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An adult comes to the crisis clinic after termination from a job of 15 years. The patient says, "I don't know what to do. How can I get another job? Who will pay the bills? How will I feed my family?" Which nursing diagnosis applies?
- A. Hopelessness
- B. Powerlessness
- C. Chronic low self-esteem
- D. Interrupted family processes
Correct Answer: B
Rationale: The patient describes feelings of lack of control over life events. No direct mention is made of hopelessness or chronic low self-esteem. The patient's family processes are not interrupted at this point.
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A nurse is discussing relapse potential with a group of clients and their families. The nurse should include which of the following statements about relapse prevention?
- A. Relapses should be expected and be looked at as an opportunity.
- B. Relapses signal failure of the abstinence plan, and the plan must be changed.
- C. Relapses may indicate that the client has very little willpower.
- D. Relapses are rare and unlikely to occur.
Correct Answer: A
Rationale: Relapses should be expected and viewed as an opportunity to learn and grow in the recovery process. This perspective helps clients and families understand that relapse is a part of the journey and not a sign of failure.
Which assessment finding for a patient in the community deserves priority intervention by the psychiatric nurse? The patient:
- A. receives Social Security disability income plus a small check from a trust fund every month.
- B. was absent from two of six planned Alcoholics Anonymous meetings in the past 2 weeks.
- C. lives in an apartment with two patients who attend partial hospitalization programs.
- D. has a sibling who was recently diagnosed with a mental illness.
Correct Answer: B
Rationale: Patients who use alcohol or illegal substances often become medication noncompliant. Medication noncompliance, along with the disorganizing influence of substances on cellular brain function, promotes relapse. The distracters do not suggest problems.
What is meant by the term 'revolving door effect' in mental health care?
- A. An overall reduction in incidence of severe mental illness
- B. Shorter and more frequent hospital stays for persons with severe and persistent mental illness
- C. Flexible treatment settings for mentally ill
- D. Most effective and least expensive treatment settings
Correct Answer: B
Rationale: The revolving door effect refers to shorter, but more frequent, hospital stays. Clients are quickly discharged into the community where services are not adequate; without adequate community services, clients become acutely ill and require rehospitalization. The revolving door effect does not refer to flexible treatment settings for mentally ill. Even though hospitalization is more expensive than outpatient treatment, if utilized appropriately could result in stabilization and less need for emergency department visits and/or rehospitalization. The revolving door effect does not relate to the incidence of severe mental illness.
Which behavior shows that a nurse values autonomy? The nurse
- A. suggests one-on-one supervision for a patient who has suicidal thoughts.
- B. informs a patient that the spouse will not be in during visiting hours.
- C. discusses options and helps the patient weigh the consequences.
- D. sets limits on a patient's romantic overtures toward the nurse.
Correct Answer: C
Rationale: A high level of valuing is acting on one's belief. Autonomy is supported when the nurse helps a patient weigh alternatives and their consequences before the patient makes a decision.
A nurse wants to find a description of diagnostic criteria for anxiety disorders. Which resource would have the most complete information?
- A. Nursing Outcomes Classification (NOC)
- B. Diagnostic and Statistical Manual of Mental Disorders (DSM-5)
- C. The ANAs Psychiatric-Mental Health Nursing Scope and Standards of Practice
- D. International Statistical Classification of Diseases and Related Health Problems (ICD-10)
Correct Answer: B
Rationale: The DSM-5 details the diagnostic criteria for psychiatric clinical conditions. The other references are good resources but do not define the diagnostic criteria.