(1)A patient in the psychological unit asks the nurse. Am I in a special radioactive shelter?.When was it last checked for radioactivity?.Which of the following responses, if made by the nurse should be the most appropriate?.
I am sure your safety is of concern to you, but this is hospital.
(2)A patient with anorexia nervosa tells the nurse, that she usually jogs five miles each day and that she must continue to exercise while in the hospital. Which of the following approaches by the nurse best meets this patient needs?.
Answer: Allow her to exercise for 30 minutes each day,if her weight and vital signs remain stable. Behavior modification.
(3)A 46years old man is admitted to the surgery center for a liver biopsy. He refuses to stay seated when talking to the nurse about the biopsy and he keeps repeating. ” I wish this were over”.Based on this patient behavior, which of the following nursing intervention would be most appropriate?.
Answer: The nurse should minimize environmental stimuli and stay with patient.
(4)During the admission interview, a 25 years old man tells the nurse, ” voices are telling me that the end is near and that I should prepare to go to heaven “.In planning this patient care the nurse should give the highest priority to which nursing diagnosis?.
Answer:Potential for violence directed toward self related to hallucinatory commands.
(5) Which of the following medications should the nurse anticipate administering to a patient for the relief of narcotic withdrawal symptoms.
Answer: Dolophine(methadone)It delays withdrawal and severity of symptoms.
(6) The nurse prioritizes care of a patient during acute narcotic withdrawal. Which of the following action is most important.
Answer:Monitor the patient’s physical condition.
(7) Before the beginning of ECT,a patient says ” I doubt that these ECT treatment will help me”.What response by the nurse will be most appropriate?.
Answer: Are you saying that you’re feeling hopeless ,and that any treatment will help you with this problem.
(8) A man is admitted to the hospital with Schizophrenia. The nurse assesses the patient and finds his appearance disheveled and unkempt. Which of the following approaches by the nurse is likely to be the most successful in providing for the patient personal hygiene needs while he is acutely ill?.
Answer: The nurse should direct the patient to shower himself, offer assist as necessary.
(9)How does the nurse establish a therapeutic nurse patient relationship.
Answer: The boundaries of the relationship should be clear.
(10 )The nurse plans care for a patient receiving ECT immediately following a treatment, the nurse should take which of the following actions.
Answer: Orient the patient to Time and Place.
(11) Desipramine (Norpramin) is ordered by the doctor for a 65years old man admitted to the Psychiatric unit. After two weeks on the medication, the nurse notices that the patient’s energy level has increased and that he has become more involved with others. It would be most justifiable for the nurse to reach which of the following conclusions based on the patient’s behavior.
The patient’s suicide risk is greater now,he should be closely monitored.
(12) After completing an assessment the nurse determined that a 45years woman is exhibiting early symptom of a dystonia reaction related to the use of an antipsychotic medication. Which of the following actions by the nurse would be most appropriate?.
Notify the doctor and obtain an order for intramuscular injection of benadryl .
Rationale: Emergency situation can occlude airway.
(13) A 28years old man is admitted to the Psychiatric hospital with a diagnosis of obsessive compulsive disorder. He is unable to stay employed because his ritualistic behavior causes him to be late to work. Which of the following interpretations of the patient’s behavior by the nurse is most accurate?.
He is attempting to reduce anxiety by taking control of the environment, unconscious attempt to reduce anxiety.
(14)A 20 years old woman delivers a healthy male infant and is transferred to the postpartum unit.When her son is brought to her the patient becomes anxious and restless. Based on the nurse knowledge of the crisis intervention theory, which of the following subjects should the nurse discusses with the patient first?.
What are the issues that are of immediate concern to you.