NCLEX RN Psychiatric Assessment and

NCLEX RN Psychiatric Assessment and Fundamentals of Mental Health and Psychiatric Nursing

• Nurse Monette is aware that extremely depressed clients seem to do best in settings where

they have:

• Multiple stimuli

• Routine Activities
• Minimal decision making
• Varied Activities

Correct Answer: B. Routine Activities

Depression usually is both emotional & physical. A simple daily routine is the best, least stressful, and least anxiety-producing. Initially, provide activities that require minimal concentration (e.g., drawing, playing simple board games). Depressed people lack concentration and memory. Activities that have no “right or wrong” or “winner or loser” minimizes opportunities for the client to put himself/herself down.Option A: Involve the client in gross motor activities that call for very little concentration (e.g., walking). Such activities will aid in relieving tensions and might help in elevating the mood. When the client is in the most depressed state, involve the client in a one-to-one activity. Maximizes the potential for interactions while minimizing anxiety levels.Option C: Eventually involve the client in group activities (e.g., group discussions, art therapy, dance therapy). Socialization minimizes feelings of isolation. Genuine regard for others can increase feelings of self-worth. Eventually maximize the client’s contacts with others (first one other, then two others, etc.). Contact with others distracts the client from self-preoccupation.Option D: Allow the patient to engage in simple recreational activities, advancing to more complex activities in a group environment. The patient may feel overwhelmed at the start when participating in a group setting. Give positive feedback after a task is achieved. Positive reinforcement has a big part in building self-esteem.

• Conney with borderline personality disorder who is to be discharged soon threatens to “do

something” to herself if discharged. Which of the following actions by the nurse would be most important?

• Ask a family member to stay with the client at home temporarily.

• Discuss the meaning of the client’s statement with her.
• Request an immediate extension for the client.
• Ignore the client's statement because it’s a sign of manipulation.

Correct Answer: B. Discuss the meaning of the client’s statement with her. 1 / 4

Any suicidal statement must be assessed by the nurse. The nurse should discuss the client’s statement with her to determine its meaning in terms of suicide. Determine whether the person has any thoughts of hurting him or herself. Suicidal ideation is highly linked to completed suicide. Some inexperienced clinicians have difficulty asking this question. They fear the inquiry may be too intrusive or that they may provide the person with an idea of suicide. In reality, patients appreciate the question as evidence of the clinician’s concern. A positive response requires further inquiry.Option A: The individual must not be left alone. In the ED, such a recommendation is handled easily by hospital security personnel. In other settings, summon assistance quickly. In an isolated place, call

• Involve family or friends; they can remain with the patient while treatment arrangements are

made.Option C: Determine what the patient believes his or her suicide would achieve. This suggests how seriously the person has been considering suicide and the reason for death. For example, some believe that their suicide would provide a way for family or friends to realize their emotional distress.Others see their death as a relief from their own psychic pain. Still others believe that their death would provide a heavenly reunion with a departed loved one. In any scenario, the clinician has another gauge of the seriousness of the planning.Option D: A clear and complete evaluation and clinical interview provide the information upon which to base a suicide intervention. Although risk factors offer major indications of the suicide danger, nothing can substitute for a focused patient inquiry. However, although all the answers a patient gives may be inclusive, a therapist often develops a visceral sense that his or her patient is going to commit suicide. The clinician’s reaction counts and should be considered in the intervention.

• A characteristic that would suggest to Nurse Anne that an adolescent may have bulimia would

be:

• Frequent regurgitation & re-swallowing of food.
• Previous history of gastritis

• Badly stained teeth
• Positive body image

Correct Answer: C. Badly stained teeth

Dental enamel erosion occurs from repeated self-induced vomiting. Patients with bulimia nervosa who purge by vomiting often brush their teeth immediately after purging, which can accelerate dental erosion. The clinician should instruct the patients who persist in vomiting to rinse their mouths with water or fluoride rather than brushing their teeth within 30 minutes of each episode.Option A: A review of systems in patients with bulimia nervosa demonstrates sore throat, irregular menstruation, constipation, headache, fatigue, lethargy, abdominal pain, and bloating. When conducting a physical exam on a patient with diagnosed or suspected bulimia nervosa, obtain the height, weight, vital signs, and orthostatic blood pressures. It is also necessary to examine a patient’s skin, mouth, and abdomen. A neurological examination is essential to check for primary neurological causes of weight loss or vomiting before diagnosing bulimia nervosa. 2 / 4

Option B: Bulimia nervosa can lead to a variety of general medical complications, including metabolic alkalosis, dehydration, constipation, and cardiac arrhythmias. The most common cause of metabolic alkalosis in patients with bulimia nervosa is fluid volume depletion, for which saline administration is indicated in addition to the cessation of the purging behavior.Option D: Common physical exam signs associated with bulimia nervosa include hypotension, dry skin, parotid gland swelling, dental erosion, and calluses on the dorsal aspect of the hand (known as “Russel’s sign.”) Bulimia nervosa can also be associated with hair loss, edema, and epistaxis.

• Mario is complaining to other clients about not being allowed by staff to keep food in his room.

Which of the following interventions would be most appropriate?

• Allowing a snack to be kept in his room.
• Reprimanding the client.
• Ignoring the client's behavior.

• Setting limits on the behavior.

Correct Answer: D. Setting limits on the behavior

The nurse needs to set limits on the client’s manipulative behavior to help the client control dysfunctional behavior. A consistent approach by the staff is necessary to decrease manipulation.Interventions such as employing limit-setting techniques help reduce stress and hostility for both patients and staff. To successfully limit problem behavior, limits must be consistent and reinforced by everyone, including the family and all health care personnel. Staff working with manipulative patients are best prepared when they establish firm rules that are rigidly interpreted and consistently enforced among all members of the health care team. Frequent discussions regarding the patient’s progress can help reduce staff frustration and isolation and minimize the patient’s attempts at staff splitting.Option A: State limits and the behavior you expect from the patient in a matter-of-fact, non- threatening tone. State the consequences if behaviors are not forthcoming. Written limits and consequences can be useful (one copy for the patient and one for the staff). Be direct and assertive, if necessary, in a neutral, factual manner, not in anger.Option B: Anger is a natural response to being manipulated. Deal with your own feelings of anger toward the patient. Peer supervision can be useful. Assess your feelings toward patients who use manipulation, and work on being assertive in stating limits. Workshops in assertiveness can be very helpful for nurses.Option C: Confronting unacceptable, inappropriate, or harmful behavior needs to be done immediately, and setting limits on patient behaviors is the pivotal intervention when working with manipulative patients. Clear, enforceable consequences of continuing unacceptable behaviors need to be spelled out and consistently and matter-of-factly enforced by all staff involved in the patient’s care. The most effective approach with the patient is to maintain a professional therapeutic relationship with clear boundaries. A professional relationship is based on the patient’s therapeutic needs, not on being liked or the nurse’s personal feelings. People who manipulate others need clear and firm boundaries with clear and firm consequences identified for overstepping those boundaries. 3 / 4

• Nurse Joey is aware that the signs & symptoms that would be most specific for diagnosis

anorexia are?

• Excessive weight loss, amenorrhea & abdominal distension
• Slow pulse, 10% weight loss & alopecia
• Compulsive behavior, excessive fears & nausea
• Excessive activity, memory lapses & an increased puls

Correct Answer: A. Excessive weight loss, amenorrhea & abdominal distension

These are the major signs of anorexia nervosa. Weight loss is excessive (15% of expected weight).Patients will report symptoms such as amenorrhea, cold intolerance, constipation, extremity edema, fatigue, and irritability. They may describe restrictive behaviors related to food like calorie counting or portion control, and purging methods, for example, self-induced vomiting or use of diuretics or laxatives.Many exercise compulsively for extended periods of time. Patients with anorexia nervosa develop multiple complications related to prolonged starvation and purging behaviors.Option B: Anorexia nervosa — often simply called anorexia — is an eating disorder characterized by an abnormally low body weight, an intense fear of gaining weight and a distorted perception of weight. People with anorexia place a high value on controlling their weight and shape, using extreme efforts that tend to significantly interfere with their lives.Option C: The physical signs and symptoms of anorexia nervosa are related to starvation. Anorexia also includes emotional and behavioral issues involving an unrealistic perception of body weight and an extremely strong fear of gaining weight or becoming fat. It may be difficult to notice signs and symptoms because what is considered a low body weight is different for each person, and some individuals may not appear extremely thin. Also, people with anorexia often disguise their thinness, eating habits, or physical problems.Option D: Some people who have anorexia binge and purge, similar to individuals who have bulimia.But people with anorexia generally struggle with abnormally low body weight, while individuals with bulimia typically are normal to above normal weight. Starvation affects the brain and influences mood changes, rigidity in thinking, anxiety, and reduction in appetite. Starvation and weight loss may change the way the brain works in vulnerable individuals, which may perpetuate restrictive eating behaviors and make it difficult to return to normal eating habits.

• A 39-year-old mother with obsessive-compulsive disorder has become immobilized by her

elaborate hand washing and walking rituals. Nurse Trish recognizes that the basis of O.C.

disorder is often:

• Problems with being too conscientious
• Problems with anger and remorse

• Feelings of guilt and inadequacy
• Feeling of unworthiness and hopelessness
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