SP 23 Questions Students

A nurse at a mental health facility is about to assess their patient who was brought in due to a situational crisis. Which of the following would be appropriate questions for the nurse to ask as apart of their assessment. (SATA)

• Do you have any thoughts of harming yourself?

• Do you have a support system?

• Are there any cultural or religious needs I should know about?

• Have you had any loses recently? 

• What do you do for work?

A 21 year presents to the ED and she has an eating disorder. She states "I am so fat." and has a vigorous workout schedule. Which options suggest to the nurse that the patient should be admitted? SATA

• Weight loss of more than 30% over the last 6 months.

• Sinus brady with a rate of 38.

• Uncontrollable use of laxatives

• Potassium level of 3.2

• Routine use of diuretics

A client is admitted to the unit with rapid speech, flight of ideas, impulsivity, and euphoria. When the nurse asks if the client is sleeping, he replies "I have no time for sleep, I am on a mission from God."

The nurse recognizes which interventions will help this client. SATA.

• Decrease stimulation

• Offer the client an SSRI.

• Assess for delusions and/or hallucinations

• Place the client in restraints to help them relax

• Perform suicide risk assessment

A 30 year old male with a history of alcoholism is experiencing anxiety as a result of the stress in maintaining their sobriety. Which of the following tools are types of biofeedback methods that the patient can utilize to help reduce their stress? SATA

• Monitor their heart rate daily and during their periods of increased stress/anxiety.

• Perform physical activity when feeling anxious.

• The patient receives an electroencephalogram.

• Taking their temperature orally during moments of stress.

• The patient takes their blood pressure when they are anxious.

Jessica, a star college track student, was running one night after class when she was attacked by a man. Since the event, she reports not trusting men, being scared of night-time, and has stopped running. Her therapist decides to use Cognitive Reframing to help Jessica cope. Which statements by Jessica indicate the therapy is working?

• I will find an activity other than running such as tv watching.

• From now on, I will only socialize in all-female groups to feel safe

• I accepted a Friday night outing with a long-time male friend. He's never hurt me before, so why would he have bad intentions now? 

• I accept responsibility for what happened to me. Everyone knows that running alone at night is dangerous. 

• I will only do activities outside during the day-time when I feel most comfortable. 

A nurse is caring for a pt that is exhibiting signs of severe panic anxiety. What interventions would be appropriate to provide care?

• Offer cold, high calorie fluids.

• Assess need for medication.

• Take the patient to a room with no stimuli so they can be alone.

• Quietly remain with the patient.

• Reinforce reality if distortions occur.

The nurse is assessing a patient in a psychiatric unit. Which of the following findings would alert the nurse that they need to perform a more Indepth assessment when assessing for suicidal risk factors? (Select all that apply)

• Recently married (with in the last 6 months)

• Having a family history of suicide

• Recently giving birth to a child

• Drinks excessive alcohol and drugs

• Show signs of socially isolated

A nurse is interviewing a client for possible admission. The client states they are having an unrelenting feeling of uncertainty and dread. Would of the following statements should the nurse anticipate from the client?

• Sometimes I fell like my heart is beating out of my chest.

• My family says I am scatter brained.

• Sometimes I wish everything would just stop.

• I quit drinking a few years ago. I recently started again to take the edge off.

• I recently started CBT. I can see a significant change on the way I cope with stress.