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CDC – Psychiatric Nursing

Situation: Jimmy developed this goal for hospitalization. “To get a handle on my nervousness.” The nurse is
going to collaborate with him to reach his goal. Jimmy was admitted to the hospital because he called his
therapist that he planned to asphyxiate himself with exhaust from his car but frightened instead. He
realized he needed help.

The nurse recognized that Jimmy had conceptualized his problem and the next priority goal in the care
plan is:
 C. help the client cope with the present problem

The nurse is guided that Jimmy is aware of his concerns of the “here and now” when he crossed out
which item from this “list of what to know”.
 C. early signs of anxiety

While Jimmy was discussing the signs and symptoms of anxiety with his nurse, he recognized that
complete disruption of the ability to perceive occurs in:
 B. severe anxiety

Jimmy initiates independence and takes an active part in his self care with the following EXCEPT:
 A. agreeing to contact the staff when he is anxious

The nurse notes effectiveness of interventions in using subjective and objective data in the:
 D. progress notes

Situation: For more than a month now, Cecilia is persistently feeling restless, worried and feeling as if
something dreadful is going to happen. She fears being alone in places and situations where she thinks
that no one might come to rescue her just in case something happens to her.

Cecilia is demonstrating:
 C. agoraphobia

Cecilia’s problem is that she always sees and thinks negative things hence she is always fearful. Phobia
is a symptom described as:
 D. neurotic

Cecilia has a lot of irrational thoughts: The goal of therapy is to modify her:
 B. cognition

Cognitive therapy is indicated for Cecilia when she is already able to handle anxiety reactions. Which of
the following should the nurse implement?
 A. assist her in recognizing irrational beliefs and thoughts

After discharge, which of these behaviors indicate a positive result of being able to overcome her
 A. She reads a book in the public library

Situation 2 – A research study was undertaken in order to identify and analyze a disabled boy’s coping
reaction pattern during stress.

This study which is an in depth study of one boy is a:
 D. evaluative study

The process recording was the principal tool for data collection. Which of the following is NOT a part of
a process recording?
 B. Analysis and interpretation

Which of these does NOT happen in a descriptive study?
 D. Manipulation of variable

The investigator also provided the nursing care of the subject. The investigator is referred to as a/an:
 A. Participant-observer

To ensure reliability of the study, the investigator’s analysis and interpretations were:
 A. subjected to statistical treatment

the outgoing nurse informed the nursing staff that Regina. this is a gauge for the nurse’s:  A. our interaction is confidential provided the information you tell me is not detrimental to your safety. Which of these information LEAST communicate attention and care for her needs for information about her medicine?  D. 35 years old. “I like taking this sleeping pill. collaboration  All of the following responses are non therapeutic.” . “The best time to talk is during the nurse-client interaction time.  The nurse engages Regina in the process of mutual inquiry to provide an opportunity for Regina to:  D.  The nurse’s most unique tool in working with the emotionally ill client is his/her  D. Tolerating all behavior in the client. This is a demonstration of the nurse’s role as:  B. therapist Situation: The nurse engages the client in a nurse-patient interaction. Ask her what time she would like to watch the informative video about the medication. The client asks to visit the nurse after his discharge.”  Regina commits to herself that she understood and will observe all the medicine precautions by:  A. mother surrogate C. trustworthiness  Rapport has been established in the nurse-client relationship. perceive her participation in an experience  Which of these responses indicate that Regina needs further discussion regarding special instructions?  D. Responding in a punitive manner to the client. congruence of behavior?  C. “Yes.  Which of the following approaches of the nurse validates the data gathered?  A. Each individual has the potential for growth and change in the direction of positive mental health. at the start of the relationship  The client says. The appropriate response of the nurse would be:  A. A.  The best time to inform the client about terminating the nurse-patient relationship is:  D. I am committed to have this time available for us while you are at the hospital and ends after your discharge. affixing her signature to the teaching plan that she has understood the nurse NURSE – PATIENT INTERACTION Situation: The nurse-patient relationship is a modality through which the nurse meets the client’s needs. communication skills  The psychiatric nurse who is alert to both the physical and emotional needs of clients is working from the philosophical framework that states:  C.  The mentally ill person responds positively to the nurse who is warm and caring.”  When the nurse respects the client’s self-disclosure. I wish I can take it for life. Which is the MOST direct violation of the concept. It solves my problem of insomnia. Before approaching Regina. “I want to tell you something but can you promise that you will keep this a secret?” A therapeutic response of the nurse is:  A.THERAPEUTIC TECHNIQUES OF COMMUNICATION Situation: During the morning endorsement. was given Flurazepam (Dalmane) 15mg at 10:00pm because she had trouble going to sleep. tell me what happened before you were finally able to sleep and how was your sleep?”  Regina is a high school teacher. “I learned that you were up till ten last night.  One way to increase objectivity in dealing with one’s fears and anxieties is through the process of:  D. the nurse read the observation of the night nurse.

Give a brief and simple response and focus on the client. sensory deprivation  The nurse will assist Salome and her daughter to plan a goal which is for Salome to:  A. She was observed to be talking irrelevantly and incoherently. 25 years old. “What time is it?” The nurse’s appropriate is:  B. She was diagnosed as schizophrenia disorder. has been observed to be irritable. Faulty family atmosphere and interaction  Camila’s indifference toward the environment is a compensatory behavior to overcome:  C. was reported to be gradually withdrawing and isolating herself from friends and family members.  The nurse counsels Salome’s daughter that Salome’s becoming very loud and tendency to become aggressive is a/an:  C. 80 year old widow. Inform the attending physician about the request of the client. Situation: It is common that clients ask the nurse personal questions.  The past history of Camila would most probably reveal that her premorbid personality is:  A. demanding and speaking louder than usual. minimize receiving visitors at home and no longer bothers to answer telephone calls because of deterioration of hearing.  When the nurse is asked a personal question.“It is confidential I just don’t give it to anyone. Some patients are like children in seeking recognition from the nurse.  Anticipation of personal questions is given adequate attention during which phase of the nurse patient relationship?  B. which of these responses is NOT appropriate?  A. adjust to the loss of sensory and perceptual function  The daughter understood. which of these reactions indicates a need for her to introspect?  D. The client has not been visited by relatives for months. She would prefer to be alone and take her meals by herself. schizoid  Camila refuses to relate with to others because she:  C. Narcissistic behavior  Schizophrenia is a:  C. An appropriate action of the nurse would be:  A. the following ways to assist Salome meet her needs and avoiding which of the following:  D. psychosis CARE OF THE ELDERLY Situation: Salome. the MOST appropriate response is:  B. anticipates rejection  Which of the following disturbances in interpersonal relationships MOST often predispose to the development of schizophrenia?  B. She became neglectful of her personal hygiene. She was brought by her daughter to the Geriatric clinic for assessment and treatment. Working phase  If the client asks for the nurse’s telephone number. “It is 10 o’clock.  It is 10 o’clock on your watch. overcompensation for hearing  A nursing diagnosis for Salome is:  A. He gives a telephone number and requests the nurse to call. Allowing her to take her meals alone .”  When the client asks about the family of the nurse.” SCHIZOPHRENIA Situation: Camila. The client asks.

The MOST appropriate action the nurse would take is to:  A. potential for injury  A healthy adaptation to aging is primarily related to an individual’s…  C. Physical health throughout life  The frequent use of the older client’s name by the nurse is MOST effective in alleviating which of the following responses to old age?  D.  It is unethical to tell one’s friends and family members data about patients because doing so is a violation of patients’ rights to:  B. should a nurse receive telephone orders. which of these nursing diagnoses should have priority?  A. Confusion  An elderly confused client gets out of bed at night to go to the bathroom and tries to go to another bed when she returns. you will change your bed linen and wash the sheets. Has periods of crying. sympathize for the child  A therapeutic verbal approach that communicates strong disapproval is:  C. “If you bed wet. the device is turned on and adjusted to a:  D. frequently verbalizes fear of what diagnostic tests will reveal  Nursing care plans provide very meaningful data for the patient profile and initial plan because the focus is on the:  D. extinction  To help Marie who bed wets at night practice acceptable and appropriate behavior. the order has to be correctly written and signed by the physician within:  A. it is important for the parents to be consistent with the following approaches EXCEPT:  C.  B. unhappy and miserable is experiencing:  B.  Which of the following is the MOST common physiological cause of night bed wetting?  A. EXCEPT one compromise the concepts of behavior therapy program. What is the objective data?  B.” . audible level  In planning care for a patient with Parkinson’s disease. Confidentiality  The nurse must see to it that the written consent of mentally ill patients must be taken from:  C. Salome was fitted a hearing aid. Step by step procedures for the management of common problems ENURESIS Situation: Marie is 5½ years old and described by the mother as bedwetting at night. She understood the proper use and wear of this device when she says that the battery should be functional. During the orientation. deep sleep factors  All of the following. Despair LEGAL ISSUES Situation: It is the first day of clinical experience of nursing students at the Psychiatry Ward. 24 hours NURSING CARE PLAN  The following are SOAP (Subjective – Objective – Analysis – Plan) statements on a problem: Anxiety about diagnosis. Parents or legal guardian  In an extreme situation and when no other resident or intern is available. Assign client to a single room  An elderly who has lots of regrets. the nurse emphasizes that the team members including nursing students are legally responsible to safeguard patient’s records from loss or destruction or from people not authorized to read it.

Your response which is an immediate intervention would be:  A. client clenched his jaw/teeth. AGGRESSION Situation: The nurse is often met with the following situations when clients become angry and hostile. e.  Part of discharge plan is for the nurse to give instructions about the care of Graciela’s cast to the mother. Vomiting  Graciela is assessed to have no head injury. Which of these finding is a concern of immediate attention that must be reported to the physician immediately?  D.”  To encourage thought. A plaster of Paris hip spica is applied. Give a star each time she wakes up dry and every set of five stars. Her mother observed that she is having problems relating with her friends. Imipramine (Tofranil) . Graciela is placed on Bryant’s traction. Hands by sides but palms turned outwards  During the pre-interaction phase of the N-P relationship.g. keep an “open” posture. The Bryant’s traction is removed. neurotic depression  This is a tricyclic antidepressant drug:  D. “Stop! Put that chair down. therefore they would be useful in which type of depression?  B. the nurse recognizes this normal INITIAL reaction to an assaultive or potentially assaultive person.  A.  While on Bryant’s traction. the parent inquires how to motivate Marie to be dry in the morning. “Why do you feel angry?”  A patient grabs and about to throw it.” ORTHOPEDIC NURSING Situation: Graciela 1½ year old is admitted to the hospital from the emergency room with a fracture of the left femur due to a fall down a flight of stairs. which of the following approaches is NOT therapeutic?  A.  To maintain a therapeutic eye contact and body posture while interacting with angry and aggressive individual. The nurse is unable to insert a finger under the edge of Graciela’s cast on her left foot. The nurse best responds saying.  Jolina is put on antidepressant drugs. Display empathy towards the patient  Which of the following is an accurate way of reporting and recording an incident?  B. which of these observations of Graciela and her traction apparatus would indicate a decrease in the effectiveness of her traction?  A. Which of these statements indicate that the mother understood an important aspect of cast care?  D. give a prize. the nurse should:  D. “When asked about his relationship with his father. I will reinforce cracked areas on the cast with adhesive tape. Autonomy DEPRESSION Situation: Jolina is an 18 year old beginning college student. These drugs act on the brain chemistry. lost interest in anything and complained of constant tiredness. made a fist and turned away from the nurse.  The nurse notes that the fall might also cause a possible head injury. She is undecided about her future.  B. During your conference. She has lost insight. Graciela’s buttocks are resting on the bed.  The nurse counsels Graciela’s mother ways to safeguard safety while providing opportunities for Graciela to develop a sense of:  D. She will be observed for signs of increased intracranial pressure which include:  B.

provision of social welfare benefits for the poor  The MOST cost effective way to meet the mental health needs of the public is through programs with a priority goal of:  B. After one week of antidepressant medication. Experiences feelings of frustration in the group  Which of the following questions illustrates the group role of encourager?  B. She is not mixing well with other clients. Encourage her to join socialization hour so she will start to relate with others.  The psychodynamic therapy of substance abuse is based upon the premise that drug abuse is:  B. dance music  The parents of special children who are behaviorally disturbed need mental health education. Jolina still manifests depression. Which of these topics would the school nurse consider as priority for their parent’s class?  C. ego . Productivity  The treatment of the family as a unit is based on the belief that the family:  A. The nurse evaluates this as:  C. One of the nurse’s important considerations for Jolina INITIALLY is:  C. Child abuse DRUG DEPENDENCE Situation: Nurses in all practice areas are likely to come in contact with clients suffering from acute or chronic drug abuse. To de-escalate possible anger and aggression among the clients it is BEST to play:  B. caused by multiplicity of factors  Being in contact with reality and the environment is a function of the:  B. malnutrition and social ills such as street children. the nurse suggests vocational guidance because it should help Jolina to:  C.  Jolina continues to verbalize feeling sad and hopeless. cut out fabric and use a sewing machine to make simple outfits that will help her earn in the future. Vocational therapy  In a residential treatment home for adolescent girls. relaxation music C. Who wants to respond next?  The goal of remotivation therapy is to facilitate:  B. Realistically assess her assets and limitations GROUP APPROACH IN NURING  Membership dropout generally occurs in group therapy after a member:  C.  During the predischarge conference. A community approach to cope with this problem is for the nurse to support:  B. Effective parenting B. homeless and prostitution is a predisposing factor to mental illness. the clients were becoming increasingly tense and upset because of shortening of their recreation time.  Poverty as reflected in prevalence of communicable diseases. Expected because therapeutic effectiveness takes 2-4 weeks. is a social system and all the members are interrelated components of that system  The working phase in a therapy group is usually characterized by which of the following?  B. What type of therapy is this?  C. prevention  Lorelie upon discharge was referred to a volunteer group where she has learned to read patterns. Cohesiveness FUNCTIONS OF A PSYCHIATRIC NURSE Situation: The mental health – psychiatric nurse functions in a variety of setting with different types of clients.

Competitive sport Ricky’s IQ falls within the range of 50-55. He stands 5’ ½” and weighs 100 lbs. he is slim and walks sluggishly with a limp. promote homeostasis and minimize the client’s withdrawal symptoms  Commonly known as “shabu” is:  D.Sudden death from cardiac or respiratory depression  The mother of a drug dependent would never consider referring her son to a drug rehabilitation agency because she fears her son might just become worse while relating with other drug users.  The nurse should recognize that the unit primarily responsible for education and awareness of the members of the family on the ill effects of dangerous drugs is the:  D. LSD  The nurse evaluates that her health teaching to a group of high school boys is effective if these students recognize which of the following dangers of inhalant abuse. loss of train of thought. substance dependence:  D. he can be expected to:  C. The mother understood that for her son to learn to cope and be independent. The mother’s behavior can be described as:  A. Methamphetamine hydrochloride Situation: The abuse of dangerous drugs is a serious public health concern that nurses need to address. Unhelpful MENTAL RETARDATION Situation: Ricky is a 12 year old boy with Down’s syndrome. she should constantly provide activities for Ricky to be able to:  D.repression  This drug produces mirthfulness. Needs for safety and security    Ricky’s mother visited the school nurse. Ricky’s:  C. it is a priority for the nurse to:  D. He wears a neck brace as a support for his neck. fantasies. “What should I do when Ricky fondles his genitalia?” An appropriate response of the nurse is for the mother to:  A. Perform simple tasks in closely supervised settings . Divert Ricky’s attention and engage him in satisfying activities  The nurse had one on one health education sessions with Ricky’s mother.  A. family  A drug dependent utilizes this defense mechanism and enables him to forget shame and pain. He attends a school for a special education.  The classroom teacher consults the school nurse for guidance on how to take care of Ricky while inside of the classroom. The nurse considers as priority.  B. X-ray of cervical spine showed “subluxation of C1 in relation to C2 with cord compression”. Substance abuse is different from substance dependence in that. and “bloodshot eyes” due to dilated pupils. distance and time.  A. flight of ideas. distortion of size. do activities of daily living All of the following activities are appropriate for Ricky EXCEPT:  B. includes characteristics of tolerance and withdrawal  During the detoxification stage. She asked.