Question 1

As the nurse plans care for a newly admitted patient, identification of dysfunctional behaviors will provide the focus for which component of the nursing process?

Accepted Answer

A)  Evaluation 
B)  Nursing diagnosis 
C)  Nursing interventions 
D)  Outcome identification

Question 2

A newly admitted patient tells the nurse, "The voices are bothering me." What should be the nurse's initial intervention?

Accepted Answer

A)  Ignoring the patient's reference to voices 
B)  Distracting the patient from the hallucinations 
C)  Telling the patient that the voices do not exist 
D)  Seeking a description of the voices to identify themes

Question 3

Objective data obtained from family in an initial assessment of a patient are of particular value when which situation exists?

Accepted Answer

A)  The patient is too ill to participate. 
B)  The patient's admission is involuntary. 
C)  Family members have admitted the patient. 
D)  The patient has been transferred from a subacute setting.

Question 4

What activity would be involved in achieving an appropriate short-term goal for a patient diagnosed with situational low self-esteem?

Accepted Answer

A)  Writing a list of strengths, abilities, and talents 
B)  Role-playing with others to improve social skills 
C)  Replacing a negative self-image with a positive one 
D)  Responding with positive self-esteem in all encounters

Question 5

A patient with a history of self-mutilation says to the nurse, "I want to stop hurting myself." What is the initial step of the problem-solving process to be taken toward resolution of a patient's identified problem?

Accepted Answer

A)  Deciding on a plan of action 
B)  Determining necessary changes 
C)  Considering alternative behaviors 
D)  Describing the problem or situation

Question 6

A patient tells the nurse, "I was raped a month ago. Since then I've felt anxious and have been unable to talk normally to my husband. I've had frequent thoughts about cutting my wrists." What is the priority nursing concern regarding this patient?

Accepted Answer

A)  The risk for self-directed violence 
B)  The development of rape traumatic syndrome 
C)  The damage that could result in poor self-esteem 
D)  The demonstration of signs and symptoms of acute anxiety

Question 7

Which nursing intervention will initially be most helpful for trust building with a suspicious patient?

Accepted Answer

A)  Enforcing rules 
B)  Keeping appointments and promises 
C)  Agreeing not to document the patient's disclosures 
D)  Openly challenging unclear statements by the patient

Question 8

A nurse tells a patient, "I know how you feel. My spouse can be very insensitive too. I am also considering divorce." What behavior is the nurse demonstrating?

Accepted Answer

A)  Inappropriate self-disclosing 
B)  Countertransference 
C)  Establishment of trust with the patient 
D)  Encouraging the patient to express negative feelings

Question 9

A patient playing pool with another patient throws down the pool cue and begins swearing. What action should the nurse implement initially to address this situation?

Accepted Answer

A)  Asking other patients to leave the room 
B)  Calling for assistance to restrain the patient 
C)  Suggesting a time-out in the patient's room 
D)  Restating rules of the milieu related to swearing

Question 10

What fact about a particular patient will have the greatest impact on nurse-patient collaboration?

Accepted Answer

A)  Involuntary admission 
B)  Advance age 
C)  Hallucinations 
D)  Terminal diagnosis

Question 11

What statement made by a nursing is most helpful when moving into the working stage of a therapeutic relationship with a patient?

Accepted Answer

A)  "I want to be helpful to you as we explore your problems and the way you express feelings." 
B)  "A good long-term goal for someone your age would be to develop better job-related skills." 
C)  "Of the problems we have discussed so far, which ones would you most like to work on at this time?" 
D)  "When someone gives you a compliment, I notice that you become very quiet and appear uncomfortable."

Question 12

A nurse and patient who developed a therapeutic relationship enter into the final phase of their relationship as the patient prepares for discharge. What is an important nursing intervention for this stage of the relationship?

Accepted Answer

A)  Providing structure and intensive support 
B)  Informing the patient of the progress made 
C)  Encouraging the patient to describe goals for change 
D)  Discussing feelings about termination with the patient

Question 13

A psychotic patient tells the nurse, "Get away from me or I'll hit you. You're sucking the thoughts out of my head." To best de-escalate the situation, what intervention should the nurse implement?

Accepted Answer

A)  Directing the patient to a chair 
B)  Deny taking the patient's thoughts 
C)  Increasing the distance between nurse and patient 
D)  Telling the patient, "You will be restrained if you hit me"

Question 14

A nurse plans to teach a group of patients the basics of the change process. How should the elements be sequenced for the presentation? (Select all that apply.)

Accepted Answer

A)  Assess the success of new behaviors. 
B)  Observe to gain awareness. 
C)  Draw conclusions about the problem. 
D)  Test new behaviors. 
E)  Assume that change is necessary.

Question 15

Which statement is most therapeutic when working with a patient believed to be experiencing emotional pain?

Accepted Answer

A)  "I hear how painful this is for you. I would like to help you deal with it." 
B)  "I'm so sorry this has happened to you. You don't deserve it." 
C)  "What would you like me to do to help you through this pain?" 
D)  "I don't think this is as serious as you believe it is."

Question 16

During a mental status examination (MSE) a patient says, "I am a special messenger sent to provide the world a cure for cancer." The patient's statement indicates the presence of what form of dysfunctional thought content?

Accepted Answer

A)  Phobia 
B)  Delusion 
C)  Hypervigilance 
D)  Loose associations

Question 17

A student states, "I do not see the value of process recordings." The response to this concern should be based on what information related to process recording?

Accepted Answer

A)  It is a tool for analyzing communication. 
B)  It is a verbatim record of a patient interview. 
C)  It is a legal document that becomes part of the medical record. 
D)  It is a note written at the time of a patient interview to provide information to team members.

Question 18

Which statement by a patient would the nurse interpret as willingness to collaborate in the nurse-patient relationship?

Accepted Answer

A)  "I know you are here to help me, and will do whatever you tell me to do." 
B)  "I didn't want to deal with this at first, but I'm glad you made me face it." 
C)  "I realize that I have some issues that I need help resolving." 
D)  "I will do anything to get out of this hospital."

Question 19

Which goal statement is most appropriate for a newly admitted patient currently in the orientation stage of the nurse-patient relationship?

Accepted Answer

A)  By the end of the orientation stage of the therapeutic relationship, the patient will demonstrate greater independence. 
B)  By the end of the orientation stage of the therapeutic relationship, the patient will demonstrate increased self-responsibility. 
C)  By the end of the orientation stage of the therapeutic relationship, the patient will demonstrate trust and rapport with two staff members. 
D)  By the end of the orientation stage of the therapeutic relationship, the patient will demonstrate ability to problem-solve one issue.

Question 20

A patient says, "I went out drinking only one time last week. At least I'm trying to change." The nurse responds, "I appreciate your effort, but you agreed to abstain from alcohol completely." The nurse's response demonstrates the ability to manage what potential patient centered problem?

Accepted Answer

A)  Cognitive restructuring 
B)  Manipulation 
C)  Hostility 
D)  Denial

Exam 9: Working With an Individual Patient