COMPREHENSIVE EXAMINATION ANSWERS AND RATIONALES
1. 1. The nurse should determine the lithium level, but it is not the first intervention the nurse should implement.
2. The nurse should assess the behavior that prompted the admission, but this is not the first intervention.
3. The nurse should first assess the client’s physiologic needs because the client in the manic state may not have slept, bathed, or had anything to eat for days. The client’s physiologic needs are priority.
4. Lithium takes 2 to 3 weeks to become ther- apeutic; therefore, a stat dose of lithium orally will not help the client’s manic state. This is not the nurse’s first intervention.
2. 1. A democratic manager is people oriented and emphasizes efficient group functioning. The environment is open and communica- tion flows both ways, which includes having meetings to discuss concerns.
2. This statement is that of an autocratic man- ager who uses an authoritarian approach to direct the activities of others.
3. This statement is that of a laissez-faire manager who maintains a permissive climate with little direction or control. Instructing the staff to handle the situa- tion on their own does not support the staff.
4. This statement is taking control of the situ- ation; therefore, this is not a statement indicating a laissez faire manager.
3. 1. Unless the client is anorexic and there is a court order, the nurse cannot force-feed a client.
2. This is client abuse, and the charge nurse must investigate the allegation immediately with the nurse. If the alle- gations are true, they should be docu- mented in writing and reported to the client abuse committee.
3. The charge nurse should not ask the client about the situation first. The nurse and MHW should be involved in the investiga- tion of the allegation. Then, if needed, the client can be asked about the situation. 4. The charge nurse should investigate the
allegations first and then, if needed, have the MHW write down the situation.
4. 1, 2, and 5 are correct.
1. The nurse should assess the client for any injury, side effects of medication, and general well-being every 2 to 4 hours.
2. As soon as possible, the nurse must inform the client of what behavior will allow the client to be released from the seclusion room.
3. According to the Joint Commission Restraint and Seclusion Standards for Behavioral Health, the client’s family is notified promptly of the initiation of restraint or seclusion.
4. The nurse’s goal is to release the client as soon as possible from the seclusion room. When the client has calmed down and is able to verbalize feelings and concerns in a rational manner, the client should be released. The seclusion order must be renewed every 24 hours, but the client should not be kept for 24 hours unless absolutely necessary.
5. Clients must be checked at least every 10 to 15 minutes in person and may be continuously monitored on video cameras. 5. 1. The nurse should first separate the
MHW from the client; therefore, asking the MHW to go to the nurse’s station would be the first intervention.
2. The nurse should not correct the MHW in front of the client and should not use the word “arguing”; therefore, this would not be an appropriate action.
3. The psychiatric nurse should handle this situation immediately. If this is a pattern of behavior of the MHW, then the clinical manager should be notified.
4. This behavior may or may not need to be reported to the client abuse committee, but if the nurse overhears the MHW and client arguing, the nurse should stop the behavior.
6. 1. The psychiatric social worker can refer clients, but the nurse should assess the client to see what type of help she wants. 2. The psychiatric social worker does not
perform or participate in ECT treatment; therefore, this client should not be referred. 3. The nurse needs to assess the client to
determine why the client is having difficulty going to work. For example, is it sedation secondary to medications?
4. The psychiatric social worker can assist with financial arrangements, referrals, and nonphysiologic concerns.
7. 1. Two times in one week is becoming a pat- tern of behavior. The clinical manager should talk informally to the nurse to find out what is going on.
2. This is only the second time the nurse has taken 45 minutes for lunch and does not warrant formal counseling. The clinical manager should assess the situation before formally documenting the behavior. 3. This is very punitive behavior for the psy-
chiatric nurse. The clinical manager should talk to the nurse before taking this type of action.
4. The clinical manager should talk to the nurse informally and find out what is going on. This behavior cannot con- tinue, but it is not behavior that requires anything more than infor- mally finding out why the nurse has been late.
8. 1. The client diagnosed with Alzheimer’s dis- ease would be expected to be confused; therefore, this would not warrant immedi- ate intervention.
2. The client diagnosed with Alzheimer’s dis- ease has difficulty completing simple rou- tine activities of daily living. This would not warrant immediate intervention.
3. The client diagnosed with Alzheimer’s disease should not be difficult to arouse from sleep. This is not a typical symptom of this disease and would warrant immediate intervention from the nurse.
4. The client diagnosed with Alzheimer’s dis- ease has difficulty completing simple rou- tine activities of daily living. This would not warrant immediate intervention.
9. 1. This is a therapeutic response that helps the client to ventilate feelings, but this statement does not support the ethical principle of veracity.
2. Veracity is the ethical principle “to tell the truth.” The truth is that schizo- phrenia is a thought disorder caused by a chemical imbalance of the brain. An- tipsychotic medication can control the client’s hallucinations and delusions.
3. This is interviewing the client, and this statement does not support the ethical principle of veracity.
4. Schizophrenia is a mental illness, but if the client takes the antipsychotic medica- tion, the client may be able to work, get married, and live a productive life. This is a false statement.
10. 1. Tegretol is a medication that is often pre- scribed for clients diagnosed with bipolar disorder even though it is classified as an anticonvulsant. Many times, a medication
with a different classification is prescribed for another disease process.
2. Antacids neutralize gastric acid and may reduce the effects of antipsychotic medications and lead to medication failure. The client diagnosed with schizophrenia would be on an antipsy- chotic medication; therefore, the nurse should discuss this client with the psychiatric HCP.
3. The client receiving antitubercular med- ications must receive them to prevent resistant strains of tuberculosis and pro- tect the community. The nurse would not need to discuss this client with the HCP. 4. Elavil has shown efficacy in promoting
weight gain in clients with anorexia nervosa; therefore, the nurse would not discuss this medication with the HCP.
11. 1. The nurse must know the bomb scare policy of the facility, and in many cases the nurse looks for the bomb but does not touch it if it is found. In some instances, the nurse should not attempt to look for a bomb, but because the client is on a psychiatric unit, the nurse should look for a suspicious-looking object before notifying the bomb squad and evacuating the clients.
2. The nurse would implement the bomb scare protocol if there was a bomb or suspicious-looking bag, but the nurse should first investigate the comment because the client is on a psychiatric unit. 3. The nurse would evacuate the clients if a
bomb or suspicious-looking bag was under the couch. The nurse should have the clients leave the lobby area, but not the unit.
4. Just because the client is in a psychiatric unit does not mean that someone did or did not put a bomb under the couch. The nurse should look under the couch and take appropriate action.
12. 1. The response is closed and does not allow the new nurse to voice her opinion and be part of the team.
2. The charge nurse should be open to change. Just because something has been done the same way for years does not mean it can’t be done another way. 3. The charge nurse should not make the
new nurse talk to the other nurses just because she doesn’t like the way shift report is done.
4. The best response is to allow the new nurse to share any new ideas with the charge nurse. The charge nurse could then talk to the other staff members and take the change to the clinical manager to determine whether the change should be instituted.
13. 1. The client may eventually be able to go to the activity area, but while the client is confined to the unit, the nurse should refer the client to a recreational therapist to be provided with activities to alleviate boredom.
2. Allowing the client to ventilate feelings will not help alleviate the client’s boredom on the unit.
3. According to the NSCBN RN-NCLEX test blueprint, the nurse must be knowledgeable of the multidisciplinary team. The recreational therapist helps the client to balance work and play in his or her life and provides activities that promote constructive use of leisure or unstructured time.
4. The nurse should acknowledge the client’s concern and contact the recreational therapist.
14. 1. A client who was raped would be expected to be upset and crying. This client would not require the most experienced nurse. 2. The client who is diagnosed with bipolar
disorder would be agitated in the manic state. This client would not require the most experience nurse.
3. The client who was found wandering in a daze has no diagnosis and requires an in-depth assessment. This client should be assigned to the most experi- enced nurse.
4. The client diagnosed with schizophrenia would have hallucinations if not taking antipsychotic medication. The client would not require the most experienced nurse.
15. 1. When a person is admitted to a psychi- atric unit, the client does not lose any rights. The client has a right to refuse treatment, but if the client is a danger to herself, then the psychiatric team must go to court and obtain an order to force-feed the client. This could be with nasogastric tube feedings or total parenteral nutrition.
2. The client has a right to refuse treatment, but if the client is a danger to herself, then the psychiatric team must intervene. If the client does not eat, the client will die.
3. If the client is discharged and dies, the psychiatric team will be responsible. If a person is mentally ill, the psychiatric team must protect the client.
4. This is against the client’s rights. The nurse cannot restrain a client without a court order.
16. 1. The nurse would notify the police depart- ment if the client ran away from the unit.
2. The nurse’s first intervention is to place the unit on high alert, which includes putting signs on the exit doors warning all people coming in and out that there is a client threaten- ing to leave the unit.
3. The nurse should talk to the client, but the first intervention is to prevent the client from making good on the threat of running away.
4. The client who is on an involuntary admission loses the right to sign out of the psychiatric unit against medical advice (AMA).
17. 1. The nurse does not have a right to ask the caller for his or her name. Mr. Jones has a right to telephone calls.
2. Mr. Jones retains all his civil rights when admitted to a psychiatric unit unless phone restriction is part of the individual- ized care plan.
3. The access code for client information is requested when the caller is asking ques- tions about the client. It is not used when the caller wants to talk directly to the client.
4. The nurse should find Mr. Jones and tell him he has a phone call. The client cannot have rights restricted unless it is a part of the client’s individualized care plan. For example, the client may not be able to use the phone if he or she is calling 911 and making false reports.
18. 1. The psychiatric nurse should not make promises he or she cannot keep. If the information must be shared with the health-care team, then the nurse will have to break a promise to the client. This will destroy the nurse-client relationship.
2. This is the nurse’s best response. The nurse is being honest with the client but will keep the information confidential if it does not affect the client’s care.
3. The client may need to share information that is pertinent to the client’s care and should not tell the client he or she cannot talk to the nurse.
4. Asking the client why may put the client on the defensive and he or she would not share the information.
19. 1. The client diagnosed with schizophrenia would be expected to be delusional; there- fore, this situation would not warrant immediate intervention.
2. The charge nurse has the entire shift to arrange for another nurse to cover the LPN; therefore, this situation does not warrant immediate intervention.
3. The loss of a unit key is priority because the nurse must determine when the MHW last had the key and determine whether it may be lost on the psychiatric unit. If a client finds the key, then the unit is no longer secure.
4. The signing of HCP’s orders is
important, but it does not warrant imme- diate intervention.
20. 1. The local police department needs to be called, but the nurse must first talk to the man and attempt to diffuse the situation. This action tries to ensure safety for the man, the other clients, and the staff. 2. Ensuring safety of the other clients and
staff is important, but the nurse should first attempt to make contact with the man. 3. The nurse should not encourage the client
to talk about his feelings until the gun is removed. The anger may cause the client to shoot an innocent person accidentally or on purpose.
4. The nurse should first try to talk to the client and diffuse the situation. This action is attempting to ensure the safety of the man, the other clients, and the staff.