONS score has gone from a 4 to a 2.
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He focuses on problem solving and hope for the future.
Correct Answer
A. He focuses on problem solving and hope for the future.Explanation
The observation that the adolescent focuses on problem solving and hope for the future indicates that he may be ready for discharge to outpatient care. This suggests that he has developed coping skills and a positive mindset, which are important factors in preventing future self-harm. Denying suicide ideation and intent, having family support, and a decrease in SAD PERSONS score are also positive indicators, but focusing on problem solving and hope for the future shows a more comprehensive improvement in the adolescent's mental state.Rate this question:
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- 9.
A patient with schizophrenia has received typical (first-generation) antipsychotics for a year. His hallucinations are less intrusive, but he remains apathetic, has a poverty of thought, cannot work, and is socially isolated. To address these symptoms, the nurse might consult the prescribing health care provider to suggest a change to:
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Haloperidol (Haldol).
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Olanzapine (Zyprexa).
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Diphenhydramine (Benadryl).
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Chlorpromazine (Thorazine).
Correct Answer
A. Olanzapine (Zyprexa).Explanation
The patient's symptoms of apathy, poverty of thought, inability to work, and social isolation suggest negative symptoms of schizophrenia. Typical antipsychotics, such as haloperidol and chlorpromazine, are more effective in treating positive symptoms like hallucinations. Olanzapine, an atypical antipsychotic, has been shown to be more effective in treating negative symptoms. Therefore, switching to olanzapine would be a suitable suggestion to address the patient's remaining symptoms. Diphenhydramine is an antihistamine and is not indicated for treating schizophrenia.Rate this question:
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- 10.
An adolescent whose peer committed suicide attempts suicide himself and is admitted to an inpatient mental health unit and assessed as being at high risk for self-harm. Which of the following nursing actions would be most appropriate to assure his safety during his first few days in the hospital?
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Place him on every-15-minute checks while awake.
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Search the patient and his belongings for dangerous material.
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Have him sign a no-suicide contract on arrival to the unit.
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Place him on direct one-to-one observation 24 hours a day.
Correct Answer
A. Place him on direct one-to-one observation 24 hours a day.Explanation
Placing the adolescent on direct one-to-one observation 24 hours a day would be the most appropriate nursing action to assure his safety during his first few days in the hospital. This level of observation ensures constant monitoring and supervision to prevent any self-harm or suicide attempts. It allows for immediate intervention and support if any signs of distress or risk are observed. This action prioritizes the safety and well-being of the adolescent, providing a higher level of care and support during this critical period.Rate this question:
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- 11.
16. A patient, aged 82 years, has Alzheimer’s disease. She lives with her daughter’s family and goes to a day care facility on weekdays. The nurse at the day care center noticed the patient was unkempt and had multiple bruises. When the daughter arrived to pick her up, the nurse discussed her observations. The daughter became defensive and said that her mother was very difficult to manage. She stated, “My mother is not my mother anymore. She is confused, and she wanders all night. We have to watch her constantly. Last night I fell asleep, and she fell down the stairs. Sometimes I just cannot bear to care for her.” Which nursing diagnosis would be most important to address for this patient?
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Risk for injury related to impaired cognition, judgment, and coordination and lack of caregiver supervision
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Nonadherence related to confusion and disorientation, as evidenced by lack of cooperation
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Anxiety related to increasing disorientation, as evidenced by the patient wandering at night Anxiety related to increasing disorientation, as evidenced by the patient wandering at night
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Impaired verbal communication related to brain impairment, as evidenced by the patient's confusion
Correct Answer
A. Risk for injury related to impaired cognition, judgment, and coordination and lack of caregiver supervisionExplanation
The most important nursing diagnosis to address for this patient is the risk for injury related to impaired cognition, judgment, and coordination and lack of caregiver supervision. The patient's Alzheimer's disease has caused confusion and disorientation, leading to wandering at night and the potential for falls and injuries. The daughter's statement about her mother being difficult to manage and the incident of falling down the stairs highlight the need for increased caregiver supervision to prevent further harm.Rate this question:
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- 12.
18. A nurse is working with a perpetrator of family violence who has a long history of violent rages when frustrated, with periods of remorse after each outburst. The nurse is most likely to establish the nursing diagnosis of:
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Risk for injury related to victim reprisal.
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Risk for other-directed violence related to stress.
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Ineffective coping related to poor anger management.
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Caregiver role strain related to feelings of being overwhelmed.
Correct Answer
A. Ineffective coping related to poor anger management.Explanation
The correct answer is "Ineffective coping related to poor anger management." This nursing diagnosis is most appropriate for a perpetrator of family violence who has a long history of violent rages when frustrated. The individual's inability to effectively cope with their anger and manage their emotions contributes to their violent outbursts. By identifying this nursing diagnosis, the nurse can develop interventions to help the individual develop healthier coping strategies and anger management skills, ultimately reducing the risk of further violence.Rate this question:
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- 13.
13. A victim of partner abuse, parent of one child, describes the partner as someone who is easily frustrated and more likely to be abusive after a experiencing an event in which self-esteem is challenged. The most recent episodes of violence were related to feeling “upset” over a job loss. What type of therapy would provide the greatest help to the victim?
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Individual therapy
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Group therapy
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Couples therapy
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Family therapy
Correct Answer
A. Group therapyExplanation
Group therapy would provide the greatest help to the victim of partner abuse in this scenario. This type of therapy allows individuals to share their experiences and receive support from others who have gone through similar situations. It can help the victim feel less isolated and alone, while also providing a safe space to discuss their feelings and learn coping strategies. Additionally, group therapy can help the victim gain insight into their own patterns of behavior and develop healthier ways of dealing with challenges.Rate this question:
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- 14.
21. Several children a day are seen in the emergency department for treatment of illnesses and injuries. The situation that would create a high index of suspicion of child abuse is a child who:
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Has repeated middle ear infections.
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Complains of abdominal cramps and upset stomach.
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Has perineal bruises and urinary tract infections.
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Displays reduced functioning at school.
Correct Answer
A. Has perineal bruises and urinary tract infections.Explanation
A child who has perineal bruises and urinary tract infections would create a high index of suspicion of child abuse because these symptoms could indicate sexual abuse. Perineal bruises could suggest physical trauma, and urinary tract infections can be a result of sexual abuse. This combination of symptoms raises concerns about the child's safety and well-being.Rate this question:
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- 15.
22. The nurse at the clinic is interviewing a patient who offers a number of vague somatic complaints that might not ordinarily prompt a visit to a caregiver: fatigue, back pain, headaches, and sleep disturbance. The patient seems tense, and after having spoken of the symptoms, seems reluctant to provide more information and is in a hurry to leave. The nurse can best serve the patient by:
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Asking if the patient has ever had psychiatric counseling.
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Completing a structured abuse assessment protocol.
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Exploring the possibility of patient social isolation.
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Asking the patient to disrobe to check for signs of abuse.
Correct Answer
A. Completing a structured abuse assessment protocol.Explanation
Based on the given information, the patient presents with vague somatic complaints and exhibits signs of tension and reluctance to provide more information. These symptoms, combined with the patient's hurry to leave, suggest the possibility of abuse. Completing a structured abuse assessment protocol would be the best course of action for the nurse to ensure the patient's safety and well-being. This protocol would help identify any potential signs or indicators of abuse and allow for appropriate intervention and support.Rate this question:
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- 16.
23. A woman has concerns about a man she recently began to date. She confides to her friend, a nurse in the clinic, that she recently discovered that he had been charged with domestic violence in a previous relationship. She asks if this means he will also hurt her and what signs would indicate that he is likely to be abusive. What should the nurse tell her friend?
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“If he hasn’t been abusive or controlling so far. chances are he won’t be abusive later.”
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“Abuse occurs within dysfunctional relationships, so it may not occur in your situation.”
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“Danger signs include pathological jealousy and controlling the partner’s activities.”
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“Because you are not masochistic or provocative, it is unlikely you will be abused.”
Correct Answer
A. “Danger signs include pathological jealousy and controlling the partner’s activities.”Explanation
The nurse should tell her friend that danger signs of an abusive partner include pathological jealousy and controlling the partner's activities. This answer provides important information about what to look out for in a potentially abusive relationship. It acknowledges that there are warning signs that can indicate a person's likelihood to be abusive.Rate this question:
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- 17.
1. A woman was bound, taken to a remote location, and raped at gunpoint. When found, she was examined and treated in the emergency department. Which aspect of this crisis produced the greatest amount of psychological trauma?
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The threat to her life
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Collection of evidence
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Physical pain experienced
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Being in a remote location
Correct Answer
A. The threat to her lifeExplanation
The threat to her life produced the greatest amount of psychological trauma because it represents a direct danger to her survival. The fear and helplessness she experienced during the assault, knowing that her life was at risk, would have a profound impact on her mental well-being. The physical pain experienced and being in a remote location may also contribute to the trauma, but the immediate threat to her life would likely be the most significant factor. The collection of evidence, although important for legal purposes, may not have had as much of a direct impact on her psychological trauma.Rate this question:
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- 18.
2. A woman, abducted and raped at gunpoint by an unknown assailant, was found confused and disoriented. The nurse makes these observations about the patient: o talking rapidly in disjointed phrases o unable to concentrate o indecisive when asked to make simple decisions What is the patient’s level of anxiety?
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Weak
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Mild
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Moderate
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Severe
Correct Answer
A. SevereExplanation
The patient's level of anxiety is severe based on the nurse's observations. The patient is talking rapidly in disjointed phrases, unable to concentrate, and indecisive when asked to make simple decisions. These symptoms suggest high levels of anxiety, which can significantly impair a person's ability to function and make decisions.Rate this question:
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- 19.
3. After a person was abducted and raped at gunpoint by an unknown assailant, which assessment finding best indicates the acute phase of the rape-trauma syndrome?
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Decreased motor activity
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Confusion and disbelief
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Flashbacks and dreams
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Fears and phobias
Correct Answer
A. Confusion and disbeliefExplanation
After experiencing a traumatic event such as abduction and rape, it is common for individuals to feel confused and disbelieve what has happened to them. This is a normal reaction during the acute phase of the rape-trauma syndrome. Decreased motor activity may be a sign of depression or withdrawal, flashbacks and dreams are more commonly associated with the reorganization phase, and fears and phobias may develop later on as the individual tries to cope with the trauma.Rate this question:
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- 20.
4. 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?
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Somatization
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Repression
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Projection
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Denial
Correct Answer
A. DenialExplanation
The patient's present coping strategy is denial. This can be inferred from the patient's statement that they "can't talk about it" and that "nothing happened." This suggests that the patient is refusing to acknowledge or accept the traumatic experience they went through, possibly as a way to protect themselves from the emotional pain and distress associated with it. Denial is a defense mechanism often used to avoid facing uncomfortable or distressing realities.Rate this question:
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- 21.
5. An emergency department nurse prepares to assist with evidence collection for a sexual assault victim. Prior to photographs and pelvic examination, what documentation is important?
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The patient’s vital signs
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Consent signed by the patient
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Supervision and credentials of the examiner
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Storage location of the patient’s personal effects
Correct Answer
A. Consent signed by the patientExplanation
Prior to conducting any evidence collection procedures, it is crucial to have the patient's consent. This ensures that the patient is aware of and agrees to the procedures being performed on them. Consent is an essential aspect of providing ethical and patient-centered care, especially in sensitive situations such as sexual assault cases. The other options, while important in the overall process, do not take precedence over obtaining the patient's consent.Rate this question:
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- 22.
6. Which aspect of assessment has priority when a nurse interviews a rape victim?
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Coping mechanisms the patient is using
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The patient’s previous sexual experiences
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Adequacy of the patient’s interpersonal relationships
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Whether the patient has ever had a sexually transmitted disease
Correct Answer
A. Coping mechanisms the patient is usingExplanation
When a nurse interviews a rape victim, the priority aspect of assessment is to determine the coping mechanisms the patient is using. This is important because it helps the nurse understand how the patient is dealing with the traumatic experience and provides insights into their emotional well-being. By assessing coping mechanisms, the nurse can identify any maladaptive behaviors or signs of distress that may require immediate intervention or support. Understanding the patient's coping mechanisms also helps in developing a comprehensive care plan tailored to their specific needs.Rate this question:
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- 23.
8. A rape victim tells the nurse, “I should not have been out on the street alone.” Select the nurse’s most helpful response.
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“Rape can happen anywhere.”
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“Blaming yourself increases your anxiety and discomfort.”
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“You are right. You should not have been alone on the street at night.”
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“You feel as though this would not have happened if you had not been alone.”
Correct Answer
A. “You feel as though this would not have happened if you had not been alone.”Explanation
The nurse's most helpful response is "You feel as though this would not have happened if you had not been alone." This response acknowledges and validates the victim's feelings without blaming or shaming them. It shows empathy and understanding towards the victim's perspective, which can help build trust and rapport between the nurse and the victim.Rate this question:
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- 24.
11. A victim of rape says, “My family is not very supportive.” Which belief contributes to a negative family response?
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No one asks to be raped.
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Rape is an act of aggression.
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Rape should not be discussed.
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Anyone is a potential rape victim.
Correct Answer
A. Rape should not be discussed.Explanation
The belief that "Rape should not be discussed" can contribute to a negative family response because it implies that talking about rape is taboo or inappropriate. This belief may lead the family to avoid discussing the issue, which can result in a lack of support for the victim. By not discussing rape, the family may fail to provide the necessary emotional support, understanding, and resources that the victim needs to cope with the trauma.Rate this question:
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- 25.
12. A nurse works a rape telephone hotline. Communication should focus on:
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Explaining immediate steps victims should take.
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Providing callers with a sympathetic listener.
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Obtaining information for law enforcement.
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Arranging long-term counseling.
Correct Answer
A. Explaining immediate steps victims should take.Explanation
In the context of a rape telephone hotline, the most important focus of communication should be on explaining immediate steps that victims should take. This is crucial because victims of rape need immediate support and guidance on what actions they should take to ensure their safety and well-being. Providing callers with a sympathetic listener is important, but it is secondary to ensuring that victims receive the necessary information and guidance to handle the immediate aftermath of the incident. Obtaining information for law enforcement and arranging long-term counseling may also be important, but they are not the primary focus of communication on a rape hotline.Rate this question:
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- 26.
15. When a victim of sexual assault is discharged from the emergency department, the nurse should:
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Notify the patient’s family of the event to ensure support for the patient.
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Offer to stay with the patient until stability is regained.
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Advise the patient to try not to think about the assault.
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Provide referral information verbally and in writing.
Correct Answer
A. Provide referral information verbally and in writing.Explanation
When a victim of sexual assault is discharged from the emergency department, it is important for the nurse to provide referral information verbally and in writing. This ensures that the patient has access to the necessary resources and support services, such as counseling, legal assistance, and support groups. Providing this information in both verbal and written form helps to ensure that the patient can easily access the information when needed and can make informed decisions about their next steps in seeking help and support.Rate this question:
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- 27.
17. A patient in the long-term phase of the rape-trauma syndrome had intrusive thoughts of the attack and developed fears of being alone. Which finding best demonstrates the patient has improved? The patient:
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Uses increased activity to reduce fear.
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Plans coping strategies for fearful situations.
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Temporarily withdraws from social situations.
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Expresses willingness to engage in sexual activity.
Correct Answer
A. Plans coping strategies for fearful situations.Explanation
The finding that the patient plans coping strategies for fearful situations demonstrates improvement because it indicates that the patient is actively taking steps to manage their fears and regain control over their life. This shows that they are developing a proactive approach to deal with their intrusive thoughts and fears, which is a positive sign of progress in the long-term phase of the rape-trauma syndrome.Rate this question:
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- 28.
19. A friend brings a teenager to the emergency department. The friend found the patient unconscious in a bedroom at a party. Semen is observed on the patient’s underclothes. Priority actions by the nurse should focus on:
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Preserving rape evidence.
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Maintaining the patient’s airway.
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Obtaining a description of the rape.
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Determining what drugs were ingested.
Correct Answer
A. Maintaining the patient’s airway.Explanation
The priority actions by the nurse should focus on maintaining the patient's airway. This is because the patient is found unconscious, indicating a potential risk to their breathing and oxygenation. Ensuring a clear airway is crucial for the patient's immediate safety and well-being. While preserving rape evidence and obtaining a description of the rape are important considerations, they are not the immediate priority in this situation. Determining what drugs were ingested may be relevant for the patient's overall care, but it is not the priority action at this moment.Rate this question:
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- 29.
20. A victim of a violent rape was treated in the emergency department. As discharge preparation begins, the victim says softly, “I will never be the same again. I can’t face my friends. There is no reason to go on.” Select the nurse’s most appropriate response.
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“Are you thinking of harming yourself?”
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“It will take time, but you will feel the same.”
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“Your friends will understand when you explain it was not your fault.”
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“You will be able to find meaning in this experience as time goes on.”
Correct Answer
A. “Are you thinking of harming yourself?”Explanation
The nurse's most appropriate response is "Are you thinking of harming yourself?" because the victim expressed feelings of hopelessness and mentioned that there is no reason to go on. This response shows concern for the victim's well-being and acknowledges the possibility of suicidal thoughts, which is important in assessing the level of risk and ensuring appropriate intervention is provided if needed.Rate this question:
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- 30.
21. A nurse cares for a rape victim who was given flunitrazepam (Rohypnol) by the assailant. Which intervention has priority? Monitoring for:
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Coma
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Seizures
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Hypotonia
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Respiratory depression
Correct Answer
A. Respiratory depressionExplanation
The priority intervention for a rape victim who was given flunitrazepam (Rohypnol) by the assailant is monitoring for respiratory depression. Flunitrazepam is a benzodiazepine that can cause central nervous system depression, including respiratory depression. This can be life-threatening and requires immediate attention. Coma, seizures, and hypotonia may also occur as a result of the drug, but respiratory depression poses the greatest immediate risk to the patient's life.Rate this question:
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- 31.
1. An adult confides to a nurse, “The cancer in my neck spread in only 2 months. That is how my whole life has been. No matter what I do, I am sabotaged.” As this patient faces the prospect of dying, which motif is evident?
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Quest: seeking meaning in dying
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Volatile: unresolved and unresigned
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Endurance: triumph of inner strength
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Incorporation: belief system accommodates death
Correct Answer
A. Volatile: unresolved and unresignedExplanation
The correct answer is "Volatile: unresolved and unresigned." This motif is evident in the patient's statement about how their cancer spread quickly and how their whole life has been sabotaged, indicating a sense of unresolved anger, frustration, and lack of acceptance. This suggests that the patient is not resigned to their fate and is still grappling with the emotional and psychological impact of their illness.Rate this question:
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- 32.
2. Four teenagers died in an automobile accident. One week later, which behavior by parents indicates adaptive mourning? The parents who:
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Isolate themselves at home.
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Return immediately to employment.
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Forbid other teens in the household to drive a car.
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Create a scholarship fund at their child’s high school.
Correct Answer
A. Create a scholarship fund at their child’s high school.Explanation
Creating a scholarship fund at their child's high school indicates adaptive mourning because it shows that the parents are finding a positive way to remember and honor their child's memory. By creating a scholarship fund, they are helping other students and contributing to their child's school community, which can bring a sense of purpose and healing during the grieving process. This behavior also shows resilience and a desire to make a difference in their child's name.Rate this question:
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- 33.
8. A patient who was widowed 18 months ago says, “I can remember good times we had without getting upset. Sometimes I even think about the disappointments. I am still trying to become accustomed to sleeping in the bed all alone.” The work of mourning:
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Is beginning.
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Has not begun.
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Is at or near completion.
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Is progressing abnormally.
Correct Answer
A. Is at or near completion.Explanation
The patient's statement indicates that they are able to remember the good times without getting upset and are even thinking about the disappointments. They also mention that they are still trying to become accustomed to sleeping alone. These statements suggest that the patient has already gone through the process of mourning and is at or near completion.Rate this question:
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- 34.
13. Which finding indicates successful completion of an individual’s grieving process?
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For 2 years after her husband’s death, a widow has kept her husband’s belongings in their usual places.
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After 15 months, a widower realistically remembers both the pleasures and disappointments of his relationship with his wife.
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Three years after her husband’s death, a widow talks about her husband as if he is alive and weeps when others mention his name.
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Eighteen months after a spouse’s death, a person says, “I have never cried or had feelings of loss, even though we were very close.”
Correct Answer
A. After 15 months, a widower realistically remembers both the pleasures and disappointments of his relationship with his wife.Explanation
This finding indicates successful completion of an individual's grieving process because it shows that the widower is able to remember the positive and negative aspects of his relationship with his wife in a realistic manner. This suggests that he has come to terms with the loss and has processed his emotions, allowing him to reflect on the past without being overwhelmed by grief.Rate this question:
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- 35.
14. A child drowned while swimming in a local lake 2 years ago. Which behavior indicates the child’s parents are mourning in an effective way? The parents who:
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Forbid their other children from going swimming.
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Keep a place set for the dead child at the family dinner table.
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Sealed their child’s room exactly as the child left it 2 years ago.
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Throw flowers on the lake at each anniversary date of the accident.
Correct Answer
A. Forbid their other children from going swimming.Explanation
The behavior that indicates the child's parents are mourning in an effective way is forbidding their other children from going swimming. This behavior shows that the parents are taking precautions to ensure the safety of their remaining children and are actively trying to prevent a similar tragedy from happening again.Rate this question:
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- 36.
28. A nurse asks a hospice nurse, “Who should be referred for hospice care?” Select the correct reply.
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“Hospice is for terminally ill patients with cancer.”
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“Patients in the end stage of any disease are eligible.”
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“We are best equipped to care for patients with end-stage renal disease.”
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“Patients with degenerative neurological disease are eligible after respiration is affected.”
Correct Answer
A. “Patients in the end stage of any disease are eligible.”Explanation
The correct answer is "Patients in the end stage of any disease are eligible." This answer is correct because hospice care is not limited to patients with cancer. Hospice care is provided to individuals who are in the final stages of any disease, regardless of the specific diagnosis. Hospice care focuses on providing comfort and support to patients and their families during this difficult time.Rate this question:
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- 37.
1. Which statement about aggression would accurately serve as a basis for care planning?
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Brain injury or disorders are often blamed for, but rarely contribute to, violence.
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Some people are biologically predisposed to become irritated or angry more easily.
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Aggression is an innate behavior rather than a learned response to frustration.
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Mature persons with patterns of effective coping almost never behave violently.
Correct Answer
A. Some people are biologically predisposed to become irritated or angry more easily.Explanation
Some people are biologically predisposed to become irritated or angry more easily. This statement accurately serves as a basis for care planning because it recognizes that aggression can be influenced by biological factors. Understanding this predisposition can help healthcare professionals develop appropriate interventions and strategies to manage and prevent aggressive behaviors in individuals who are more prone to becoming easily irritated or angry.Rate this question:
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- 38.
4. A patient is admitted for psychiatric observation after being arrested for breaking windows in the home of his former girlfriend, who had refused to see him. His history reveals abuse as a child by a punitive father, torturing family pets, and one arrest for disorderly conduct. The priority nursing diagnosis that should be considered is:
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Stress overload.
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Ineffective coping.
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Risk for self-directed violence.
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Risk for other-directed violence.
Correct Answer
A. Risk for other-directed violence.Explanation
Based on the patient's history of breaking windows in his former girlfriend's home and his previous arrest for disorderly conduct, it is evident that he has a risk for other-directed violence. This behavior suggests that he may pose a threat to others, specifically his former girlfriend. Therefore, the priority nursing diagnosis should be focused on assessing and managing this risk to ensure the safety of both the patient and others.Rate this question:
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- 39.
6. A patient who has been seen responding to auditory hallucinations earlier in the morning approaches the nurse and shakes his fist, saying, “Back off, bitch!” and then goes into the day room. Which intervention would be most important to undertake before the nurse follows the patient into the day room?
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Contact the patient’s physician to obtain an order for seclusion.
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Review the patient’s history for clues about his risk of violence.
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Assure that adequate staff are available and nearby for backup.
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Check for orders for PRN medication and prepare a sedative.
Correct Answer
A. Assure that adequate staff are available and nearby for backup.Explanation
Before following the patient into the day room, the most important intervention would be to assure that adequate staff are available and nearby for backup. The patient's aggressive behavior indicates a potential risk of violence, and having enough staff present ensures the safety of both the patient and the nurse. It allows for immediate assistance if the situation escalates and helps prevent any harm or injury. Contacting the patient's physician, reviewing the patient's history, and preparing a sedative may be important interventions as well, but ensuring the presence of sufficient staff is the priority in this situation.Rate this question:
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- 40.
9. Which characteristics of the unit milieu are most likely to result in a low incidence of violent behavior?
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A milieu that emphasizes maintaining control and structure
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A unit that is adequately staffed and not overcrowded
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A unit that has a high percentage of newer, fresher staff
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A milieu that focuses on privileges to reward or punish behavior
Correct Answer
A. A unit that is adequately staffed and not overcrowdedExplanation
A unit that is adequately staffed and not overcrowded is likely to result in a low incidence of violent behavior because having enough staff ensures that patients receive appropriate care and attention, reducing the likelihood of conflicts or aggression. Additionally, an overcrowded unit can create a stressful and tense environment, increasing the chances of violent behavior.Rate this question:
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- 41.
14. A cognitively impaired patient who has been a widow for 30 years is frantically trying to leave the unit, saying, “I have to go home to start dinner before my husband comes home from work.” To intervene with validation therapy, the nurse should say:
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“Please, you must come away from the door.”
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“Mrs. Smith, you have been a widow for many years.”
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“You want to go home to get your husband’s dinner.”
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“I think your husband said he is going to eat out tonight.”
Correct Answer
A. “You want to go home to get your husband’s dinner.”Explanation
The correct answer is "You want to go home to get your husband’s dinner." This response acknowledges and validates the patient's feelings and desires, demonstrating understanding and empathy. By affirming the patient's need to go home and prepare dinner for her husband, the nurse is using validation therapy to validate the patient's reality and help her feel heard and understood. This approach can help reduce the patient's anxiety and agitation, promoting a sense of calm and well-being.Rate this question:
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- 42.
18. The emergency department nurse realizes that the husband of a patient appears increasingly irritable as he waits alone in the waiting room. Which intervention would best prevent further escalation?
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Periodically update the husband about his wife and what is being done for her.
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Explain that waiting is necessary because patients are treated in order of need.
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Reassure him that everything possible is being done and suggest ways to relax.
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Suggest that he return home and await an update from the physician in 3 hours.
Correct Answer
A. Periodically update the husband about his wife and what is being done for her.Explanation
Periodically updating the husband about his wife and what is being done for her would best prevent further escalation. This intervention shows empathy and provides the husband with information, helping to alleviate his anxiety and irritability. It keeps him engaged and informed, reducing his feelings of helplessness and frustration. By regularly updating him, the nurse acknowledges his concerns and demonstrates that his wife's care is a priority. This intervention promotes effective communication and helps to maintain a positive and supportive environment in the waiting room.Rate this question:
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- 43.
22. When a patient’s aggression quickly escalates, on which principle should nursing intervention be based?
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Staff should match their tone of voice and level of intensity to the patient’s.
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When there is no time to de-escalate, immediate use of restraint is necessary.
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Always ask the patient what will be most helpful to increase his sense of control.
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Choose the least restrictive measure that will keep the patient and others safe.
Correct Answer
A. Choose the least restrictive measure that will keep the patient and others safe.Explanation
The correct answer is to choose the least restrictive measure that will keep the patient and others safe. This principle is based on the ethical concept of promoting autonomy and minimizing harm. It recognizes the importance of respecting the patient's rights and dignity while ensuring the safety of everyone involved. By prioritizing the least restrictive intervention, nurses aim to maintain a therapeutic and supportive environment that encourages the patient's sense of control and autonomy. This approach also aligns with the principles of trauma-informed care, which emphasizes the importance of minimizing retraumatization and promoting empowerment.Rate this question:
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- 44.
23. A newly admitted patient required seclusion immediately on entering the inpatient unit. His assessment was incomplete, and no medical orders had been written. Immediately after secluding the patient, the priority action of the nurse should be to:
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Provide a chance for the patient to use the bathroom.
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Notify the physician and obtain an order for seclusion.
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Complete necessary forms and notify the unit manager.
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Debrief the staff and any witnesses to the incident.
Correct Answer
A. Notify the physician and obtain an order for seclusion.Explanation
In this scenario, the patient required seclusion immediately upon entering the inpatient unit. However, the assessment was incomplete and no medical orders had been written. The priority action for the nurse should be to notify the physician and obtain an order for seclusion. This is important to ensure that the patient's safety and well-being are properly addressed and that the appropriate legal and ethical procedures are followed.Rate this question:
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- 45.
24. A newly admitted patient required seclusion immediately on entering the inpatient unit. What criteria would the nurse use to decide when to discontinue the use of seclusion?
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Seclusion can be discontinued when the patient seems calm.
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Discontinuation is based on outcomes developed for each patient.
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Seclusion continues until the patient has been calm for at least 4 hours.
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Seclusion lasts until the physician orders its discontinuation.
Correct Answer
A. Discontinuation is based on outcomes developed for each patient.Explanation
The nurse would use the criteria of outcomes developed for each patient to decide when to discontinue the use of seclusion. This means that the decision to discontinue seclusion would be based on the specific goals and progress of the individual patient, rather than a set time frame or the physician's orders.Rate this question:
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- 46.
25. A patient requires as-needed sedation. What would the nurse keep in mind when choosing a PRN sedative for an agitated patient?
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Intramuscular injection can be traumatic, so oral meds should be used where possible.
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Benzodiazepines are less sedating but have the advantage of no side effects.
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Lithium carbonate works well but only for those already taking regular daily dosages.
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Diazepam (Valium) is the preferred benzodiazepine because it is a short-acting sedative.
Correct Answer
A. Intramuscular injection can be traumatic, so oral meds should be used where possible.Explanation
The nurse should keep in mind that intramuscular injection can be traumatic, so oral medications should be used whenever possible. This means that if there is an option to administer the sedative orally, it should be chosen over the intramuscular route. This is because intramuscular injections can be painful and may cause discomfort for the patient. Using oral medications can provide a more comfortable and less invasive method of administering the sedative.Rate this question:
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- 47.
1. A patient with schizophrenia, aged 60 years, spent 5 years in a state hospital before being discharged to a community residence. The patient requires persistent direction to accomplish daily activities of living, has difficulty determining what to do with his time, and is resistant to behaving independently, expecting others to provide meals or wash his clothes. The nurse assesses this passive behavior as being the probable result of:
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Dependency caused by institutionalization.
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Cognitive deterioration from schizophrenia.
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Brain damage from recreational drug use.
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Side effects of neuroleptic medications.
Correct Answer
A. Dependency caused by institutionalization.Explanation
The patient's passive behavior and difficulty in performing daily activities of living, as well as the expectation for others to provide meals and wash clothes, suggest that the behavior is likely a result of dependency caused by institutionalization. Spending 5 years in a state hospital may have led to the patient becoming accustomed to relying on others for their needs, resulting in a lack of independence and difficulty in determining how to spend their time. This explanation is supported by the information provided in the question.Rate this question:
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- 48.
3. A man with schizophrenia states: “I will not take medicine—there is nothing wrong with me! Why would I take medicine when I’m not sick! They only put me here because they want to steal my thoughts so they can sell them.” What is this patient demonstrating?
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Denial
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Anosognosia
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Rationalization
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Hallucinations
Correct Answer
A. AnosognosiaExplanation
The patient is demonstrating anosognosia, which is a lack of awareness or denial of their own illness. The patient believes that there is nothing wrong with them and refuses to take medicine because they do not perceive themselves as being sick. They also have delusions that the hospital staff wants to steal their thoughts, which is a symptom of schizophrenia.Rate this question:
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- 49.
4. A severely mentally ill man neglects to pay his rent and becomes homeless, so he sleeps in 24-hour laundromats and washes in public restrooms. His SSI checks are returned as undeliverable. Without money he cannot buy food, and as a result he steals a bag of chips, leading to incarceration. Which nursing diagnosis would most likely apply?
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Social isolation
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Risk for low self-esteem
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Impaired social interaction
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Self-care deficit
Correct Answer
A. Risk for low self-esteemExplanation
The nursing diagnosis that would most likely apply in this situation is "Risk for low self-esteem." This is because the individual's mental illness and subsequent homelessness can lead to feelings of worthlessness and a negative self-perception. The lack of social interaction, inability to meet basic needs, and resorting to stealing further contribute to the risk of low self-esteem.Rate this question:
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Current Version
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Mar 22, 2023Quiz Edited by
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Jun 11, 2015Quiz Created by
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