Mental Health Nursing Exam
Answer Key
Course Introduction
Mental Health Nursing is a comprehensive course that introduces students to the principles and practices involved in providing care for individuals experiencing mental health challenges. The course covers foundational knowledge of psychiatric disorders, therapeutic communication, psychosocial interventions, and the ethical and legal considerations unique to mental health nursing. Students will learn to apply evidence-based practices in various clinical settings, support patient recovery, and collaborate with interdisciplinary teams to promote holistic well-being. Emphasis is placed on developing compassionate, culturally competent care strategies and building therapeutic relationships that empower patients and their families throughout the mental health care continuum.
Recommended Textbook
Essentials of Psychiatric Mental Health Nursing 3rd Edition by Varcarolis
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28 Chapters
803 Verified Questions
803 Flashcards
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Page 2
Chapter 1: Practicing the Science and Art of Psychiatric Nursing
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15 Verified Questions
15 Flashcards
Source URL: https://quizplus.com/quiz/2047
Sample Questions
Q1) Which patient statements identify qualities of nursing practice with high therapeutic value? (Select all that apply.) "My nurse:
A) talks in language I can understand."
B) helps me keep track of my medications."
C) is willing to go to social activities with me."
D) lets me do whatever I choose without interfering."
E) looks at me as a whole person with different needs."
Answer: A, B, E
Q2) A patient is hospitalized for depression and suicidal ideation after their spouse asks for a divorce. Select the nurse's most caring comment.
A) "Let's discuss some means of coping other than suicide when you have these feelings."
B) "I understand why you're so depressed. When I got divorced, I was devastated too."
C) "You should forget about your marriage and move on with your life."
D) "How did you get so depressed that hospitalization was necessary?"
Answer: A
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Chapter 2: Mental Health and Mental Illness
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17 Verified Questions
17 Flashcards
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Sample Questions
Q1) A participant at a community education conference asks, "What is the most prevalent type of mental disorder in the United States?" Select the nurse's best response.
A) "Why do you ask?"
B) "Schizophrenia"
C) "Affective disorders"
D) "Anxiety disorders"
Answer: D
Q2) A nurse must assess several new patients at a community mental health center. Conclusions concerning current functioning should be made on the basis of:
A) the degree of conformity of the individual to society's norms.
B) the degree to which an individual is logical and rational.
C) a continuum from mentally healthy to unhealthy.
D) the rate of intellectual and emotional growth.
Answer: C
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4
Chapter 3: Theories and Therapies
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27 Verified Questions
27 Flashcards
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Sample Questions
Q1) A nurse supports parental praise of a child who is behaving in a helpful way. When the individual behaves with politeness and helpfulness in adulthood, which feeling will most likely result?
A) Guilt
B) Anxiety
C) Loneliness
D) Self-esteem
Answer: D
Q2) A patient comments, "I never know the right answer" and "My opinion is not important." Using Erikson's theory, which psychosocial crisis did the patient have difficulty resolving?
A) Initiative versus Guilt
B) Trust versus Mistrust
C) Autonomy versus Shame and Doubt
D) Generativity versus Self-Absorption
Answer: C
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Chapter 4: Biological Basis for Understanding
Psychopharmacology
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Sample Questions
Q1) A patient has delusions and hallucinations. Before beginning treatment with a psychotropic medication, the health care provider wants to rule out the presence of a brain tumor. For which test will a nurse need to prepare the patient?
A) Cerebral arteriogram
B) Functional magnetic resonance imaging (fMRI)
C) Computed tomography (CT) scan or magnetic resonance imaging (MRI)
D) Positron emission tomography (PET) or single-photon emission computed tomography (SPECT)
Q2) A nurse cares for patients taking various medications, including buspirone (BuSpar), haloperidol (Haldol), trazodone (Desyrel), and phenelzine (Nardil). The nurse will order a special diet for the patient taking:
A) buspirone.
B) haloperidol.
C) trazodone.
D) phenelzine.
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Chapter 5: Settings for Psychiatric Care
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Sample Questions
Q1) Which assessment finding for a patient living in the community requires priority intervention by the nurse? The patient:
A) receives Social Security disability income plus a small check from a trust fund.
B) lives in an apartment with two patients who attend day hospital programs.
C) has a sibling who is interested and active in care planning.
D) purchases and uses marijuana on a frequent basis.
Q2) A suspicious and socially isolated patient lives alone, eats one meal a day at a nearby shelter, and spends the remaining daily food allowance on cigarettes. Select the community psychiatric nurse's best initial action.
A) Report the situation to the manager of the shelter.
B) Tell the patient, "You must stop smoking to save money."
C) Assess the patient's weight; determine the foods and amounts eaten.
D) Seek hospitalization for the patient while a new plan is being formulated.
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Chapter 6: Legal and Ethical Basis for Practice
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Sample Questions
Q1) An adolescent hospitalized after a violent physical outburst tells the nurse, "I'm going to kill my father, but you can't tell anyone." Select the nurse's best response.
A) "You're right. Federal law requires me to keep that information private."
B) "Those kinds of thoughts will make your hospitalization longer."
C) "You really should share this thought with your psychiatrist."
D) "I am required to share information with the treatment team."
Q2) A psychiatric nurse best implements the ethical principle of autonomy when he or she:
A) intervenes when a self-mutilating patient attempts to harm self.
B) stays with a patient who is demonstrating a high level of anxiety.
C) suggests that two patients who are fighting be restricted to the unit.
D) explores alternative solutions with a patient, who then makes a choice.
Q3) Which individual with a mental illness may need emergency or involuntary hospitalization for mental illness? The individual who:
A) resumes using heroin while still taking methadone.
B) reports hearing angels playing harps during thunderstorms.
C) throws a heavy plate at a waiter at the direction of command hallucinations.
D) does not show up for an outpatient appointment with the mental health nurse.
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Chapter 7: Nursing Process and QSEN: The Foundation for Safe and Effective Care
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28 Verified Questions
28 Flashcards
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Sample Questions
Q1) A nurse documents: "Patient is mute, despite repeated efforts to elicit speech. Makes no eye contact. Is inattentive to staff. Gazes off to the side or looks upward rather than at the speaker." Which nursing diagnosis should be considered?
A) Defensive coping
B) Decisional conflict
C) Risk for other-directed violence
D) Impaired verbal communication
Q2) When a nurse assesses an older adult patient, the patient's answers seem vague or unrelated to the questions. The patient also leans forward and frowns, listening intently to the nurse. An appropriate question for the nurse to ask would be:
A) "Are you having difficulty hearing when I speak?"
B) "How can I make this assessment interview easier for you?"
C) "I notice you are frowning. Are you feeling annoyed with me?"
D) "You're having trouble focusing on what I'm saying. What is distracting you?"
Q3) The acronym QSEN refers to:
A) Qualitative Standardized Excellence in Nursing.
B) Quality and Safety Education for Nurses.
C) Quantitative Effectiveness in Nursing.
D) Quick Standards Essential for Nurses.
Page 9
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Chapter 8: Communication Skills: Medium for All Nursing Practice
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22 Verified Questions
22 Flashcards
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Sample Questions
Q1) Which technique will best communicate to a patient that the nurse is interested in listening?
A) Restate a feeling or thought the patient has expressed.
B) Ask a direct question, such as, "Did you feel angry?"
C) Make a judgment about the patient's problem.
D) Say, "I understand what you're saying."
Q2) A school-age child tells the school nurse, "Other kids call me mean names and will not sit with me at lunch. Nobody likes me." Select the nurse's most therapeutic response.
A) "Just ignore them and they will leave you alone."
B) "You should make friends with other children."
C) "Call them names if they do that to you."
D) "Tell me more about how you feel."
Q3) A patient is having difficulty making a decision. The nurse has mixed feelings about whether to provide advice. Which principle usually applies? Giving advice:
A) is rarely helpful.
B) fosters independence.
C) lifts the burden of personal decision making.
D) helps the patient develop feelings of personal adequacy.
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Chapter 9: Therapeutic Relationships and the Clinical
Interview
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30 Flashcards
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Sample Questions
Q1) A patient says, "I'm still on restriction, but I want to attend some off-unit activities. Would you ask the doctor to change my privileges?" What is the nurse's best response?
A) "Why are you asking me when you're able to speak for yourself?"
B) "I will be glad to address it when I see your doctor later today."
C) "That's a good topic for you to take up with your doctor."
D) "Do you think you can't speak to a doctor?"
Q2) Which statement shows a nurse has empathy for a patient who made a suicide attempt?
A) "You must have been very upset when you tried to hurt yourself."
B) "It makes me sad to see you going through such a difficult experience."
C) "If you tell me what is troubling you, I can help you solve your problems."
D) "Suicide is a drastic solution to a problem that may not be such a serious matter."
Q3) A nurse wants to demonstrate genuineness with a patient diagnosed with schizophrenia. The nurse should:
A) restate what the patient says.
B) use congruent communication strategies.
C) use self-disclosure in patient interactions.
D) consistently interpret the patient's behaviors.
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Chapter 10: Trauma and Stress-Related Disorders
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Sample Questions
Q1) A professor's 4-year-old child has a temperature of 101.6° F, diarrhea, and complains of stomach pain. The professor is scheduled to teach three classes today. Which actions by the professor demonstrate effective parenting? (Select all that apply.)
A) Telephoning a grandparent to stay with the child at home for the day.
B) Telephoning a colleague to teach his classes and staying home with the sick child.
C) Taking the child to the university and keeping the child in a private office for the day.
D) Taking the child to a day care center and hoping day care workers will not notice the child is sick.
E) Giving the child one dose of ibuprofen (Motrin) and taking the child to the day care center.
Q2) A person with a fear of heights drives across a high bridge. Which structure will stimulate a response from the autonomic nervous system?
A) Thalamus
B) Parietal lobe
C) Hypothalamus
D) Pituitary gland
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Chapter 11: Anxiety, Anxiety Disorders, and
Obsessive-Compulsive and Related Disorders
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39 Verified Questions
39 Flashcards
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Sample Questions
Q1) A nurse plans health teaching for a patient diagnosed with generalized anxiety disorder (GAD) who takes lorazepam (Ativan). What information should be included? (Select all that apply.)
A) Use caution when operating machinery.
B) Allow only tyramine-free foods in diet.
C) Restrict intake of caffeine.
D) Avoid using alcohol and other sedatives.
E) Take the medication on an empty stomach.
Q2) A person who feels unattractive repeatedly says, "Although I'm not beautiful, I am smart." This is an example of:
A) repression.
B) devaluation.
C) identification.
D) compensation.
Q3) For a patient experiencing panic, which nursing intervention should be implemented first?
A) Teach relaxation techniques.
B) Administer an anxiolytic medication.
C) Provide calm, brief, directive communication.
Page 13
D) Gather a show of force in preparation for gaining physical control.
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Chapter 12: Somatic Symptom Disorders and Dissociative Disorders
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Sample Questions
Q1) An adult diagnosed with conversion (functional neurobiological symptom) disorder says, "Our family has gotten along over the years by working together. My partner cooks and the children clean house." Nursing interventions should recognize that the patient likely:
A) receives secondary gains from the symptoms.
B) has problems with sexual identity and satisfaction.
C) will be resistant to developing a trusting relationship.
D) will benefit from confrontation about physical complaints.
Q2) A patient diagnosed with depersonalization disorder tells the nurse, "It's starting again. I feel as though I'm going to float away." The nurse should help the patient by:
A) encouraging meditation.
B) administering an anxiolytic medication.
C) helping the patient visualize a pleasant scene.
D) helping the patient focus on the here and now.
Q3) The causes of somatic system disorders may be related to:
A) faulty perceptions of body sensations.
B) traumatic childhood events.
C) culture-bound phenomena.
D) mood instability.
Page 14
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Chapter 13: Personality Disorders
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28 Verified Questions
28 Flashcards
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Sample Questions
Q1) Which statement made by a patient diagnosed with borderline personality disorder indicates the treatment plan is effective?
A) "I think you are the best nurse on the unit."
B) "I'm never going to get high on drugs again."
C) "I hate my doctor for not giving me what I ask for."
D) "I felt empty and wanted to cut myself, so I called you."
Q2) What is an appropriate initial outcome for a patient diagnosed with a personality disorder who frequently manipulates others? The patient will:
A) identify when feeling angry.
B) use manipulation only to get legitimate needs met.
C) acknowledge manipulative behavior when it is called to his or her attention.
D) accept fulfillment of his or her requests within an hour rather than immediately.
Q3) The history shows that a newly admitted patient has impulsivity. The nurse would expect behavior characterized by:
A) adherence to a strict moral code.
B) manipulative, controlling strategies.
C) postponing gratification to an appropriate time.
D) little time elapsed between thought and action.
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Chapter 14: Eating Disorders
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29 Verified Questions
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Sample Questions
Q1) Which nursing diagnosis is more applicable for a patient diagnosed with anorexia nervosa who restricts intake and is 20% below normal weight than for a 130-pound patient diagnosed with bulimia nervosa who purges?
A) Powerlessness
B) Ineffective coping
C) Disturbed body image
D) Imbalanced nutrition: less than body requirements
Q2) A patient referred to the eating disorders clinic has lost 35 pounds in 3 months and has developed amenorrhea. For which physical manifestations of anorexia nervosa should a nurse assess? (Select all that apply.)
A) Peripheral edema
B) Parotid swelling
C) Constipation
D) Hypotension
E) Dental caries
F) Lanugo
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16
Chapter 15: Mood Disorders: Depression
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33 Verified Questions
33 Flashcards
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Sample Questions
Q1) A priority nursing intervention for a patient diagnosed with major depressive disorder is:
A) distracting the patient from self-absorption.
B) carefully and inconspicuously observing the patient around the clock.
C) allowing the patient to spend long periods alone in self-reflection.
D) offering opportunities for the patient to assume a leadership role in the therapeutic milieu.
Q2) A patient became severely depressed when the last of six children moved out of the home 4 months ago. The patient repeatedly says, "No one cares about me. I'm not worth anything." Which response by the nurse would be the most helpful?
A) "Things will look brighter soon. Everyone feels down once in a while."
B) "The staff here cares about you and wants to try to help you get better."
C) "It is difficult for others to care about you when you repeatedly say negative things about yourself."
D) "I'll sit with you for 10 minutes now and return for 10 minutes at lunchtime and again at 2:30 this afternoon."
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17
Chapter 16: Bipolar Spectrum Disorders
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Sample Questions
Q1) Which dinner menu is best suited for the patient diagnosed with bipolar disorder experiencing acute mania?
A) Spaghetti and meatballs, salad, a banana
B) Beef and vegetable stew, a roll, chocolate pudding
C) Broiled chicken breast on a roll, an ear of corn, apple
D) Chicken casserole, green beans, flavored gelatin with whipped cream
Q2) A patient experiencing acute mania has exhausted the staff members by noon. The patient has joked, manipulated, insulted, and fought all morning. Staff members are feeling defensive and fatigued. Which is the best action?
A) Confer with the health care provider regarding use of seclusion for this patient.
B) Hold a staff meeting to discuss consistency and limit setting approaches.
C) Conduct a meeting with all patients to discuss the behavior.
D) Explain to the patient that the behavior is unacceptable.
Q3) The cause of bipolar disorder has not been determined, but:
A) several factors, including genetics, are implicated.
B) brain structures were altered by trauma early in life.
C) excess norepinephrine is probably a major factor.
D) excess sensitivity in dopamine receptors may exist.
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Chapter 17: Schizophrenia Spectrum Disorders and Other
Psychotic Disorders
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Sample Questions
Q1) A patient with delusions of persecution about being poisoned has refused all hospital meals for 3 days. Which intervention is most likely to be acceptable to the patient?
A) Allow the patient to have supervised access to food vending machines
B) Allow the patient to telephone a local restaurant to deliver meals
C) Offer to taste each portion on the tray for the patient
D) Begin tube feedings or total parenteral nutrition
Q2) A nurse sits with a patient diagnosed with schizophrenia. The patient starts to laugh uncontrollably, although the nurse has not said anything funny. Select the nurse's best response.
A) "Why are you laughing?"
B) "Please share the joke with me."
C) "I don't think I said anything funny."
D) "You are laughing. Tell me what's happening."
Q3) Patients diagnosed with schizophrenia who are suspicious and withdrawn:
A) universally fear sexual involvement with therapists.
B) are socially disabled by the positive symptoms of schizophrenia.
C) exhibit a high degree of hostility as evidenced by rejecting behavior.
D) avoid relationships because they become anxious with emotional closeness.
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Chapter 18: Neurocognitive Disorders
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Sample Questions
Q1) Goals and desired outcomes for an older adult patient experiencing delirium caused by fever and dehydration will focus on:
A) returning to premorbid levels of function.
B) identifying stressors negatively affecting self.
C) demonstrating motor responses to noxious stimuli.
D) exerting control over responses to perceptual distortions.
Q2) A patient diagnosed with Alzheimer disease wanders at night. Which action should the nurse recommend for a family to use in the home to enhance safety?
A) Place throw rugs on tile or wooden floors.
B) Place locks at the tops of doors.
C) Encourage daytime napping.
D) Obtain a bed with side rails.
Q3) A patient experiencing fluctuating levels of awareness, confusion, and disturbed orientation shouts, "Bugs are crawling on my legs! Get them off!" Which problem is the patient experiencing?
A) Aphasia
B) Dystonia
C) Tactile hallucinations
D) Mnemonic disturbance
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Page 20
Chapter 19: Substance-Related and Addictive Disorders
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Sample Questions
Q1) A patient admitted yesterday for injuries sustained in a fall while intoxicated believes snakes are crawling on the bed. The patient is anxious, agitated, and diaphoretic. What is the priority nursing diagnosis?
A) Disturbed sensory perception
B) Ineffective coping
C) Ineffective denial
D) Risk for injury
Q2) A patient has smoked two packs of cigarettes daily for many years. When the patient does not smoke or tries to cut back, anxiety, craving, poor concentration, and headache result. What does this scenario describe?
A) Substance abuse
B) Substance addiction
C) Substance intoxication
D) Recreational use of a social drug
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Chapter 20: Crisis and Mass Disaster
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Sample Questions
Q1) Which premise is most useful to a nurse planning crisis intervention for any patient? The patient:
A) is experiencing a state of disequilibrium.
B) is experiencing a type of mental illness.
C) poses a threat of violence to others.
D) has a high potential for self-injury.
Q2) A nurse driving home after work comes upon a serious automobile accident. The driver gets out of the car with no apparent physical injuries. Which assessment findings would be expected from the driver immediately after this event? (Select all that apply.)
A) Difficulty using a cell phone
B) Long-term memory losses
C) Fecal incontinence
D) Rapid speech
E) Trembling
Q3) Which scenario is an example of an adventitious crisis?
A) Death of a child from sudden infant death syndrome
B) Being fired from a job because of company downsizing
C) Retirement of a 55-year-old
D) A riot at a rock concert
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Page 22
Chapter 21: Child, Partner, and Elder Violence
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Sample Questions
Q1) Which referral is most appropriate for a woman who is severely beaten by her husband, has no relatives or friends in the community, is afraid to return home, and has limited financial resources?
A) Support group
B) Law enforcement
C) Women's shelter
D) Vocational counseling
Q2) A 10-year-old child cares for siblings while the parents work because the family cannot afford a babysitter. This child says, "My father doesn't like me. He calls me stupid all the time." The mother says the father is easily frustrated and has trouble disciplining the children. The community health nurse should consider which resources to stabilize the home situation? (Select all that apply.)
A) Parental sessions to teach child-rearing practices
B) Anger management counseling for the father
C) Continuing home visits to provide support
D) Safety plan for the wife and children
E) Foster placement of the children in foster care
F) Determine a code word to signal children that it is time to leave.
G) Assemble birth certificates, Social Security cards, and licenses.
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Page 23
Chapter 22: Sexual Violence
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Sample Questions
Q1) A victim of a violent rape has been in the emergency department for 3 hours. Evidence collection is complete. As discharge counseling begins, the victim says softly, "I will never be the same again. I can't face my friends. There is no sense of trying to go on."
Select the nurse's most important response.
A) "Are you thinking of suicide?"
B) "It will take time, but you will feel the same as before."
C) "Your friends will understand when you tell them."
D) "You will be able to find meaning in this experience as time goes on."
Q2) A rape victim tells the nurse, "I should not have been out on the street alone." Which is the nurse's most therapeutic response?
A) "Rape can happen anywhere."
B) "Blaming yourself only increases your anxiety and discomfort."
C) "You believe this would not have happened if you had not been alone?"
D) "You are right. You should not have been alone on the street at night."
Q3) When working with rape victims, immediate care focuses first on:
A) collecting evidence.
B) notifying law enforcement.
C) helping the victim feel safe.
D) documenting the victim's comments.
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Page 24
Chapter 23: Suicidal Thoughts and Behavior
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Sample Questions
Q1) A nurse assesses five newly hospitalized patients. Which patients have the highest suicide risk? (Select all that apply.)
A) 82-year-old white man
B) 17-year-old white female adolescent
C) 39-year-old African-American man
D) 29-year-old African-American woman
E) 22-year-old man with a traumatic brain injury
Q2) A nurse and patient construct a no-suicide contract. Select the preferable wording for the contract.
A) "I will not try to harm myself during the next 24 hours."
B) "I will not make a suicide attempt while I am hospitalized."
C) "For the next 24 hours, I will not kill or harm myself in any way."
D) "I will not kill myself until I call my primary nurse or a member of the staff."
Q3) Which change in brain biochemical function is most associated with suicidal behavior?
A) Dopamine excess
B) Serotonin deficiency
C) Acetylcholine excess
D) Gamma-aminobutyric acid deficiency
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Page 25
Chapter 24: Anger, Aggression, and Violence
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Sample Questions
Q1) An intramuscular dose of antipsychotic medication needs to be administered to a patient who is becoming increasingly more aggressive. The patient is in the day room where there are other patients. The nurse should enter the day room:
A) and say, "Would you like to come to your room and take some medication your doctor prescribed for you?"
B) accompanied by three staff members and say, "Please come to your room so I can give you some medication that will help you feel more comfortable."
C) and place the patient in a basket-hold and then say, "I am going to take you to your room to give you an injection of medication to calm you."
D) accompanied by two security guards and tell the patient, "You can come to your room willingly so I can give you this medication or the security guards will take you there."
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Chapter 25: Care for the Dying and Those Who Grieve
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Sample Questions
Q1) Psychotherapy for individuals at risk for complicated grief focuses on which goals? (Select all that apply.)
A) Exploring emotional responses to a loss
B) Identifying ways to break bonds with the deceased
C) Solving problems related to moving forward in life
D) Learning about the stages and symptoms of grieving
E) Using antipsychotic medications for dysfunctional grief
Q2) The mourning process is more difficult when the bereaved:
A) was relatively independent of the deceased.
B) has experienced many previous losses.
C) accepts that death is expected for everyone.
D) had resolved conflicts with the deceased.
Q3) A recently widowed patient tells the health care provider, "I have so much epigastric discomfort. I wonder if I have an ulcer." Diagnostic tests are negative. The symptom demonstrates:
A) early reorganization behavior.
B) disorganization and depression.
C) preoccupation with the deceased.
D) normal phenomenon of mourning.
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Page 27
Chapter 26: Children and Adolescents
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Q1) What are the primary distinguishing factors between the behavior of children diagnosed with oppositional defiant disorder (ODD) and those diagnosed with conduct disorder (CD)? (Select all that apply.) The child diagnosed with:
A) ODD relives traumatic events by acting them out.
B) ODD tests limits and disobeys authority figures.
C) ODD has difficulty separating from the parents.
D) CD uses stereotypical or repetitive language.
E) CD often violates the rights of others.
Q2) Which behavior indicates that the treatment plan for a child diagnosed with autism spectrum disorder was effective? The child:
A) plays with one toy for 30 minutes.
B) repeats words spoken by a parent.
C) holds the parent's hand while walking.
D) spins around and claps hands while walking.
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Chapter 27: Adults
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31 Verified Questions
31 Flashcards
Source URL: https://quizplus.com/quiz/2073
Sample Questions
Q1) Before working with patients regarding sexual concerns, a prerequisite for providing nonjudgmental care is:
A) sympathy.
B) assertiveness training.
C) sexual self-awareness.
D) effective communication.
Q2) Severe and persistent mental illness is best characterized as a:
A) mental illness with longer than 2 weeks' duration.
B) major ongoing mental illness marked by significant functional impairments.
C) mental illness accompanied by physical impairment and severe social problems. D) major mental illness that cannot be treated to prevent deterioration of cognitive and social abilities.
Q3) A nurse prepares for an initial interview with a patient with suspected adult attention deficit hyperactivity disorder (ADHD). Questions should be focused to elicit information about which problem?
A) Headaches
B) Inattention
C) Sexual impulses
D) Trichotillomania
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Chapter 28: Older Adults
Available Study Resources on Quizplus for this Chatper
31 Verified Questions
31 Flashcards
Source URL: https://quizplus.com/quiz/2074
Sample Questions
Q1) When admitting older adult patients, health care agencies receiving federal funds must provide written information about:
A) advance health care directives.
B) the financial status of the institution.
C) how to sign out against medical advice.
D) the institution's policy on the use of restraints.
Q2) A patient tells the nurse of the recent deaths of a spouse of 50 years as well as an adult child in an automobile accident. The patient has no other family and only a few friends in the community. What is the priority nursing diagnosis?
A) Spiritual distress, related to being angry with God for taking the family
B) Risk for suicide, related to recent deaths of significant others
C) Anxiety, related to sudden and abrupt lifestyle changes
D) Social isolation, related to loss of existing family
Q3) If an older adult patient must be physically restrained, who is responsible for the patient's safety?
A) Nurse assigned to care for the patient
B) Nursing assistant who applies the restraint
C) Health care provider who ordered the application of the restraint
D) Family member who agrees to the application of the restraint
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