The nurse is assigned to the care of a patient admitted to the mental health unit. Which behaviors by the nurse reflect the essential principles of
... [Show More] therapeutic relationship? Select all that apply.
a. Empowering the patient to make decisions regarding care
b. Looking beyond the illness when interacting with the patient
c. Trying to see things from the unique perspective of the patient
d. Sharing personal insights that are relevant to the patient's problems
e. Ensuring that all physical and emotional needs are met by the nurse
A, B, C
a. Empowering the patient to make decisions regarding care
b. Looking beyond the illness when interacting with the patient
c. Trying to see things from the unique perspective of the patient
In the context of the therapeutic relationship, nurses strive to empathize with the patient and fully value the perspective of the patient, whether or not it differs from that of the nurse. Nurses also view patients holistically, realizing that they are more than just the sum of the symptoms they present with. Interactions are based on the growth of the patient and interventions should promote as much autonomy and independence as the patient is capable of. Sharing personal interests violates the boundaries of the therapeutic relationship and shifts the focus of the relationship back to the nurse. Acting to meet every patient need is generally inappropriate; nurses should act to promote growth and independence by encouraging patients and families to meet their own needs whenever possible.
The nurse is working with a patient who is struggling to over- come a serious mental illness. The patient begins crying after learning that her family will no longer be visiting. Which response by the nurse demonstrates empathy?
A. "I am not sure what I would do if I were in your shoes."
B. "You must be wondering why they are acting this way."
C. "My sense is that this experience has been very painful for you."
D. "I understand because I went through something similar one time."
C. "My sense is that this experience has been very painful for you."
Rationale: The nurse using empathy separates the nurse's own feelings, experiences, and reactions and fully engages with the patient an attempt to get a sense of how the patient is feeling at that moment in time. In this instance, the nurse must be present to what the patient is conveying and act to validate the observation of distress, without conditions or judgment. Options a and d shift focus back to the nurse and fail to recognize the patient's experience as unique. Option b does not validate the patient's verbal or nonverbal messages, but instead makes an assumption that is likely to be based on the own nurse's perspectives.
The nurse is acting as a preceptor to a recent nurse graduate who wants to obtain a job on the mental health unit. The new nurse has been struggling to differentiate between social and therapeutic interactions because so many of the patients are around his own age. Which evaluation finding indicates that nurse is acting in accordance with appropriate professional boundaries? Select all that apply.
A. The nurse sets limits on inappropriate behaviors.
B. The nurse uses colloquial language to foster trust.
C. The nurse brings in clothing for a homeless patient.
D. The nurse offers a video collection for a group movie night.
E. The nurse lets a patient know when their time together will end.
A, D, E
A. The nurse sets limits on inappropriate behaviors.
D. The nurse offers a video collection for a group movie night.
E. The nurse lets a patient know when their time together will end.
New nurses frequently fall back on relationship skills that have been learned in the context of families and or friendships. When nurses set limits on behaviors they are acting in the role of a counselor, educator and caretaker. Nurses act to meet the needs of all patients, and bringing in movies is an example of sharing a resource that all patients can use. When the nurse maintains the time frames associated with professional and not personal relationships the nurse is upholding boundaries appropriate to nursing role and acting in a manner that is consistent with professional and ethical standards. The use of colloquial language conveys a sense of familiarity that is not consistent with a professional relationship. Bringing in clothing for an individual patient may be construed as "special treatment," and demonstrates an inability to differentiate between professional and personal relationships.
The nurse is working with a patient who presents in the outpa- tient setting for the treatment of situational depression. The patient has begun to try out new coping strategies and has taken advantage of a support group the nurse recommended. The nurse recognizes that the patient has entered which phase of therapeutic nurse-patient relationship?
A. Orientation
B. Working
C. Exploitation
D. Resolution
C. Exploitation
During the exploitation phase, the patient begins to make use of the resources and tools that have been offered. The orientation phase consists gaining an understanding of the goals and needs for care. The working phase consists of initial engagement in treatment. The resolution phase consists of reviewing progress and terminating the relationship.
The nurse is working with the patient admitted to the mental health unit. The nurse learns that the patient has a history of exposure to trauma that that the nurse can relate to on a per- sonal level. Which rationale best supports nondisclosure on the part of the nurse?
A. The patient may use the disclosure against the nurse.
B. The nurse may be assuming that the experiences are similar.
C. There is a risk of distortion or shifting of caregiver boundaries.
D. The patient will not have the same resources to cope as the nurse.
C. There is a risk of distortion or shifting of caregiver boundaries.
The essential underlying rationale for maintaining professional boundaries is to keep the focus on meeting patient needs. Disclosure may distort this role as the patient may feel compelled to support or care for the nurse or question the nurse's ability to remain focused on the patient's unique needs or experiences. The nurse may have difficulty retaining a focus on the patient's needs while relating aspects of their own experience. In some instances patients may use personal information against the nurse, but the primary reason for non-disclosure relates to the patient's needs, not the nurses. The nurse may be making assumptions about the patient's needs, but this option fails to address the outcome of this assumption or the primary threat to the therapeutic relationship. It may or may not be true that the patient resources differ from that of the nurse; however, this is not as important as the threat to the overall effectiveness of the therapeutic relationship.
The nurse is working in an outpatient mental health clinic. The clinic is implementing an initiative to use telecommunication to deliver care to patients living in remote areas. The nurse understands that this change will be most likely to affect which aspects of communication?
A. Nonverbal communication only
B. Nonverbal and meta-communication
C. Verbal and nonverbal communication
D. Meta-, nonverbal, and verbal communication
B. Nonverbal and meta-communication
Verbal communication consists of the words used. Nonverbal communication includes gestures, appearance, tone and volume as well as a variety of other factors. Meta communication refers to those involved in the interaction, how the message is sent, and the context of the message. Telecommunication will impact the ability to convey and receive nonverbal content. Even if visual images are used, the visual field or the quality of the images may be limited, and other sensory information may not be available. Because the context and mode of communication will change with telecommunication, meta-communication will also be impacted. The words or the language used to deliver care will not necessarily be impacted by the use of telecommunication.
The nurse is working with a patient in the context of the therapeutic relationship. Which evaluation finding supports the effectiveness of active listening techniques?
A. The patient remains focused on the purpose of the interaction.
B. The patient takes advantage of opportunities to verbalize concerns.
C. The patient affirms the nurse's interpretation of what was communicated.
D. The patient provides sufficient information for the nurse to make care decisions.
C. The patient affirms the nurse's interpretation of what was communicated.
The purpose of active listening is to partner with the patient to determine patient needs. The nurse conveys interest in what the patient is communicating and then actively seeks to interpret and validate interpretations. An essential element is the patient's affirmation of the nurse's interpretation. Patient focus, willingness to take advantage of opportunities to talk, and the amount and quality of the information do not necessarily relate to the effectiveness of the nurses active listening skills.
The nurse is caring for a patient who has been in an abusive relationship. The patient relates being concerned that leaving the relationship will result in judgment by family and friends. How should the nurse respond?
A. Acknowledge that the decision may not be accepted by others.
B. Ask the patient why she cares so much about what others think.
C. Remind the patient that everyone has difficult decisions to make.
D. Advise the patient to share details of the abuse with family and friends.
A. Acknowledge that the decision may not be accepted by others.
Acknowledging is a therapeutic response in which the nurse expresses recognition of or validates the existence of the patient's reality. The nurse can then assist the patient to identify strategies that may minimize negative consequences or assist the patient to cope with them. Asking the patient why she cares about what others think direct questioning is a form of challenging that can present a barrier to therapeutic communication. Telling the patient that everyone has difficult decisions to make is a "pat" response that fails to consider the full experience or individuality of the patient. Advice about sharing details of the abuse with family and friends is based on the nurse's opinion and does not necessarily address the patient's concern.
The nurse manager is employing tools to assist staff to maintain a sense of objectivity and balance in the context of the therapeutic inpatient psychiatric milieu. Which intervention is most likely to be effective for new nurses?
A. Formal education
B. Journaling exercises
C. Individual supervision
D. Peer-led support groups
C. Individual supervision
Clinical supervision is one of the most important tools for reflective practice in the psychiatric setting. An experienced psychiatric nurse provides valuable insight and feedback in the context of working sessions. Formal education is important, but may not consider the unique experiences and feedback evoked in the context of therapeutic relationships. Journaling may be useful for reflective practice but offers less opportunity for input/feedback from a more experienced clinician. Peer support may provide an emotional outlet, but again lacks the element of guidance from a more experienced nurse.
The nurse educator is orienting a group of new nurses to the mental health unit. Which statement by the educator best represents the essential purpose of the nursing process in providing nursing care to patients experiencing mental illness?
A. "The nursing process is what differentiates mental health nursing care from that of other professions."
B. "The nursing process is a framework for planning and delivering holistic patient- and family-centered care."
C. "The nursing process provides a structure for applying knowledge of mental illnesses and their management."
D. "The nursing process provides a model for carrying out linear tasks that are intended to lead to a fixed patient outcome."
B. "The nursing process is a framework for planning and delivering holistic patient- and family-centered care."
The essential purpose of the nursing process is to provide comprehensive nursing care that considers all aspects of the person's life. While the nursing process may distinguish nursing care from that of other professions, its primary purpose is focused on meeting patient and family needs. The focus of the nursing process is not just on the application of knowledge but also on integrating the unique experiences and perspectives of the patient to deliver humanistic, patient-centered care. Although patient outcomes are a component of the nursing process, the model is cyclical and goals and outcomes are constantly reconsidered and redefined.
The nurse is carrying out an assessment of a patient presenting with a sudden onset of psychiatric symptoms. Which describes the best approach for the nurse to determine the priority con- cern for the patient?
A. The nurse asks the patient directly why he or she is seeking treatment at this time.
B. The nurse analyzes the patient's pre-setting background for evidence of a precipitating event.
C. The nurse defers to the diagnosis made after all members of the team have interviewed the patient.
D. The nurse refers to the primary symptoms identified in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5).
A. The nurse asks the patient directly why he or she is seeking treatment at this time.
The nurse carries out assessment as an independent function and recognizes the patient's statements or communication about why the patient is seeking treatment as most important. The patient's perspective of the situation, not the nurse's, is most essential. The identification of priority nursing problems does not require input from the entire team. The DSM-5 classifies diagnostic information that is specific to particular illnesses. While this tool may be used to inform aspects of nursing care, it is not used to determine the patient's priority concern.
The nurse is performing an assessment of a patient being admitted to the inpatient psychiatric unit. Which aspect of the pre-setting background would best assist the nurse to deter- mine the patient's current interest and motivation in treatment?
A. The patient's socioeconomic status and living situation
B. The patient's and family's understanding of mental illness
C. The patient's previous history of treatment for mental illness
D. The patient's circumstances that led to the decision to seek treatment
D. The patient's circumstances that led to the decision to seek treatment
The circumstances or context leading to the decision to seek treatment would be the best indicators of the patient's current interest and motivation in treatment. The nurse would consider whether the patient was brought to the hospital voluntarily and who made the decision to seek help. All of the other factors may contribute to compliance and motivation to seek help, but are less relevant to the patient's current interest in treatment.
The nurse is performing a mental status exam. Which technique would be best to determine the patient's affect?
A. Having the patient complete a feelings rating scale
B. Observing the patient's current behavioral presentation
C. Asking the patient to describe his or her current emotional state
D. Having the patient respond to a series of cognitive exercises
B. Observing the patient's current behavioral presentation
Affect is an observed interpretation of a patient's emotional status that takes into account objective factors such as the patient's facial expressions and posture. Options a and c are used to determine the patient mood or subjective interpretation of their own emotional state. Exercises are generally used to determine cognitive function, such as memory, concentration and orientation.
The nurse has completed an assessment of a patient present- ing with acute mental health concerns. The nurse concludes that patient has an alteration in mood characterized by mania. Which component of the diagnostic statement will this finding comprise?
A. The focal pattern
B. The assessment of cause
C. The supporting evidence
D. The associated symptoms
A. The focal pattern
The nurse is identifying a problem or focal pattern that based on an assessment of the patient's presentation. The cause has not been identified, such as "related to steroid use," and evidence to support the pattern (e.g. "as evidenced by pressured speech") has not been provided. Associated symptoms such as insomnia have not been identified.
The nurse is caring for a patient presenting with symptoms of anxiety that are interfering with the patient's ability to function at work. The patient states that the anxiety began soon after a traumatic event and is severely impacting the patient's functioning. Which issue will be the focal point for making a nursing diagnosis?
A. Patient's anxiety due to exposure to a traumatic event
B. Patient's difficulty coping
C.Patient's inability to function at work due to underlying anxiety and stress
D. Making a diagnosis of post-traumatic stress disorder
A. Patient's anxiety due to exposure to a traumatic event
The nursing problem focuses on the focal pattern of anxiety, which appears to be related to exposure to a traumatic event. A nursing diagnosis of Anxiety due to exposure to a traumatic event would be appropriate. The patient's difficulty coping and functioning at work may be related to either trauma or experience of anxiety, but the patient's anxiety is the focus, as relief of anxiety may improve coping and functioning. Although the patient may require further evaluation for posttraumatic stress disorder, the focus for the nurse at this time is the patient's anxiety level.
The nurse is carrying out the components of the planning phase for a patient experiencing a mood disorder. Which step will the nurse take first?
A. Determine which problem will be addressed as the priority
B. Determine which interventions will support the patient's goals
C. Differentiate between collaborative and nursing
interventions
D. Identify what the nurse wants to achieve as a result of interventions
A. Determine which problem will be addressed as the priority
Once nursing diagnoses are identified, the nurse identifies problems and their priority in care. The prioritization aids in identifying interventions that will be carried out immediately. The next step would be to determine what the patient, not the nurse, wants to achieve and then selecting appropriate nursing interventions to support that goal.
The nurse is evaluating the outcomes of interventions for a patient who is in the recovery phase of depression. Which find- ing best indicates that treatment goals have been met?
A. The patient agrees to report suicidal thoughts.
B. The patient has resumed occupational functioning.
C. The patient manages increased interaction with peers.
D. The patient identifies goals to improve further function.
B. The patient has resumed occupational functioning.
At the stage of recovery, evaluation focuses on progress toward interpersonal, vocational, and spiritual goals. Resumption of occupational function is an evaluation finding appropriate to this phase of illness. The ability to report suicidal thoughts is an evaluation finding that supports the achievement of a short-term goal in the crisis stage of the illness. Management of increased group interactions and the identification of longer-term goals are evaluation findings that are more appropriate in the acute illness phase.
The nurse is developing a plan of care for a patient experiencing an acute mental health crisis. Which action would be most likely to be carried out during the intervention phase of the illness?
A. Ensuring the safety of the physical environment
B. Performing vital signs and a mental status exam
C. Determining what factors precipitated the crisis
D. Identifying which problem the patient wants to focus on
A. Ensuring the safety of the physical environment
Ensuring the safety of the physical environment is an action consistent with the intervention phase of the nursing process. Vital signs and mental status exams are assessment activities. Determining which factors precipitated the crisis is an assessment activity. Prioritizing problems is part of the planning phase of the nursing process.
The nurse is assessing a patient with an anxiety disorder. Which key finding best supports a neurobiological basis for the illness?
A. The patient has a family history of anxiety.
B. The patient has a co-morbid medical illness.
C. The patient has multiple stressors.
D. The patient has had positive responses to anti-anxiety medication.
A. The patient has a family history of anxiety.
Research on anxiety disorders has demonstrated a strong genetic neurobiological basis for the illness. A family history establishes a genetic predisposition to the illness. Studies have shown that the genetics have a strong influence on the individual's ability to cope environmental and physiological stressors. The presence of a physiological illness does not necessarily support a neurobiological predisposition to anxiety. The ability to cope with stressors is mediated by genetic factors, and the number of stressors does not relate to a neurobiological basis for the illness. Anti-anxiety medications treat the symptoms of the anxiety; they would not support a genetic predisposition to the illness.
The nurse is documenting assessment findings for a patient presenting with symptoms of anxiety. Under which category would the nurse include the observation that the patient is constantly scanning the environment to detect threats?
A. Spiritual domain
B. Cultural domain
C. Biological domain
D. Psychological domain
C. Biological domain
The patient who constantly scans the environment for threats is exhibiting hypervigilance, a finding that relates to hyperarousal and biological aspects of illness. The finding would be documented under the category of the biological domain.
The nurse is working with a patient who is overcome by feelings of anxiety, each time experiencing thoughts of losing control. The patient states that reorganizing the environment temporarily relieves the anxiety. The nurse correctly interprets this as the use of which defense mechanism?
A. Denial
B. Undoing
C. Projection
D. Conversion
B. Undoing
Undoing is a defense mechanism in which the individual takes action to counteract the unacceptable or threatening thought. In this case, the patient reorders the environment to "undo" the anxiety associated with thoughts of losing control. Denial refers to the refusal to believe or accept the reality of a situation or experience. Projection refers to unconsciously attributing one's thoughts or impulses onto another person. Conversion refers to the transfer of a mental conflict into a physical symptom.
The nurse is using Peplau's four levels of anxiety as a model for assessing a patient who has been experiencing panic attacks. At which stage would the nurse anticipate detecting the onset of tachycardia and tachypnea?
A. Mild +1
B. Moderate +2
C. Severe +3
D. Panic +4
B. Moderate +2
According to Peplau, stage 2 of anxiety is characterized by the onset of physiological symptoms including increased respirations and heart rate. During stage one the patient experiences psychological changes. Stages 3 and 4 are characterized by progressive and more distressing physiological and psychological symptoms.
The nurse is caring for a patient presenting with symptoms of anxiety. The patient states that he has started to avoid any situations that induce panic, such as going to the mall or the theater without a family member. The nurse recognizes that the patient's symptoms are most consistent with which type of anxiety disorder?
A. Agoraphobia
B. Social anxiety
C. Panic disorder
D. Separation anxiety
A. Agoraphobia
Agoraphobia is characterized by a marked fear of situations where escape would be difficult or not immediately accessible. Individuals with this disorder may avoid situations such as going to the mall or theater and or may depend on the assistance of another person to help them manage the situation. Social anxiety is a disorder characterized by fear or anxiety in situations where there is a potential for embarrassment or scrutiny related to interaction or performance, which is not generally associated with these activities. Panic disorder is characterized by recurrent, unpredictable panic attacks. The stimulus generally is not recognized. Separation anxiety is characterized by a developmentally inappropriate fear of separation from or abandonment by other persons. In this case, the client relies on another person to help him manage anxiety related to certain environmental variables, not general fears of separation or abandonment.
The nurse is evaluating a patient who has been taking fluvox- amine (Luvox) for the management of obsessive-compulsive disorder (OCD) for 1 week. Which statements by the patient would be cause for concern? Select all that apply.
A. "My thoughts and compulsions are still bothersome sometimes."
B. "I have needed to drink more because my mouth is frequently dry."
C. "I take this medication when I experience the compulsion to clean."
D. "My spouse is concerned that I will become addicted to this medication."
E. "I have been using Ativan as needed when I have trouble getting to sleep."
C, D
C. "I take this medication when I experience the compulsion to clean."
D. "My spouse is concerned that I will become addicted to this medication."
Fluvoxamine is a selective-serotonin inhibiter (SSRI) that is used in the management of select anxiety disorders. Patients need to take the medication every day, generally for several weeks before experiencing the desired effects of the medication. Fluvoxamine does not cause dependency. The nurse would be concerned that the patient is taking the medication only when experiencing symptoms of anxiety. The nurse would correct misinformation suggesting that the patient is at risk for dependence. Benzodiazepines may still be used as prescribed to manage the acute symptoms of anxiety and insomnia, especially in the period before the SRRI becomes effective. Common side effects of SSRIs include dry mouth, which can be alleviated by interventions such as drinking more fluids.
The nurse is planning care for a patient experiencing an anxiety disorder. Which variable is essential for the nurse to consider first?
A. The research supporting various treatment modalities
B. The patient's personal perspective on the anxiety disorder
C. The behavioral manifestations related to mental health domains
D. The nurse's previous experience with patients with similar disorders
B. The patient's personal perspective on the anxiety disorder
It is essential that the nurse consider the patient's individual perspective and preferences when formulating a plan of care. All patients have unique experiences and needs, and the goals for treatment should be determined with patient input whenever possible. Further assessment would consider other objective data related to mental health domains. Research and experience can then be used to formulate a care plan that best addresses individual patient needs. [Show Less]