Practice Test 2
Which of the following statements would be considered as the most helpful for the nurse to deal with a patient with severe anxiety?
- Urging the patient to focus on what the nurse is saying
- Giving specific instructions with the use of concise statements
- Urging the patient to focus on what he speaks
- Asking the patient to identify the cause of his/her anxiety
- Explaining in detail the plan of care
Correct Answer: B. Giving specific instructions with the use of concise statements
The patient cannot follow lengthy explanations as the patient has narrowed perceptual field in case of severe anxiety. The patient should not be urged to focus on speaking or hearing. The patient cannot identify the cause of anxiety. In case of severe anxiety, the patient cannot follow the developed plan of care explained by the nurse.
Which is considered as the most appropriate way for facilitation of nursing interaction with a mentally ill patient who understands only a foreign language?
- Using the services of a language interpreter
- Speaking in universal phrases
- Using smile and actions
- Using symbolic pictures for the interactions
- Using nonverbal communication
Correct Answer: A. Using the services of a language interpreter
A language interpreter can make the nurse understand the patient’s problems and needs. Non-verbal cues like smile and actions are needed but for fully assessing the patient’s problems and needs, the help of a language interpreter is important. The use of universal phrases and symbolic pictures helps the nurse in understanding the self care needs of the patient, but that is insufficient to assess the patient’s psychiatric problem.
A 44-year-old patient is diagnosed with bipolar disorder with current episode mania. He is agitated and is having delusions of grandeur and command hallucinations. Which of the following nursing diagnoses becomes the priority?
- Disturbed sensory-perception
- Risk for other-directed violence
- Impaired social interaction
- Imbalanced nutrition
Correct Answer: B. Risk for other-directed violence
A maniac patient with command type hallucination will have poor impulse control. The patient is prone to injury directed towards self or others. It is therefore considered as harm to himself and others. All the other above-mentioned nursing diagnoses are used in this patient with mania, but the priority diagnosis is risk for others-directed violence.
The nurse performs mental status examination on a 34-year-old patient with cognitive impairment. The nurse questions the patient about the present date, month, and year. The nurse also questions the patient about where he is. In this case the nurse is assessing:
Correct Answer: D. Orientation
The nurse who performs a mental status examination would initially assess a patient with cognitive impairment, for his orientation to time, place, and person. The nurse will assess for confabulation and perseveration in this patient, but the questions of time and place are not used to elicit them. In delirium, the patient has cognitive impairment but other symptoms are needed to prove the diagnosis.
A teenage girl returns home followed by a treatment of anorexia nervosa in a hospital. The girl’s family members complain to the nurse who visits the girl’s house that the girl is stubborn about eating. But she always pleases the family members in all other ways possible by her. The nurse assesses the family situation and understands it as a characteristic of a relationship style. Which is it?
Correct Answer: A. Enmeshment
Enmeshment is over-involvement among family members where there are expectations and family members think and act in the same manner. The girl in this case is always acting to please the family members. This shows enmeshment affects development. A girl develops anorexia nervosa, to have control only in the area of eating behavior. All other above-mentioned terms, do not appropriately describe the presented situation.
A 43-year-old male patient with obsessive-compulsive disorder is admitted in a neurotic unit. Which nursing response is considered as the most beneficial?
- Rejecting the patient’s obsessive-compulsive behaviors
- Challenging the patient’s obsessive-compulsive behaviors
- Accepting the patient’s obsessive-compulsive behaviors
- Dejecting the patient’s obsessive-compulsive behaviors
- Preventing the patient’s obsessive-compulsive behaviors
Correct Answer: C. Accepting the patient’s obsessive-compulsive behaviors
A patient with obsessive-compulsive disorder uses obsessions and compulsions to decrease anxiety. If the nurse accepts the patient with the behavior, the nurse can make the patient feel secured. All other above-mentioned nursing responses would increase the patient’s anxiety.
A 78-year-old patient is diagnosed with dementia of the Alzheimer’s type. He confabulates when interacting with the home nurse. The nurse understands that this patient:
- Fills the memory gap with fantasies
- Rationalizes his behaviors
- Pretends to act like somebody else
- Avoids confusion by being jovial
- Summarizes the past life
Correct Answer: A. Fills the memory gap with fantasies
A patient with Alzheimer’s type dementia will confabulate frequently. Confabulation is a communication device used by patients with dementia to compensate the memory gaps. They fill the memory gaps with the misinterpreted memories about self or the world, without the conscious intention. All other above-mentioned options are incorrect.
The parents of a 30-year-old man with schizophrenia express feelings of responsibility and guilt for their son’s disease. How would the nurse educate the parents?
- Teaching the parents the ways they could change
- Referring the family to a support group
- Explaining the biological nature of schizophrenia
- Acknowledging that it is the parent’s responsibility
- Telling about the disease prognosis to the parents
Correct Answer: C. Explaining the biological nature of schizophrenia
The parents are feeling responsible for the disease in the patient. The parents’ self-blame can be avoided by ensuring them with the facts about the biologic basis of schizophrenia. Teaching the parents about the various ways to change such thinking and telling about the disease prognosis, implies that the parents’ behavior is incorrect. So this must be avoided. Support groups are useful after specific treatment but here the nurse can handle the parents’ self-blame and guilt directly, without making a referral. Acknowledging the parent’s responsibility is not helpful for the parents, as it reinforces the feelings of guilt.
A psychiatrist ordered for an intra-muscular injection of haloperidol 2.5 mg to a violent patient. The medication is labeled as haloperidol 10 mg /2 ml. How many milliliters in the syringe would the nurse draw to prepare the correct dose?
Correct Answer: C. 0.5 ml
The correct dose is calculated as follows. As a first step the ordered dose (2.5mg) is divided by total number of mg in the drug (10mg). For finding out the correct dose (X), the second step is used. Here X is divided by the total ml in the drug (2ml). The answer will be 0.5ml.
A 45-year-old female patient tells a nurse that her family members would have been happy if she wasn’t alive. Which nursing diagnosis is considered appropriate based on this statement?
- Impaired social interaction
- Disturbed thought processes
- Risk for infection
- Ineffective coping
- Risk for self-directed violence
Correct Answer: E. Risk for self-directed violence
The nurse must note that the patient is having suicidal ideations. So this must be considered as a serious problem. The nurse must take measures to avoid self-directed violence. All other above mentioned diagnoses are not considered important in the present case.
A 23-year-old male patient abuses alcohol. He tells the nurse that he drinks alcohol in order to manage his stressful job. Which defense mechanisms is this patient using?
- Reaction formation
Correct Answer: B. Rationalization
Rationalization is used by the patient. Rationalization involves providing reasons for the improper behavior. The patient is protecting his alcohol abuse by providing excuses related to his job stressors. It is a commonly used defense mechanism against substance abuse. All other above-mentioned defense mechanisms are incorrect.
A 25-year-old female patient is dependent on heroin during her pregnancy; the family nurse understands that the baby will be at risk of developing:
- Heroin dependence
- Mental retardation
- Psychological disturbances
- Addiction in adulthood
- Addiction in old age
Correct Answer: A. Heroin dependence
If the mother is heroin-dependent, the baby becomes heroin dependent after birth. The baby goes through the stage of withdrawal. There is no supporting evidence for the relation of heroin and the other above-mentioned options.
A family nurse practitioner collects data and asks family members regarding their names and where they live. Which of the following does the nurse try to know?
Correct Answer: A. Boundaries
Family boundaries define who is inside and outside the family. The most suitable method to obtain the family boundary information is by asking the family members whom they consider to be family members. All other above-mentioned options are not correct.
Which plan of nursing care is considered as the most appropriate initially, for a 14-year-old girl with anorexia nervosa?
- Explaining to the patient about the physical consequence of anorexia
- Using preferences and restrictions based on compliance with re-feeding
- Ignoring the patient’s food-avoiding behavior
- Educating about the importance of good nutrition
- Telling the girl not to see the mirror
Correct Answer: B. Using preferences and restrictions based on compliance with re-feeding
Initially, re-feeding is done to combat the effects of starvation. Re-feeding is attained with the help of behavioral therapy. It uses rewards and reinforcements to establish weight restoration. Teaching the patient about the physical consequences of anorexia and educating on nutrition is not appropriate in initial treatment. The nurse must assess the patient’s food behavior continuously to know the treatment effectiveness.
A nurse is speaking with the parents of a hospitalized adolescent. He is diagnosed with alcohol abuse. The nurse understands the situation and accepts the adolescent’s perspective about his family rules. Which nursing intervention is the most appropriate for this case?
- The nurse must remain objective and encourage mutual negotiation of problems
- The nurse must ask the adolescent to comply with parental rules
- The nurse must ask the parents to set realistic rules
- The nurse must support the adolescent
- The nurse must support the parents
Correct Answer: A. The nurse must remain objective and encourage mutual negotiation of problems
The nurse must remain neutral. Supporting either parents or adolescent in the given situation will not help any of them. If the nurse supports the adolescent, the nurse must blame the parents for the problem, so this would not help the parents. Expecting the parents to set realistic rules or asking the adolescent to get adjusted with the parental rules will not help to sort out the problems.