NCLEX Practice Questions for Foundations of Psychiatric Mental Health Nursing (RN) – Flashcards
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1. A patient with a diagnosis of major depression who has attenpted suicide says to the nurse, "I should have died. I've always been a failure. Nothing ever goes right for me." Which response demonstrates therapeutic communication? a. "You have everything to live for" b. "Why do you see yourself as a failiure?" c. "Feeling like this is all part of being depressed." d. "You've been feeling like a failure for a while?"
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(D) "You've been feeling like a failure for a while?" RATIONALE: Responding to the feelings expressed by a patient is an effective therapeutic communication technique. The correct option is an example of the use of restating. The remaining options block communication because they minimize the patient's experience and do not facilitate exploration of the patient's expressed feelings. In additions, use of the word "why" is nontherapeutic.
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2. When the community health nurse visits a patient at home, the patitent states, "I haven't slept at all the last cople of nights. Which response by the nurse illustrates a therapeutic communication response to this patient." a. "I see." b. "Really?" c. "You're having difficulty sleeping?" d. "Sometimes, I have trouble sleeping too."
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(C) "You're having difficulty sleeping?" RATIONALE: The correct option uses the therapeutic communication technique of restatement. Although restatement is a technique that has a prompting component to it, it repeats the patients major theme, which assists the nurse to obtain a more specific perception of the problem from the patient. The remaining options are not therapeutic responses since none encourage the patient to expand on the problem. Offering personal experiences moves the focus away from the patient and onto the nurse.
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3. A patient experiencing disturbed thought processes believes that his food is being poisoned. Which communication technique should the use to encourage the patient to eat? a. Using open-ended questions and silence b. Sharing personal prefernce regarding food choices c. Documenting reasons why the patient does not wat to eat d. Offering opinions about the necessity of adequate nutrition
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(A) Using open-ended questions and silence RATIONALE: Open-ended questions and silence are strategies use to encourage patients to discuss their problems. Sharing personal food preferences is not a patient-centered intervention. The remaining options are not helpful to the patient because they do not encourage the patient to express feelings. The nurse should not offer opinions and should encourage the patient to identify the reasons for the behavior.
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4. A patient admitted to a nental health unit for treatment of psychotic behavior spends hours at teh locked exit door shouting. "Let me out. Ther's nothing wrong with me. I don't belong here." What defense mechanism is the patient implementing? a. Denial b. Projection c Regression d. Rationalization
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(A) Denial RATIONALE: Denial is refusal to admit to a painful reality, which is treated as if it does not exist. In projection, a person unconsciously rejects emotionally unacceptable features and attributes them to other persons, objects, or situations. Regression allows the patient to return to an ealier, more comforting, although less mature, way of behaving. Rationalization is justifying illogical or unreasonable ideas, actions, or feelings by developing acceptable explanations that satisfy the teller and the listener.
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5. A patient diagnosed with terminal cancer says to the nurse "I'm going ot die, and I wish my family would stop hoping for a cure! I get so angry when they carry on like this. After all, I'm the one who's dying." Which response by the nurse is therapeutic? a. "Have you shared your feelings with your family?" b. "I think we should talk more about your anger with your family." c. "You're feeling angry that your family continues to hope for you to be cured?" d. "You are probably very depressed, which is understanble with such a diagnosis"
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(C) "You're feeling angry that your family continues to hope for you to be cured?" RATIONALE: Restating is a therapeutic communication technique in which the nurse repeats what the patient says to show understanding and to review what was said. While it is appropriate for the nurse to attempt to assess the patient's ability to discuss feelings openly with family members, it does not help the patient discuss the feelings causing the anger. The nurse's attempt to focus on the central issue of anger is premature. The nurse would never make a judgment regarding the reason for the patient's feeing, this is non-therapeutic in the one-to-one relationship.
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6. On review of the patients record, the nurse notes the admission was voluntary. Based on this information, the nurse anticipates which patient behavior? a. Fearfulness regarding treatment measures. b. Anger and agressiveness directed toward others. c. An understanding of the pathology and syptoms of the diagnosis d. A willingness to participte in the planning of the care and treatment plan
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(D) A willingness to participate in the planning of the care and treatment plan RATIONALE: In general, patients seek voluntary admission. If a patient seeks voluntary admission, the most likely expectations is the patient will participate in the treatment program since they are actively seeking help. The remaining options are not characteristics of this type of admission. Fearfulness, anger, and aggressiveness are more characteristic of an involuntary admission. Voluntary admission does not guarantee a patients understanding of their illness, only of their desire for help.
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7. A patient admitted voluntarily for treatment of an anxiety disorder demands to be released from the hospital. Which action shoul dthe nurse take INITIALLY? a. Contact the patients health care provider (HCP) b. Call the patients family to arrange for transportations. c. Attempt to persuade the pationt to stay "for only a few more days" d. Tell the patient tha tleaving would likely result in an involuntary commitment
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(A) Contact the patients health care provider (HCP) RATIONALE: In general, patients seek, voluntary admission. Voluntary patients have the right to demand and obtain release. The nurse needs ot be familiar with the state and facility policies and procedures. The best nursing action is to contact the HCP, who has the authority to discuss discharge with the patient. While arranging for safe transportation is appropriate it is premature in this situation and should be done only with the patients' permission. While it is appropriate to discuss why the patient feels the need to leave and the possible outcomes of leaving against medical advice, attempting to get the patient to agree to staying "a few more days" has little value and will not likely be successful. Many states require that the patient submit a written release notice to the facility staff members, who reevaluate the patient's condition for possible conversion to involuntary status if necessary, according to criteria established by law. While this is a possibility, it should not be used as a threat to the patient.
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8. When reviewing the admission assessment, the nurse notes that a patient was admitted to the mental health unity involuntarily. Based on this type of admission, the nurse should provide which intervention for this patient? a. Monitor closely for harm to self or others b. Assist in completing an applicaiont for admission c. Supply the patient with written information about their mental illness d. Provide an opprotunity fo the family to discuss why they felt the admission was needed
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(A) Monitor closely for harm to self or others RATIONALE: Involuntary admission is necessary when a person is a danger to self or others or is in need of psychiatric treatment regardless of the patient's willingness to consent to the hospitalization. A written request is a component of a voluntary admission. Providing written information regarding the illness is likely premature initially. The family may have had no role to play in the patients' admission.
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9. The nurse is preparing a patient for the termination phase of the nurse-patient relationship. The nurse prepares to implement which nursing task that is MOST APPROPRIATE for this phase? a. Planning short-term goals b. Making appropriate referrals c. Developing realistic solutions d. Identifying expected outcomes
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(B) Making appropriate referrals RATIONALE: Tasks of the termination phase include evaluating patient performance, evaluating achievement of expected out-comes, evaluating future needs, making appropriate referrals and dealing with the common behaviors associated with termination. The remaining options identify tasks appropriate for the working phase of the relationship.
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10. The nurse employed in a mental health clinic is greeted by a neighbor in a local grocery store. The neighbors says to the nurse, "How is Carol doing? She is my best friend and is seen at your clinic every week." Which is the MOST APPROPRIATE nursing response? a. "I can not discuss any patient situation with you." b. "If you want to know about Carol, you need t ask her yourself." c. "Only because you're worried aobut a friend, I'll tell you that she is improving." d. "Being her friend, you know she is having a difficult time and derserves her privacy."
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(A) "I cannot discuss any patient situation with you." RATIONALE: The nurse is required to maintain confidentiality regarding the patient and the patient's care. Confidentiality is basic to the therapeutic relationship and is a patient's right. The most appropriate response to the neighbor is the statement of that responsibility in a direct, but polite manner. A blunt statement that does not acknowledge why the nurse cannot reveal patient information may be taken as disrespectful and uncaring. The remaining options identify statements that do not maintain patient confidentiality.
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11. The nurse calls security and has physical restraints applied when a cliet who was admitted voluntarily becomes both physically and verbally abusive while demading to be discharged from the hospital. Which represens the possile legal ramifications for the nurse associated with these interventions? SELECT ALL THAT APPLY a. Libel b. Battery c. Assault d. Slander e. False Imprisonment
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(B, C, E) Battery, Assault, False Imprisonment RATIONALE: False imprisonment is an act with the intent to confine a person to a specific are. The nurse can be charged with false imprisonment if the nurse prohibits a patient from leaving the hospital if the patient has been admitted voluntarily and if no agency or legal policies exist for detaining the patient. Assault and battery are related to the act of restraining the patient in a situation that did not meet criteria for such an intervention. Libel and slander are not applicable here since the nurse did not write or verbally make untrue statements about the patient.
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12. The nurse in the mental health unit recognizes ___ as being therapeutic communication techniques? SELECT ALL THAT APPLY a. Restating b. Listening c. Asking the patient "Why?" d. Maintaing neutral responses e. Providing acknowledgment and feedback f. Giving advice and approval or disapproval
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(A, B, D, E) Restating, Listening, Maintaining neutral responses, Providing acknowledgment and feedback RATIONALE: Therapeutic communication techniques include listening, maintaining silence, maintaining neutral responses, using broad openings and open-ended questions, focusing nd refocusing, restating, clarifying and validating, sharing perceptions, reflecting, providing acknowledgment and feedback, giving information, presenting reality, encouraging formulation of a plan of action, providing nonverbal encouragement, and summarizing Asking why is often interpreted as being accusatory by the patient and should also be avoided. Providing advice or giving approval or disapproval are barriers to communication.
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13. A patient being seen in the emergency department immediately after being sexually assaulted sppears calm and controlled. The nurse analyzes this behavior as indicating which defense mechanism? a. Deial b. Projection c. Rationalization d. Intellecualization
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(A) Denial RATIONALE: Enial is refusal to admit to a painful reality and may be a response by a victim of sexual abuse. In this case the patient is not acknowledging the trauma of the assault either verbally or nonverbally. Projection is transferring one's internal feelings, thoughts, and unacceptable ideas and traits to someone else. Rationalization is justifying the unacceptable attributes about oneself. Intellectualization is the excessive use of abstract thinking or generalizations to decrease painful thinking.
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14. A patient's unresolved feelings related to loss would be MOST LIKELY observed during which phase of the therapeutic nurse-patient relationship? a. Trusting b. Working c. Orientation d. Termination
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(D) Termination RATIONALE: In the termination phase, the relationship comes to a close. Ending treatment sometimes may be traumatic for patients who have come to value the relationship and the help. Because loss is an issue, any unresolved feelings related to loss may resurface during this phase. The remaining options are not specifically associated with this issue of unresolved feelings.
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15. The nurse is working with a patient who despite making a heoric effort was unable to resuce a neigbor trapped in a house fire. Which patient focused action should the nurse engage in during the working phase of the nurse-patient relationship. a. Exploring the patient's ability to function b Exploring the patiens potential for self-harm c. Inquiring about the patients perception or appraisal of why the resuce was unsuccessful d. Inquiring about and examining the patient's feelings for any that may block adaptive coping
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(D) Inquiring about and examining the patient's feelings for any that may block adaptive coping RATIONALE: The patient must first deal with feelings and negative responses before the patient can work through the meaning the crisis. The correct option pertains directly to the patient's feelings and is patient-focused. The remaining options do not directly focus on or address the patient's feelings.
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16. Which statement demonstrates the BEST understanding of the nurse's role regarding ensuring taht each client's rights are respected? a. "Autonomy is the fundamental right of each and every client." b. "A patient's rights are guaranteed by both state and federal laws." c. "Being respectful and concerned will ensure that I'm attentinve to my patient's rights." d. "Regardless of the patient's conditions, all nurses have the duty to respect patient rights."
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(C) "Being respectful and concerned will ensure that I'm attentive to my patients' rights." RATIONALE: The nurse needs to respect and have concern for the patient; this is vital to protecting the patient's rights. While it is true the autonomy is a basic client right, there are other rights that must also be both respected and facilitated. State and federal laws do protect a patient's rights, but it is sensitivity to those rights that will ensure that the nurse secures these rights for the patient. It is a fact that safeguarding a patient's rights are a nursing responsibility, but stating that fact does not show understanding or respect for the concept.
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1.TEST-TAKING STRATEGIES: Use knowledge of therapeutic communication techniques to direct you to the option that directly addresses the patient's feelings and concerns. Also, the correct option is the only one stated in the form of a question that is open-ended; it will encourage the verbalization of feelings.
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REVIEW: Therapeutic Communication Techniques LEVEL OF COGNITIVE ABILITY: Applying PATIENT NEEDS: Psychosocial Integrity INTEGRATED PROCESS: Communication and Documentation CONTENT AREA: Mental Health PRIORITY CONCEPTS: Anxiety; Communication REFERENCE: Varcarolis (2013) pg. 121, 123
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2.TEST-TAKING STRATEGY: Use knowledge of therapeutic communication techniques. "I see" is a general lead but does not provide the patient with the opportunity to continue the discussion. "Really" can be a response that may make the patient feel that they are not believable. Providing personal experiences focuses on the nurse's problem and thus minimizes the patients concerns. The correct option will provide the perception of the problem from the patients perspective
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REVIEW: Therapeutic Communication Techniques LEVEL of COGNITIVE ABILITY: Applying CLIENT NEEDS: Psychosocial Integrity INTEGRATED PROCESS: Communication and Documentation CONTENT AREA: Mental Health PRIORITY CONCEPTS: Communication; and Documentation
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3. TEST-TAKING STRATEGY: Use knowledge of therapeutic communication techniques. First eliminate options that do not support the patient's expression of feelings. Any option that is not patient centered should be eliminated next. Focusing on the patient's feelings will direct you to the correct option.
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REVIEW: Therapeutic Communication Techniques LEVEL of COGNITIVE ABILITY: Applying CLIENT NEEDS: Psychosocial Integrity INTEGRATED PROCESS: Nursing Process - Implementation CONTENT AREA: Mental Health PRIORITY CONCEPTS: Communication; Psychosis
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4. TEST-TAKING STRATEGY: Focus on the subject, defense mechanisms. The words in the question that should direct you to the correct option are "There's nothing wrong with me." Select the option that recognizes the patients' attempt to avoid looking at the reality of the situation. The other options lack this characteristic.
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REVIEW: Defense Mechanisms LEVEL of COGNITIVE ABILITY: Understanding CLIENT NEEDS: Psychosocial Integrity INEGRATED PROCESS: Nursing Process - Assessment CONTENT AREA: Mental Health PRIORITY CONCEPTS: Coping; Psychosis
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5. TEST-TAKING STEATEGY: use knowledge of therapeutic communication techniques. The correct option is the only one that identifies the use of a therapeutic technique (restatement) and focuses on the patients feelings.
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REVIEW: Therapeutic Communication Techniques LEVEL of COGNITIVE ABILITY: Applying CLIENT NEEDS: Psychosocial Integrity INTEGRATED PROCESS: Communication and Documentation CONTENT AREA: Mental Health PRIORITY CONCEPTS: Communication; Family Dynamics
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6. TEST-TAKING STRATEGY: Focus on the subject, voluntary admission. This should direct you to the correct options. Note the relationship between the word voluntary and the correct option.
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REVIEW: Various types of hospital admission processes LEVEL of COGNITIVE ABILITY: Understanding CLIENT NEEDS: Psychosocial Integrity INTEGRATED PROCESS: Nursing Process - Planning CONTENT AREA: Mental Health PRIORITY CONCEPTS: Care giving; Mood and Affect
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17. The nurse is providing care to a client admitted to the hospital with a diagnosis of acute anxiety disorer. The patient say s to the nurse "I have a secret that I want to tell you. You won't tell anyone about it, will you?" What is the MOST APPROPRIATE nursing response? a. "No, I won't tell anyone." b. "I cannot promise to keep a secret." c. "It depends on what the secret is about." d. "If you tell me the secret, I may need to document it."
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(B) "I cannot promise to keep a secret." RATIONALE: The nurse should never promise to keep a secret. Secret are never appropriate in a therapeutic relationship. The nurse needs to be honest and tell the patient that a promise cannot be made to keep the secret. The remaining options are inappropriate responses since they either promise to keep the secret or provide the criteria for when a secret may be appropriately kept.
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7. TEST-TAKING STRATEGY: Note the strategic word initially. Noting the type of hospital admission will assist in directing you to the correct options while eliminating those that are unlikely to occur. Calling the family should be eliminated, based on the issues of patient rights and confidentiality. To "persuade" a patient to stay in the hospital is inappropriate. Threatening the patient is inappropriate and illegal.
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REVIEW: Various types' hospital admission and discharge processes LEVEL of COGNITIVE ABILITY: Applying PATIENT NEEDS: Psychosocial Integrity INTEGRATED PROCESS: Nursing Process - Implementation CONTENT AREA: Leadership/Management - Ethical/Legal PRIORITY CONCEPTS: Clinical Judgment; Health Care Law
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8. TEST-TAKING STRATEGY: Focus on the subject, involuntary admission. Use Maslow's Hierarchy of Needs Theory: Safety is the priority if a physiological need does not exist. This should direct you to the correct option. Also, note that the remaining options are not always true of an involuntary admission.
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REVIEW: Involuntary admission LEVEL of COGNITIVE ABILITY: Applying CLIENT NEEDS: Psychosocial Integrity INTEGRATED PROCESS: Nursing process - Implementations CONTENT AREA: Mental Health PRIORITY CONCEPTS: Interpersonal Violence; Safety
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9. TEST-TAKING STRATEGY: note the strategic words most appropriate. Focus on the subject, the termination phase, should direct you to the correct option.
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REVIEW: Phases of the nurse-patient relationship LEVEL of COGNITIVE ABILITY: Applying CLIENT NEEDS: Psychosocial Integrity INTEGRATED PROCESS: Nursing Process - Planning CONTENT AREA: Mental Health PRIORITY CONCEPTS: Care giving; Professionalism
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10. TEST-TAKING STRATEGY: Note the strategic words "most appropriate". Focusing on maintain confidentiality will direct you to the correct option. This focus will also assist you in eliminating options that inappropriately give such information without being unnecessarily blunt or rude.
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REVIEW: Confidentiality issues LEVEL of COGNITIVE ABILITY: Applying CLIENT NEEDS: Safe and effective care environment INTEGRATED PROCESS: Nursing process - Implementation CONTENT AREA: Leadership/Management - Ethical /Legal PRIORITY CONCEPTS: Ethics; Health Care Law
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11. TEST-TAKING STRATEGY: Focus on the subject, legal ramifications of nursing actions related to hospital admission. Noting the words admitted voluntarily will assist you in selecting the options related to inappropriately preventing the patient from leaving the hospital; a right to which a voluntarily committed patient is entitled. The remaining options do not relate to acts that prevent the patient from leaving the hospital.
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REVIEW: Client rights related to hospital admission LEVEL of COGNITIVE ABILITY: Analyzing CLIENT NEEDS: Safe and Effective Care Environment INTEGRATED PROCESS: Nursing Process-Implementation CONTENT AREA: Leadership/Management-Ethical/Legal PRIORITY CONCEPTS: Health Care Law; Safety
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12. TEST-TAKING STRATEGY: use knowledge of therapeutic communication techniques. This will assist you in both selecting the correct answers and eliminating the examples of nontherapeutic communication.
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REVIEW: Therapeutic and non-therapeutic communication techniques LEVEL of COGNITIVE ABILITY: Understanding PATIENT NEEDS: Psychosocial Integrity NTEGRATED PROCESS: Communication and Documentation CONTENT AREA: Mental Health PRIORITY CONCEPTS: Care giving; Communication
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13. TEST-TAKING STRATEGY: Focus on the subject, a defense mechanism, and note the words "calm and controlled." These behaviors indicate denial in a sexually abused victim.
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REVIEW: Defense mechanisms LEVEL of COGNITIVE ABILITY: Analyzing PATIENT NEEDS: Psychosocial Integrity INTEGRATED PROCESS: Nursing Process-Assessment CONTENT AREA: Mental Health PRIORITY CONCEPTS: Anxiety; Coping
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14. TEST-TAKING STRATEGY: Note the strategic words most likely and the words unresolved and loss in the question. Considering the phases of the therapeutic nurse-patient relationship will direct you to the correct option.
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REVIEW: Phases of the nurse-patient relationship LEVEL of COGNITIVE ABILITY: Understanding INTEGRATED PROCESS: Caring CONTENT AREA: Mental Health
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15. TEST-TAKING STRATEGY: Focus on the subject, the working phase of the nurse-patient relationship. Also, note the words "patient-focused action". Think about the interventions that occur in this phase. Select the option that focuses on the feelings of the patient.
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REVIEW: Phases of the nurse-patient relationship LEVEL of COGNITIVE ABILITY: Applying PATIENT NEEDS: Psychosocial Integrity INTEGRATED PROCESS: Nursing Process; Implementation CONTENT AREA: Mental health PRIORITY CONCEPTS: Communication; Coping
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16. TEST-TAKING STRATEGY: Note the strategic word "best". Focus on the broad issue of patient's rights and how the nurse will respect and preserve these rights. This is the umbrella option. Also note the word "respected" I the question and "respectful in the correct option.
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REVIEW: The nurse's role with regard to patient rights LEVEL of COGNITIVE ABILITY: Understanding PATIENT NEEDS: Safe and effective care environment INTEGRATED PROCESS: Nursing Process-Implementation CONTENT AREA: Leadership/Management-Ethical/Legal PRIORITY CONCEPTS: Ethics, Professionalism
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17. TEST-TAKING STRATEGY: Note the strategic words most appropriate. Understanding the need for open, honest communication with the patient will direct you to the correct option. The remaining options can be eliminated because they do not foster the nurse-patient relationship
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REVIEW: Therapeutic communication techniques LEVEL of COGNITIVE ABILITY: Applying CLIENT NEEDS: Psychosocial Integrity INTEGRATED PROCESS: Communication and Documentation CONTENT AREA: Leadership/Management - Ethical/Legal PRIORITY CONCEPTS: Clinical Judgment; Ethics
