PSYCHE Exam (25 items)

Psyche-Nx

1. After the client who attempted suicide regains consciousness, she says to the nurse, "I can't even kill myself. I can't even do that right." Which of the following responses by the nurse would be most therapeutic at this time?
a. "These feelings will pass."
b. "Tell me more about how you are feeling."
c. "Why would you feel that way?"
d. "You have a great deal to live for."

2. The client is admitted to the hospital because of threatening, aggressive behavior toward his family. Which of the following factors is most important for the nurse to consider when assessing the angry client's potential for violence?
a. The time of day and level of activity on the unit.
b. The attitude of the staff toward the angry client.
c. The staff-to-client ratio.
d. The client's past history of violent behavior.

3. For the client experiencing delirium, the nurse prioritizes interventions to first maintain:
a. Orientation.
b. Physical safety.
c. Optimal level of functioning.
d. Consistency in routine.

4. A client with an obsessive-compulsive disorder washes his feet frequently. Which of the following nursing diagnoses is specifically related to this behavior?
a. Self-Care Deficit.
b. Ineffective Coping.
c. Risk for Impaired Skin Integrity.
d. Anxiety.

5. The nurse assesses a client who has Alzheimer’s disease. Her hair is dirty; her clothing is soiled and has an odor of urine. The nurse's best action would be to:

a. Ask the client when was the last time she bathed and changed her clothes.
b. Help the client with her bath, allowing her to do as much for herself as she is able.
c. Ask the daughter to bathe her mother.
d. Instruct the client to bathe and put on clean clothing.

6. When upset, the client curls into a fetal position in bed. The nurse judges the client to be exhibiting:
a. Fixation.
b. Regression
c. Substitution
d. Symbolization

7. The nurse would be most concerned about a client's depression when the client states that she:

a. Feels tired.
b. Has difficulty falling asleep and wakes up early in the morning.
c. No longer watches her favorite television programs.
d. Is gaining weight.

8. A client with major depression states to the nurse, "My heart is turning to stone." Which reply by the nurse is most therapeutic?
a. "You are alive and breathing."
b. "Your depression makes you think that way."
c. "What makes you say that?"
d. "You sound like you feel frightened."

9. When a client expresses feelings of unworthiness, how would the nurse best respond?
a. "Your family loves you even if you feel unworthy."
b. "Your feelings of being unworthy are just your imagination."
c. "It would be best to try to forget the idea that you are unworthy."
d. "As you begin to feel better, your feelings of unworthiness will begin to disappear."

10. As the nurse stands near the window in the client's room, the client shouts, "Come away from the window! They'll see you!" Which of the following responses by the nurse would be best?
a. "Who are ‘they?’"
b. "No one will see me."
c. "You have no reason to be afraid."
d. "What will happen if they do see me?"

11. The nurse attempts to interact with a client who barely responds with yes or no. The client states, "Don't bother me. I want to die." The nurse's best action is to:
a. Leave the client alone.
b. Send another staff member to interact with the client.
c. Sit with the client for 10 minutes.
d. Turn on the television for the client.

12. Which of the following rights does a client lose by being admitted involuntarily to a psychiatric hospital? The right to:
a. Send and receive mail.
b. Vote in a national election.
c. Make a will or legally binding contract.
d. Sign out of the hospital against medical advice.

13. Which of the following variables should the nurse judge as least likely to indicate high risk when assessing a client's potential for suicide?
a. Age 60 and older.
b. Angry behaviour.
c. Living alone.
d. Previous suicidal attempts

14. A client's face is flushed. He is swearing, yelling, and pushing chairs around the day room of a mental health center. The nurse judges the client to be in which phase of the assault cycle?
a. Triggering
b. Escalation
c. Crisis
d. Aggressive
15. At an emergency shelter, an earthquake victim tells the nurse that he is going to spend the night in his own bed at home. Which defense mechanism is the client exhibiting?
a. Intellectualization
b. Denial
c. Rationalization
d. Undoing

16. A client in an inpatient psychiatric unit tells the nurse, "I'm going to divorce my no-good husband. I hope he rots in hell. But I miss him so bad. I love him. When's he going to come get me out of here?" The nurse interprets the client’s statements as indicative of which of the following?
a. Ambivalence.
b. Autistic thinking.
c. Associative looseness.
d. Auditory hallucinations.

17. In terminating the relationship with the nurse, which client reaction should be considered the most healthy?
a. A lack of response
b. A display of anger
c. An attempt of humor
d. An expression of grief

18. An adolescent client is admitted to the psychiatric unit for rapid weight loss associated with anorexia nervosa. She is 5 feet, 2 inches tall, and weighs 70 pounds. Physical manifestations most likely to be found during nursing assessment include:
a. Tachycardia, hypertension, and hyperthyroidism.
b. Tachycardia, hypertension, and iron-deficiency anemia.
c. Hypotension, elevated serum potassium level, and vitamin C deficiency.
d. Bradycardia, hypotension, and cold sensitivity.

19. Which of the following methods of treatment would initially be least helpful to a client with obsessive-compulsive disorder?
a. Relaxation Exercises.
b. Meditation.
c. Listening to soothing music.
d. Exposure therapy.

20. A client with bipolar disorder, manic phase, just sat down to watch television in the lounge. As the nurse approaches the lounge area, the client states, "The sun is shining. Where is my son? I love Lucy. Let's play ball." The client is displaying:
a. Concreteness
b. Flight of Ideas
c. Depersonalization
d. Use of Neologisms

21. The client with an Axis I diagnosis of posttraumatic stress disorder tells the nurse he wishes that he had been on the airplane that crashed and killed his wife and children a month ago. The nurse assesses the client's statement to be indicative of:
a. Suicidal ideation.
b. Survivor guilt.
c. Dysfunctional grieving.
d. Numbness of responsiveness.

22. A client with bulimia binges twice a day. The nurse interprets these binges as most likely involving which of the following for the client?
a. Feelings of euphoria and gratification.
b. Feeling out of control and disgusted with self.
c. Leaving traces of food around to attract attention.
d. Eating increasing amounts of food for substantial weight gain.

23. The nurse is conducting a mental status examination on a client with a cognitive disorder. Which of the following statements does the nurse judge to be an impairment in abstract thinking? The client's:
a. Ability to remember her wedding day.
b. Inability to find a similarity between a bird and a butterfly.
c. Memories regarding her vacation 5 years ago.
d. Inability to state her home address.

24. The client thinks he is being followed by foreign agents who are after secret papers in his briefcase. What thought disorder does this indicate?
a. Idea of reference.
b. Idea of influence
c. Delusion of grandeur.
d. Delusion of persecution.

25. An attitude by the nurse that would most likely foster a therapeutic relationship between the nurse and the client who tries to manipulate people is:
a. Strictness
b. Sympathy
c. Aloofness
d. Consistency