Nursing Board Review: Psychiatric Nursing Practice Test Part 1

A therapeutic relationship is a helping relationship.

By establishing a one-to-one relationship, the nurse helps the patient learn how to interact with other people in new situations. The other options are appropriate but should take place only after the nurse-patient relationship is established.

Tachycardia, a heart rate of 120 to 140 beats/minute, is a common sign of alcohol withdrawal. Blood pressure may be labile throughout withdrawal, fluctuating at different stages. Hypertension typically occurs in early withdrawal. Hypotension, although rare during the early withdrawal stages, may occur in later stages. Hypotension is associated with cardiovascular collapse and most commonly occurs in clients who don't receive treatment. The nurse should monitor the client's vital signs carefully throughout the entire alcohol withdrawal process.

Encouraging the patient to reflect enables her to think about the events and feelings and reach a conclusion. This may be help her gain confidence in making assessments and decisions, and it may encourage self-reliance.

Patients who have attempted suicide are at much higher risk for repeat attempts in the future.

The proper procedure for dealing with harmful behavior is to first try to calm patient verbally. When verbal and psychopharmacologic interventions are not adequate to handle the aggressiveness, seclusion or restraints may be applicable. Options A, B and C are appropriate approaches during the escalation phase of aggression.

When caring for a client with OCD, the goal is to systematically decrease the undesirable behavior. (Therapy may not completely extinguish certain behaviors.) Expecting to omit one behavior each day is unrealistic because the client may have used ritualistic behavior would perpetuate the undesirable behavior.

Touch has many meanings to patients. Although many patients are eager for human touch, others may perceive touch as human-boundary violation. Therefore, touching requires sensitivity on the part of the nurse.

During the orientation phase of the therapeutic relationship, the nurse and patient make an agreement that they will be working together to solve one or more of the patient’s problems.

The manic client is hyperactive and may engage in injurious activities. A quiet environment and consistent and firm limits should be set to ensure safety. Option B, clear, concise directions are given because of the distractibility of the client but this is not the priority. Option C, the manic client tend to externalize hostile feelings, however only non-destructive methods of expression should be allowed. Option D, nurses set limit as needed. Assigning a staff to be with the client at all times is not realistic.

Encouraging a patient to be as independent as possible will promote self-reliance and self-confidence, both of which are components of a healthy self-esteem. An effective means of encouraging this independence is enlisting the patient in the planning of his won care. Teaching self-care measures and eliciting his peers to encourage him will be beneficial, but they are not as focused on fostering a healthy self-esteem. Moving Mr. Kevin to a different hospital environment isn’t indicated based on the data given.

Projection is a defense mechanism where one attributes ones feelings and inadequacies to others to reduce anxiety. Option A, is not true in all instances of projection. Options C and D focuses on the self rather than others.

Mr. Kevin is going through the grief-loss process because he has permanently lost the use of his legs due to paralysis. His comment suggests that he’s in denial, the first stage of the process. Denial is a coping mechanism that allows the individual time to assimilate the major changes associated with body function loss.

Palilalia is defined as the repetition of sounds and words. Echolalia is the act of repeating the words of others. Apraxia is the inability to carry out motor activities, and aphonia is the inability to speak.

During the initial phase of the nurse-patient relationship in this situation, tasks include establishing boundaries of the relationship, identifying problems, assessing anxiety levels, and identifying expectations. All other responses aren’t part of this phase of the relationship.

An anorexic client who requires hospitalization is in poor physical condition from starvation and may die as a result of arrhythmias, hypothermia, malnutrition, infection, or cardiac abnormalities secondary to electrolyte imbalances. Therefore, monitoring the client's vital signs, serum electrolyte level, and acid base balance is crucial. Option A may worsen anxiety. Option B is incorrect because a weight obtained after breakfast is more accurate than one obtained after the evening meal. Option D would reward the client with attention for not eating and reinforce the control issues that are central to the underlying psychological problem; also, the client may record food and fluid intake inaccurately.

The predominant behavioral characteristic of the client with borderline personality disorder is impulsiveness, especially of a physically self-destructive sort. The observation that the client has scratched wrists doesn't substantiate the other options.

Focusing on the client’s blindness can positively reinforce the blindness and further promote the use of maladaptive behaviors to obtain secondary gains. The client should be encouraged to participate in his own care as much as possible to avoid fostering dependency. To promote self-esteem, give positive reinforcement for what the client can do. Blindness and other physical symptoms in a conversion disorder aren’t under the client’s control and are real to him. Eye exercises won’t resolve the client’s blindness because no organic pathology is causing the symptoms.

Anxiety is caused by a subjectively perceived threat. Option A, Fear is caused by an objective threat. Option C, a depressed client internalizes hostility. Option D, mania is due to masked depression.

Information regarding the patient’s relationship with her spouse is important because spousal abuse is the leading cause of attempted and actual suicides in adult women.

Frequent vomiting causes tenderness and swelling of the parotid glands. The reduced metabolism that occurs with severe weight loss produces bradycardia and cold extremities. Soft, downlike hair (called lanugo) may cover the extremities, shoulders, and face of an anorexic client.

Haloperidol is the drug of choice for treating Tourette syndrome. Prozac, Luvox, and Paxil are antidepressants and aren't used to treat Tourette syndrome.

Asking for clarification and restating or paraphrasing the patient’s statements are techniques used to further elicit and clarify the patient’s feelings. The other options aren’t recommended methods for promoting communication.

The client’s manifestations indicate severe anxiety. Option A, mild anxiety is manifested by slight muscle tension, slight fidgeting, alertness, ability to concentrate and capable of problem solving. Option B, moderate muscle tension, increased vital signs, periodic slow pacing, increased rate of speech and difficulty in concentrating are noted in moderate anxiety. Option D, panic level of anxiety is characterized immobilization, incoherence, feeling of being overwhelmed and disorganization

Agree on a consistent approach among the staff assigned to the client. A consistent firm approach is appropriate. This is a therapeutic way of to handle attempts of exploiting the weakness in others or create conflicts among the staff. Bargaining should not be allowed. Option B, this is not therapeutic because the client tends to control and dominate others. Option C, limits are set for interaction time. Option D, allowing the client to negotiate may reinforce manipulative behavior.