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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.
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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.
After the client discusses her relationship with her father, the nurse says, 'Tell me whether I am understanding your relationship with your father. You feel dominated and controlled by him?' This is an example of:
- A. verbalizing the implied.
- B. seeking consensual validation.
- C. encouraging evaluation.
- D. suggesting collaboration.
Correct Answer: B
Rationale: Consensual validation is a technique used to check one's understanding of what the client has said. Consensual validation is the process by which people come to agreement about the meaning and significance of specific symbols. Through this experience, individuals develop the ability to relate effectively.
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.
During a well-baby check of a 6-month-old infant, the nurse notes abrasions and petechiae of the palate. The nurse should:
- A. inquire about foods the child is eating.
- B. ask about the possibility of sexual abuse.
- C. request to see the type of bottle used for feedings.
- D. question the parent about objects the child plays with.
Correct Answer: B
Rationale: Generally oral sex leaves little physical evidence. Injury to the soft palate (such as bruising, abrasions, and petechiae) and pharyngeal gonorrhea are the only signs. Infants are at risk for sexual abuse.
Which of the following diseases places a client at risk for developing cirrhosis?
- A. type I diabetes
- B. alcoholism
- C. leukemia
- D. glaucoma
Correct Answer: B
Rationale: Alcoholism places a client at risk for developing cirrhosis. None of the other choices are related to cirrhosis.