PNLE PRACTICE QUESTIONS: lost interest in her usual activities.

You recognize these as the

PSYCHIATRIC NURSING primary symptoms of
A. Depression.
1. The nurse in the psychiatric ward informed the male client B. Schizophrenia.
that he will be attending the 9:00 AM group therapy sessions. C. Suicidal ideation.
The client tells the nurse that he must wash his hands from D. Bipolar manic episodes.
9:00 AM to 9:30 AM each day and therefore he cannot attend.
Which concept does the nursing staff need to keep in mind in
planning nursing intervention for this client? Rationale:
A. Depression underlines ritualistic behavior Depressed mood and anhedonia (loss of interest or pleasure in
B. Fear and tensions are often expressed in disguised form activities) are the primary symptoms of major depression.
through symbolic processes.
C. Ritualistic behavior makes others uncomfortable. 5. Your patient is ready for discharge after a 30-day
D. Unmet needs are discharged through ritualistic behavior. hospitalization for manic depression. About 30 minutes before
his discharge, his roommate comes to you and says, 'He is
Rationale: talking crazy.' When you ask your patient how he is feeling, he
Anxiety is generated by group therapy at 9:00 AM. The states, 'I feel like Superman. I can do anything. I can fly home
ritualistic behavioral defense of hand washing decreases today and then become a U.S. Senator.' Which type of mania-
anxiety by avoiding group therapy. related symptoms is this patient exhibiting?
A. Social.
2. The nurse assesses the health condition of the female client. B. Cognitive.
The client tells the nurse that she discovered a lump in the C. Behavioral.
breast last year and hesitated to seek medical advice. The D. Perceptual.
nurse understands that women who tend to delay seeking
medical advice after discovering the disease are displaying Rationale:
what common defense mechanism? Cognitive symptoms include inflated self-esteem and
A. Intellectualization grandiosity
B. Suppression
C. Repression 6. You need to assess whether a patient who has a mood
D. Denial disorder is ready for discharge. Which statement would
indicate readiness for discharge?
Rationale: A. Right now, I can't bathe myself or dress myself, but I feel
Denial is a very strong defense mechanism used to allay the good about that.
emotional effects of discovering a potential threat. Although B. Going home will be fun, but if it isn't fun, I can always
denial has been found to be an effective mechanism for make my mother help me or tell her to do so. She better help
survival in some instances, such as during natural disasters, it me.
may in greater pathology in a woman with potential breast C. I will take my medicines as I should and know to call the
carcinoma number you gave me if I have bad thoughts.
D. Taking care of myself is important, but it's okay if I don't
3. A 48-year-old Hispanic woman is seen by a psychiatric want to do anything.
clinical nurse specialist after receiving a call by her son.
According to the son, since his father's death 7 months ago, his Rationale:
mother has lost 30 pounds and can't sleep. During her initial Verbalization of a plan for help and demonstration of care are
visit, the patient states, 'My husband talks to me in his visits, realistic discharge criteria.
but his words make no sense to me. I don't understand what he
wants me to do.' What is an appropriate nursing diagnosis? 7. An angry patient is in the community room. She picks up a
A. Ineffective denial. chair and uses it to hit another patient on the head. When you
B. Bipolar mood disorder. come into the community room, what should your first
C. Hyper-religiosity. response to the patient holding the chair be?
D. Grieving. A. Are you crazy? Hitting people can hurt them!
B. Hitting others is unacceptable. Please put the chair
Rationale: completely down on the floor.
Grieving may be characterized by weight loss, sleep C. How would you like it if I hit you over the head with a
disturbances, and messages from beyond. chair?
D. You're in big trouble now. It's probably prison you are
looking at!
4. Your neighbor's husband comes to talk to you. He says his
wife has not left the house in 2 weeks, has a flat mood, and has Rationale:
Use words to indicate your lack of acceptance of the patient's
behavior in a nonthreatening voice or tone. Rationale:
The patient improvement is based on increased socialization
8. A 22-year-old female is admitted to the unit following a and increased appetite.
suicide attempt. She has a 2-week history of depression as
well as a history of abusing multiple substances and anorexia 12. A 21-year-old patient has a diagnosis of schizophrenia and
nervosa. What is your first nursing priority? is stuporous, yet exhibits sudden, excessive motor activity
A. Socialization. with repetitive sit-ups. What is this behavior called?
B. Contracting for eating behavior. A. Delusional.
C. Safety. B. Hallucinogenic.
D. Administering the Beck depression scale. C. Paranoid.
D. Catatonic.
Rationale:
Safety is the major principle underlying psychiatric nursing. Rationale:
Catatonic schizophrenia occurs suddenly and includes motor
9. Gerald was admitted to the psychiatric acute care unit immobility or excessive motor activity.
because he stood in the center of a main two-way street in his
underwear and a T-shirt, shouting, 'I am being held against my 13. A 16-year-old girl is admitted for her first psychotic break.
will. I have personal rights.' Gerald was diagnosed with Her parents feel very guilty. What is your best nursing
bipolar disorder, manic type. Which of the following response?
interventions will add to everyone's safety in the acute care A. No one really knows the cause of schizophrenia. It is not
environment? your fault and is not due to anything you did in the past. It is
A. Have hectic surroundings. important to understand this, to support your daughter, and to
B. Have consistent unit routines. find support for yourselves.
C. Minimize staff interventions. B. Does anyone in your family have schizophrenia, as this
D. Medicate the patient only if he has private health insurance. disease is known to be genetic?
C. You may feel bad now, but there are so many other bad
Rationale: things out there, such as cancer and paralysis.
Quiet environments with consistent routines will help calm D. Let me share with you some websites to help you deal with
patients and add to safety. your guilt.

10. Your patient has just been physically cleaned up after Rationale:
slicing his left arm 8 times. To show an appropriate evaluative Schizophrenia has a multifocal origin and its cause may
response, which of the following would be your best include a genetic component. Support is needed for both
statement? patients and caregivers.
A. I could care less if you cut yourself. It doesn't hurt me.
B. If you wouldn't cut yourself, you would have a much 14. A physical indicator of possible abuse in a battered woman
happier life. would be a fracture of the distal bones, such as the skull, face,
C. You are lucky someone found you in time. Now you can or extremities.
help us make you better. A. TRUE
D. The behavior of cutting is not acceptable. B. FALSE

Rationale: Rationale:
Focus on the behavior, not the person. Be neutral, but not Musculoskeletal fractures and sprains, especially of distal
indifferent. versus proximal bones, are indications of battering. Also
assess for dislocated shoulders and old fractures.
11. A 22-year-old female was admitted to the mental health
unit with major depression and suicidal ideation. She has a 15. Which of the following statements indicates that your
history of cutting her wrists intermittently throughout the last patient, who has schizophrenia, is ready to manage a relapse?
2 years. On days 1 and 2, the patient stays in her room and eats A. I will think of a plan of action before I get these racing
only 20% of her meals. On day 3, she eats 80% of her meals thoughts again.
and is talking to others in group. The nurse should consider B. I will not drink alcohol and will exercise daily. This will
that the patient is help me stay well.
A. Showing improvement. C. If I start feeling badly and don't sleep very much, then I will
B. Highly suicidal. tell my friend Sandy and talk to her. She or I will call my
C. Exhibiting mood swings. therapist.
D. In need of electroshock therapy.
D. When I feel stressed, I will sit near my bed and wait to feel Rationale:
better. Asking what the patient talks about with family or friends and
what types of activities he or she engages in can help assess
Rationale: relationships.
Managing a relapse includes a plan of action, involvement of a
friend or family member, and, after identification of signs, 20. Which type of therapy helps patients with personality
notification of a therapist. disorders explore ways to enjoy themselves and increase their
socialization skills?
16. Your patient has a diagnosis of schizophrenia and believes A. Occupational therapy.
that his thoughts are broadcast from his head. What is the most B. Recreational therapy.
appropriate nursing diagnosis? C. Music therapy.
A. Risk for self-directed violence. D. Medication therapy.
B. Disturbed sensory perception.
C. Impaired verbal communication. Rationale:
D. Disturbed thought processes. Recreational therapy helps patients explore ways to enjoy
themselves without using alcohol or drugs and strengthens
Rationale: social skills.
Thought broadcasting and thought withdrawal are disturbed
thought processes. 21. Which of the following symptoms of alcohol
detoxification would you be most concerned about?
17. As a nurse, you wish to reinforce functional behavior in A. Vitamin and mineral depletion.
your schizophrenic patient. Which intervention will B. Diaphoresis.
accomplish reinforcement? C. Increased heart rate.
A. Praise the patient for reality-based perceptions and D. Hallucinations and delusions.
cessation of acting-out behaviors.
B. Educate the patient about the symptoms of schizophrenia. Rationale:
C. Facilitate learning about the importance of medication Hallucinations and delusions can result in problems with
compliance using written materials for reinforcing medication safety and possibly lead to suicide.
use.
D. Focus on the feelings of delusion to reinforce reality and 22. What is the priority nursing intervention to help orient a
decrease false beliefs by talking to the patient. patient who has Alzheimer's disease?
A. Post a schedule in the dining room of daily activities.
Rationale: B. Use an overhead loudspeaker to announce upcoming
Reinforcement by praise increases functional behavior. events.
C. Provide a daily routine and easy-to-read clocks.
18. Your patient is preoccupied with perfection and control, D. Have the patient live alone in a private room.
has difficulty relaxing, exhibits rule-conscious behavior, and
cannot discard anything. What type of personality disorder Rationale:
does this behavior reflect? Daily routines and large clocks help patients' functional status.
A. Antisocial personality.
B. Obsessive-compulsive personality. 23. You are caring for a patient and pour out his evening
C. Manic behavior. risperidone (Risperdal) 2 mg tablet. The pill falls on the
D. Anxiety disorder. countertop. What is your next intervention?
A. Pick the pill up from the counter and place it in a cup.
Rationale: B. Wash the pill off with alcohol and place it in a cup.
Obsessive-compulsive disorder is a personality disorder that C. Discard the pill and repour the medication.
includes perfection, control, procrastination, excessive D. Call the patient up to the pill line to receive his medication.
devotion to work, difficulty relaxing, rule-conscious behavior,
and inability to discard anything. Rationale:
The pill is contaminated once dropped, so for infection control
19. Which of the following questions is appropriate to assess purposes you discard it and repour the medication.
for disturbances in a patient's relationships?
A. What are your main worries? 24. Your patient has just shown you some fresh, self-inflicted,
B. Have you ever used alcohol or illegal drugs? superficial cuts-eight of them going up and down his right
C. How has your appetite been in the past month? arm. What is your initial intervention based on infection
D. What do you talk about with friends? control principles?
A. Send the patient back to his room as part of behavioral A. Use a thick diaper or pad.
modification. B. Wear gloves and use some paper towels or toilet paper.
B. Suture the cuts using a large-bore needle and nondissolving C. Wear gloves, use toilet paper, and wash the area with a 1:10
sutures. bleach solution.
C. Cleanse the wounds with soap and water. D. Wear a gown, shoe covers, mask, and chemotherapy-
D. Administer tetanus toxoid injection intramuscularly. impervious gloves, and wash the area with an ammonia with
bleach 1:1 solution.
Rationale:
Cleansing the wound with soap and water is the initial Rationale:
intervention. Clean all body fluids with an appropriate disinfectant such as
1:10 bleach solution, using universal precautions.
25. A hypomanic patient tells you that she has been 'picking up
energy from my car engine and car CD player' while driving 29. Your patient is scheduled for a one-on-one therapy session.
and has received five speeding tickets in the past 6 months. Upon his entry into your office, you note that the patient has a
What would be one effective intervention to avoid fast cough, is sweating, is coughing up a small amount of blood,
driving? and has a fever. What is your initial intervention regarding
A. Make a contract not to drive more than 55 miles per hour infection control?
and drive with the CD played turned off. A. Wash all of the patient's sheets and clothes.
B. Call the local police and alert them to the patient's car B. Place a mask on the patient and yourself.
license plate number and the make and model of her car. C. Take the patient's temperature.
C. Ask the patient to "hand over the keys" to you, and tell her D. Place resuscitation equipment in the patient's room.
that now she must use a cab or other public transportation until
your next session. Rationale:
D. Share with the patient that she cannot drink and drive. The patient might have tuberculosis, so wear a mask,
especially given that the patient is coughing.
Rationale:
Contracts can see a patient through period of hypomanic 30. You have just given your patient an intramuscular injection
agitation. of fluphenazine (Prolixin) with a syringe that does not have a
safety lock. What is your next step?
26. Patients who require close surveillance due to the potential A. Recap the needle.
for safety hazards give up the right of B. Snap the needle off and place it in the needle box.
A. Continued confusion. C. Immediately place the syringe in a nearby impermeable
B. Decision making. container.
C. Social contact. D. Clip the needle off with a syringe needle cutter (SNC).
D. Privacy.
Rationale:
Rationale: Place the syringe in a nearby container specific for needles.
Privacy and autonomy are often given up for the sake of Do not recap, bend, clip, or manipulate the needle in any way.
safety.
31. In an inpatient acute psychiatric unit, it is important to shut
27. Patient is extremely agitated and is throwing body fluids at and lock the unit door behind you.
anyone who comes near him. What is the best way to protect A. TRUE
yourself as you and others physically restrain the patient? B. FALSE
A. Wash your clothes within 30 minutes of becoming soiled
with body fluids. Rationale:
B. Wear protective eyewear and a face shield. This behavior enhances safety.
C. Check that your tetanus and hepatitis B titers are within
normal limits. 32. You drive up to the house of your patient, who is known to
D. Wear a gown over your clothes and shoe covers. have schizophrenia with manic episodes. This is your fifth
visit. On this occasion, the patient is sitting on his front porch
Rationale: in a rocking chair with a shotgun in his arms. What should
Protective gear helps prevent infections that may gain entry your next intervention be?
through openings in the skin, the eyes, or the mouth. A. Beep your car horn to get your patient's attention.
B. Yell your patient's name out your car window and wave at
28. A patient who is psychotic has a formed bowel movement him to say hello.
on the floor of his room. How should you clean up this C. Keep driving in a path that is going away from the patient's
excrement? house.
D. Stop the car in the patient's driveway and call your boss on Rationale:
your cell phone. Patient confidentiality is required, and there is no way to
verify the identity of the person calling.
Rationale:
Safety includes not placing yourself in vulnerable situations. 36. Your patient has been hospitalized for acute alcohol
withdrawal. It is the fifth day, and he is having visual
33. Your patient, who is in a community psychiatric program, hallucinations followed by a seizure. What is the most likely
shows up at your home peeping through your kitchen window. source of the patient's problem?
You also noticed the patient yesterday when you went to the A. Autonomic dysreflexia (AD).
grocery store and the hairdresser. You believe he is stalking B. A brain tumor.
you. What should you do? C. Sleep deprivation.
A. Call the local police and report your suspicion of stalking. D. Delirium tremens (DTs).
B. Call the patient's spouse and discuss his behavior.
C. Invite the patient to have a cup of coffee with you at a local Rationale:
café to discuss his behavior. Delirium tremens occurs as acute alcohol withdrawal
D. Wait until the patient's next group meeting to discuss his progresses. It includes symptoms such as clouding of
stalking behavior. sensorium, hallucinations, seizures, and autonomic
hyperactivity.
Rationale:
Stalking behavior needs to be dealt with by the police for your 37. Which of the following assessments is used to confirm
safety. alcohol intake?
A. Pupil dilation.
34. Your patient's auditory, visual, and tactile hallucinations B. Serum sample.
are controlled with bimonthly injections of haloperidol C. Hair shaft analysis.
(Haldol) that the community health nurse administers during D. Sputum sample.
home visits. You are the new nurse on this case; the previous
nurse has retired. The previous nurse has stated in her care Rationale:
plan that the patient will let the nurse in the house only if the Urine and serum samples are toxicology specimens used to
nurse carries a public health-issued blue bag and wears black assess and monitor alcohol withdrawal.
pants. You are scheduled to visit this patient tomorrow. What
should you do? 38. Which of the following questions is most appropriate to
A. Call the patient and tell her that you are a new nurse and ask in screening for a potential problem of high alcohol
will be wearing white pants. intake?
B. Show up as scheduled carrying only a stethoscope, vial, A. Have you felt you should cut down on your alcohol
alcohol wipe, and medication syringe. consumption?
C. Show up as scheduled with a police officer. B. Do you enjoy getting smashed?
D. Telephone the patient, introduce yourself, and show up C. Have you ever thought about killing someone?
carrying a blue bag and wearing black pants. D. In the last week, have you had a glass of wine?

Rationale: Rationale:
The patient needs her medication, and following the care plan Screening requires questions associated with cutting down,
is the optimal course of action. feelings of guilt about drinking, and having a first drink in the
morning.
35. Your patient has an admitting diagnosis of alcohol
withdrawal syndrome. You receive a phone call at the nurses' 39. Your patient in the Emergency Department has a diagnosis
station from a person who says he is the patient's minister and of acute alcohol withdrawal syndrome (AWS). He is acting
wants to know if the patient 'fell off the wagon again' and euphoric, yet shy. The APN has prescribed the following care:
when visitation hours are. What is your best response? CAGE questionnaire, serum for toxicology, IV of D5 1/2 NS
A. Yes, the patient drank too much, but he should be fine in a and 1 amp multivitamin (MVI) at 75 mL/h, neuro check q 1 h.
few days. Visiting hours are 9 A.M. to 6 P.M. What is your first priority?
B. We do not give out any information. Visitation hours in the A. Administer the CAGE questionnaire.
hospital are from 9 A.M. to 6 P.M. daily. B. Start the IV.
C. Please pray for the patient; he is in bad shape. You can visit C. Do the neuro check.
him anytime between 9 A.M. and 6 P.M. daily. D. Obtain a serum blood sample.
D. Please contact the hospital's chief executive officer, who
can give you the information you are requesting. Rationale:
Obtain a toxicology sample, as the patient is too euphoric to B. Alcoholics Anonymous.
answer the CAGE questionnaire. The IV and neuro checks can C. Depression support group.
wait. D. Suicide support group.

40. Your patient sees you at a preplanned postoperative visit 4 Rationale:

weeks after being hospitalized for acute alcohol withdrawal. Alcoholics Anonymous is the most appropriate resource for
Upon questioning, she states that her husband is abusive, so alcoholism, although depression may or may not be involved
she drinks to 'drown out his yelling.' The patient also in this case.
complains of depression and severe pain in the epigastric
region that radiates to her back and has been constant since 45. Which of the following is a common symptom of a major
yesterday. She has vomited twice in the past 12 hours. What is depressive episode?
your first priority? A. Loss of hearing.
A. Refer her immediately for treatment of depression. B. Increased energy.
B. Call social services and report spousal abuse. C. Hopelessness.
C. Assess her for pancreatitis. D. Recurrent thoughts of well-being.
D. Administer a test or scale that assesses alcohol withdrawal.
Rationale:
Rationale: Hopelessness, loss of pleasure, and a profound sense of
Approximately 65% of cases of pancreatitis are related to sadness are symptoms of a major depressive episode.
alcohol. This patient is exhibiting the classic symptoms of this
disease. 46. Which of the following statements would indicate a
depressed mood?
41. Prolonged alcohol ingestion can cause disorders of the A. I can't wait to go to the ballgame today; it should be fun.
liver such as B. I feel sad today, just like yesterday.
A. Pancreatitis. C. I feel like going to the gym for a workout today, then
B. Hypomagnesemia. maybe to a movie.
C. Cirrhosis. D. Since it's raining outside, how about a game of chess?
D. Colitis
Rationale:
Rationale: A subjective report of feeling sad or empty is a sign of
Cirrhosis is a liver disorder that can result from prolonged depression.
ingestion of alcohol.
47. Which of the following medical conditions has similar
42. Adolescent suicide has increased over the past and is signs and symptoms as those seen in a major depressive
among the top five causes of death in U.S. adolescents. episode?
A. TRUE A. Pancreatitis.
B. FALSE B. Cholecystitis.
C. Tuberculosis.
Rationale: D. Hypothyroidism.
Adolescent suicides have quadrupled since 1950 and are the
third leading cause of death in U.S. adolescents. Rationale:
Signs and symptoms of hypothyroidism include changes in
43. Alcohol tolerance develops as a result of the central weight, sleep disturbances, decreased energy, and difficulty in
nervous system's adaptive mechanisms. thinking—just like in depression.
A. TRUE
B. FALSE 48. Once a patient is diagnosed with a major depressive
episode, the primary nursing intervention should be associated
Rationale: with
The central nervous system adapts, so more alcohol is needed A. Safety.
to obtain the initial effects of alcohol ingestion, especially B. Pharmacology.
euphoria. C. Administration of gastric lavage.
D. Hemodialysis.
44. Your patient experienced alcohol withdrawal syndrome
and now admits he 'needs help.' Which of the following is the Rationale:
most appropriate resource to which you should direct the Safety is the primary focus for an intervention, as 25% to 30%
patient? of depressed patients are at risk for suicide.
A. Reach to Recovery.
49. A 35-year-old male patient has been brought to your
hospital unit after making a suicide attempt at his workplace. 53. Which of the following is an example of a bite/sting that
Which of the following interventions can you legally can cause a poison exposure?
implement? A. Butterfly.
A. Call the patient's girlfriend and inform her of his admission B. Grass seed.
and visiting hours. C. Jellyfish.
B. Physically search the patient for weapons and harmful D. Fly.
materials.
C. Call the patient's boss at work and report him as in need of Rationale:
extended medical leave. A jellyfish sting can cause a poison exposure.
D. Place the patient in four-point restraints and begin an IV for
sedation. 54. When a patient shares with a psychiatrist that he plans to
harm a specific person and includes the person's name, the
Rationale: health professional must notify the intended identified victim.
A suicide attempt is a serious and self-destructive behavior What is this rule called?
that demands searching for weapons and harmful materials to A. Seclusion and restraints rule.
increase safety. B. Voluntary commitment rule.
C. Right to treatment rule.
50. Your patient has just received his sixth electro convulsant D. Duty to warn rule.
therapy outpatient treatment. He tells you that he plans to
drive himself home because his wife is working at her part- Rationale:
time job today. What is your best response? Duty to warn is a protective privilege and ends where public
A. Be careful and drive slowly. peril begins, so an intended, identifiable victim needs to be
B. You need to wait 30 minutes and then you will be safe to notified.
drive.
C. Let me take your vital signs; if they are stable, then you can 55. When documenting the behavior of a patient with a mental
drive. health diagnosis, which chart entry includes the patient's
D. You cannot drive. I can call you a cab, or would you prefer action and responses?
to call your wife or someone for a ride home? A. The patient is less expressive today in group therapy.
B. The patient appears to drift in and out of reality.
Rationale: C. The patient is wearing shorts and a sleeveless top even
Patients cannot drive after ECT, as its effects can include though it's January and wintertime. When asked about her
disorientation, muscle pain, central nervous system clothing choices, she states, "The devil told me what to wear.
depression, and cardiac dysrhythmias. To make things different, I need an exorcism."
D. The patient is wearing pants and a long-sleeved shirt, is
51. Which of the following patients is at risk for depression? appropriately dressed for group therapy, and refrains from
A. A patient with history of diabetes mellitus. sleeping as she did in last group sessions.
B. A patient with a depressive genetic predisposition.
C. A patient who recently bought a puppy. Rationale:
D. A patient who had only 6 hours of sleep last night due to Action and responses include what one does and says.
watching a TV movie.
56. During a group session, one patient states that he will be
Rationale: released soon because he is superior to his therapist, who is a
Risk factors include genetic predisposition, a recent loss or female. This is an example of which bias or prejudice?
trauma, and a feeling of sadness or hopelessness. A. Racism.
B. Sexism.
52. A patient has been admitted to your unit with a drug C. Ageism.
overdose, and you need to assess for acidosis and hypoxemia. D. Neonatalism.
Which test should you perform?
A. Complete blood count (CBC). Rationale:
B. Serum electrolytes. Sexism is the belief that members of one sex are superior to
C. Partial thromboplastin time (PTT). members of the other sex.
D. Arterial blood gases (ABG).
57. The nurse is assigned to the care of a patient admitted to
Rationale: the mental health unit. Which behaviors by the nurse reflect
ABGs assess for acidosis [pH, bicarbonate, and hypoxemia the essential principles of therapeutic relationship? Select all
(pO2)]. that apply.
A. Empowering the patient to make decisions regarding care A. The nurse sets limits on inappropriate behaviors.
B. Looking beyond the illness when interacting with the B. The nurse uses colloquial language to foster trust.
patient C. The nurse brings in clothing for a homeless patient.
C. Trying to see things from the unique perspective of the D. The nurse offers a video collection for a group movie night.
patient E. The nurse lets a patient know when their time together will
D. Sharing personal insights that are relevant to the patient's end.
problems
E. Ensuring that all physical and emotional needs are met by Rationale:
the nurse New nurses frequently fall back on relationship skills that
have been learned in the context of families and or friendships.
Rationale: When nurses set limits on behaviors they are acting in the role
In the context of the therapeutic relationship, nurses strive to of a counselor, educator and caretaker. Nurses act to meet the
empathize with the patient and fully value the perspective of needs of all patients, and bringing in movies is an example of
the patient, whether or not it differs from that of the nurse. sharing a resource that all patients can use. When the nurse
Nurses also view patients holistically, realizing that they are maintains the time frames associated with professional and not
more than just the sum of the symptoms they present with. personal relationships the nurse is upholding boundaries
Interactions are based on the growth of the patient and appropriate to nursing role and acting in a manner that is
interventions should promote as much autonomy and consistent with professional and ethical standards. The use of
independence as the patient is capable of. Sharing personal colloquial language conveys a sense of familiarity that is not
interests violates the boundaries of the therapeutic relationship consistent with a professional relationship. Bringing in
and shifts the focus of the relationship back to the nurse. clothing for an individual patient may be construed as "special
Acting to meet every patient need is generally inappropriate; treatment," and demonstrates an inability to differentiate
nurses should act to promote growth and independence by between professional and personal relationships.
encouraging patients and families to meet their own needs
whenever possible. 60. The nurse is working with a patient who presents in the
outpatient setting for the treatment of situational depression.
58. The nurse is working with a patient who is struggling to The patient has begun to try out new coping strategies and has
over- come a serious mental illness. The patient begins crying taken advantage of a support group the nurse recommended.
after learning that her family will no longer be visiting. Which The nurse recognizes that the patient has entered which phase
response by the nurse demonstrates empathy? of therapeutic nurse-patient relationship?
A. "I am not sure what I would do if I were in your shoes." A. Orientation
B. "You must be wondering why they are acting this way." B. Working
C. "My sense is that this experience has been very painful for C. Exploitation
you." D. Resolution
D. "I understand because I went through something similar
one time." Rationale:
During the exploitation phase, the patient begins to make use
Rationale: of the resources and tools that have been offered. The
The nurse using empathy separates the nurse's own feelings, orientation phase consists gaining an understanding of the
experiences, and reactions and fully engages with the patient goals and needs for care. The working phase consists of initial
an attempt to get a sense of how the patient is feeling at that engagement in treatment. The resolution phase consists of
moment in time. In this instance, the nurse must be present to reviewing progress and terminating the relationship.
what the patient is conveying and act to validate the
observation of distress, without conditions or judgment. 61. The nurse is working with the patient admitted to the
Options a and d shift focus back to the nurse and fail to mental health unit. The nurse learns that the patient has a
recognize the patient's experience as unique. Option b does not history of exposure to trauma that that the nurse can relate to
validate the patient's verbal or nonverbal messages, but instead on a personal level. Which rationale best supports
makes an assumption that is likely to be based on the own nondisclosure on the part of the nurse?
nurse's perspectives. A. The patient may use the disclosure against the nurse.
B. The nurse may be assuming that the experiences are similar.
59. The nurse is acting as a preceptor to a recent nurse C. There is a risk of distortion or shifting of caregiver
graduate who wants to obtain a job on the mental health unit. boundaries.
The new nurse has been struggling to differentiate between D. The patient will not have the same resources to cope as the
social and therapeutic interactions because so many of the nurse.
patients are around his own age. Which evaluation finding
indicates that nurse is acting in accordance with appropriate Rationale:
professional boundaries? Select all that apply.
The essential underlying rationale for maintaining professional interpret and validate interpretations. An essential element is
boundaries is to keep the focus on meeting patient needs. the patient's affirmation of the nurse's interpretation. Patient
Disclosure may distort this role as the patient may feel focus, willingness to take advantage of opportunities to talk,
compelled to support or care for the nurse or question the and the amount and quality of the information do not
nurse's ability to remain focused on the patient's unique needs necessarily relate to the effectiveness of the nurses active
or experiences. The nurse may have difficulty retaining a listening skills.
focus on the patient's needs while relating aspects of their own
experience. In some instances, patients may use personal 64. The nurse is caring for a patient who has been in an
information against the nurse, but the primary reason for non- abusive relationship. The patient relates being concerned that
disclosure relates to the patient's needs, not the nurses. The leaving the relationship will result in judgment by family and
nurse may be making assumptions about the patient's needs, friends. How should the nurse respond?
but this option fails to address the outcome of this assumption A. Acknowledge that the decision may not be accepted by
or the primary threat to the therapeutic relationship. It may or others.
may not be true that the patient resources differ from that of B. Ask the patient why she cares so much about what others
the nurse; however, this is not as important as the threat to the think.
overall effectiveness of the therapeutic relationship. C. Remind the patient that everyone has difficult decisions to
make.
62. The nurse is working in an outpatient mental health clinic. D. Advise the patient to share details of the abuse with family
The clinic is implementing an initiative to use and friends.
telecommunication to deliver care to patients living in remote
areas. The nurse understands that this change will be most Rationale:
likely to affect which aspects of communication? Acknowledging is a therapeutic response in which the nurse
A. Nonverbal communication only expresses recognition of or validates the existence of the
B. Nonverbal and meta-communication patient's reality. The nurse can then assist the patient to
C. Verbal and nonverbal communication identify strategies that may minimize negative consequences
D. Meta-, nonverbal, and verbal communication or assist the patient to cope with them. Asking the patient why
Rationale: she cares about what others think direct questioning is a form
Verbal communication consists of the words used. Nonverbal of challenging that can present a barrier to therapeutic
communication includes gestures, appearance, tone and communication. Telling the patient that everyone has difficult
volume as well as a variety of other factors. Meta decisions to make is a "pat" response that fails to consider the
communication refers to those involved in the interaction, how full experience or individuality of the patient. Advice about
the message is sent, and the context of the message. sharing details of the abuse with family and friends is based on
Telecommunication will impact the ability to convey and the nurse's opinion and does not necessarily address the
receive nonverbal content. Even if visual images are used, the patient's concern.
visual field or the quality of the images may be limited, and
other sensory information may not be available. Because the 65. The nurse manager is employing tools to assist staff to
context and mode of communication will change with maintain a sense of objectivity and balance in the context of
telecommunication, meta-communication will also be the therapeutic inpatient psychiatric milieu. Which
impacted. The words or the language used to deliver care will intervention is most likely to be effective for new nurses?
not necessarily be impacted by the use of telecommunication. A. Formal education
B. Journaling exercises
63. The nurse is working with a patient in the context of the C. Individual supervision
therapeutic relationship. Which evaluation finding supports the D. Peer-led support groups
effectiveness of active listening techniques?
A. The patient remains focused on the purpose of the Rationale:
interaction. Clinical supervision is one of the most important tools for
B. The patient takes advantage of opportunities to verbalize reflective practice in the psychiatric setting. An experienced
concerns. psychiatric nurse provides valuable insight and feedback in the
C. The patient affirms the nurse's interpretation of what was context of working sessions. Formal education is important,
communicated. but may not consider the unique experiences and feedback
D. The patient provides sufficient information for the nurse to evoked in the context of therapeutic relationships. Journaling
make care decisions. may be useful for reflective practice but offers less opportunity
for input/feedback from a more experienced clinician. Peer
Rationale: support may provide an emotional outlet, but again lacks the
The purpose of active listening is to partner with the patient to element of guidance from a more experienced nurse.
determine patient needs. The nurse conveys interest in what
the patient is communicating and then actively seeks to
66. The nurse educator is orienting a group of new nurses to A. The patient's socioeconomic status and living situation
the mental health unit. Which statement by the educator best B. The patient's and family's understanding of mental illness
represents the essential purpose of the nursing process in C. The patient's previous history of treatment for mental
providing nursing care to patients experiencing mental illness? illness
A. "The nursing process is what differentiates mental health D. The patient's circumstances that led to the decision to seek
nursing care from that of other professions." treatment
B. "The nursing process is a framework for planning and
delivering holistic patient- and family-centered care." Rationale:
C. "The nursing process provides a structure for applying The circumstances or context leading to the decision to seek
knowledge of mental illnesses and their management." treatment would be the best indicators of the patient's current
D. "The nursing process provides a model for carrying out interest and motivation in treatment. The nurse would consider
linear tasks that are intended to lead to a fixed patient whether the patient was brought to the hospital voluntarily and
outcome." who made the decision to seek help. All of the other factors
may contribute to compliance and motivation to seek help, but
Rationale: are less relevant to the patient's current interest in treatment.
The essential purpose of the nursing process is to provide
comprehensive nursing care that considers all aspects of the 69. The nurse is performing a mental status exam. Which
person's life. While the nursing process may distinguish technique would be best to determine the patient's affect?
nursing care from that of other professions, its primary A. Having the patient complete a feeling rating scale
purpose is focused on meeting patient and family needs. The B. Observing the patient's current behavioral presentation
focus of the nursing process is not just on the application of C. Asking the patient to describe his or her current emotional
knowledge but also on integrating the unique experiences and state
perspectives of the patient to deliver humanistic, patient- D. Having the patient respond to a series of cognitive
centered care. Although patient outcomes are a component of exercises
the nursing process, the model is cyclical and goals and
outcomes are constantly reconsidered and redefined. Rationale:
Affect is an observed interpretation of a patient's emotional
67. The nurse is carrying out an assessment of a patient status that takes into account objective factors such as the
presenting with a sudden onset of psychiatric symptoms. patient's facial expressions and posture. Options a and c are
Which describes the best approach for the nurse to determine used to determine the patient mood or subjective interpretation
the priority concern for the patient? of their own emotional state. Exercises are generally used to
A. The nurse asks the patient directly why he or she is seeking determine cognitive function, such as memory, concentration
treatment at this time. and orientation.
B. The nurse analyzes the patient's pre-setting background for
evidence of a precipitating event. 70. The nurse has completed an assessment of a patient
C. The nurse defers to the diagnosis made after all members of presenting with acute mental health concerns. The nurse
the team have interviewed the patient. concludes that patient has an alteration in mood characterized
D. The nurse refers to the primary symptoms identified in the by mania. Which component of the diagnostic statement will
Diagnostic and Statistical Manual of Mental Disorders, 5th this finding comprise?
edition (DSM-5). A. The focal pattern
B. The assessment of cause
Rationale: C. The supporting evidence
The nurse carries out assessment as an independent function D. The associated symptoms
and recognizes the patient's statements or communication
about why the patient is seeking treatment as most important. Rationale:
The patient's perspective of the situation, not the nurse's, is The nurse is identifying a problem or focal pattern that based
most essential. The identification of priority nursing problems on an assessment of the patient's presentation. The cause has
does not require input from the entire team. The DSM-5 not been identified, such as "related to steroid use," and
classifies diagnostic information that is specific to particular evidence to support the pattern (e.g., "as evidenced by
illnesses. While this tool may be used to inform aspects of pressured speech") has not been provided. Associated
nursing care, it is not used to determine the patient's priority symptoms such as insomnia have not been identified.
concern.
71. The nurse is caring for a patient presenting with symptoms
68. The nurse is performing an assessment of a patient being of anxiety that are interfering with the patient's ability to
admitted to the inpatient psychiatric unit. Which aspect of the function at work. The patient states that the anxiety began
pre-setting background would best assist the nurse to deter- soon after a traumatic event and is severely impacting the
mine the patient's current interest and motivation in treatment?
patient's functioning. Which issue will be the focal point for
making a nursing diagnosis? 74. The nurse is developing a plan of care for a patient
A. Patient's anxiety due to exposure to a traumatic event experiencing an acute mental health crisis. Which action
B. Patient's difficulty coping would be most likely to be carried out during the intervention
C. Patient's inability to function at work due to underlying phase of the illness?
anxiety and stress A. Ensuring the safety of the physical environment
D. Making a diagnosis of post-traumatic stress disorder B. Performing vital signs and a mental status exam
C. Determining what factors precipitated the crisis
Rationale: D. Identifying which problem the patient wants to focus on
The nursing problem focuses on the focal pattern of anxiety,
which appears to be related to exposure to a traumatic event. A Rationale:
nursing diagnosis of Anxiety due to exposure to a traumatic Ensuring the safety of the physical environment is an action
event would be appropriate. The patient's difficulty coping and consistent with the intervention phase of the nursing process.
functioning at work may be related to either trauma or Vital signs and mental status exams are assessment activities.
experience of anxiety, but the patient's anxiety is the focus, as Determining which factors precipitated the crisis is an
relief of anxiety may improve coping and functioning. assessment activity. Prioritizing problems is part of the
Although the patient may require further evaluation for planning phase of the nursing process.
posttraumatic stress disorder, the focus for the nurse at this
time is the patient's anxiety level. 75. The nurse is assessing a patient with an anxiety disorder.
Which key finding best supports a neurobiological basis for
72. The nurse is carrying out the components of the planning the illness?
phase for a patient experiencing a mood disorder. Which step A. The patient has a family history of anxiety.
will the nurse take first? B. The patient has a co-morbid medical illness.
A. Determine which problem will be addressed as the priority C. The patient has multiple stressors.
B. Determine which interventions will support the patient's D. The patient has had positive responses to anti-anxiety
goals medication.
C. Differentiate between collaborative and nursing
interventions Rationale:
D. Identify what the nurse wants to achieve as a result of Research on anxiety disorders has demonstrated a strong
interventions genetic neurobiological basis for the illness. A family history
establishes a genetic predisposition to the illness. Studies have
Rationale: shown that the genetics have a strong influence on the
Once nursing diagnoses are identified, the nurse identifies individual's ability to cope environmental and physiological
problems and their priority in care. The prioritization aids in stressors. The presence of a physiological illness does not
identifying interventions that will be carried out immediately. necessarily support a neurobiological predisposition to
The next step would be to determine what the patient, not the anxiety. The ability to cope with stressors is mediated by
nurse, wants to achieve and then selecting appropriate nursing genetic factors, and the number of stressors does not relate to a
interventions to support that goal. neurobiological basis for the illness. Anti-anxiety medications
treat the symptoms of the anxiety; they would not support a
73. The nurse is evaluating the outcomes of interventions for a genetic predisposition to the illness.
patient who is in the recovery phase of depression. Which
finding best indicates that treatment goals have been met? 76. The nurse is documenting assessment findings for a patient
A. The patient agrees to report suicidal thoughts. presenting with symptoms of anxiety. Under which category
B. The patient has resumed occupational functioning. would the nurse include the observation that the patient is
C. The patient manages increased interaction with peers. constantly scanning the environment to detect threats?
D. The patient identifies goals to improve further function. A. Spiritual domain
B. Cultural domain
Rationale: C. Biological domain
At the stage of recovery, evaluation focuses on progress D. Psychological domain
toward interpersonal, vocational, and spiritual goals.
Resumption of occupational function is an evaluation finding Rationale:
appropriate to this phase of illness. The ability to report The patient who constantly scans the environment for threats
suicidal thoughts is an evaluation finding that supports the is exhibiting hypervigilance, a finding that relates to
achievement of a short-term goal in the crisis stage of the hyperarousal and biological aspects of illness. The finding
illness. Management of increased group interactions and the would be documented under the category of the biological
identification of longer-term goals are evaluation findings that domain.
are more appropriate in the acute illness phase.
77. The nurse is working with a patient who is overcome by performance, which is not generally associated with these
feelings of anxiety, each time experiencing thoughts of losing activities. Panic disorder is characterized by recurrent,
control. The patient states that reorganizing the environment unpredictable panic attacks. The stimulus generally is not
temporarily relieves the anxiety. The nurse correctly interprets recognized. Separation anxiety is characterized by a
this as the use of which defense mechanism? developmentally inappropriate fear of separation from or
A. Denial abandonment by other persons. In this case, the client relies on
B. Undoing another person to help him manage anxiety related to certain
C. Projection environmental variables, not general fears of separation or
D. Conversion abandonment.

Rationale: 80. The nurse is evaluating a patient who has been taking
Undoing is a defense mechanism in which the individual takes fluvoxamine (Luvox) for the management of obsessive-
action to counteract the unacceptable or threatening thought. compulsive disorder (OCD) for 1 week. Which statements by
In this case, the patient reorders the environment to "undo" the the patient would be cause for concern? Select all that apply.
anxiety associated with thoughts of losing control. Denial A. "My thoughts and compulsions are still bothersome
refers to the refusal to believe or accept the reality of a sometimes."
situation or experience. Projection refers to unconsciously B. "I have needed to drink more because my mouth is
attributing one's thoughts or impulses onto another person. frequently dry."
Conversion refers to the transfer of a mental conflict into a C. "I take this medication when I experience the compulsion to
physical symptom. clean."
D. "My spouse is concerned that I will become addicted to this
78. The nurse is using Peplau's four levels of anxiety as a medication."
model for assessing a patient who has been experiencing panic E. "I have been using Ativan as needed when I have trouble
attacks. At which stage would the nurse anticipate detecting getting to sleep."
the onset of tachycardia and tachypnea?
A. Mild +1 Rationale:
B. Moderate +2 Fluvoxamine is a selective-serotonin inhibiter (SSRI) that is
C. Severe +3 used in the management of select anxiety disorders. Patients
D. Panic +4 need to take the medication every day, generally for several
weeks before experiencing the desired effects of the
Rationale: medication. Fluvoxamine does not cause dependency. The
According to Peplau, stage 2 of anxiety is characterized by the nurse would be concerned that the patient is taking the
onset of physiological symptoms including increased medication only when experiencing symptoms of anxiety. The
respirations and heart rate. During stage one the patient nurse would correct misinformation suggesting that the patient
experiences psychological changes. Stages 3 and 4 are is at risk for dependence. Benzodiazepines may still be used as
characterized by progressive and more distressing prescribed to manage the acute symptoms of anxiety and
physiological and psychological symptoms. insomnia, especially in the period before the SRRI becomes
effective. Common side effects of SSRIs include dry mouth,
79. The nurse is caring for a patient presenting with symptoms which can be alleviated by interventions such as drinking
of anxiety. The patient states that he has started to avoid any more fluids.
situations that induce panic, such as going to the mall or the
theater without a family member. The nurse recognizes that 81. The nurse is planning care for a patient experiencing an
the patient's symptoms are most consistent with which type of anxiety disorder. Which variable is essential for the nurse to
anxiety disorder? consider first?
A. Agoraphobia A. The research supporting various treatment modalities
B. Social anxiety B. The patient's personal perspective on the anxiety disorder
C. Panic disorder C. The behavioral manifestations related to mental health
D. Separation anxiety domains
Rationale: D. The nurse's previous experience with patients with similar
Agoraphobia is characterized by a marked fear of situations disorders
where escape would be difficult or not immediately accessible.
Individuals with this disorder may avoid situations such as Rationale:
going to the mall or theater and or may depend on the It is essential that the nurse consider the patient's individual
assistance of another person to help them manage the perspective and preferences when formulating a plan of care.
situation. Social anxiety is a disorder characterized by fear or All patients have unique experiences and needs, and the goals
anxiety in situations where there is a potential for for treatment should be determined with patient input
embarrassment or scrutiny related to interaction or whenever possible. Further assessment would consider other
objective data related to mental health domains. Research and D. The patient's delivery was complicated by a hypoxic
experience can then be used to formulate a care plan that best episode.
addresses individual patient needs. E. The patient's father was 50 years old when the patient was
born.
82. The nurse is counseling a couple planning to start a family.
The couple reveals a family history of schizophrenia and asks Rationale:
about the risks of having a child who develops the illness. Sociocultural conditions/events include both biological and
Which response by the nurse is accurate? psychosocial risk factors spanning the period before birth
A. "Many factors may lead to schizophrenia, but genetics through young adulthood. Although the reason is not
account for the highest proportion of risk." understood, being born in late winter or early spring is
B. "Genetic factors are considered significant only when one associated with a 5-10 percent greater likelihood of SSDs.
or both parents have been affected by this mental illness." Maternal stress, illness, and malnutrition during the first
C. "When considering risk factors for this disease, genetic semester of pregnancy are associated with an increased risk of
influences are less important than environmental variables." SSDs. Delivery complications double the risk of an SSD.
D. "Although genetics are a suspected factor in development Living in urban, not rural, areas is associated with a higher
of schizophrenia, to date there is really limited evidence to incidence of SSDs. Paternal age of greater than 60 years is
support this theory." associated with SSDs.

Rationale: 85. A patient is taking haloperidol (Haldol) for the

While many factors place individuals at risk for developing management of schizophrenia. When evaluating the efficacy
the disease, genetics accounts for approximately 80 percent of of this treatment, the nurse knows this medication is least
the risk. Although one or both parents having the illness likely to address which manifestation of the illness?
increases the chances of having the disease, any family history A. Avolition
is significant. The genetic basis for schizophrenia has been B. Delusions
documented and supported by research. C. Hallucinations
D. Disorganized speech
83. The nurse is assisting a patient with schizophrenia to
complete activities of daily living. Which category of Rationale:
symptoms is being addressed when the nurse lists all the steps Avolition, or lack of motivation, is a negative symptom of
that the patient needs to carry out? schizophrenia. First generation antipsychotics such as Haldol
A. Positive symptoms are considered less effective in managing the negative
B. Negative symptoms symptoms of the disorder. Efficacy for treating positive
C. Cognitive symptoms symptoms including delusions, hallucinations, and
D. Prodromal symptoms disorganized speech is comparable for first and second-
generation antipsychotics.
Rationale:
Cognitive symptoms include memory and attention deficits, 86. A patient with a diagnosis of schizophrenia is in the
language difficulties, and problems with executive rehabilitation phase of the illness. Which assessments would
functioning. Executive functioning includes the ability to order constitute the focus of nursing care? Select all that apply.
sequential behaviors, such as carrying out a multi-step process. A. Ensuring the absence of positive, negative, and cognitive
The nurse is addressing cognitive symptoms of the disease by symptoms of the illness
writing out the steps of a task or process. Positive symptoms B. Determining whether the patient has resumed functioning
include hallucinations, delusions, as well as speech and consistent with premorbid status
movement abnormalities. Negative symptoms include lack of C. Ascertaining whether family and community supports are
motivation, thought blocking, poverty of speech, withdrawal, available and appropriate to patient needs
and flat affect. Prodromal symptoms include nonspecific D. Evaluating the patient for extrapyramidal symptoms and
behaviors that represent a change from premorbid functioning other side effects of medication
and precede the emergence of psychotic symptoms. E. Appraising the patient's readiness to replace medications
with non-pharmacologic treatment interventions
84. The nurse is caring for a patient diagnosed with
schizophrenia. When reviewing the patient's chart, the nurse Rationale:
recognizes that which sociocultural events are associated with Because EPS and other side effects of medications can occur
the development of SSDs? Select all that apply. at any point in treatment and may be a factor in treatment
A. The patient was raised in a rural area. adherence, the nurse would continue to assess for these in the
B. The patient's birthday is in the end of February. rehabilitation phase of the illness. It is also essential to
C. The patient's mother did not have access to prenatal care. determine the stability of family and community supports.
Patients with schizophrenia who are in recovery are likely to
continue to experience some degree of negative and cognitive expressing confidence in the patient's ability to manage tasks,
symptoms of the illness. It also is unrealistic to expect that the and discussing the benefits of employment. Patients in
patient with schizophrenia resume a level of functioning that is remission are capable of being productive and should be
consistent with premorbid functioning. Recovery is a lifelong encouraged to pursue manageable employment or vocational
process and pharmacological management of the illness is an activities. Avolition does not necessarily indicate that the
essential component of ongoing treatment. patient is paranoid; suggesting an increase in medication is
inappropriate at this time. Minimizing the parent's concern or
87. The nurse is developing a plan of care for the patient in the suggesting the parent is negative or responsible for patient
rehabilitation phase of treatment of schizophrenia who is relapse is not therapeutic.
struggling to maintain a healthy weight. Which approach is
most likely to be effective? 89. The nurse is working on an inpatient psychiatric unit and
A. Provide a stimulating multimedia presentation on the notices a patient pacing with fists clenched. The nurse
deleterious effects of poor lifestyle choices. approaches the patient with the understanding that this
B. Work with the patient to develop simple, manageable goals behavior is usually a manifestation of which of the following?
related to portion control and healthy choices. A. A lack of regard for others
C. Focus efforts on encouraging aerobic exercise for at least 1 B. An unmet need with anxiety
hour daily to compensate for increased appetite. C. Poor environmental controls and limits
D. Aim teaching efforts at family members or other support D. Predatory instincts with cognitive deficits
persons who are more capable of influencing the patient's diet.
Rationale:
Rationale: The patient pacing with fist clenched is demonstrating
Nurses should plan simple diet teaching that takes into account behaviors that are indicative of escalating anger and the
the neurological and cognitive deficits that accompany the potential for aggression. The nurse recognizes that this
illness. Patients with schizophrenia respond to concrete behavior most often represents an unmet need with anxiety.
examples, positive reinforcement, repetition, and reminders Efforts to de-escalate the patient would initially focus on
and should be encouraged to identify manageable goals. By trying to determine the unmet need and reducing the patient's
partnering with the patient to identify goals, the nurse is anxiety. There is no evidence to indicate that the patient lacks
reinforcing the patient's self-efficacy and sense of mastery and regard for others or that environmental controls are
the patient is more likely to adhere to the plan. Highly inadequate. Predatory behaviors are characterized by
stimulating multimedia presentations are likely to be deliberation and premeditation; in this case the patient is
overwhelming. Focusing teaching efforts on support persons demonstrating behavior consistent with impulsive aggression.
undermines the patient's right to self-determination. The
patient should be encouraged to engage in manageable 90. The nurse is caring for a patient with a history of injury to
exercise, such as walking or a similar activity for 30 minutes a the frontal lobe of the brain. The nurse recognizes that the
day 5 times a week. impact of this injury on the ability to manage aggressive
88. The nurse is providing teaching to the parent of a patient impulses results from an alteration in which key neurological
with schizophrenia who has been in remission for 6 months. function?
The parent complains that the patient is no longer ill but sits A. Stimulation of the limbic axis
on the sofa all day watching television instead of looking for B. Hypothalamic hormone release
work. Which response is most appropriate? C. The responsiveness of the amygdala
A. "Your child is lacking any kind of drive to work. It is D. Executive function and inhibition of impulse
unrealistic to expect your child to get a job at this time."
B. "Negative symptoms of schizophrenia include a lack of Rationale:
motivation. Let's discuss practical solutions to address this The prefrontal cortex is responsible for executive function and
behavior." top-down inhibition of threatening stimuli, which activate the
C. "Social isolation and withdrawal may indicate the HPA axis and produce a flight or fight response. An injury to
recurrence of paranoid delusions. Your child may need an the frontal lobe may result in problems with executive
increase in medication." function and the ability to inhibit aggressive impulses.
D. "Individuals with schizophrenia have difficulty planning
and following through with job planning. Your negativity is 91. The community health nurse is working on an initiative to
placing your child at risk of relapse." reduce the incidence of violence in an inner city, impoverished
neighborhood. Which evaluation finding best indicates that a
Rationale: risk factor for community violence has been addressed?
Avolition, or lack of motivation, is one of the most disabling A. More affluent citizens begin to populate the area.
aspects of schizophrenia and may persist even when positive B. Funding is obtained for neighborhood beautification.
symptoms of the illness are managed. Practical strategies to C. Disenfranchised youth are bused to better school systems.
increase motivation include focusing on self-efficacy;
D. Members take advantage of opportunities for cohesion and assaulted. The nurse understands that it is most essential that
engagement. the care provided results in which outcome?
A. The patient agrees to undergo counseling.
Rationale: B. The patient initiates a criminal complaint.
Although there is some controversy regarding the etiology of C. The patient's physical safety is maintained.
community violence, several factors are thought to impact the D. The patient identifies the perpetrator of the assault.
risk for community violence. These include cohesion,
collective action, poverty, and inequality. By utilizing Rationale:
opportunities for cohesion and engagement, community Maintaining the patient's safety while the patient is undergoing
members can take constructive action to ameliorate a number care is the priority. The nurse will also help the patient identify
of factors contributing to community violence. More affluent how to maintain safety following discharge from the
citizens moving into the area may actually exacerbate emergency department. Undergoing counseling and initiating a
inequality. Neighborhood beautification may increase pride, criminal complaint may be helpful to the patient, but do not
but it does not address underlying factors that lead to violence. guarantee the patient's immediate safety. The patient may not
Busing disenfranchised youth to better school systems does be able to identify the perpetrator.
not necessarily decrease the incidence of violence, which
occurs across the lifespan and in the context of the community 95. The nurse is implementing evidence-based practice to
setting. reduce the incidence of injuries related to restraint and
seclusion on the inpatient mental health unit. Which approach
92. The nurse working on an inpatient mental health unit is to patient care is most likely to be effective?
attending to a colleague who was assaulted while caring for an A. Providing for the direct supervision of any patient in
agitated patient. The nurse recognizes that the colleague was a restraints
victim of which type of workplace violence? B. Ensuring that all personnel are properly trained in restraint
A. Type I techniques
B. Type II C. Emphasizing activities that build rapport and ensure that
C. Type III patient needs are met
D. Type IV D. Warning patients frequently that if behaviors escalate,
restraints will be used
Rationale:
The nurse's colleague was a victim of violence that occurred Rationale:
while conducting business; the patient or the perpetrator has a The most effective way to reduce the incidence of injuries
legitimate relationship with the healthcare staff. This type of related to restraint and seclusion is to prevent them altogether.
workplace violence is categorized as Type II workplace Because aggression often escalates from anxiety and an unmet
violence. need, it is important to build rapport with patients and
maintain a supportive and responsive environment. Direct
93. The nurse is completing an assessment of a patient being supervision and training around the use of restraints may
admitted to the inpatient mental health unit. Which initial minimize injuries, but are not as effective as preventing the
assessment is most useful for identifying the risk that the need for their use altogether. Frequent warnings that restraints
patient will become violent or assaultive? will be used as a consequence for aggression are unlikely to be
A. Level of anxiety effective, as this fails to address the anxiety and unmet needs
B. Reality orientation that precipitate violence.
C. Past episodes of violence
D. History of incarceration 96. The nurse is working with a population of anxious and
potentially aggressive patients. Which intrapersonal factor is
Rationale: most essential to the nurse's capacity to promote a safe and
Knowledge of the patient's history of violence is essential for effective care environment?
predicting further violent episodes as well as formulating A. Absence of fear or anxiety
interventions to prevent them. Anxiety and impaired reality B. Composure and self-control
orientation are factors that can lead to aggression, but it is C. Assertive communication style
most important to identify the patient's tendency to respond D. Ability to sacrifice safety for others
with violent or out-of-control behavior. Many individuals with
mental illness have a history of incarceration due to lack of Rationale:
appropriate services. Incarceration itself does not indicate that The nurse caring for patients with a potential to be aggressive
the patient is predisposed to violent behavior. must be self-aware, recognizing situations that contribute to
the nurse's own anxiety level. The nurse must also have the
94. The nurse is evaluating outcomes for a patient presenting capacity to monitor personal reactions and maintain self-
in the emergency department for treatment after being sexually control and composure. Anxiety, fear, frustration, and anger
are all normal emotions that the nurse must deal with
effectively in order to avoid escalating or negatively
influencing patients; it is unrealistic to expect them to be
absent altogether. Assertiveness may be important, but it is
less important than the ability to use coping mechanisms to
reduce anxiety. Nurses need to engage in self-care and
protection; a willingness to sacrifice their own safety does not
contribute to a safe or therapeutic care environment.

97. The nurse is caring for a patient who has been a victim of
physical abuse at the hands of a domestic partner. The nurse
recognizes that which action by the patient places the patient
at the greatest risk for imminent violence?
A. Begins planning for a safe exit
B. Reports the abuse to authorities
C. Tells the partner that the relationship is over
D. Seeks treatment for physical injuries

Rationale:
For an individual experiencing intimate partner violence, the
time of greatest risk is when the individual ends the
relationship. Nurses working with victims who are planning to
leave abusive partners should help them plan for their safety as
they leave the relationship.

98. The nurse is working with a pregnant adolescent patient

and her partner in the prenatal clinic. Which behaviors would
alert the nurse to the possibility that the patient is a victim of
interpersonal violence? Select all that apply.
A. The partner insists that they should get married after the
baby is born.
B. The patient states that her partner has made her cut off
contact with all her friends.
C. The patient states that her partner did not want to terminate
the pregnancy.
D. The partner is extremely jealous of the attention that the
unborn child is getting.
E. The partner makes frequent derogatory comments about the
patient's physical appearance.

Rationale:
Warning signs for interpersonal violence include social
isolation of the victim, extreme jealousy, and control and
criticism or humiliation of the victim. The partner's insistence
that they get married after the baby is born or the desire for the
patient to have the baby do not necessarily indicate warning
signs for abuse unless there is evidence that the patient is
forced to concede against her will.