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In performing a psychosocial assessment, the nurse begins by asking questions that encourage the client to describe problematic behaviors and situations. The next step is to elicit the client's:
- A. feelings about what has been described
- B. thoughts about what has been described
- C. possible solutions to the problem
- D. intent in sharing the description
Correct Answer: B
Rationale: Eliciting the client's thoughts after describing issues provides insight into their perspective and interpretation, guiding further assessment. Feelings and solutions come later.
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How does the ANA define the psychiatric nursing role?
- A. a specialized area of nursing practice that employs theories of human behavior as its science and the powerful use of self as its art.
- B. assisting the therapist to relieve the symptoms of clients.
- C. to solve clients' problems and give them the answers.
- D. having a client committed to long-term therapy with the nurse.
Correct Answer: A
Rationale: The ANA sets standards of practice for psychiatric and mental health nursing roles. Quality of care, performance appraisal, education, ethics, collaboration, and research are covered through the use of the Nursing Process.
A nurse notes that an elderly client suddenly does not keep appointments and is not wearing appropriate clothing. Which statement by the client raises the suspicion of financial abuse?
- A. I am having difficulty paying for this new antibiotic the physician prescribed.
- B. I am a little short on cash since my daughter moved in to help me.
- C. I have not felt like shopping since the weather has gotten worse.
- D. People do not realize how difficult it is to make ends meet on a fixed income.
Correct Answer: B
Rationale: Signs of financial abuse include an inability to pay for necessities like clothes, and the statement about being short on cash since the daughter moved in suggests possible misuse of funds by a caregiver.
Which of the following statements should the nurse use to best describe a very low-calorie diet (VLCD) to a client?
- A. This diet can be used when there is close medical supervision.'
- B. This is a long-term treatment measure that assists obese people who can't lose weight.'
- C. The VLCD consists of solid food items that are pureed to facilitate digestion and absorption.'
- D. A VLCD contains very little protein.'
Correct Answer: A
Rationale: VLCDs are used in the clinical treatment of obesity under close medical supervision. The diet is low in calories, high in quality protein, and has a minimum of carbohydrates to spare protein and prevent ketosis.
The three major sequential maturational crises for females include:
- A. puberty, pregnancy, and menopause.
- B. death of a spouse, menopause, and childbirth.
- C. rape, divorce, and menarche.
- D. dating, engagement, and separation.
Correct Answer: A
Rationale: The three major sequential maturational crises affecting females are puberty, pregnancy, and menopause. These are life events that have been studied by many researchers and are considered the major events in a woman's life. Puberty is the onset menarche. Pregnancy is a turning point in one's life from which there is no return. Menopause is the cessation of menses. The nurse has the responsibility to assess, plan, implement appropriate concepts to facilitate effective functioning, and enhance growth and development. Other options are not sequential maturational crises.
A client receiving preoperative instructions asks questions repeatedly about when to stop eating the night before the procedure. The nurse tries to refocus the client. The nurse notes that the client is frequently startled by noises in the hall. Assessment reveals rapid speech, trembling hands, tachypnea, tachycardia, and elevated blood pressure. The client admits to feeling nervous and having trouble sleeping. Based on the assessment, the nurse documents that the client has:
- A. mild anxiety.
- B. moderate anxiety.
- C. severe anxiety.
- D. a panic attack.
Correct Answer: C
Rationale: In severe anxiety, a client focuses on small or scattered details. The person is unable to solve problems. With mild anxiety, stimuli are readily perceived and processed, and the ability to learn and solve problems is enhanced. Moderate anxiety narrows the perceptual field, but the client notices things brought to his attention. During a panic attack, the person is disorganized and might be hyperactive or unable to speak or act.