NURS (413)
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Q1           Score:  1
 Feeling unworthy of food.
 Being preoccupied with trivialities.
 Thinking the food is poisoned.
 Not slowing down long enough to eat.
Q2           Score:  1
 A client with delusions states, “I’m going to get them before they get me.”
 A hostile client says, “I hate all police.”
 A client says he plans to blow up the federal government.
 A client states, “If I can’t have my girlfriend back, then no one can have her.”
Q3           Score:  1
 Cheerful but not too stimulating
 Active and stimulating
 Active, interesting, and exciting
 Very permissive and stress- free
Q4           Score:  1
 Crying when discussing sadness.
 An abrupt improvement in mood.
 Statements such as "Everything will be better soon."
 Feeling overwhelmed by simple daily tasks.
Q5           Score:  1
 Complete a thorough physical assessment including lab tests.
 Remove all hazardous materials from the environment.
 Request a psychiatric consultation.
 Place the client on a one-to-one observation.
Q6           Score:  1
 Right to freedom
 Right to refuse treatment
 Right to sign legal documents
 The client loses no rights
Q7           Score:  1
 Have little contact with the client to decrease stimulation.
 Provide the client with privacy to maintain confidentiality.
 Maintain contact with the client and assure the client that seclusion is a way to maintain the client’s safety.
 Teach the client relaxation techniques and effective coping strategies to deal with anger.
Q8           Score:  1
 Irritable mood
 Labile affect
 Apathy
 Euphoria
Q9           Score:  1
 Stress
 Self-regulation
 Homeostasis
 Fight-or-flight response
Q10           Score:  1
 Maintain self-esteem
 Handle pain
 Carry out medical treatment
 Confront family problems
Q11           Score:  1
 Threat is not a delusion
 History of violence
 Potential victim(s) are identifiable
 Potential victim is easy to locate
Q12           Score:  1
 Disturbed sleep patterns R/T agitation.
 Risk for violence: self-directed R/T depressive symptoms.
 Altered thought processes R/T biochemical alterations.
 Social isolation R/T grandiosity.
Q13           Score:  1
 Promote attendance in group therapy to assist client to socialize.
 Focus on strengths and accomplishments to minimize failures.
 Encourage the client to journal to uncover underlying feelings.
 Teach assertiveness skills by role-playing situations.
Q14           Score:  1
 "Thank you. I think you are special too."
 "I suspect you want something from me. What is it?"
 "You probably say that to all your nurses."
 "Are you thinking of suicide?"
Q15           Score:  1
 Repression
 Rationalization
 Undoing
 Conversion
Q16           Score:  1
 Grandiosity.
 Flight of ideas.
 Catatonic state.
 Pressure of speech.
Q17           Score:  1
 Correct and remind the student of the importance of maintaining client confidentiality.
 Tell the student that because the client has been deemed incompetent, confidentiality is not an issue.
 Reinforce the importance of accurate documentation, including the client’s name.
 Tell the student that because the client is involuntarily committed, confidentiality is not an issue.
Q18           Score:  1
 Rationalization.
 Repression.
 Undoing.
 Suppression.
Q19           Score:  1
 Sublimation
 Displacement
 Isolation
 Conversion
Q20           Score:  1
 Displacement.
 Isolation.
 Compensation.
 Regression.


   



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