Title RECALLS 8 - NP5 - SC ✅

A. 1,2,3,4,5 B. 1,2,3 C. 1,3,4,5 D. 2,4,5 13. An unconscious patient was rushed to the ER and was given Naloxone (Narcan). Which of the following would indicate that the antidote is effective? 1. decreased pulse rate 4. increased respiration 2. pinpoint pupils 5. Consciousness 3. warm skin A. 1,3,5 B. 1,2,4 C. 4,5 D. 3,4,5 14. Which of the following should the nurse on duty expect to assess in a patient manifesting late signs of heroin withdrawal? A. Vomiting and diarrhea B. yawning and diaphoresis C. lacrimation and rhinorrhea D. restlessness and irritability 15. While you are on duty as a nurse in the ICU, you witness your coworker injecting what appears to be an opioid drug into their antecubital area. As a nurse, what should you do? A. Report the incident to the nursing supervisor immediately B. Lock the coworker and ask for an explanation privately C. Ignore the situation to avoid conflict D. Document the behavior anonymously without informing anyone Situation: A patient arrives at the Crisis Intervention Unit in a state of emotional distress, expressing confusion, anxiety, and an inability to cope. As a nurse, you recognize this as a situational crisis where the individual's usual coping mechanisms have failed. 16. A 14-year-old patient who may be pregnant shares that she has been hooking up with someone she describes as her "situationship." As the nurse, what should be your initial response? A. “You mean you have sexual intercourse with your situationship? ” B. “Describe what you mean by hooking up?” C. “Tell me more about what happened during your sexual intercourse. “ D. “Why did you assume that the boy liked you? “ 17. You are a nurse reviewing the chart of a patient admitted to the mental health unit. Upon review, you note that the patient is experiencing anxiety due to a situational crisis. As a nurse, you understand that this type of crisis is typically caused by? A. Witnessing a murder in the workplace. B. Death of the patient’s sister. C. Returning from combat as a post-war veteran. D. Being married to a long-term partner. 18. A nurse is creating a plan of care for a patient in a crisis state. When developing a care plan, the nurse should consider: A. Being in a crisis means the patient is suffering from a mental or emotional disorder. B. All patients show the same symptoms during a crisis situation. C. A patient’s response to a crisis in the same way, and what is a crisis for one person is also a crisis for another. D. A patient’s response to a crisis is individualized, and what one person considers a crisis may not be the same for someone else. 19. You are a nurse in a mental health unit speaking with a patient who is the sole survivor of a plane crash. Since the incident, the patient has been experiencing recurrent nightmares and difficulty sleeping. During the conversation, the patient says, “I don’t understand why they all had to die and I didn’t!” This statement suggests the patient is experiencing: A. Night terrors B. Suicidal ideation C. Survivor’s guilt D. Stress disorder 20. Based on the situation above, as a future topnotcher, you know that the most therapeutic response would be: A. “Why do you think that way? “ B. “That sounds really difficult. Can you tell me more about how you're feeling? ” C. “It’s okay to cry. I will always be here on your side.” D. “You should be thankful for the second life that God gave you.” Situation: Defense mechanisms are cognitive distortions that a person uses unconsciously to maintain a sense of being in control of a situation, to lessen discomfort, and to deal with stress. Because defense mechanisms arise from the unconscious, the person is unaware of using them. 21. A nurse reminds a patient that it is time for his bath. The patient yells in response, “You always tell me what to do! You're just like my evil stepmother! ” This behavior is an example of: A. Symbolism B. Transference C. Countertransference D. Reaction Formation 22. A patient argues with the nurse that smoking can’t be so bad because it keeps her calm and relaxed when she is stressed. The nurse is knowledgeable that the patient is using what type of defense mechanism; A. Sublimation B. Intellectualization C. Rationalization 23. A nursing board topnotcher was brought to the emergency room following an accident related to alcohol intoxication. Once stabilized and transferred to the ward, he repeatedly rings the call bell every 15 minutes to request assistance from the nurse on duty. The nurse recognizes that the patient is demonstrating which type of ego defense mechanism? A. Regression B. Repression C. Compensation D. Displacement 24. You are a nurse working in a mental health unit. One of your patients, who holds a corporate position, was recently observed being yelled at by his spouse. During your interview with him, the patient becomes hostile and begins shouting at you. As a nurse, you recognize that the patient is exhibiting which ego defense mechanism? A. Denial B. Projection C. Displacement D. Introjection 25. The nurse is assessing a patient suspected of being in the early stages of dementia. Which defense mechanism would the nurse most likely observe? A. Reaction Formation B. Substitution C. Confabulation D. Compensation Situation: A nurse is equipped with the appropriate knowledge and skills in dealing patients with Personality Disorder. The following questions apply. 26. While caring for a patient with a personality disorder, the nurse begins to feel irritated and frustrated due to the patient’s behavior. As a psychiatric nurse, what is the most appropriate action to take? A. Tolerance B. Self-control C. Self-awareness D. Responsibility 27. Which nursing diagnosis is the priority of care at a time of admission for a patient diagnosed with antisocial personality disorder: A. Social isolation B. Risk for Violence directed at others C. Personal identity disturbance D. Risk for fluid volume deficit 28. A patient arrives for a psychiatric appointment wearing an elaborate ballgown and heavy theatrical makeup. She 2 | Page

D. 2,4 45. A client states to the nurse, “I see headless people walking down the hall at night.” Which nursing response is appropriate? A. “What makes you think there are headless people here? ” B. “Are you kidding me? A headless person would not be able to walk down the hall.” C. “It must be frightening. I realize this is real to you, but there are no headless people here.” D. “Yes, I know and I can see them too. Let us walk around the hallway to divert your attention.” Situation: Mood disorders are mental health conditions characterized by disturbances in a person’s emotional state, such as prolonged sadness, extreme elation, or mood swings, which can impair daily functioning. 46. A provocatively dressed client diagnosed with bipolar I disorder is observed laughing loudly with peers in the milieu. Which nursing action is a priority in this situation? A. Join the milieu to assess the appropriateness of the laughter. B. Redirect clients in the milieu to structured social activities, such as cards. C. Privately discuss with the client the inappropriateness of provocative dress during hospitalization. D. Administer PRN antianxiety medication to calm the client. 47. A client notifies a staff member of current suicidal ideations. Which intervention by the nurse would take priority? A. Place the client on a one-to-one observation. B. Determine if the client has a specific plan to commit suicide. C. Assess for past history of suicide attempts. D. Notify all staff members and place the client on suicide precautions. 48. A client newly admitted to an in-patient psychiatric unit who is experiencing a manic episode. The client’s nursing diagnosis is imbalanced nutrition, less than body requirements. Which meal is most appropriate for this client? A. Caesar salad and fruit shake B. Cheeseburger and milkshake C. Baked talaba and sprite D. Crackers and coffee 49. A depressed patient says to you, “You are my favorite nurse. This is a 24k 50-gram bracelet that I inherited from my great-grandfather. I want to give it to you so that you won’t forget me.” What is the most appropriate nursing response? A. “I appreciate your gift to me. I promise to take care of this forever.” B. “Are you planning to kill yourself? ” C. “This is such a wonderful gift. Is this pawnable? ” D. “Why are you giving such a precious thing to me? ” 50. Which statement describes a major difference between a client diagnosed with major depressive disorder and a client diagnosed with dysthymic disorder? A. A client diagnosed with dysthymic disorder is at higher risk for suicide. B. A client diagnosed with dysthymic disorder may experience psychotic features. C. A client diagnosed with dysthymic disorder experiences excessive guilt. D. A client diagnosed with dysthymic disorder has symptoms for at least 2 years. Situation: Clients with eating disorders are often preoccupied with food, body image, and weight. They may have distorted perceptions of their body, experience anxiety or guilt around eating, and use unhealthy behaviors like restriction, purging, or excessive exercise to cope with emotional distress. 51. A patient with the diagnosis of anorexia nervosa, who is in a state of starvation, is in a two-bed bedroom. A newly admitted patient will be assigned to this patient’s room. Which patient would be the best choice as a roommate for the patient with anorexia nervosa? A. A patient with pneumonia B. A patient undergoing diagnostic test C. A patient with severe depression and suicidal ideation D. A patient with dementia 52. A client is being admitted to the in-patient psychiatric unit with a diagnosis of anorexia nervosa. Which of the following is at highest risk for developing this disorder? A. A 2-year-old toddler whose parents are separated. B. A 69-year-old post-Vietnam War veteran. C. A 15-year-old female artistic gymnast. D. A 40-year-old mother grieving the loss of her son to cancer. 53. After a routine examination on an adolescent, the nurse suspects bulimia nervosa and reports this to the parents. Which of the following assessment findings would support this suspicion? 1. Chipmunk’s sign (sialadenosis) 4. Amenorrhea 2. Russell’s sign 5. Extreme weight loss. 3. Yellow discoloration of teeth A. 1, 2, 4 B. 1,2,3 C. 2,3,4,5 D. 2,3,5 54. After teaching a group of student nurses, the nurse judges that no further education is needed when the student nurse states which of the following? A. "Both anorexia and bulimia are eating disorders and have no differences at all." B. “A patient with an eating disorder may be treated with cognitive-behavioral therapy and antipsychotic medications but not antidepressants.” C. “Anorexia nervosa involves cycles of binge eating followed by purging, while bulimia nervosa is characterized by restriction of food intake and fear of weight gain." D. “Anorexia nervosa involves restriction of food intake and fear of weight gain, while bulimia nervosa is characterized by cycles of binge eating followed by purging." 55. Which of the following emotional elements is commonly found in clients with bulimia nervosa but is not typically associated with anorexia nervosa? A. Fear of gaining weight B. Body image distortion C. Guilt after eating D. Food restriction Situation: A fundamental component of psychiatric nursing is to understand the legal framework used to regulate the care and treatment of clients with mental illness. Nurses must be familiar with concepts such as voluntary and involuntary admission, informed consent, confidentiality, legal competence, and the rights of individuals undergoing psychiatric treatment. 56. Which statement reflects the ethical principle of utilitarianism? A. “The end justifies the means.” B. “If you mean well you will be justified.” C. “Do unto others as you would have them do unto you.” D. “What is right is what is best for me.” 57. You are the nurse on duty. While reviewing the patient’s chart, you note that another nurse documented having given the wrong medication to the patient. The patient has shown no signs of harm. Which action should you take? A. Keep the information confidential to avoid harm to others. B. Inform the nurse supervisor, and document the situation. C. Tell only the patient about the incident because the decision about actions would be determined only by the patient. D. Because the client was not harmed, the incident would not need to be reported. 58. A patient diagnosed with Generalized Anxiety Disorder (GAD) voluntarily admitted himself to a mental health facility. On the third day of admission, he approaches the nurse on duty and states, “I’m feeling better now. I want to go home.” What is the most appropriate nursing action? 4 | Page