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NCLEX Practice Questions for Foundations of Psychiatric Mental Health Nursing (RN)
NCLEX Study Guide (RN) with abbreviations
Terms in this set (17)
1. A patient with a diagnosis of major depression who has attenpted suicide says to the nurse, "I should have died. I've always been a failure. Nothing ever goes right for me." Which response demonstrates therapeutic communication?
a. "You have everything to live for"
b. "Why do you see yourself as a failiure?"
c. "Feeling like this is all part of being depressed."
d. "You've been feeling like a failure for a while?"
(D) "You've been feeling like a failure for a while?"
RATIONALE: Responding to the feelings expressed by a patient is an effective therapeutic communication technique. The correct option is an example of the use of restating. The remaining options block communication because they minimize the patient's experience and do not facilitate exploration of the patient's expressed feelings. In additions, use of the word "why" is nontherapeutic.
2. When the community health nurse visits a patient at home, the patitent states, "I haven't slept at all the last cople of nights. Which response by the nurse illustrates a therapeutic communication response to this patient."
a. "I see."
c. "You're having difficulty sleeping?"
d. "Sometimes, I have trouble sleeping too."
(C) "You're having difficulty sleeping?"
RATIONALE: The correct option uses the therapeutic communication technique of restatement. Although restatement is a technique that has a prompting component to it, it repeats the patients major theme, which assists the nurse to obtain a more specific perception of the problem from the patient. The remaining options are not therapeutic responses since none encourage the patient to expand on the problem. Offering personal experiences moves the focus away from the patient and onto the nurse.
3. A patient experiencing disturbed thought processes believes that his food is being poisoned. Which communication technique should the use to encourage the patient to eat?
a. Using open-ended questions and silence
b. Sharing personal prefernce regarding food choices
c. Documenting reasons why the patient does not wat to eat
d. Offering opinions about the necessity of adequate nutrition
(A) Using open-ended questions and silence
RATIONALE: Open-ended questions and silence are strategies use to encourage patients to discuss their problems. Sharing personal food preferences is not a patient-centered intervention. The remaining options are not helpful to the patient because they do not encourage the patient to express feelings. The nurse should not offer opinions and should encourage the patient to identify the reasons for the behavior.
4. A patient admitted to a nental health unit for treatment of psychotic behavior spends hours at teh locked exit door shouting. "Let me out. Ther's nothing wrong with me. I don't belong here." What defense mechanism is the patient implementing?
RATIONALE: Denial is refusal to admit to a painful reality, which is treated as if it does not exist. In projection, a person unconsciously rejects emotionally unacceptable features and attributes them to other persons, objects, or situations. Regression allows the patient to return to an ealier, more comforting, although less mature, way of behaving. Rationalization is justifying illogical or unreasonable ideas, actions, or feelings by developing acceptable explanations that satisfy the teller and the listener.
5. A patient diagnosed with terminal cancer says to the nurse "I'm going ot die, and I wish my family would stop hoping for a cure! I get so angry when they carry on like this. After all, I'm the one who's dying." Which response by the nurse is therapeutic?
a. "Have you shared your feelings with your family?"
b. "I think we should talk more about your anger with your family."
c. "You're feeling angry that your family continues to hope for you to be cured?"
d. "You are probably very depressed, which is understanble with such a diagnosis"
(C) "You're feeling angry that your family continues to hope for you to be cured?"
RATIONALE: Restating is a therapeutic communication technique in which the nurse repeats what the patient says to show understanding and to review what was said. While it is appropriate for the nurse to attempt to assess the patient's ability to discuss feelings openly with family members, it does not help the patient discuss the feelings causing the anger. The nurse's attempt to focus on the central issue of anger is premature. The nurse would never make a judgment regarding the reason for the patient's feeing, this is non-therapeutic in the one-to-one relationship.
6. On review of the patients record, the nurse notes the admission was voluntary. Based on this information, the nurse anticipates which patient behavior?
a. Fearfulness regarding treatment measures.
b. Anger and agressiveness directed toward others.
c. An understanding of the pathology and syptoms of the diagnosis
d. A willingness to participte in the planning of the care and treatment plan
(D) A willingness to participate in the planning of the care and treatment plan
RATIONALE: In general, patients seek voluntary admission. If a patient seeks voluntary admission, the most likely expectations is the patient will participate in the treatment program since they are actively seeking help. The remaining options are not characteristics of this type of admission. Fearfulness, anger, and aggressiveness are more characteristic of an involuntary admission. Voluntary admission does not guarantee a patients understanding of their illness, only of their desire for help.
7. A patient admitted voluntarily for treatment of an anxiety disorder demands to be released from the hospital. Which action shoul dthe nurse take INITIALLY?
a. Contact the patients health care provider (HCP)
b. Call the patients family to arrange for transportations.
c. Attempt to persuade the pationt to stay "for only a few more days"
d. Tell the patient tha tleaving would likely result in an involuntary commitment
(A) Contact the patients health care provider (HCP)
RATIONALE: In general, patients seek, voluntary admission. Voluntary patients have the right to demand and obtain release. The nurse needs ot be familiar with the state and facility policies and procedures. The best nursing action is to contact the HCP, who has the authority to discuss discharge with the patient. While arranging for safe transportation is appropriate it is premature in this situation and should be done only with the patients' permission. While it is appropriate to discuss why the patient feels the need to leave and the possible outcomes of leaving against medical advice, attempting to get the patient to agree to staying "a few more days" has little value and will not likely be successful. Many states require that the patient submit a written release notice to the facility staff members, who reevaluate the patient's condition for possible conversion to involuntary status if necessary, according to criteria established by law. While this is a possibility, it should not be used as a threat to the patient.
8. When reviewing the admission assessment, the nurse notes that a patient was admitted to the mental health unity involuntarily. Based on this type of admission, the nurse should provide which intervention for this patient?
a. Monitor closely for harm to self or others
b. Assist in completing an applicaiont for admission
c. Supply the patient with written information about their mental illness
d. Provide an opprotunity fo the family to discuss why they felt the admission was needed
(A) Monitor closely for harm to self or others
RATIONALE: Involuntary admission is necessary when a person is a danger to self or others or is in need of psychiatric treatment regardless of the patient's willingness to consent to the hospitalization. A written request is a component of a voluntary admission. Providing written information regarding the illness is likely premature initially. The family may have had no role to play in the patients' admission.
9. The nurse is preparing a patient for the termination phase of the nurse-patient relationship. The nurse prepares to implement which nursing task that is MOST APPROPRIATE for this phase?
a. Planning short-term goals
b. Making appropriate referrals
c. Developing realistic solutions
d. Identifying expected outcomes
(B) Making appropriate referrals
RATIONALE: Tasks of the termination phase include evaluating patient performance, evaluating achievement of expected out-comes, evaluating future needs, making appropriate referrals and dealing with the common behaviors associated with termination. The remaining options identify tasks appropriate for the working phase of the relationship.
10. The nurse employed in a mental health clinic is greeted by a neighbor in a local grocery store. The neighbors says to the nurse, "How is Carol doing? She is my best friend and is seen at your clinic every week." Which is the MOST APPROPRIATE nursing response?
a. "I can not discuss any patient situation with you."
b. "If you want to know about Carol, you need t ask her yourself."
c. "Only because you're worried aobut a friend, I'll tell you that she is improving."
d. "Being her friend, you know she is having a difficult time and derserves her privacy."
(A) "I cannot discuss any patient situation with you."
RATIONALE: The nurse is required to maintain confidentiality regarding the patient and the patient's care. Confidentiality is basic to the therapeutic relationship and is a patient's right. The most appropriate response to the neighbor is the statement of that responsibility in a direct, but polite manner. A blunt statement that does not acknowledge why the nurse cannot reveal patient information may be taken as disrespectful and uncaring. The remaining options identify statements that do not maintain patient confidentiality.
11. The nurse calls security and has physical restraints applied when a cliet who was admitted voluntarily becomes both physically and verbally abusive while demading to be discharged from the hospital. Which represens the possile legal ramifications for the nurse associated with these interventions? SELECT ALL THAT APPLY
e. False Imprisonment
(B, C, E) Battery, Assault, False Imprisonment
RATIONALE: False imprisonment is an act with the intent to confine a person to a specific are. The nurse can be charged with false imprisonment if the nurse prohibits a patient from leaving the hospital if the patient has been admitted voluntarily and if no agency or legal policies exist for detaining the patient. Assault and battery are related to the act of restraining the patient in a situation that did not meet criteria for such an intervention. Libel and slander are not applicable here since the nurse did not write or verbally make untrue statements about the patient.
12. The nurse in the mental health unit recognizes ___ as being therapeutic communication techniques? SELECT ALL THAT APPLY
c. Asking the patient "Why?"
d. Maintaing neutral responses
e. Providing acknowledgment and feedback
f. Giving advice and approval or disapproval
(A, B, D, E) Restating, Listening, Maintaining neutral responses, Providing acknowledgment and feedback
RATIONALE: Therapeutic communication techniques include listening, maintaining silence, maintaining neutral responses, using broad openings and open-ended questions, focusing nd refocusing, restating, clarifying and validating, sharing perceptions, reflecting, providing acknowledgment and feedback, giving information, presenting reality, encouraging formulation of a plan of action, providing nonverbal encouragement, and summarizing Asking why is often interpreted as being accusatory by the patient and should also be avoided. Providing advice or giving approval or disapproval are barriers to communication.
13. A patient being seen in the emergency department immediately after being sexually assaulted sppears calm and controlled. The nurse analyzes this behavior as indicating which defense mechanism?
RATIONALE: Enial is refusal to admit to a painful reality and may be a response by a victim of sexual abuse. In this case the patient is not acknowledging the trauma of the assault either verbally or nonverbally. Projection is transferring one's internal feelings, thoughts, and unacceptable ideas and traits to someone else. Rationalization is justifying the unacceptable attributes about oneself. Intellectualization is the excessive use of abstract thinking or generalizations to decrease painful thinking.
14. A patient's unresolved feelings related to loss would be MOST LIKELY observed during which phase of the therapeutic nurse-patient relationship?
RATIONALE: In the termination phase, the relationship comes to a close. Ending treatment sometimes may be traumatic for patients who have come to value the relationship and the help. Because loss is an issue, any unresolved feelings related to loss may resurface during this phase. The remaining options are not specifically associated with this issue of unresolved feelings.
15. The nurse is working with a patient who despite making a heoric effort was unable to resuce a neigbor trapped in a house fire. Which patient focused action should the nurse engage in during the working phase of the nurse-patient relationship.
a. Exploring the patient's ability to function
b Exploring the patiens potential for self-harm
c. Inquiring about the patients perception or appraisal of why the resuce was unsuccessful
d. Inquiring about and examining the patient's feelings for any that may block adaptive coping
(D) Inquiring about and examining the patient's feelings for any that may block adaptive coping
RATIONALE: The patient must first deal with feelings and negative responses before the patient can work through the meaning the crisis. The correct option pertains directly to the patient's feelings and is patient-focused. The remaining options do not directly focus on or address the patient's feelings.
16. Which statement demonstrates the BEST understanding of the nurse's role regarding ensuring taht each client's rights are respected?
a. "Autonomy is the fundamental right of each and every client."
b. "A patient's rights are guaranteed by both state and federal laws."
c. "Being respectful and concerned will ensure that I'm attentinve to my patient's rights."
d. "Regardless of the patient's conditions, all nurses have the duty to respect patient rights."
(C) "Being respectful and concerned will ensure that I'm attentive to my patients' rights."
RATIONALE: The nurse needs to respect and have concern for the patient; this is vital to protecting the patient's rights. While it is true the autonomy is a basic client right, there are other rights that must also be both respected and facilitated. State and federal laws do protect a patient's rights, but it is sensitivity to those rights that will ensure that the nurse secures these rights for the patient. It is a fact that safeguarding a patient's rights are a nursing responsibility, but stating that fact does not show understanding or respect for the concept.
17. The nurse is providing care to a client admitted to the hospital with a diagnosis of acute anxiety disorer. The patient say s to the nurse "I have a secret that I want to tell you. You won't tell anyone about it, will you?" What is the MOST APPROPRIATE nursing response?
a. "No, I won't tell anyone."
b. "I cannot promise to keep a secret."
c. "It depends on what the secret is about."
d. "If you tell me the secret, I may need to document it."
(B) "I cannot promise to keep a secret."
RATIONALE: The nurse should never promise to keep a secret. Secret are never appropriate in a therapeutic relationship. The nurse needs to be honest and tell the patient that a promise cannot be made to keep the secret. The remaining options are inappropriate responses since they either promise to keep the secret or provide the criteria for when a secret may be appropriately kept.
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