Psychiatric Nursing Pt. 9

1. During the initial care of rape victims the following are to be considered EXCEPT:

Assure privacy.

Touch the client to show acceptance and empathy

Accompany the client in the examination room.

Maintain a non-judgmental approach.

Touch the client to show acceptance and empathy
The client finds touch intrusive and therefore should be avoided. A. Privacy is one of the rights of a victim of rape. C.The client is anxious. Accompanying the client in a quiet room ensures safety and offers emotional support. D. Guilt feeling is common among rape victims. They should not be blamed.

Explanation

Touch the client to show acceptance and empathy
The client finds touch intrusive and therefore should be avoided. A. Privacy is one of the rights of a victim of rape. C.The client is anxious. Accompanying the client in a quiet room ensures safety and offers emotional support. D. Guilt feeling is common among rape victims. They should not be blamed.

2. Five months after the incident the client complains of difficulty to concentrate, poor appetite, inability to sleep and guilt. She is likely suffering from:

Adjustment disorder

Somatoform Disorder

Generalized Anxiety Disorder

Post traumatic disorder

Post traumatic disorder
Post traumatic stress disorder is characterized by flashback, irritability, difficulty falling asleep and concentrating following an extremely traumatic event. This lasts for more that one month A. Adjustment disorder is the maladaptive reaction to stressful events characterized by anxiety, depression and work or social impairments. This occurs within 3 months after the event B. Somatoform disorders are anxiety related disorders characterized by presence of physical symptoms without demonstrable organic basis C. Generalized anxiety disorder is characterized by chronic, excessive anxiety for at least 6 months

Explanation

Post traumatic disorder
Post traumatic stress disorder is characterized by flashback, irritability, difficulty falling asleep and concentrating following an extremely traumatic event. This lasts for more that one month A. Adjustment disorder is the maladaptive reaction to stressful events characterized by anxiety, depression and work or social impairments. This occurs within 3 months after the event B. Somatoform disorders are anxiety related disorders characterized by presence of physical symptoms without demonstrable organic basis C. Generalized anxiety disorder is characterized by chronic, excessive anxiety for at least 6 months

3. Anxiety is caused by:

An objective threat

A subjectively perceived threat

Hostility turned to the self

Masked depression

a subjectively perceived threat
Anxiety is caused by a subjectively perceived threat A. Fear is caused by an objective threat C. A depressed client internalizes hostility D. Mania is due to masked depression

Explanation

a subjectively perceived threat
Anxiety is caused by a subjectively perceived threat A. Fear is caused by an objective threat C. A depressed client internalizes hostility D. Mania is due to masked depression

4. Which of the following is included in the health teachings among clients receiving Valium?:

Avoid foods rich in tyramine.

Take the medication after meals.

It is safe to stop it anytime after long term use.

Double up the dose if the client forgets her medication.

Take the medication after meals.
Antianxiety medications cause G.I. upset so it should be taken after meals. A. This is specific for antidepressant MAOI. Taking tyramine rich food can cause hypertensive crisis. C. Valium causes dependency. In which case, the medication should be gradually withdrawn to prevent the occurrence of convulsion. D The dose of Valium should not be doubled if the previous dose was not taken. It can intensify the CNS depressant effects.

Explanation

Take the medication after meals.
Antianxiety medications cause G.I. upset so it should be taken after meals. A. This is specific for antidepressant MAOI. Taking tyramine rich food can cause hypertensive crisis. C. Valium causes dependency. In which case, the medication should be gradually withdrawn to prevent the occurrence of convulsion. D The dose of Valium should not be doubled if the previous dose was not taken. It can intensify the CNS depressant effects.

5. It would be most helpful for the nurse to deal with a client with severe anxiety by:

Give specific instructions using speak in concise statements.

Ask the client to identify the cause of her anxiety.

Explain in detail the plan of care developed

Urge the client to focus on what the nurse is saying

Give specific instructions using speak in concise statements.
The client has narrowed perceptual field. Lengthy explanations cannot be followed by the client. B. The client will not be able to identify the cause of anxiety C and D. The client has difficulty concentrating and will not be able to focus.

Explanation

Give specific instructions using speak in concise statements.
The client has narrowed perceptual field. Lengthy explanations cannot be followed by the client. B. The client will not be able to identify the cause of anxiety C and D. The client has difficulty concentrating and will not be able to focus.

6. The nurse acts as a patient advocate when she does one of the following:

She encourages the client to express her feeling regarding her experience.

She assesses the client for injuries.

She postpones the physical assessment until the client is calm

Explains to the client that her reactions are normal

She postpones the physical assessment until the client is calm
The nurse acts as a patient advocate as she protects the client from psychological harm A. The nurse acts a a counselor B. The nurse acts as a technician D. This exemplifies the role of a teacher

Explanation

She postpones the physical assessment until the client is calm
The nurse acts as a patient advocate as she protects the client from psychological harm A. The nurse acts a a counselor B. The nurse acts as a technician D. This exemplifies the role of a teacher

7. Which of the following medications will likely be ordered for the client?"

Prozac

Vaium

Risperdal

Lithium

Valium
Antianxiety A. Antidepressant C. Antipsychotic D. Antimanic

Explanation

Valium
Antianxiety A. Antidepressant C. Antipsychotic D. Antimanic

8. Situation: A 29 year old client newly diagnosed with breast cancer is pacing, with rapid speech headache and inability to focus with what the doctor was saying. The nurse assesses the level of anxiety as:

Mild

Moderate

Severe

Panic

Severe
The client’s manifestations indicate severe anxiety. A Mild anxiety is manifested by slight muscle tension, slight fidgeting, alertness, ability to concentrate and capable of problem solving. B. Moderate muscle tension, increased vital signs, periodic slow pacing, increased rate of speech and difficulty in concentrating are noted in moderate anxiety. D. Panic level of anxiety is characterized immobilization, incoherence, feeling of being overwhelmed and disorganization

Explanation

Severe
The client’s manifestations indicate severe anxiety. A Mild anxiety is manifested by slight muscle tension, slight fidgeting, alertness, ability to concentrate and capable of problem solving. B. Moderate muscle tension, increased vital signs, periodic slow pacing, increased rate of speech and difficulty in concentrating are noted in moderate anxiety. D. Panic level of anxiety is characterized immobilization, incoherence, feeling of being overwhelmed and disorganization

9. Crisis intervention carried out to the client has this primary goal:

Assist the client to express her feelings

Help her identify her resources

Support her adaptive coping skills

Help her return to her pre-rape level of function

Help her return to her pre-rape level of function
The goal of crisis intervention to help the client return to her level of function prior to the crisis. A,B and C are interventions or strategies to attain the goal

Explanation

Help her return to her pre-rape level of function
The goal of crisis intervention to help the client return to her level of function prior to the crisis. A,B and C are interventions or strategies to attain the goal

10. Situation: An 18 year old female was sexually attacked while on her way home from work. She is brought to the hospital by her mother. Rape is an example of which type of crisis:

Situational

Adventitious

Developmental

Internal

Adventitious
Adventitious crisis is a crisis involving a traumatic event. It is not part of everyday life. A. Situational crisis is from an external source that upset ones psychological equilibrium C and D. Are the same. They are transitional or developmental periods in life

Explanation

Adventitious
Adventitious crisis is a crisis involving a traumatic event. It is not part of everyday life. A. Situational crisis is from an external source that upset ones psychological equilibrium C and D. Are the same. They are transitional or developmental periods in life