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You have a patient that recently lost a loved one and would like to attend a grief meeting but does not drive, cannot afford a taxi, doesn't wish to burden family or friends. What would you do next? Correct Answer: Offer to acquire information about senior services that may help the patient. You have a dying patient and family reports that the dying patient is speaking to a deceased loved one. Family comes to the nurses station concerned about too much pain medication. How should the nurse respond? Correct Answer: This is a normal sign of approaching death and it is important that we do all we can to keep her pain tolerable. You have a patient prescribed Fluoxetine. Which response indicates further teaching is needed? Correct Answer: The patient states "I must take this medication with a full meal."
You have a patient admitted to the mental health unit. They have toothbrush, toothpaste, and dental floss in their pockets. They perform dental care as often as every 1/2 hour. How do you interpret these actions? Correct Answer: Attempt to relieve anxiety. You have a patient having an acute panic attack. What would you do? Correct Answer: Stay near the patient and reassure them they are safe. You have a patient that has a ritual that includes making and remaking their bed 30 times before they can go to sleep.Most of the time, they do not get into the bed until 3 AM. What action would you take? Correct Answer: Suggest they begin their ritual earlier in the day. Patient arrives in the ER in a severe state of anxiety following a traumatic event. What intervention would you implement? Correct Answer: Remain with the patient in a quiet room What behavior is expected from someone who just received elective convulsive therapy? Correct Answer: Confusion and short-term memory loss
What intervention would you do for a patient dressed in bright clothing that doesn't match and has been talking and pacing endlessly for the last 6 hours? Correct Answer: Offer hydration, nutrition, and consider a PRN sedative. Which condition sounds like this "weight loss, insomnia, and loss of interest in activities she use to enjoy"? Correct Answer: Depression What manifestation will indicate lithium is having the desired effect? Correct Answer: Patient reports consistent stable mood What intervention would you include for a patient that has hopelessness, headaches, sleep disturbances, and self-destructive thoughts? Correct Answer: Assess for suicidal behaviors, and assist with ADL's What symptoms would you emphasize on a patient taking lithium? Correct Answer: Vomiting, diarrhea, and tremors Which patient should you examine first? Correct Answer: Patient who recently overdosed with an opiate and was given a narcan an hour ago
What symptom would require immediate action from the nurse for a newly admitted patient has a blood alcohol level of 41%. Correct Answer: CNS depression Patient has moods between wildly euphoric and energetic to deeply melancholy and depressed. What would be your priority? Correct Answer: Symptoms related to bi-polar disorder You are working on a peds unit with a child who's father was recently deployed oversees. Child has been unusually quiet, melancholy, and disturbed sleep patterns. What would you tell the mother? Correct Answer: These are signs of situational depression related to the father leaving. Should return to normal when the father returns. Which intervention would address feelings that frequently occur in survivors of suicide victims Correct Answer: Feelings of guilt, anger, and shame You are working with a patient that has Wernicke's. The nurse anticipates giving thymine to this patient. What will this accomplish? Correct Answer: It will help prevent irreversible brain damage. What is the purpose of giving Naltrexone (Narco)?
What is the goal of assisting a patient with bi-polar in organizing medications and arranging transportation? Correct Answer: Restore the person to optimal functioning. What risks are relates to ineffective coping that you can help to prevent? Correct Answer: Destructive behavior in drug/alcohol abuse What symptoms of an acute stress response would you base your interventions on? Correct Answer: Emotional, psychological, and behavioral changes. Which factors contribute to violence in a community? Correct Answer: Poverty and lack of fulfilling work contributes to aggressive behaviors. What action will you take when planning care for a patient with cognitive impairment? Correct Answer: Structured daily routines How will theraputic massage and biofeedback help a patient? Correct Answer: By helping the patient learn to manage stress What level prevention is it when teaching people emergency stress stoppers and daily relaxation? Correct Answer: Primary (to reduce the probability)
What is the goal of screening postpartum mothers for depression? Correct Answer: Early identification and prompt intervention Patient has received several doses of Haldol (Haloperidol). A couple of hours later, they have a stiffly fixed position, lower jaw is thrusted forward and they are drooling. What would you want to give this patient? Correct Answer: You are going to administer diphenhydramine via IM How do you respond to someone who says "the voices are telling me to do things". How would the nurse respond? Correct Answer: What are the voices telling you to do? You have a patient reporting muscle stiffness, diaphoretic, drooling, and having difficulty swallowing. What action would you take? Correct Answer: Immediately notify the healthcare provider. What S&S would you look for in a patient being prescribes Haldol? Correct Answer: Sedation and muscle stiffness You have a patient that doesn't like to take the Haloperidol every day. What medication would you Correct Answer: Requesting an order for Haloperidol Decanoate IM
You have a patient concerned about ants climbing up the walls and into the room. How do you respond to this patient? Correct Answer: Share that the nurse does not see any ants. You have a patient taking clozapine. What information would you offer to this patient? Correct Answer: You should contact your healthcare provider with muscle stiffness or high fever What kind of meds would you give to a patient who reports feeling sad and thoughts of self-harm for the last 2 weeks? Correct Answer: Offer SNRI Patient has been recently dx with anorexia nervosa. What would you do next? Correct Answer: Introduce herself to the patient You have a patient running down the hallway shouting "I'm going to explode!" What would you do? Correct Answer: Stop them, tell them to take a deep breath. Which assessment finding would you report to the PCP of a patient that has anorexia nervosa? Correct Answer: Potassium level of 3.
How do you respond to a patient that frequently manipulates other patients and staff? Correct Answer: "Tell me what prompted you to act in this manner" Which behavior warrants limit-setting? Correct Answer: Yelling at other patients Preparing to administer oral medications but the patient refuses. How would you respond? Correct Answer: What are your concerns about taking this medication? What action would you take if someone has anxiety related to food consumption? Correct Answer: Ask about how you feel about their appearance? Patient stopped eating 5 months ago. They have lost 25% of their body weight. You ask about how they feel about how they look Which response require further questions? Correct Answer: I am extremely overweight You have a schizophrenic patient who frequently gets up and walks away during interactions with you. What would you do? Correct Answer: You sit at eye level across the table from them, You have a patient who is looking nervously and frequently at the door. How do you respond to this patient?
You have a patient that is a roman catholic and you are gathering information for spiritual assessment. What action would you take? Correct Answer: Assess the patient for any spiritual beliefs and document information Which patient would indicate spiritual distress? Correct Answer: Patient hesitating to talk to their church's pastor What would you do in regards to spiritual care? Correct Answer: Help patient's maintain self-awareness and inner strength. What statement by the nurse is an example of therapeutic communication? Correct Answer: "I think you need to know more about how your medications work." You have a patient undergoing electroconvulsive therapy in the morning. What do you need to do prior? Correct Answer: Allow the patient to sign the informed consent after the Dr. explains the procedure The patient is having difficulty remembering the information taught by the nurse. What would you do? Correct Answer: Give simple, clear instructions and repeat if necessary.
Which statement is true regarding coping skills? Correct Answer: Limited financial resources can be a risk for coping difficulties You have a patient admitting themselves to a psyche unit and a few days later they request to go home for a "Quinceanera" What would you say? Correct Answer: You would tell the patient she can leave and she will have the physician write the order right away. When reviewing data, which is the priority concern? Correct Answer: Patient expressing feelings of doom and hopelessness. You have a patient having difficulty communicating their medical history. What would you do? Correct Answer: Offer the patient a pen and paper which could help them communicate You are caring for a patient who has alzheimer's having difficulty in time orientation. What will you do to assist the patient to re-orient them? Correct Answer: Create a calendar full of activities, times, dates, and events. You have a patient receiving palliative care. What can you teach the patient? Correct Answer: The goal of palliative care is to relieve symptoms, life-threatening side effects, and diseases.
(4 SATA)Which of the following would mental health professionals strive to help patients develop and maintain regarding spiritual care? Correct Answer: 1. Inner strength
- Self awareness
- Life's meaning and purpose
- Relationships to others (4 SATA)Collecting data of religious beliefs and practices from patients. What should you include? Correct Answer: 1. What role does religion play in your life?
- What is your source of strength and hope?
- What brings you comfort and joy?
- Does your religion have any special days? Patient prescribed Laxopam for anxiety. What indicates needs for further teaching? Correct Answer: "I can take this medication to relieve everyday stress" You have a patient scheduled for surgery and wants to wear a bracelet that has significant meaning to them. When you ask them to remove it, they say they really wish they could wear it during the procedure. What do you do next? Correct Answer: Determine if the item may remain in place during the procedure
You have a muslim patient wishing to face MECCA. What position should the nurse place the patient's bed? Correct Answer: South East direction from the United States You have a patient that is a jehovah's witness and the physician orders 2 units of blood ASAP but she refuses to sign the consent form. What should you do next. Correct Answer: Notify the physician STAT and Report the patient's refusal
