ATI LPN
Test Bank for Essentials of Psychiatric Mental Health Nursing: A Communication Approach to Evidence-Based Care, 4e 4th Edition
Chapter 11 Questions
Question 1 of 5
A nurse wishes to teach alternative coping strategies to a patient experiencing severe anxiety. The nurse will first need to:
Correct Answer: C
Rationale: A patient experiencing severe anxiety has a significantly narrowed perceptual field and difficulty attending to events in the environment. A patient experiencing severe anxiety will not learn readily. Determining preferred modes of learning, devising outcomes, and constructing teaching plans are relevant to the task but are not the priority measure. The nurse has already assessed the patient's anxiety level. Using defense mechanisms does not apply.
Question 2 of 5
A patient approaches the nurse and impatiently blurts out, 'You've got to help me! Something terrible is happening. My heart is pounding.' The nurse responds, 'It's almost time for visiting hours. Let's get your hair combed.' Which approach has the nurse used?
Correct Answer: A
Rationale: The patient is experiencing anxiety. The nurse has closed off patient-centered communication by changing the subject. The introduction of an irrelevant topic makes the nurse feel better. The nurse may be uncomfortable dealing with the patient's severe anxiety. The nurse has not responded to the patient's physical needs. There is no evidence of false cognition. Focusing is a therapeutic communication technique used to concentrate attention on a single issue.
Question 3 of 5
A patient experiencing moderate anxiety says, 'I feel undone.' An appropriate response for the nurse would be:
Correct Answer: C
Rationale: Increased anxiety results in scattered thoughts and an inability to articulate clearly. Clarification helps the patient identify his or her thoughts and feelings. Asking the patient why he or she feels anxious is nontherapeutic, and the patient will not likely have an answer. The patient may be unable to determine what he or she would like the nurse to do to help. Telling the patient to get his or her feelings under control is a directive the patient is probably unable to accomplish.
Question 4 of 5
A patient with a high level of motor activity runs from chair to chair and cries, 'They're coming! They're coming!' The patient does not follow instructions or respond to verbal interventions from staff. The initial nursing intervention of highest priority is to:
Correct Answer: A
Rationale: Safety is of highest priority; the patient who is experiencing panic is at high risk for self-injury related to an increase in non-goal-directed motor activity, distorted perceptions, and disordered thoughts. The goal should be to decrease the environmental stimuli. Respecting the patient's personal space is a lower priority than safety. The clarification of feelings cannot take place until the level of anxiety is lowered.
Question 5 of 5
A patient with a high level of motor activity runs from chair to chair and cries, 'They're coming! They're coming!' The patient is unable to follow instructions or respond to verbal interventions from staff. Which nursing diagnosis has the highest priority?
Correct Answer: A
Rationale: A patient who is experiencing panic-level anxiety is at high risk for injury, related to an increase in non-goal-directed motor activity, distorted perceptions, and disordered thoughts. Existing data do not support the nursing diagnoses of self-care deficit or disturbed energy field. This patient has disturbed thought processes, but the risk for injury has a higher priority.