EST BANK FOR PSYCHIATRICNURSING 7TH EDITION BY KELTNER ALL CHAPTERS Chapter 01: Me, Meds, Milieu MULTIPLE CHOICE 1. Select the best description of nursing practice in the psychiatric setting. a. The nurse primarily serves in a supportive role to other members of the team. b. The multidisciplinary approach eliminates the need to clearly define the responsibilities of nursing. c. Clearly differentiated nursing actions have been identified that distinguish nursing from other professions. d. Although professional role overlap exists, nursing offers unique contributions to psychotherapeutic management. ANS: D Professional role overlap cannot be denied; however, nursing is unique in its focus on and application of psychotherapeutic management. Psychiatric social workers do not have expertise in physical care. Ideally, all team members support each other. DIF: Cognitive level: Applying REF: p. 3 TOP: Nursing process: Implementation MSC: NCLEX: Safe, Effective Care Environment 2. The primary element required to match individual patient needs with appropriate services is proper: a. planning. b. evaluation. c. assessment. d. implementation. ANS: C Proper assessment is critical for being able to determine the appropriate level of services that will provide the patient with optimal care at the lowest cost. The decision tree for the continuum of care establishes this fact. DIF: Cognitive level: Understanding REF: p. 7 TOP: Nursing process: Assessment MSC: NCLEX: Safe, Effective Care Environment 3. An adult with paranoid schizophrenia is hospitalized. This patient has frequent auditory hallucinations and walks about the unit, muttering. To use psychotherapeutic management effectively, it is most important for the nurse to: a. understand the disease process of schizophrenia. b. minimize contact between this patient and other patients. c. administer PRN medication before interacting with the patient. d. use behavior modification to decrease the frequency of hallucinations. ANS: A An understanding of psychopathology is the foundation on which the three components of psychotherapeutic management rest; it facilitates therapeutic communication and provides a basis for understanding psychopharmacology and milieu management. Minimizing contact between the patient and others and administering PRN medication indiscriminately are nontherapeutic interventions. Using behavior modification to decrease the frequency of hallucinations would need to be incorporated into the plan of care. DIF: Cognitive level: Applying REF: pp. 1-2 TOP: Nursing process: Implementation MSC: NCLEX: Safe, Effective Care Environment 4. A depressed adult is hospitalized after a suicide attempt. The patient receives an antidepressant medication, is closely supervised, attends a variety of group therapies and activities, watches television during free time, and talks to visitors in the evening. Which additional intervention is needed in the patient‘s care? a. Milieu therapy b. Adequate drug therapy c. Increased contact with significant others d. Meaningful communication with nursing staff ANS: D Two of the three elements of psychotherapeutic management are present: psychopharmacology and milieu management. There is no evidence that the psychotherapeutic nurse–patient relationship exists. Maintaining contact with significant others is not considered an element of the psychotherapeutic management model. DIF: Cognitive level: Applying REF: pp. 1-2 TOP: Nursing process: Planning MSC: NCLEX: Psychosocial Integrity 5. A patient attends outpatient programs at a community mental health center and meets with the primary nurse regularly. Last week, the patient‘s haloperidol (Haldol) dose was reduced from 5 mg to 2 mg daily to decrease side effects. The nurse will need to monitor changes in: a. the activity schedule at the center. b. the nature of the patient‘s symptoms. c. attention given to the patient by other staff. d. balance among psychotherapeutic management elements. ANS: B It will be necessary for the nurse to assess for exacerbation of the patient‘s symptoms of psychosis as well as for an amelioration of side effects. Dosage decrease might lead to the return or worsening of positive symptoms such as hallucinations and delusions, and negative symptoms such as blunted affect, social withdrawal, and poor grooming. DIF: Cognitive level: Applying REF: p. 2 TOP: Nursing process: Assessment MSC: NCLEX: Physiologic Integrity 6. Which guideline should a nurse use when applying the components of psychotherapeutic management to the care of a patient with mental illness? a. The nurse‘s role in milieu management is secondary to that of social work. b. Omitting any one component usually will result in less effective treatment. c. The most important element of psychotherapeutic management is drug therapy. d. A therapeutic nurse–patient relationship is the most important aspect of treatment. ANS: B The three components listed as choices a, c, and d above work together to provide the best treatment outcomes. When one element is missing, treatment is usually compromised. No single element is more important than the others; however, patients‘ needs govern the application of the components and permit judicious use. DIF: Cognitive level: Applying REF: pp. 1-2 TOP: Nursing process: Planning MSC: NCLEX: Safe, Effective Care Environment 7. Which statement most accurately describes a nurse‘s role regarding psychopharmacology? The psychiatric nurse: a. frequently makes decisions regarding administration of PRN medications. b. might adjust a medication dose if a patient is not responding positively. c. administers medications but is not responsible for monitoring drug effectiveness. d. should refer a patient‘s questions about drug side and adverse effects to the psychiatrist. ANS: A Nursing assessment and analysis of data might suggest the need for PRN medication as patient anxiety increases or psychotic symptoms become more acute. The nurse is the health team member who makes this determination. Nurses are responsible for monitoring drug effectiveness as well as administering medication. Nurses should assume responsibility for teaching patients about the side effects of medications. Nurses cannot alter prescribed dosages of medications unless they have prescriptive privileges. DIF: Cognitive level: Understanding REF: 2 TOP: Nursing process: Implementation MSC: NCLEX: Safe, Effective Care Environment 8. A nurse considers environmental aspects of milieu management while planning care for a newly admitted patient. Which element has the highest priority? a. Norms b. Safety c. Balance d. Structure ANS: B Milieu management provides a proactive approach to care. Safety overrides all other dimensions of the milieu. DIF: Cognitive level: Analyzing REF: 2 TOP: Nursing process: Planning MSC: NCLEX: Safe, Effective Care Environment 9. When the treatment team in an inpatient psychiatric unit institutes a new unit schedule that provides for all patients to be involved in activities continuously throughout both the day and early evening, which element of milieu management needs reflection and reconsideration? a. Norms b. Balance c. Limit setting d. Environmental modification ANS: B The situation described suggests a milieu in which patients have no time for planned therapeutic encounters with staff; hence, it is a milieu lacking balance. Environmental modification is not a core element of milieu management. Data are insufficient to permit the student to choose either the component of norms or limit setting. DIF: Cognitive level: Analyzing REF: p. 2 TOP: Nursing process: Evaluation MSC: NCLEX: Safe, Effective Care Environment 10. During an interaction with a patient, a nurse encourages the patient to express feelings, identify stressors, and review coping strategies. These nursing interventions relate most to the use of: a. risk assessment. b. behavior modification. c. therapeutic communication. d. environmental manipulation. ANS: C A nurse uses therapeutic communication techniques as part of the therapeutic nurse–patient relationship. Being therapeutic does not imply that the nurse is providing therapy, a formal, structured process. Risk assessment has a different purpose related to provision of an appropriate level of care. Environmental manipulation is more related to milieu management than to therapeutic use of self. DIF: Cognitive level: Understanding REF: p. 2 TOP: Nursing process: Implementation MSC: NCLEX: Psychosocial Integrity 11. During the risk assessment phase of care for a psychiatric patient, the nurse will: a. make an initial assessment. b. confirm the patient‘s problem. c. assess potential dangerousness to self or others. d. determine the level of supervision needed for the patient. ANS: C Risk assessment involves looking at dangerousness to self or others, the degree of disability, and whether or not the individual is acutely psychotic to determine the feasibility of community-based care versus hospital-based care. Risk assessment usually follows the initial assessment. Confirmation of the patient‘s problem is not part of the risk assessment protocol. Arranging entry into the mental health system will follow risk assessment if the patient is assessed as needing service. DIF: Cognitive level: Applying REF: pp. 2-3 TOP: Nursing process: Assessment MSC: NCLEX: Safe, Effective Care Environment 12. Risk assessment for a patient shows these findings: schizophrenia but not acutely psychotic at the moment; not a danger to self or others; lives in parents‘ home. Which decision regarding placement on the continuum of care is appropriate? a. Hospitalize the patient. b. Discharge the patient from the system. c. Refer the patient to outpatient services. d. Refer the patient to self-help resources in the community. ANS: C Referral should be made to the least restrictive, most effective, and most cost-conscious source of services. Because the patient is not a danger to self or others, hospitalization is not needed. However, follow-up as an outpatient would be more appropriate than referral to a self-help group, in which structure might be lacking, or discharge from the system. DIF: Cognitive level: Analyzing REF: pp. 2-3 TOP: Nursing process: Planning MSC: NCLEX: Safe, Effective Care Environment 13. A patient tells the nurse, ―This medicine makes me feel weird. I don‘t think I should take it anymore. Do you?‖ The most effective reply that the nurse could make is based on the psychotherapeutic management model component of: a. psychopathology. b. milieu management. c. psychopharmacology. d. therapeutic nurse–patient relationship. ANS: C Concerns about medication voiced by patients require the nurse to have knowledge about psychotherapeutic drugs to make helpful responses. The nurse–patient relationship component is based on use of self. Milieu management is concerned with the environment of care. Psychopathology provides foundational knowledge of mental disorders but would be less relevant in framing a response to the patient than knowledge of psychopharmacology. DIF: Cognitive level: Applying REF: p. 2 TOP: Nursing process: Implementation MSC: NCLEX: Physiologic Integrity 14. A patient tells the nurse, ―This medication makes me feel weird. I don‘t think I should take it anymore. Do you?‖ Select the nurse‘s best response. a. ―I wonder why you think that.‖ b. ―Tell me how it makes you feel.‖ c. ―One must never stop taking medication.‖ d. ―You need to discuss this with your psychiatrist.‖ ANS: B As part of the psychopharmacology component of psychotherapeutic management, the responsibility of the nurse is to gather data about patients‘ responses to medication and to be alert for side and adverse effects of the medication. The other responses are tangential to the real issue. DIF: Cognitive level: Applying REF: 2 TOP: Nursing process: Implementation MSC: NCLEX: Physiologic Integrity 15. The spouse of a patient with panic attacks tells the nurse, ―I am afraid my husband has a permanent disorder and will have many hospitalizations in the future. I wonder how I will be able to raise our children alone.‖ The nurse‘s reply should be based on knowledge of: a. psychopathology. b. milieu management. c. psychopharmacology. d. nursing relationship therapy. ANS: A An understanding of psychopathology will enable the nurse to communicate reassurance to the spouse regarding the treatment of panic attacks in an outpatient setting. DIF: Cognitive level: Applying REF: p. 2 TOP: Nursing process: Implementation MSC: NCLEX: Psychosocial Integrity 16. Which observation during morning rounds should receive a nurse‘s priority attention? a. Breakfast is late being served. b. A sink is leaking, leaving water on the bathroom floor. c. The daily schedule has not been posted on the unit bulletin board. d. A small group of patients is complaining that one patient turned down the TV volume. ANS: B Safety is the component of therapeutic milieu management that takes priority over the other components. A patient could be injured if he or she slipped and fell. The other problems do not pose a threat to patient safety. DIF: Cognitive level: Analyzing REF: p. 2 TOP: Nursing process: Planning MSC: NCLEX: Safe, Effective Care Environment 17. A community mental health nurse assesses a person with a psychiatric disorder on an initial visit. The nurse should refer this person to services on the care continuum that: a. are the least costly. b. are the least restrictive. c. offer psychoeducation. d. promote rapid symptom stabilization. ANS: B The concept of least restrictive treatment environment preserves individual rights to freedom. Many patients are healthy enough to receive community-based treatment. Hospitalization is reserved for short periods when patients are assessed as being a danger to self or others. Cost is a consideration but is of lesser concern than safety. All facets of the continuum should offer psychoeducation as needed by patients and families. Some aspects of the care continuum are more concerned with a patient‘s need for symptom stabilization than others (e.g., hospitals versus psychiatric rehabilitation programs). The outcome of symptom stabilization is not a need for some patients, so it is not a correct answer. DIF: Cognitive level: Applying REF: pp. 2-3 TOP: Nursing process: Implementation MSC: NCLEX: Safe, Effective Care Environment 18. An acutely psychotic patient is restricted to an inpatient unit. Which milieu element has been adapted? a. Norms b. Balance c. Therapy d. Psychopathology ANS: B Balance refers to negotiating the line between dependence and independence. The more psychotic the individual, the less independence he or she can usually handle safely. Unit restriction with careful supervision by staff helps compensate for lack of patient judgment. Norms refers to behavioral expectations for patients. Therapy is provided by advanced-practice nurses or others with advanced education. Psychopathology is not considered an environmental element. DIF: Cognitive level: Applying REF: pp. 1-2 TOP: Nursing process: Implementation MSC: NCLEX: Safe, Effective Care Environment 19. When inpatient psychiatric care is not indicated, an individual with schizophrenia who has a history of medication noncompliance should be referred to which service? a. Primary care b. Outpatient counseling c. Apartment residential living d. A group home with 24-hour supervision ANS: D Although inpatient hospitalization is unnecessary, the individual requires an environment in which medication compliance can be fostered. In this case, the group home would provide the best alternative. The other options do not provide adequate supervision. DIF: Cognitive level: Analyzing REF: pp. 2-3 TOP: Nursing process: Planning MSC: NCLEX: Safe, Effective Care Environment 20. A patient with bipolar disorder has stabilized and is being discharged from the hospital. The patient will live independently at home but lacks social skills and transportation. Which referral would be most appropriate? a. A group home b. A self-help group c. A day treatment program d. Assertive community treatment (ACT) ANS: D Assertive community treatment (ACT) provides intensive supervision, which includes assistance with medications and transportation that would support the goal of minimizing future hospitalizations. A group home is unnecessary, because the patient will reside at home. A day treatment program would provide a therapeutic program directed toward symptoms, but the patient‘s symptoms have stabilized so this service is not indicated. A self-help group would not provide the intensity of service this patient needs. DIF: Cognitive level: Analyzing REF: p