Chapter 26: Therapies: Theory and Clinical Practice My Nursing Test Banks

Fortinash: Psychiatric Mental Health Nursing, 5th Edition

Chapter 26: Therapies: Theory and Clinical Practice

Test Bank

MULTIPLE CHOICE

1. Which intervention best reflects the nursing role regarding effective implementation of behavioral therapy goals?

a.

Administering the prescribed medications accurately

b.

Interacting effectively with members of the health care team

c.

Being aware of all the patient related therapeutic modalities

d.

Evaluating patient behaviors to reward economic tokens appropriately

ANS: D

The primary role of the nurse who is involved in behavioral therapy is to assess and identify the patients problem behaviors in collaboration with the multidisciplinary team. A token economy is a system of behavior reinforcements in which patients earn tokens by performing predetermined desired behaviors. The remaining options are generalized responsibilities that are relevant to any therapy format.

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2. A new nurse asks the mentor, How can I be sure Im developing a therapeutic environment for my unit? The mentor uses as a basis for the response the fact that a therapeutic milieu is characterized by:

a.

Rigid adherence to timelines and unit routine

b.

Relaxation of boundaries when doing so is accepted by all

c.

The focus of the staff is directed to the most critically disturbed patients

d.

Specific patient-centered goals are established mutually by patient and staff

ANS: D

Factors that determine the therapeutic effectiveness of the social environment includes the presence of two-way communication between the patients and the members of the multidisciplinary team for purposes of goal setting. In a therapeutic relationship, boundaries are established early and maintained throughout and although adherence to routine is important, there is room for adjustment when it benefits the therapeutic nature of the milieu. Although short-term attention may require focus on the patient in crisis, attention of the staff is equally shared.

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3. To plan care for a patient with a psychiatric disorder, the nurse keeps in mind that the primary nursing role related to therapeutic activities is:

a.

Assisting the patient in accomplishing the activity

b.

Ensuring that the patient will comply with the rules of the activity

c.

Ensuring that the patient can accomplish the activity in a timely manner

d.

Providing a support system for the patient if they fail to complete the activity

ANS: A

The nurses role in therapeutic activities is that of a professional observer and participant who works with the therapist to enhance the patients capabilities and functioning within the parameters of the assigned activity. Assuring accomplishment, compliance, or providing failure support are not nursing roles.

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4. Which statement would the nurse use to describe the primary purpose of boundaries?

a.

Boundaries define responsibilities and duties to ones self in relation to others.

b.

Boundaries determine objectives of the various working stage of the relationship.

c.

Boundaries differentiate the assumed roles of both the nurse and of the patient.

d.

Boundaries prevent undesired material from emerging during the interaction.

ANS: A

Boundaries are the social, physical, and emotional limits of the interaction. As such, they serve to define the responsibilities and duties of the nurse in relation to the patient. Objectives and roles are determined during the orientation stage. Emergence of undesired material may be a significant issue for the patient.

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5. Which action will best facilitate the development of trust between a nurse and patient?

a.

Responding positively to the patients demands

b.

Following through with whatever was promised

c.

Clarifying with the patient whenever there is doubt

d.

Staying available to the patient for the entire shift

ANS: B

Being consistent in keeping ones word implies that the nurse is trustworthy and does what is agreed upon. Being responsive to demands may not be therapeutic. Instead, the patient will need to learn new techniques for meeting needs. Clarification is important but is not the best method for promoting trust. Trust is better served by shorter contacts at agreed-upon intervals.

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6. Which statement best defines the nurses initial role as the patients source of help in addressing interpersonal problems?

a.

Ill work with your doctor to help you get better.

b.

Ill be working with you to help solve your marital troubles.

c.

Your medications will help you feel better as soon as they take effect.

d.

You will be expected to attend the group activities while you are here.

ANS: B

This statement clearly specifies the nurses purpose as a helping professional, and establishes the relationship as therapeutic, rather than social. The nurse has independent functions and does not work exclusively with the doctor. Identifying only medication overlooks the contributions of staff and the therapeutic milieu. Giving information is appropriate, but this statement does not define the nurses role as resource.

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7. The nurse is determining whether the patients needs could be best met in a task or a process group. The decision is based on the understanding that a task group focuses on:

a.

Content issues

b.

The here and now

c.

Communication styles

d.

Relations among the members

ANS: A

Content-oriented groups focus on goals and tasks of the group. Thus a task-oriented group would focus on content issues. Process groups focus on interpersonal relationships. Communication styles are not relevant to describing task-oriented groups. Here and now refers to dealing with issues that are taking place at the present time.

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8. The treatment team was engaged in planning how group therapy could be included as a part of the structured daily activities of the unit. A new team member asked, Why is it so important to include group therapy for the patients? The most accurate response would be based on the assumption that:

a.

Hidden agendas frequently surface in group sessions.

b.

Some persons do not relate well on an individual basis.

c.

Group therapy is far more cost-effective for the patients.

d.

Psychopathology has its source in disordered relationships.

ANS: D

A key assumption of group therapy is that psychopathology has its source in disordered relationships. It follows that individuals will behave in the group as they do in other settings, so group provides an opportunity to help individuals develop more functional relationships. Ability to relate is not relevant to group work. It is dealt with in one-to-one therapy. Hidden agenda is not a reason to offer group therapy. Cost-effectiveness is not an assumption about the reason group therapy is effective.

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9. Which patient would the group co-leaders determine is demonstrating Yaloms therapeutic factor termed universality?

a.

Patient A, who states he realizes he is not the only person who has a problem with loneliness

b.

Patient B, who displays dysfunctional interaction patterns learned in his family of origin

c.

Patient C, who states he finally feels a strong sense of belonging

d.

Patient D, who openly expresses his anger about his work

ANS: A

Universality is the factor that refers to understanding that one is not unique, that others share thoughts, reactions, and discomforts like your own. Dysfunctional interaction refers to corrective recapitulation of the family group. A strong sense of belonging provides an example of cohesiveness. Display of anger is an example of catharsis.

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10. A nurse, leading an inpatient group dealing with womens issues, identifies a patient who is assuming the role of aggressor. Which behavior characterizes this role?

a.

Attempting to manipulate others

b.

Mediating conflicts and disagreements

c.

Criticizing the contributions of others

d.

Seeking a position between contending sides

ANS: C

An aggressor acts in negative ways, displaying hostility, attacking the group, or criticizing the members. Seeking a position between contending sides describes the compromiser. Mediating conflicts and disagreements describes the harmonizer. Attempting to manipulate others describes the dominator.

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11. Which statement by a 16-year-old is considered as positive evidence that the familys involvement in therapy is moving them towards effective functioning?

a.

My dad has finally stopped giving me advice on how to live my life.

b.

I stopped playing football since practice required me to be away from home so often.

c.

Since my mother quit her job, she is more available to keep the home running smoothly.

d.

Eating dinner with my parents on Sunday nights has helped us be more aware of each others needs.

ANS: D

This statement shows the family has made an effort to improve communication and deal with alienation without any one member bearing complete responsibility. Withdrawing from the team suggests he felt solely responsible for the family problem. Quitting the job suggests the mother saw herself as responsible; however, being home does not guarantee unification. A lack of advisement suggests withdrawal of the father from participation in family matters.

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12. In response to the nurses statement, Tell me about your family, the patient became silent and displayed nonverbally that he is uncomfortable. Which statement by the nurse reflects sensitivity to the patient?

a.

Im so sorry. I didnt realize your family was a problem for you.

b.

Learning to express negative feelings will assist you in getting well.

c.

Perhaps you can talk about your feelings to the physician next time you meet.

d.

That seems to be a difficult subject for you. We can discuss when you are ready.

ANS: D

This response acknowledges the situation, is respectful, and allows the patient to choose when to refocus the therapeutic interaction. Referring to the family as a problem is not sensitively worded. Offering false reassurance implies that feelings are negative. Suggesting postponing the discussion represents avoidance of dealing with the patients feelings.

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13. When sharing her feelings about separating from a therapy group, the patient stated, I feel a bit sad and empty that I wont be seeing you folks again. What is the most accurate evaluation of the patients statement?

a.

It indicates regression and her lack of readiness to terminate.

b.

Unconsciously, she is hoping she will be permitted to continue the group.

c.

She is demonstrating normal feelings associated with termination of therapy.

d.

She needs further evaluation by her therapist to determine readiness to terminate.

ANS: C

The patient is expressing feelings of sadness over the loss of the therapeutic group relationships that have been helpful to her. Such feelings are considered normal, just as they are considered normal when the nurse-patient relationship terminates. The feelings expressed are normal, not regressive. No hidden meaning is present; the patient openly expressed genuine feelings. Further evaluation is not needed.

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14. A patient asks the nurse manager to help resolve a situation between her and another patient. Which action would best support the patients feelings of safety when experimenting with new ways of being?

a.

Encouraging the patient to report the incident to the other patients physician

b.

Intervening on the patients behalf and sorting out the incident with the other patient

c.

Suggesting that the patient ignore the situation since the other patient was probably not aware of her behavior

d.

Offering to be present and help the patient discusses her feelings about the incident with the other patient

ANS: D

Offering to be with the patient affords her a safe nonthreatening opportunity to assume responsibility for meeting her own needs assertively by encouraging skills that affect positive communication. Intervening removes the responsibility from the patient. Ignoring supports passive behavior. There is no need to bring in another person. The patient is capable of addressing the problem herself.

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15. A patient tells the nurse, I really like you. Youre the only true friend I have. The patients remarks call for the nurse to revisit the issue of:

a.

Trust

b.

Safety

c.

Boundaries

d.

Countertransference

ANS: C

The patients remarks call for the nurse to remind the patient of the parameters of the nurse-patient relationship. The remark would also give the nurse the opening to go on to discuss the matter of friendship. The patients remarks do not suggest the need to deal with trust, safety, or countertransference.

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16. By the end of the orientation phase, which outcome can be identified for a newly admitted patient? The patient will demonstrate:

a.

Ability to problem solve one issue

b.

Trust in at least one nurse on the unit

c.

Positive transference with a staff member

d.

Ability to ask for help in meeting needs

ANS: B

Establishing trust in the nurse is a fundamental task of the orientation phase of the relationship; thus it is an appropriate outcome to identify. When trust is present, the patient is free to focus on the work and tasks of therapy. The ability to problem solve is an outcome appropriate for the working phase. Positive transference would not be an identified outcome. The ability to ask for help would not be an identified outcome for the orientation phase.

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MSC: NCLEX: Psychosocial Integrity

17. The patient and the nurse have agreed on problems to be addressed during a short course of outpatient therapy. At the beginning of the appointment, the patient states, Id like to work on the issue of relationships today. Which assessment can be made?

a.

Nurse-patient roles have not been clearly delineated.

b.

The nurse should suggest several alternative behaviors.

c.

The patient must be able to manage emotions before continuing.

d.

The relationship is moving from orientation to working phase.

ANS: D

Once the patient and nurse have collaborated to define and prioritize problems, the relationship moves from orientation to working phase. The remaining options have no relevance to the scenario since there is no reference to roles, alternative behaviors, or managing behaviors.

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18. A nurse and patient are entering the termination phase in the group experience. An important nursing intervention will be to:

a.

Encourage the group to describe goals for change.

b.

Inquire whether the group needs more time to accomplish goals.

c.

Assist the group to explore alternative coping strategies for problems.

d.

Discuss feelings about leaving the group and the support found with the group.

ANS: D

Healthy termination is facilitated when the group and nurse express reactions to termination. The nurse serves as a role model by being open and genuine as the feelings about the losses incurred with ending are discussed. On a positive note, accomplishments and growth are acknowledged and the transfer of safety and trust to the group members is accomplished. Describing goals is accomplished in the orientation phase. Accomplishing goals is part of the working phase in a relationship that does not have a strict time limit. Exploring alternative coping strategies would be part of the working stage.

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19. A patient attending group therapy mentions, In the beginning, I was so sick that everyone had to help me. For the last few days, its felt good to be able to give something back to the group. This statement can be assessed as an example of Yaloms factor of:

a.

Altruism

b.

Harmonizing

c.

Cohesiveness

d.

Imitative behavior

ANS: A

Altruism refers to the experience of being helpful to others and is clearly what the patient is displaying in the scenario. The other factors are not applicable.

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20. During the first family therapy session, the mother of a child being treated for truancy and emotional outbursts asks the nurse, Why are you bothering to ask the rest of us questions? My son is the one with the problems. The best response for the nurse would be:

a.

Well get more accurate information if the entire family is involved.

b.

It may seem strange to you, but well get better results doing it this way.

c.

When one family member is sick, the whole family system is sick as well.

d.

Every family members perceptions are very important to the total picture.

ANS: D

This response orients the family to the idea that each persons opinion will be valued. Having the family present for assessment prepares them for working together to identify family issues, identify outcomes, and solve problems. It may or may not be true that this will result in accurate information. Getting better results doesnt convey the real reason. Referring to the family as sick is pessimistic and conveys a threatening message.

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21. A novice mental health nurse shares that, Ill never get used to playing cards or other games with patients. It seems like a poor use of scarce nursing time. The best response for the nurses mentor would be:

a.

Perhaps youll want to rethink your transfer to this unit if youre really uncomfortable.

b.

Your comments make a point about scarce resources. Ill ask the treatment team to review our position on activities.

c.

Activity co-leadership puts us in a position to help patients develop social skills and support them as they take small risks.

d.

Managed care has cost us activities therapists. Activities are necessary to give patients something to do, so we have to fill in.

ANS: C

Nurses who engage in co-leadership of therapeutic activities recognize that each activity contributes to outcome attainment. During activities, patients practice skills needed in life situations, process emotions, and give and receive validation and feedback. Suggesting a rethink is not supportive of the nurse. The remaining options do not acknowledge the value of activities therapy.

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22. What is the primary reason for the nurse to have an understanding of the various types of activity and adjunct therapies?

a.

The nurse chooses the most cost-effective therapy group.

b.

The nurse is expected to encourage patients involvement in the therapies.

c.

The nurse is responsible for placing the patient in the appropriate group.

d.

The nurse needs to be supportive of the treatment team members who direct these therapies.

ANS: B

The nurse must interpret to patients and others that the purpose of activity therapies is to increase patient awareness of feelings and behaviors and to minimize pathology and promote mental health. Although they are important, supportiveness, encouragement, and economics are not the primary reason.

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23. Which activity therapy should the nurse recommend to the treatment team to assist the patient to relieve tension and achieve increased body awareness?

a.

Psychodrama

b.

Music therapy

c.

Dance therapy

d.

Recreation

ANS: C

The large movements involved in dance therapy would enable the patient to relieve tension and move with greater body awareness and freedom. The other options will not promote body awareness.

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24. To effectively plan care for a patient, the nurse will understand that activity and adjunct therapies may be more useful in some situations than verbal therapies because adjunct therapies:

a.

Are readily available in the treatment setting

b.

Do not require specific training or expertise to facilitate

c.

Provide the patient the opportunity to use ego-protective mechanisms

d.

Allow the patient to express feelings on multiple levels at the same time

ANS: D

A patient is able to express feelings on the emotional, physical, and symbolic levels during activity therapy, whereas verbal therapies are limited to one dimension. The primary facilitator of the selected therapy is required to have formal education and supervised experience. Adjunct therapy does not provide this opportunity, which would be considered nontherapeutic. Treatment settings are not always readily available.

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25. A patient is scheduled to attend an occupational therapy group to work on the identified goal of recognizing and using more effective coping techniques. What measure can the nurse use to continue to support the patients attainment of this goal after he returns to the unit?

a.

Isolating him from more seriously ill patients

b.

Praising him for positive behavioral changes

c.

Avoiding setting limits that would increase his anxiety level

d.

Permitting him to make mistakes prior to intervening on his behalf

ANS: B

Recognizing and pointing out positive changes provides encouragement to continue pursuing change. The remaining option would not achieve the nurses goal of supporting the patients use of effective coping techniques.

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26. How can the nurse encourage an extremely shy patient to participate therapeutically in a dance activity group?

a.

Offer to dance with the patient.

b.

Ask the patient if this is the first dance he has attended.

c.

Sit with the patient away from the group.

d.

Encourage another patient to ask him to dance.

ANS: A

If trust has been established, the patient may feel safe enough to dance with the nurse. If trust has not yet been established, the patient will see the nurses invitation as demonstrating respect and reaching out to him. Either way, the action will encourage participation. The nurse should not make another patient responsible for this patients participation. The remaining options do not encourage participation.

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27. When leading a therapeutic group, the nurse demonstrates an understanding of the need to act as the groups executive when:

a.

Restating rules when a new member joins

b.

Being available to orient the new members

c.

Helping a member defuse the anger they are experiencing

d.

Working with a member to help improve their communication skills

ANS: A

Executive functioning refers to monitoring and attending to group rules and procedures. Caring demonstrates expressions of kindness. Meaning attribution includes accepting of feelings, although emotional stimulation would reflect working communication skills.

DIF: Cognitive Level: Application REF: Page 609 TOP: Nursing Process: Planning

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28. When another patient serves as alter ego during an outpatient group session, the nurse documents that the group had been engaged in:

a.

Role-playing

b.

Psychodrama

c.

Cognitive therapy

d.

Consensus building

ANS: B

Psychodrama uses spontaneous dramas to act out emotional problems to promote health through development of new perceptions, behaviors, and connections with others. Others in the group take the role of significant others. Role-playing and cognitive therapy do not use the technique of alter egos. Consensus building is not a form of therapy.

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29. The nurse is collecting the paintings from the patients after the art session is over. After art therapy, a patient hands the nurse a paper that consists of several black scribbles. Which statement demonstrates the nurse understands the goals and objectives of the therapy?

a.

Do you want to complete your painting?

b.

I see that you dont take this very seriously.

c.

Can you tell me what happened to prompt such work?

d.

Thank you. Ill put this away in a safe place for you.

ANS: D

Art therapy is used to help resolve conflicts and promote self-awareness. The nurse should not comment on the quality of the art or the patients talents, but rather treat the project with respect and value. The work is simply each patients self-expression. The other options make judgments about the work or the patients willingness to participate.

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30. When asked, Why do you go to music therapy every morning at 10? The nurse explains that the nurses role in music therapy as:

a.

Fostering and encouraging performance talent

b.

Teaching patients about various styles of music

c.

Noting patient verbal and nonverbal expression of feelings

d.

Selecting and playing numbers that will reduce anxiety and stress

ANS: C

A goal of music therapy is to promote expression and social connection. The nurse should observe and document expression of feelings as they occur. The observations may be used later, as a basis for further consideration by the nurse and patient. The other options do not reflect aspects of the nurses role in music therapy.

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31. When a novice nurse asks why the unit has a multidisciplinary approach to therapeutic activities, the nurse should explain that multidisciplinary collaboration:

a.

Produces a higher level of insurance reimbursement

b.

Reduces the incidence of aggressive behavior by patients

c.

Produces quicker results and earlier discharge to the community

d.

Produces better outcomes than when only one perspective is used

ANS: D

Broader input in problem identification and resolution enhances patient outcomes. The remaining options are either untrue or irrelevant.

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32. When a patient asks the nurse, How can jolting me with an electrical shock possibly do me any good? the answer most reflective of current biologic theory would be:

a.

ECT must sound like a very frightening treatment alternative to you.

b.

ECT produces a change in brain chemistry that results in improved mood.

c.

ECT interrupts brain impulses that are causing hallucinations and delusions.

d.

ECT provides you with external punishment so you can stop punishing yourself.

ANS: B

Current theory regarding use of ECT is that the electrical stimulus causes electrochemical changes within the brain, resulting in increased availability of neurotransmitters at the synapses and improvement of mood. To suggest that the treatment is frightening does not answer the patients question. The treatment is not appropriate for hallucinations or delusions. The remaining option is not appropriate or founded in psychiatric therapy.

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MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

33. Which statement made by a patient just prior to being transported for a scheduled ECT treatment would result in cancellation of the treatment?

a.

Ill be so glad when this treatment is over.

b.

Will I remember having this treatment?

c.

Did eating some crackers cause any problems?

d.

Im so tired of being depressed; I dont think I can go on.

ANS: C

Because the patient is to receive general anesthesia and has orders to remain without food or liquids (NPO), the nurse should notify the physician immediately. The introduction of food into the stomach could result in aspiration of stomach contents during treatment. An expression of hopelessness related to depression would be reason to continue with the treatment. The other options offer no contraindication to treatment.

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34. The physician has ordered atropine 0.5 mg intramuscularly (IM) for a patient to be administered 30 minutes prior to ECT. The rationale for use of this medication is that it reduces secretions and:

a.

Protects against vagal bradycardia

b.

Improves the scope of convulsive activity

c.

Reduces the need for recovery room staff

d.

Prevents incontinence of bladder and bowel

ANS: A

Atropine is used for its ability to prevent vagal bradycardia associated with the electrical stimulus. The other options are neither relevant nor true.

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35. Which statement by a patient who has given informed consent for ECT confirms that the patient understands the side effects of this treatment?

a.

I wont remember the pain.

b.

It will take several weeks before I feel good again.

c.

My short-term memory loss will be only temporary.

d.

I will be at increased risk for developing epilepsy later.

ANS: C

Temporary impairment of recent memory is an expected side effect that occurs to some degree during the course of ECT. The other options suggest the patients understanding of treatment and side effects is flawed.

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36. In the ECT treatment preparation period the morning of treatment, the nurse should:

a.

Adequately hydrate the patient.

b.

Assess the patients cognitive function.

c.

Have the patient exercise for 10 minutes.

d.

Ensure that the patient produces a urine sample.

ANS: B

Patient assessment is advisable to provide a baseline against which changes resulting from ECT can be measured. Although taking vital signs and performing other preparatory tasks, the nurse can assess orientation, immediate memory, thought processes, and attention span. The other options are interventions the nurse should not undertake.

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37. Immediately after electroconvulsive therapy (ECT), nursing care of the patient is most similar to care of a patient:

a.

With severe dementia

b.

With delirium tremens

c.

Recovering from conscious sedation

d.

Recovering from general anesthesia

ANS: D

The patient who has ECT receives a short-acting IV anesthetic and a skeletal muscle relaxant. Thus care is most similar to the patient recovering from general anesthesia. The nurse will assess vital signs, quality of respirations, presence or absence of the gag reflex, level of consciousness, orientation, and motor abilities during the post-treatment period.

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38. A novice nurse who will be assessing a patient after electroconvulsive therapy (ECT) asks her mentor, What sort of memory impairment is present after several ECT treatments? The best response for the mentor would be:

a.

Its hard to say. Treatment affects everyone differently.

b.

Usually the patient has severe difficulty remembering remote events.

c.

Patients have mild difficulty remembering recent events, like what was eaten for breakfast.

d.

Both recent and remote memory is affected, producing profound confused, cognitive states.

ANS: C

Most patients experience transient recent memory impairment after electroconvulsive therapy (ECT). The cognitive deficit becomes more pronounced as the number of treatments increases. When the course of treatments is completed, cognitive deficit generally improves to the pretreatment level. The other options are incorrect.

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MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

39. About an hour after the patient has ECT, he complains of having a headache. The nurse should:

a.

Notify the physician stat.

b.

Administer an as needed (prn) dose of acetaminophen.

c.

Take the patient through a progressive relaxation sequence.

d.

Advise going to activities to expend energy and relieve tension.

ANS: B

Post-ECT headache is common. Most physicians routinely write an as needed (prn) order for a headache remedy. Notifying the physician is unnecessary, because this is an expected side effect. Options c and d would not be as useful as medication in this instance.

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TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

40. For which patient is the nurse most likely to need to schedule a pre-ECT workup and teaching?

a.

Patient A, who is newly diagnosed with dysthymic disorder

b.

Patient B, who has melancholic depression that responded well to ECT 2 years ago

c.

Patient C, who was unresponsive to a 6-week trial of SSRI antidepressant therapy

d.

Patient D, who has depression associated with diagnosis of inoperable brain tumor

ANS: B

Indications for ECT include patients with major mood disorders; patients who have responded to ECT in the past; patients who are unresponsive to antidepressants or unable to tolerate their side effects; and patients who are acutely suicidal or in danger of fluid and electrolyte imbalance related to inability to eat due to depression, severe mania, or severe catatonia. Patients with dysthymia are not candidates for ECT. The patient has not run out of medication options when prescribed only an SSRI. Patients with space-occupying lesions of the brain are not candidates for ECT.

DIF: Cognitive Level: Application REF: Page 618 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

41. Which intervention will the nurse implement in the first half hour after the patient has received ECT?

a.

Continually stimulate patient to respond, using physical and verbal means.

b.

Continue bagging patient to improve respiratory function until patient is responsive for 10 minutes.

c.

Reorient as necessary to time, place, and person as level of consciousness improves.

d.

Encourage walking and eating breakfast as quickly as possible.

ANS: C

Patient memory is likely to be impaired in the immediate post-ECT period. Reorientation will be necessary to help the individual return to a functional state. Continual stimulation is not necessary. Bagging is unnecessary. The patient may be allowed to rest and recover at his own pace.

DIF: Cognitive Level: Application REF: Page 620

TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

42. What milieu factor would need most attention from the nurse who is caring for a patient who has received six ECT treatments and has two more scheduled?

a.

Safety

b.

Trust attainment

c.

Therapeutic activities

d.

Boundary maintenance

ANS: A

To feel safe, patients need to know what is expected of them in their role as patients. The patient receiving ECT often has impaired recent memory and may become confused about the milieu and expectations. The nurse will need to reorient and reteach the patient with cognitive deficit. Options b, c, and d will require attention but not to the same extent as safety.

DIF: Cognitive Level: Analysis REF: Page 620 TOP: Nursing Process: Planning

MSC: NCLEX: Psychosocial Integrity

MULTIPLE RESPONSE

1. Which behaviors are reflective of legitimate phases of a groups development? Select all that apply.

a.

Stating the goals of the group

b.

Establishing who will assume the leadership role

c.

Inviting family members to attend and provide their input

d.

Feeling safe enough to discuss painful personal situations

e.

Showing concern about assuming personal responsibility for life

ANS: A, B, E

All groups progress through the phases of development that are governed by group dynamics and include orientation where goals are identified, conflict where leadership is determined and tested, cohesion where a sense of safety is achieved, and termination where discharge concerns are acted out and addressed. Family input may not necessarily be introduced unless it was a defined goal of the group.

DIF: Cognitive Level: Application REF: Pages 611-612

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

Copyright 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.

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