Nurse in Psychiatry Test Bank

Correct Answer: C

Rationale: The correct answer is C because Lewy body disease can affect a patient's ability to communicate pain, making specialized pain assessment tools crucial. Special scales designed for patients with dementia can help in accurately assessing pain levels. These tools consider non-verbal cues and behavioral changes that may indicate pain. Asking the patient's family (A) may not always provide an accurate assessment of pain perception. Using a visual analog scale (B) may be challenging for a patient with cognitive impairment. Focusing solely on mental status (D) may overlook important indicators of pain in patients with Lewy body disease.

Correct Answer: B

Rationale: The correct answer is B: Implementation. In the nursing process, implementation involves carrying out the plan of care. Encouraging the patient to attend a psychoeducational group daily is an action that is part of implementing the care plan to improve social skills. This step focuses on putting the plan into action and actively supporting the patient in achieving the desired outcomes. A: Assessment is incorrect because assessment involves collecting data and information about the patient's condition, not actively implementing interventions. C: Analysis is incorrect as it involves interpreting and making sense of the assessment data to identify problems and strengths, not implementing interventions. D: Evaluation is incorrect because it involves assessing the effectiveness of the interventions implemented, not actively carrying out the interventions themselves.

Correct Answer: A

Rationale: The correct answer is A: Tightness in the chest. This physical disturbance is commonly associated with acute grief due to the emotional pain experienced. It is a manifestation of the intense feelings of sadness and loss that accompany grief. Tightness in the chest can be a result of the stress response triggered by grief, leading to physical symptoms such as chest pain and difficulty breathing. Summary: B: Hypersomnia and C: Increased appetite are more commonly associated with conditions like depression, while D: Cardiovascular problems may be a long-term consequence of chronic stress but are not typically assessed as a primary physical disturbance in acute grief.

Correct Answer: A

Rationale: The correct answer is A because it demonstrates active listening and shows empathy towards the patient, which can help them feel heard and understood. By inviting the patient to express their feelings and concerns, the nurse can help de-escalate the situation by addressing the underlying issues. Choice B is incorrect because it may come across as confrontational and could further provoke the patient's aggression. Choice C is also incorrect as it threatens the patient with consequences, which can escalate the situation. Choice D is not appropriate as it distracts from addressing the current issue of aggression and may not be well-received by the patient in that moment.

Correct Answer: A

Rationale: The correct answer is A because positive transference with a staff member in the orientation phase indicates a developing therapeutic relationship, which is crucial for effective treatment. This outcome shows the patient is beginning to trust and feel safe with a staff member, enhancing their engagement in therapy. Choice B is incorrect because the ability to ask for help in meeting needs may not be fully developed by the end of the orientation phase. Choice C is incorrect as commitment to long-term therapy is usually not established this early in the process. Choice D is incorrect because the ability to manage symptoms independently typically requires more time and therapy progress.