Middle age female with no previous mental illness and the family states that she is
having paranoid thoughts, pt states: “I want to find out why people are stalking me”.
(ANSTherapeutic response: “it sounds like this experience is frightening for you”
Pt is mad at mom for turning him in and wants mom to bring belongings and does
not want to talk to her. What action does the nurse need to take before the visit?
(ANSDiscuss methods of clear communication
Duty to warn question: Pt tells the nurse that he wants to kill his boss, nurse tells
healthcare provider, healthcare provider tells his boss. What disciplinary action is
needed? (ANSNone. The action was appropriate
Defense mechanism question: for projection
(ANS-
“I am here because the police said I did something wrong”
pt with stress admits to taking care of the ex-husband ‘s parents. Which defense
mechanism is this?
(ANSRegression
therapeutic Milieu: Pt had a recent suicide attempt after his wife offered divorce, lost
his job, and his best friend moved away. What is the best nursing intervention to
support therapeutic Milieu ?
1 / 2
(ANSEncourage activities that will allow him to take control over his environment
Interview noting taking question
(ANSarrange the setting and decrease any stimuli
Prep from D/C from the psychic unit, what should the nurse include ?
(ANSExplore that pt’s feelings regarding the discharge
People in a group home and they are wiping feces on the wall. What is the nurse’s
highest priority?
(ANS- Infection control
Pt refuses to take medications and in defiance sits in the middle of the hallway floor.
Best nursing action?
(ANS- To move other clients to another room
Nurse and client trade roles: nurse demonstrates bad behavior of the client. Why is
this important?
(ANS- Role play assists the client to recognize their own behavior
Pt states, “I don’t know, I just can’t think”. What is the best activity by the nurse?
(ANS- Set daily goals
Adolescent interrupts group to talk about pets during group therapy. Best nursing
action?
(ANS- Redirect him with a handout