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A 16-year-old female patient who is Chinese American is admitted to the unit with reports of sadness and suicidal ideation. The patient is accompanied by many family members, including her mother and father. The patient and her family emigrated from mainland China five years ago. Regarding the family, the psychiatric-mental health nurse:
- A. encourages the patient to communicate her need for privacy to her family
- B. gently asks the family members to leave the room
- C. privately asks the mother for her assistance in clearing the room
- D. provides care for the patient while the family members are present
Correct Answer: C
Rationale: Involving the mother respects cultural family dynamics while facilitating a private assessment, balancing sensitivity and need.
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The nurse at the clinic is interviewing a patient who offers a number of vague somatic complaints that might not ordinarily prompt a visit to a caregiver: fatigue, back pain, and seems tense. After having spoken of the symptoms, the nurse can best serve the patient by:
- A. Asking if the patient has ever had psychiatric counseling.
- B. Completing a structured abuse assessment protocol.
- C. Suggesting the patient take a break from work.
- D. None of the above.
Correct Answer: B
Rationale: The correct answer is B: Completing a structured abuse assessment protocol. In this scenario, the patient presents with vague somatic complaints that could potentially be indicative of underlying abuse. By completing an abuse assessment protocol, the nurse can uncover any possible abuse the patient may be experiencing, which could be the root cause of their symptoms. This approach is crucial in ensuring the patient's safety and well-being.
Choice A is incorrect because assuming the symptoms are solely related to psychiatric issues without exploring other potential causes can lead to overlooking important factors. Choice C is incorrect as suggesting a break from work may not address the underlying issue and could potentially worsen the patient's situation. Choice D is incorrect as taking no action could result in the patient's condition worsening without proper intervention.
The parent of a seriously mentally ill adult asks the nurse, 'Why are you making a referral to a vocational rehabilitation program? My child wont ever be able to hold a job.' Which is the nurses best reply?
- A. We make this referral to continue eligibility for federal funding.'
- B. Are you concerned that were trying to make your child too independent?'
- C. If you think the program would be detrimental, we can postpone it for a time.'
- D. Most patients are capable of employment at some level, competitive or supported.'
Correct Answer: D
Rationale: Studies have shown that most patients who complete vocational rehabilitation programs are capable of some level of employment. They also demonstrate significant improvement in assertiveness and work behaviors as well as decreased depression.
A patient with schizophrenia is admitted to the psychiatric unit in an acutely disturbed, violent state. He is given several doses of haloperidol (Haldol) and becomes calm and approachable. During rounds the nurse notices the patient has his head rotated to one side in a stiffly fixed position. His lower jaw is thrust forward and he appears severely anxious. The patient has ______, and the nurse should ______.
- A. a dystonic reaction"¦administer PRN IM benztropine (Cogentin)
- B. tardive dyskinesia"¦seek a change in the drug or its dosage
- C. waxy flexibility"¦continue treatment with antipsychotic drugs
- D. akathisia"¦administer PRN diphenhydramine (Benadryl) PO
Correct Answer: A
Rationale: The correct answer is A: a dystonic reaction"¦administer PRN IM benztropine (Cogentin).
1. Step: Identify the symptoms - The patient has head rotation, stiff fixed position, and lower jaw thrust forward, indicating dystonia.
2. Step: Understand dystonic reactions - Dystonia is an extrapyramidal side effect of antipsychotic medications like haloperidol.
3. Step: Choose appropriate treatment - Benztropine is an anticholinergic medication used to treat acute dystonic reactions.
4. Step: Administer the medication - IM benztropine is the correct route for acute treatment of dystonia.
Summary:
- Choice B (tardive dyskinesia) is incorrect because the symptoms described are acute and not consistent with the gradual onset of tardive dyskinesia.
- Choice C (waxy flexibility) is incorrect because it is a symptom of catatonia, not a side effect of ant
While planning care for a preschool child who has been physically and sexually abused, the nurse includes play therapy because it assists the child to:
- A. Act out aggression in an acceptable manner
- B. Express feelings that cannot easily be verbalized
- C. Interact with other children in the appropriate age group
- D. Learn adaptive behaviors through acting
Correct Answer: B
Rationale: The correct answer is B: Express feelings that cannot easily be verbalized. Play therapy allows preschool children to express their emotions, trauma, and experiences through play activities, as they may not have the verbal skills to communicate their feelings effectively. This form of therapy helps the child process their emotions and experiences in a safe and non-threatening environment.
Incorrect Choices:
A: Acting out aggression in an acceptable manner is not the primary goal of play therapy for abused children. It is more about emotional expression and healing.
C: Interacting with other children in the appropriate age group is not the focus of play therapy for abused children. The primary goal is to address the trauma and emotional distress.
D: Learning adaptive behaviors through acting is not the main purpose of play therapy for abused children. It is more about emotional healing and expression.
The priority nursing focus for the period immediately after electroconvulsive therapy treatment should be on:
- A. Monitoring for the return of the capacity for full range of motion.
- B. Assessing the degree of accumulating memory impairment.
- C. Making positive comments while the patient is more receptive.
- D. Assessing the level of consciousness and normal body functions.
Correct Answer: D
Rationale: The correct answer is D: Assessing the level of consciousness and normal body functions. After electroconvulsive therapy (ECT), it is crucial to monitor the patient's level of consciousness and ensure all body functions are normal to detect any potential complications immediately. This includes assessing vital signs, neurological status, respiratory function, and cardiovascular stability. Monitoring for the return of full range of motion (A) is not a priority immediately post-ECT. Assessing memory impairment (B) may be important but is not the immediate priority. Making positive comments (C) is helpful for emotional support but does not address the critical need to assess physical status.