pedia part 1

1. Children with cleft palate are prone to frequent episodes of otitis media owing to which of, the following?
a. Lowered resistance due to malnutrition
b. ineffective functioning of Eustachian tube
c. Plugging of the Eustachian tubes with food particles
d. Constant leaning of the middle ear

2. which of the following assessment would suggest that the child has developed infection under the cast
a. Cold toes
b. Absent pedal pulses
c. " Hot spots' in cast
d. Cyanotic extremities

3. in caring for a child after surgery for cleft repair, the nurse should watch for which of the following immediate postoperative complications?
a. Bleeding and respiratory difficulty
b. Scarring problems and infection
c. infection and respiratory distress
d. pneumonia and infection

4. Which of the following organisms is responsible for the development of rheumatic fever?
a. Streptococcus infection
b. Haemophilus influenza
c. Group A beta hemolytic strptococcus
d. staphylococcus aureus

5. the priority nursing goal for a child with acute lymphocytic leukemia is
a. decrease risk of infection
b. encourage intake of iron rich foods
c. discuss death and dying
d. discourage injection

6. the reason why children with cystic fibrosis receive pancrease
a. to soften their stools
b. to aid in digestion
c. to prevent diabetes
d. to help heal complications like pneumonia

7. which of the ofollowing is the rationale behind the use of croupette (mist tent) for children who has acut larycotracheobronchitis
a. have child bring favourite toy
b. it liquefy secretions
c. it warms respiratory tract
d. it provides reverse isolation

8. in treating a child with developmental dysplasia of the hip, which if the following position should be maintained
a. extended and abducted
b. extended and adducted
c. flexed and abducted
d. flexed and adducted

9. which of the following assessment findings would be noted for a child with pyloric stenosis?
a. Projectile vomiting
b. Choking after feeding
c. Currant jelly stool
d. Vomitus with bile

10. Which of the following structural defects are found in the tetralogy of Fallot?
a. Pulmonary stenosis, ventricular septal defect, overriding of aorta, hypertrophy of the left ventricle
b. Pulmonary stenosis, ventricular septal defect, overriding of aorta, hypertrophy of right ventricle
c. Aortic stenosis, ventricular septal defect, overriding of aorta, hypertrophy of right ventricle
d. Aortic stenosis, ventricular septal defect, overriding of aorta, hypertrophy of left ventricle

11. Among the following positions, the child wihh tetralogy of fallot will assume what?
a. Semi fowlers
b. Tripod/ orthopnic
c. Supine
d. Squatting

12. A 9-year-oirl girl is admitted to the hospital with a diagnosis of rheumatic fever. Which of the following is most likely to be noted in her history?
a. She was treated for pneumonia 3 weeks ago
b. She was born with a congenital heart defect
c. She had chicken pox 1 month ago
d. She had an untreated fever and sore throat 2 weeks ago

13. Nephroblastoma may go unnoticed by parents and the health care team because it does not manifests symptoms in the early stages. Which of the following is the most common symptom noted
a. Abdominal pain
b. Hematuria
c. Hypertension
d. Abdominal mass

14. What would be the most appropriate nursing intervention to a 3- year ol child who arrives in the emergency room with temperature of 105 degrees, inspiratory stridor, restlessness, leaning forward and drooling?
a. Have a thorough physical exam of the respiratory system
b. Put him in semi fowlers position and encourage fluid intake
c. Examine throat and have a throat culture
d. Notify physician immediately and prepared intubation set

15. Aspirin, rectal temperature and intramuscular injections should be avoided in children with
a. Iron deficiency anemia
b. Haemophilia
c. Sickle cell anemia
d. Thalassemia

16. A child with haemophilia complains of a sudden, severe headache. He is confused, lethargic, and vomiting. The nurse should suspect
a. Intracranial bleeding
b. Hemorrhagic shock
c. Medication overdose
d. AIDS

17. The teaching plan for a child with sickle cell disease should include the following except
a. Regular aerobic exercise
b. Avoid persons who have infection
c. Well balanced diet
d. Increase fluid intake

18. What is the most common cause of non communicating hydrocephalus?
a. Developmental malformation
b. Meningitis
c. Birth trauma
d. NOTA

19. Which of the following phrases best describes the pathophysiology of non-communicating hydrocephalus?
a. Precursor of spina bifida occulta
b. Obstruction of cerebrospinal fluid flow in the ventricular system
c. Hypervolemia
d. Tumor formation in the cerebral hemisphere

20. The most significant prenatal maternal disorder in the development of myelomeningocele
a. IDA
b. Diabetes Mellitus
c. Diabetes Insipidus
d. Folic acid deficiency

21. Which of the following is most characterize cerebral palsy, spastic type
a. Athetosis
b. Dyskenesia
c. Wide base gait
d. Hypertonicity

22. All of the following manifestations are characteristic of all clients with cerebral palsy except
a. Delayed gross motor development
b. Decrease cognitive functioning
c. Abnormal muscle performance
d. Altered muscle tone

23. Characteristics of down’s syndrome include
a. Small tongue
b. Tranverse palmar crease
c. Marked motor delays
d. Inability to walk

24. Passing a soft no. 8 or 10 French catheter through the nares (bilaterally) to confirm diagnosis of this condition is essential
a. Bronchopulmonary dysplasia
b. Tetralogy of fallot
c. Down’s symdrome
d. Choanal atresia

pedia matching type

Matching Type: match column A to Column B
Write answer in the space before the number

A


1. Cat’s cry
2. Down’s syndrome
3. Cretinism
4. Prone position
5. Olive like mass
6. Sausage like mass
7. Gluten free diet
8. Ribbon like stool
9. Medicine dropper
10. Hypoxia and dehydration
11. Vitamin K
12. Iron
13. Vitamin B12
14. Never palpate abdomen
15. Proteinuria
16. Sunset eyes
17. Prevent adduction and extension
18. Rotate injection site
19. Squatting
20. Do not use tongue depressor

B


a. Sickle cell anemia
b. Trisomy 18
c. Trisomy 21
d. Cri-du-chat syndrome
e. Phenylketonuria
f. SIDS
g. Erythroblastosis fetalis
h. Development dysplasia of the hips
i. Choanal atresia
j. Otitis media
k. Croup
l. Cystic fibrosis
m. TOF
n. PDA
o. Atrial septal defect
p. Hypothyroidism
q. hyperthyriodism
r. Congestive heart disease
s. Transesophageal fistula
t. Pyloric stenosis
u. Hirschprung disease
v. Intussuception
w. Celiac disease
x. IDA
y. Aplastic anemia
z. Leukemia
aa. IDDM
bb. NIDDM
cc. hydrocephalus

pedia matching type

Matching Type: match column A to Column B
Write answer in the space before the number

A


1. Cat’s cry
2. Down’s syndrome
3. Cretinism
4. Prone position
5. Olive like mass
6. Sausage like mass
7. Gluten free diet
8. Ribbon like stool
9. Medicine dropper
10. Hypoxia and dehydration
11. Vitamin K
12. Iron
13. Vitamin B12
14. Never palpate abdomen
15. Proteinuria
16. Sunset eyes
17. Prevent adduction and extension
18. Rotate injection site
19. Squatting
20. Do not use tongue depressor

B


a. Sickle cell anemia
b. Trisomy 18
c. Trisomy 21
d. Cri-du-chat syndrome
e. Phenylketonuria
f. SIDS
g. Erythroblastosis fetalis
h. Development dysplasia of the hips
i. Choanal atresia
j. Otitis media
k. Croup
l. Cystic fibrosis
m. TOF
n. PDA
o. Atrial septal defect
p. Hypothyroidism
q. hyperthyriodism
r. Congestive heart disease
s. Transesophageal fistula
t. Pyloric stenosis
u. Hirschprung disease
v. Intussuception
w. Celiac disease
x. IDA
y. Aplastic anemia
z. Leukemia
aa. IDDM
bb. NIDDM
cc. hydrocephalus

Psychiatric Nursing Practice Test Part 1

Psychiatric Nursing Practice Test Part 1

1. Marco approached Nurse Trish asking for advice on how to deal with his alcohol addiction. Nurse Trish should tell the client that the only effective treatment for alcoholism is:
a. Psychotherapy
b. Alcoholics anonymous (A.A.)
c. Total abstinence
d. Aversion Therapy
2. Nurse Hazel is caring for a male client who experience false sensory perceptions with no basis in reality. This perception is known as:
a. Hallucinations
b. Delusions
c. Loose associations
d. Neologisms
3. Nurse Monet is caring for a female client who has suicidal tendency. When accompanying the client to the restroom, Nurse Monet should…
a. Give her privacy
b. Allow her to urinate
c. Open the window and allow her to get some fresh air
d. Observe her
4. Nurse Maureen is developing a plan of care for a female client with anorexia nervosa. Which action should the nurse include in the plan?
a. Provide privacy during meals
b. Set-up a strict eating plan for the client
c. Encourage client to exercise to reduce anxiety
d. Restrict visits with the family
5. A client is experiencing anxiety attack. The most appropriate nursing intervention should include?
a. Turning on the television
b. Leaving the client alone
c. Staying with the client and speaking in short sentences
d. Ask the client to play with other clients
6. A female client is admitted with a diagnosis of delusions of GRANDEUR. This diagnosis reflects a belief that one is:
a. Being Killed
b. Highly famous and important
c. Responsible for evil world
d. Connected to client unrelated to oneself
7. A 20 year old client was diagnosed with dependent personality disorder. Which behavior is not most likely to be evidence of ineffective individual coping?
a. Recurrent self-destructive behavior
b. Avoiding relationship
c. Showing interest in solitary activities
d. Inability to make choices and decision without advise
8. A male client is diagnosed with schizotypal personality disorder. Which signs would this client exhibit during social situation?
a. Paranoid thoughts
b. Emotional affect
c. Independence need
d. Aggressive behavior
9. Nurse Claire is caring for a client diagnosed with bulimia. The most appropriate initial goal for a client diagnosed with bulimia is?
a. Encourage to avoid foods
b. Identify anxiety causing situations
c. Eat only three meals a day
d. Avoid shopping plenty of groceries
10. Nurse Tony was caring for a 41 year old female client. Which behavior by the client indicates adult cognitive development?
a. Generates new levels of awareness
b. Assumes responsibility for her actions
c. Has maximum ability to solve problems and learn new skills
d. Her perception are based on reality
11. A neuromuscular blocking agent is administered to a client before ECT therapy. The Nurse should carefully observe the client for?
a. Respiratory difficulties
b. Nausea and vomiting
c. Dizziness
d. Seizures
12. A 75 year old client is admitted to the hospital with the diagnosis of dementia of the Alzheimer’s type and depression. The symptom that is unrelated to depression would be?
a. Apathetic response to the environment
b. “I don’t know” answer to questions
c. Shallow of labile effect
d. Neglect of personal hygiene
13. Nurse Trish is working in a mental health facility; the nurse priority nursing intervention for a newly admitted client with bulimia nervosa would be to?
a. Teach client to measure I & O
b. Involve client in planning daily meal
c. Observe client during meals
d. Monitor client continuously
14. Nurse Patricia is aware that the major health complication associated with intractable anorexia nervosa would be?
a. Cardiac dysrhythmias resulting to cardiac arrest
b. Glucose intolerance resulting in protracted hypoglycemia
c. Endocrine imbalance causing cold amenorrhea
d. Decreased metabolism causing cold intolerance
15. Nurse Anna can minimize agitation in a disturbed client by?
a. Increasing stimulation
b. limiting unnecessary interaction
c. increasing appropriate sensory perception
d. ensuring constant client and staff contact
16. A 39 year old mother with obsessive-compulsive disorder has become immobilized by her elaborate hand washing and walking rituals. Nurse Trish recognizes that the basis of O.C. disorder is often:
a. Problems with being too conscientious
b. Problems with anger and remorse
c. Feelings of guilt and inadequacy
d. Feeling of unworthiness and hopelessness
17. Mario is complaining to other clients about not being allowed by staff to keep food in his room. Which of the following interventions would be most appropriate?
a. Allowing a snack to be kept in his room
b. Reprimanding the client
c. Ignoring the clients behavior
d. Setting limits on the behavior
18. Conney with borderline personality disorder who is to be discharge soon threatens to “do something” to herself if discharged. Which of the following actions by the nurse would be most important?
a. Ask a family member to stay with the client at home temporarily
b. Discuss the meaning of the client’s statement with her
c. Request an immediate extension for the client
d. Ignore the clients statement because it’s a sign of manipulation
19. Joey a client with antisocial personality disorder belches loudly. A staff member asks Joey, “Do you know why people find you repulsive?” this statement most likely would elicit which of the following client reaction?
a. Depensiveness
b. Embarrassment
c. Shame
d. Remorsefulness
20. Which of the following approaches would be most appropriate to use with a client suffering from narcissistic personality disorder when discrepancies exist between what the client states and what actually exist?
a. Rationalization
b. Supportive confrontation
c. Limit setting
d. Consistency
21. Cely is experiencing alcohol withdrawal exhibits tremors, diaphoresis and hyperactivity. Blood pressure is 190/87 mmhg and pulse is 92 bpm. Which of the medications would the nurse expect to administer?
a. Naloxone (Narcan)
b. Benzlropine (Cogentin)
c. Lorazepam (Ativan)
d. Haloperidol (Haldol)
22. Which of the following foods would the nurse Trish eliminate from the diet of a client in alcohol withdrawal?
a. Milk
b. Orange Juice
c. Soda
d. Regular Coffee
23. Which of the following would Nurse Hazel expect to assess for a client who is exhibiting late signs of heroin withdrawal?
a. Yawning & diaphoresis
b. Restlessness & Irritability
c. Constipation & steatorrhea
d. Vomiting and Diarrhea
24. To establish open and trusting relationship with a female client who has been hospitalized with severe anxiety, the nurse in charge should?
a. Encourage the staff to have frequent interaction with the client
b. Share an activity with the client
c. Give client feedback about behavior
d. Respect client’s need for personal space
25. Nurse Monette recognizes that the focus of environmental (MILIEU) therapy is to:
a. Manipulate the environment to bring about positive changes in behavior
b. Allow the client’s freedom to determine whether or not they will be involved in activities
c. Role play life events to meet individual needs
d. Use natural remedies rather than drugs to control behavior
26. Nurse Trish would expect a child with a diagnosis of reactive attachment disorder to:
a. Have more positive relation with the father than the mother
b. Cling to mother & cry on separation
c. Be able to develop only superficial relation with the others
d. Have been physically abuse
27. When teaching parents about childhood depression Nurse Trina should say?
a. It may appear acting out behavior
b. Does not respond to conventional treatment
c. Is short in duration & resolves easily
d. Looks almost identical to adult depression
28. Nurse Perry is aware that language development in autistic child resembles:
a. Scanning speech
b. Speech lag
c. Shuttering
d. Echolalia
29. A 60 year old female client who lives alone tells the nurse at the community health center “I really don’t need anyone to talk to”. The TV is my best friend. The nurse recognizes that the client is using the defense mechanism known as?
a. Displacement
b. Projection
c. Sublimation
d. Denial
30. When working with a male client suffering phobia about black cats, Nurse Trish should anticipate that a problem for this client would be?
a. Anxiety when discussing phobia
b. Anger toward the feared object
c. Denying that the phobia exist
d. Distortion of reality when completing daily routines
31. Linda is pacing the floor and appears extremely anxious. The duty nurse approaches in an attempt to alleviate Linda’s anxiety. The most therapeutic question by the nurse would be?
a. Would you like to watch TV?
b. Would you like me to talk with you?
c. Are you feeling upset now?
d. Ignore the client
32. Nurse Penny is aware that the symptoms that distinguish post traumatic stress disorder from other anxiety disorder would be:
a. Avoidance of situation & certain activities that resemble the stress
b. Depression and a blunted affect when discussing the traumatic situation
c. Lack of interest in family & others
d. Re-experiencing the trauma in dreams or flashback
33. Nurse Benjie is communicating with a male client with substance-induced persisting dementia; the client cannot remember facts and fills in the gaps with imaginary information. Nurse Benjie is aware that this is typical of?
a. Flight of ideas
b. Associative looseness
c. Confabulation
d. Concretism
34. Nurse Joey is aware that the signs & symptoms that would be most specific for diagnosis anorexia are?
a. Excessive weight loss, amenorrhea & abdominal distension
b. Slow pulse, 10% weight loss & alopecia
c. Compulsive behavior, excessive fears & nausea
d. Excessive activity, memory lapses & an increased pulse
35. A characteristic that would suggest to Nurse Anne that an adolescent may have bulimia would be:
a. Frequent regurgitation & re-swallowing of food
b. Previous history of gastritis
c. Badly stained teeth
d. Positive body image
36.
37. Nurse Monette is aware that extremely depressed clients seem to do best in settings where they have:
a. Multiple stimuli
b. Routine Activities
c. Minimal decision making
d. Varied Activities
38. To further assess a client’s suicidal potential. Nurse Katrina should be especially alert to the client expression of:
a. Frustration & fear of death
b. Anger & resentment
c. Anxiety & loneliness
d. Helplessness & hopelessness
39. A nursing care plan for a male client with bipolar I disorder should include:
a. Providing a structured environment
b. Designing activities that will require the client to maintain contact with reality
c. Engaging the client in conversing about current affairs
d. Touching the client provide assurance
40. When planning care for a female client using ritualistic behavior, Nurse Gina must recognize that the ritual:
a. Helps the client focus on the inability to deal with reality
b. Helps the client control the anxiety
c. Is under the client’s conscious control
d. Is used by the client primarily for secondary gains
41. A 32 year old male graduate student, who has become increasingly withdrawn and neglectful of his work and personal hygiene, is brought to the psychiatric hospital by his parents. After detailed assessment, a diagnosis of schizophrenia is made. It is unlikely that the client will demonstrate:
a. Low self esteem
b. Concrete thinking
c. Effective self boundaries
d. Weak ego
42. A 23 year old client has been admitted with a diagnosis of schizophrenia says to the nurse “Yes, its march, March is little woman”. That’s literal you know”. These statement illustrate:
a. Neologisms
b. Echolalia
c. Flight of ideas
d. Loosening of association
43. A long term goal for a paranoid male client who has unjustifiably accused his wife of having many extramarital affairs would be to help the client develop:
a. Insight into his behavior
b. Better self control
c. Feeling of self worth
d. Faith in his wife
44. A male client who is experiencing disordered thinking about food being poisoned is admitted to the mental health unit. The nurse uses which communication technique to encourage the client to eat dinner?
a. Focusing on self-disclosure of own food preference
b. Using open ended question and silence
c. Offering opinion about the need to eat
d. Verbalizing reasons that the client may not choose to eat
45. Nurse Nina is assigned to care for a client diagnosed with Catatonic Stupor. When Nurse Nina enters the client’s room, the client is found lying on the bed with a body pulled into a fetal position. Nurse Nina should?
a. Ask the client direct questions to encourage talking
b. Rake the client into the dayroom to be with other clients
c. Sit beside the client in silence and occasionally ask open-ended question
d. Leave the client alone and continue with providing care to the other clients
46. Nurse Tina is caring for a client with delirium and states that “look at the spiders on the wall”. What should the nurse respond to the client?
a. “You’re having hallucination, there are no spiders in this room at all”
b. “I can see the spiders on the wall, but they are not going to hurt you”
c. “Would you like me to kill the spiders”
d. “I know you are frightened, but I do not see spiders on the wall”
47. Nurse Jonel is providing information to a community group about violence in the family. Which statement by a group member would indicate a need to provide additional information?
a. “Abuse occurs more in low-income families”
b. “Abuser Are often jealous or self-centered”
c. “Abuser use fear and intimidation”
d. “Abuser usually have poor self-esteem”
48. During electroconvulsive therapy (ECT) the client receives oxygen by mask via positive pressure ventilation. The nurse assisting with this procedure knows that positive pressure ventilation is necessary because?
a. Anesthesia is administered during the procedure
b. Decrease oxygen to the brain increases confusion and disorientation
c. Grand mal seizure activity depresses respirations
d. Muscle relaxations given to prevent injury during seizure activity depress respirations.
49. When planning the discharge of a client with chronic anxiety, Nurse Chris evaluates achievement of the discharge maintenance goals. Which goal would be most appropriately having been included in the plan of care requiring evaluation?
a. The client eliminates all anxiety from daily situations
b. The client ignores feelings of anxiety
c. The client identifies anxiety producing situations
d. The client maintains contact with a crisis counselor
50. Nurse Tina is caring for a client with depression who has not responded to antidepressant medication. The nurse anticipates that what treatment procedure may be prescribed?
a. Neuroleptic medication
b. Short term seclusion
c. Psychosurgery
d. Electroconvulsive therapy
51. Mario is admitted to the emergency room with drug-included anxiety related to over ingestion of prescribed antipsychotic medication. The most important piece of information the nurse in charge should obtain initially is the:
a. Length of time on the med.
b. Name of the ingested medication & the amount ingested
c. Reason for the suicide attempt
d. Name of the nearest relative & their phone number


Answers and Rationale Psychiatric Nursing Practice Test Part 1

1. C. Total abstinence is the only effective treatment for alcoholism.
2. A. Hallucinations are visual, auditory, gustatory, tactile or olfactory perceptions that have no basis in reality.
3. D. The Nurse has a responsibility to observe continuously the acutely suicidal client. The Nurseshould watch for clues, such as communicating suicidal thoughts, and messages; hoarding medications and talking about death.
4. B. Establishing a consistent eating plan and monitoring client’s weight are important to this disorder.
5. C. Appropriate nursing interventions for an anxiety attack include using short sentences, staying with the client, decreasing stimuli, remaining calm and medicating as needed.
6. B. Delusion of grandeur is a false belief that one is highly famous and important.
7. D. Individual with dependent personality disorder typically shows indecisiveness submissiveness and clinging behavior so that others will make decisions with them.
8. A. Clients with schizotypal personality disorder experience excessive social anxiety that can lead to paranoid thoughts.
9. B. Bulimia disorder generally is a maladaptive coping response to stress and underlying issues. The client should identify anxiety causing situation that stimulate the bulimic behavior and then learn new ways of coping with the anxiety.
10. A. An adult age 31 to 45 generates new level of awareness.
11. A. Neuromuscular Blocker, such as SUCCINYLCHOLINE (Anectine) produces respiratory depression because it inhibits contractions of respiratory muscles.
12. C. With depression, there is little or no emotional involvement therefore little alteration in affect.
13. D. These clients often hide food or force vomiting; therefore they must be carefully monitored.
14. A. These clients have severely depleted levels of sodium and potassium because of their starvation diet and energy expenditure, these electrolytes are necessary for cardiac functioning.
15. B. Limiting unnecessary interaction will decrease stimulation and agitation.
16. C. Ritualistic behavior seen in this disorder is aimed at controlling guilt and inadequacy by maintaining an absolute set pattern of behavior.
17. D. The nurse needs to set limits in the client’s manipulative behavior to help the client control dysfunctional behavior. A consistent approach by the staff is necessary to decrease manipulation.
18. B. Any suicidal statement must be assessed by the nurse. The nurse should discuss the client’s statement with her to determine its meaning in terms of suicide.
19. A. When the staff member ask the client if he wonders why others find him repulsive, the client is likely to feel defensive because the question is belittling. The natural tendency is to counterattack the threat to self image.
20. B. The nurse would specifically use supportive confrontation with the client to point out discrepancies between what the client states and what actually exists to increase responsibility for self.
21. C. The nurse would most likely administer benzodiazepine, such as lorazepan (ativan) to the client who is experiencing symptom: The client’s experiences symptoms of withdrawal because of the rebound phenomenon when the sedation of the CNS from alcohol begins to decrease.
22. D. Regular coffee contains caffeine which acts as psychomotor stimulants and leads to feelings of anxiety and agitation. Serving coffee top the client may add to tremors or wakefulness.
23. D. Vomiting and diarrhea are usually the late signs of heroin withdrawal, along with muscle spasm, fever, nausea, repetitive, abdominal cramps and backache.
24. D. Moving to a client’s personal space increases the feeling of threat, which increases anxiety.
25. A. Environmental (MILIEU) therapy aims at having everything in the client’s surrounding area toward helping the client.
26. C. Children who have experienced attachment difficulties with primary caregiver are not able to trust others and therefore relate superficially
27. A. Children have difficulty verbally expressing their feelings, acting out behavior, such as temper tantrums, may indicate underlying depression.
28. D. The autistic child repeat sounds or words spoken by others.
29. D. The client statement is an example of the use of denial, a defense that blocks problem by unconscious refusing to admit they exist.
30. A. Discussion of the feared object triggers an emotional response to the object.
31. B. The nurse presence may provide the client with support & feeling of control.
32. D. Experiencing the actual trauma in dreams or flashback is the major symptom that distinguishes post traumatic stress disorder from other anxiety disorder.
33. C. Confabulation or the filling in of memory gaps with imaginary facts is a defense mechanismused by people experiencing memory deficits.
34. A. These are the major signs of anorexia nervosa. Weight loss is excessive (15% of expected weight).
35. C. Dental enamel erosion occurs from repeated self-induced vomiting.
36. B. Depression usually is both emotional & physical. A simple daily routine is the best, least stressful and least anxiety producing.
37. D. The expression of these feeling may indicate that this client is unable to continue the struggle of life.
38. A. Structure tends to decrease agitation and anxiety and to increase the client’s feeling of security.
39. B. The rituals used by a client with obsessive compulsive disorder help control the anxiety level by maintaining a set pattern of action.
40. C. A person with this disorder would not have adequate self-boundaries.
41. D. Loose associations are thoughts that are presented without the logical connections usually necessary for the listening to interpret the message.
42. C. Helping the client to develop feeling of self worth would reduce the client’s need to use pathologic defenses.
43. B. Open ended questions and silence are strategies used to encourage clients to discuss their problem in descriptive manner.
44. C. Clients who are withdrawn may be immobile and mute, and require consistent, repeated interventions. Communication with withdrawn clients requires much patience from the nurse.The nurse facilitates communication with the client by sitting in silence, asking open-ended question and pausing to provide opportunities for the client to respond.
45. D. When hallucination is present, the nurse should reinforce reality with the client.
46. A. Personal characteristics of abuser include low self-esteem, immaturity, dependence, insecurity and jealousy.
47. D. A short acting skeletal muscle relaxant such as succinylcholine (Anectine) is administered during this procedure to prevent injuries during seizure.
48. C. Recognizing situations that produce anxiety allows the client to prepare to cope with anxiety or avoid specific stimulus.
49. D. Electroconvulsive therapy is an effective treatment for depression that has not responded to medication.
50. B. In an emergency, lives saving facts are obtained first. The name and the amount of medication ingested are of outmost important in treating this potentially life threatening situation.

Psychiatric Nursing Practice Test Part 2

1. Francis who is addicted to cocaine withdraws from the drug. Nurse Ron should expect to observe:
a. Hyperactivity
b. Depression
c. Suspicion
d. Delirium

2. Nurse John is aware that a serious effect of inhaling cocaine is?
a. Deterioration of nasal septum
b. Acute fluid and electrolyte imbalances
c. Extra pyramidal tract symptoms
d. Esophageal varices

3. A tentative diagnosis of opiate addiction, Nurse Candy should assess a recently hospitalized client for signs of opiate withdrawal. These signs would include:
a. Rhinorrhea, convulsions, subnormal temperature
b. Nausea, dilated pupils, constipation
c. Lacrimation, vomiting, drowsiness
d. Muscle aches, papillary constriction, yawning

4. A 48 year old male client is brought to the psychiatric emergency room after attempting to jump off a bridge. The client’s wife states that he lost his job several months ago and has been unable to find another job. The primary nursing intervention at this time would be to assess for:
a. A past history of depression
b. Current plans to commit suicide
c. The presence of marital difficulties
d. Feelings of excessive failure

5. Before helping a male client who has been sexually assaulted, nurse Maureen should recognize that the rapist is motivated by feelings of:
a. Hostility
b. Inadequacy
c. Incompetence
d. Passion

6. When working with children who have been sexually abused by a family member it is important for the nurse to understand that these victims usually are overwhelmed with feelings of:
a. Humiliation
b. Confusion
c. Self blame
d. Hatred

7. Joy who has just experienced her second spontaneous abortion expresses anger towards her physician, the hospital and the “rotten nursing care”. When assessing the situation, the nurse recognizes that the client may be using the coping mechanism of:
a. Projection
b. Displacement
c. Denial
d. Reaction formation

8. The most critical factor for nurse Linda to determine during crisis intervention would be the client’s:
a. Available situational supports
b. Willingness to restructure the personality
c. Developmental theory
d. Underlying unconscious conflict

9. Nurse Trish suggests a crisis intervention group to a client experiencing a developmental crisis.These groups are successful because the:
a. Crisis intervention worker is a psychologist and understands behavior patterns
b. Crisis group supplies a workable solution to the client’s problem
c. Client is encouraged to talk about personal problems
d. Client is assisted to investigate alternative approaches to solving the identified problem

10. Nurse Ronald could evaluate that the staff’s approach to setting limits for a demanding, angry client was effective if the client:
a. Apologizes for disrupting the unit’s routine when something is needed
b. Understands the reason why frequent calls to the staff were made
c. Discuss concerns regarding the emotional condition that required hospitalizations
d. No longer calls the nursing staff for assistance

11. Nurse John is aware that the therapy that has the highest success rate for people with phobias would be:
a. Psychotherapy aimed at rearranging maladaptive thought process
b. Psychoanalytical exploration of repressed conflicts of an earlier development phase
c. Systematic desensitization using relaxation technique
d. Insight therapy to determine the origin of the anxiety and fear

12. When nurse Hazel considers a client’s placement on the continuum of anxiety, a key in determining the degree of anxiety being experienced is the client’s:
a. Perceptual field
b. Delusional system
c. Memory state
d. Creativity level

13. In the diagnosis of a possible pervasive developmental autistic disorder. The nurse would find it most unusual for a 3 year old child to demonstrate:
a. An interest in music
b. An attachment to odd objects
c. Ritualistic behavior
d. Responsiveness to the parents

14. Malou with schizophrenia tells Nurse Melinda, “My intestines are rotted from worms chewing on them.” This statement indicates a:
a. Jealous delusion
b. Somatic delusion
c. Delusion of grandeur
d. Delusion of persecution

15. Andy is admitted to the psychiatric unit with a diagnosis of borderline personality disorder. Nurse Hilary should expects the assessment to reveal:
a. Coldness, detachment and lack of tender feelings
b. Somatic symptoms
c. Inability to function as responsible parent
d. Unpredictable behavior and intense interpersonal relationships

16. PROPRANOLOL (Inderal) is used in the mental health setting to manage which of the following conditions?
a. Antipsychotic – induced akathisia and anxiety
b. Obsessive – compulsive disorder (OCD) to reduce ritualistic behavior
c. Delusions for clients suffering from schizophrenia
d. The manic phase of bipolar illness as a mood stabilizer

17. Which medication can control the extra pyramidal effects associated with antipsychotic agents?
a. Clorazepate (Tranxene)
b. Amantadine (Symmetrel)
c. Doxepin (Sinequan)
d. Perphenazine (Trilafon)

18. Which of the following statements should be included when teaching clients about monoamine oxidase inhibitor (MAOI) antidepressants?
a. Don’t take aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs)
b. Have blood levels screened weekly for leucopenia
c. Avoid strenuous activity because of the cardiac effects of the drug
d. Don’t take prescribed or over the counter medications without consulting the physician

19. Kris periodically has acute panic attacks. These attacks are unpredictable and have no apparent association with a specific object or situation. During an acute panic attack, Kris may experience:
a. Heightened concentration
b. Decreased perceptual field
c. Decreased cardiac rate
d. Decreased respiratory rate

20. Initial interventions for Marco with acute anxiety include all except which of the following?
a. Touching the client in an attempt to comfort him
b. Approaching the client in calm, confident manner
c. Encouraging the client to verbalize feelings and concerns
d. Providing the client with a safe, quiet and private place

21. Nurse Jessie is assessing a client suffering from stress and anxiety. A common physiological response to stress and anxiety is:
a. Uticaria
b. Vertigo
c. Sedation
d. Diarrhea

22. When performing a physical examination on a female anxious client, nurse Nelli would expect to find which of the following effects produced by the parasympathetic system?
a. Muscle tension
b. Hyperactive bowel sounds
c. Decreased urine output
d. Constipation

23. Which of the following drugs have been known to be effective in treating obsessive-compulsive disorder (OCD)?
a. Divalproex (depakote) and Lithium (lithobid)
b. Chlordiazepoxide (Librium) and diazepam (valium)
c. Fluvoxamine (Luvox) and clomipramine (anafranil)
d. Benztropine (Cogentin) and diphenhydramine (benadryl)

24. Tony with agoraphobia has been symptom-free for 4 months. Classic signs and symptoms of phobia include:
a. Severe anxiety and fear
b. Withdrawal and failure to distinguish reality from fantasy
c. Depression and weight loss
d. Insomnia and inability to concentrate

25. Which nursing action is most appropriate when trying to diffuse a client’s impending violent behavior?
a. Place the client in seclusion
b. Leaving the client alone until he can talk about his feelings
c. Involving the client in a quiet activity to divert attention
d. Helping the client identify and express feelings of anxiety and anger

26. Rosana is in the second stage of Alzheimer’s disease who appears to be in pain. Which question by Nurse Jenny would best elicit information about the pain?
a. “Where is your pain located?”
b. “Do you hurt? (pause) “Do you hurt?”
c. “Can you describe your pain?”
d. “Where do you hurt?”

27. Nursing preparation for a client undergoing electroconvulsive therapy (ECT) resemble those used for:
a. General anesthesia
b. Cardiac stress testing
c. Neurologic examination
d. Physical therapy

28. Jose who is receiving monoamine oxidase inhibitor antidepressant should avoid tyramine, a compound found in which of the following foods?
a. Figs and cream cheese
b. Fruits and yellow vegetables
c. Aged cheese and Chianti wine
d. Green leafy vegetables

29. Erlinda, age 85, with major depression undergoes a sixth electroconvulsive therapy (ECT) treatment. When assessing the client immediately after ECT, the nurse expects to find:
a. Permanent short-term memory loss and hypertension
b. Permanent long-term memory loss and hypomania
c. Transitory short-term memory loss and permanent long-term memory loss
d. Transitory short and long term memory loss and confusion

30. Barbara with bipolar disorder is being treated with lithium for the first time. Nurse Clint should observe the client for which common adverse effect of lithium?
a. Polyuria
b. Seizures
c. Constipation
d. Sexual dysfunction

31. Nurse Fred is assessing a client who has just been admitted to the ER department. Which signs would suggest an overdose of an antianxiety agent?
a. Suspiciousness, dilated pupils and incomplete BP
b. Agitation, hyperactivity and grandiose ideation
c. Combativeness, sweating and confusion
d. Emotional lability, euphoria and impaired memory

32. Discharge instructions for a male client receiving tricyclic antidepressants include which of the following information?
a. Restrict fluids and sodium intake
b. Don’t consume alcohol
c. Discontinue if dry mouth and blurred vision occur
d. Restrict fluid and sodium intake

33. Important teaching for women in their childbearing years who are receiving antipsychotic medications includes which of the following?
a. Increased incidence of dysmenorrhea while taking the drug
b. Occurrence of incomplete libido due to medication adverse effects
c. Continuing previous use of contraception during periods of amenorrhea
d. Instruction that amenorrhea is irreversible

34. A client refuses to remain on psychotropic medications after discharge from an inpatient psychiatric unit. Which information should the community health nurse assess first during the initial follow-up with this client?
a. Income level and living arrangements
b. Involvement of family and support systems
c. Reason for inpatient admission
d. Reason for refusal to take medications

35. The nurse understands that the therapeutic effects of typical antipsychotic medications are associated with which neurotransmitter change?
a. Decreased dopamine level
b. Increased acetylcholine level
c. Stabilization of serotonin
d. Stimulation of GABA

36. Which of the following best explains why tricyclic antidepressants are used with caution in elderly patients?
a. Central Nervous System effects
b. Cardiovascular system effects
c. Gastrointestinal system effects
d. Serotonin syndrome effects

37. A client with depressive symptoms is given prescribed medications and talks with his therapist about his belief that he is worthless and unable to cope with life. Psychiatric care in this treatment plan is based on which framework?
a. Behavioral framework
b. Cognitive framework
c. Interpersonal framework
d. Psychodynamic framework

38. A nurse who explains that a client’s psychotic behavior is unconsciously motivated understands that the client’s disordered behavior arises from which of the following?
a. Abnormal thinking
b. Altered neurotransmitters
c. Internal needs
d. Response to stimuli

39. A client with depression has been hospitalized for treatment after taking a leave of absence from work. The client’s employer expects the client to return to work following inpatient treatment. The client tells the nurse, “I’m no good. I’m a failure”. According to cognitive theory, these statements reflect:
a. Learned behavior
b. Punitive superego and decreased self-esteem
c. Faulty thought processes that govern behavior
d. Evidence of difficult relationships in the work environment

40. The nurse describes a client as anxious. Which of the following statement about anxiety is true?
a. Anxiety is usually pathological
b. Anxiety is directly observable
c. Anxiety is usually harmful
d. Anxiety is a response to a threat

41. A client with a phobic disorder is treated by systematic desensitization. The nurse understands that this approach will do which of the following?
a. Help the client execute actions that are feared
b. Help the client develop insight into irrational fears
c. Help the client substitutes one fear for another
d. Help the client decrease anxiety

42. Which client outcome would best indicate successful treatment for a client with an antisocial personality disorder?
a. The client exhibits charming behavior when around authority figures
b. The client has decreased episodes of impulsive behaviors
c. The client makes statements of self-satisfaction
d. The client’s statements indicate no remorse for behaviors

43. The nurse is caring for a client with an autoimmune disorder at a medical clinic, where alternative medicine is used as an adjunct to traditional therapies. Which information should the nurse teach the client to help foster a sense of control over his symptoms?
a. Pathophysiology of disease process
b. Principles of good nutrition
c. Side effects of medications
d. Stress management techniques

44. Which of the following is the most distinguishing feature of a client with an antisocial personality disorder?
a. Attention to detail and order
b. Bizarre mannerisms and thoughts
c. Submissive and dependent behavior
d. Disregard for social and legal norms

45. Which nursing diagnosis is most appropriate for a client with anorexia nervosa who expresses feelings of guilt about not meeting family expectations?
a. Anxiety
b. Disturbed body image
c. Defensive coping
d. Powerlessness

46. A nurse is evaluating therapy with the family of a client with anorexia nervosa. Which of the following would indicate that the therapy was successful?
a. The parents reinforced increased decision making by the client
b. The parents clearly verbalize their expectations for the client
c. The client verbalizes that family meals are now enjoyable
d. The client tells her parents about feelings of low-self esteem

47. A client with dysthymic disorder reports to a nurse that his life is hopeless and will never improve in the future. How can the nurse best respond using a cognitive approach?
a. Agree with the client’s painful feelings
b. Challenge the accuracy of the client’s belief
c. Deny that the situation is hopeless
d. Present a cheerful attitude

48. A client with major depression has not verbalized problem areas to staff or peers since admission to a psychiatric unit. Which activity should the nurse recommend to help this client express himself?
a. Art therapy in a small group
b. Basketball game with peers on the unit
c. Reading a self-help book on depression
d. Watching movie with the peer group

49. The home health psychiatric nurse visits a client with chronic schizophrenia who was recently discharged after a prolong stay in a state hospital. The client lives in a boarding home, reports no family involvement, and has little social interaction. The nurse plan to refer the client to a day treatment program in order to help him with:
a. Managing his hallucinations
b. Medication teaching
c. Social skills training
d. Vocational training

50. Which activity would be most appropriate for a severely withdrawn client?
a. Art activity with a staff member
b. Board game with a small group of clients
c. Team sport in the gym
d. Watching TV in the dayroom







































Answers and Rationale Psychiatric Nursing Part 2


1. B. There is no set of symptoms associated with cocaine withdrawal, only the depression that follows the high caused by the drug.
2. A. Cocaine is a chemical that when inhaled, causes destruction of the mucous membranes of the nose.
3. D. These adaptations are associated with opiate withdrawal which occurs after cessation or reduction of prolonged moderate or heavy use of opiates.
4. B. Whether there is a suicide plan is a criterion when assessing the client’s determination to make another attempt.
5. A. Rapists are believed to harbor and act out hostile feelings toward all women through the act of rape.
6. C. These children often have nonsexual needs met by individual and are powerless to refuse.Ambivalence results in self-blame and also guilt.
7. B. The client’s anger over the abortion is shifted to the staff and the hospital because she is unable to deal with the abortion at this time.
8. A. Personal internal strength and supportive individuals are critical factors that can be employed to assist the individual to cope with a crisis.
9. D. Crisis intervention group helps client reestablish psychologic equilibrium by assisting them to explore new alternatives for coping. It considers realistic situations using rational and flexible problem solving methods.
10. C. This would document that the client feels comfortable enough to discuss the problems that have motivated the behavior.
11. C. The most successful therapy for people with phobias involves behavior modification techniques using desensitization.
12. A. Perceptual field is a key indicator of anxiety level because the perceptual fields narrow as anxiety increases.
13. D. One of the symptoms of autistic child displays a lack of responsiveness to others. There is little or no extension to the external environment.
14. B. Somatic delusions focus on bodily functions or systems and commonly include delusion about foul odor emissions, insect manifestations, internal parasites and misshapen parts.
15. D. A client with borderline personality displays a pervasive pattern of unpredictable behavior, mood and self image. Interpersonal relationships may be intense and unstable and behavior may be inappropriate and impulsive.
16. A. Propranolol is a potent beta adrenergic blocker and producing a sedating effect, therefore it is used to treat antipsychotic induced akathisia and anxiety.
17. B. Amantadine is an anticholinergic drug used to relive drug-induced extra pyramidal adverse effects such as muscle weakness, involuntary muscle movements, pseudoparkinsonism and tar dive dyskinesia.
18. D. MAOI antidepressants when combined with a number of drugs can cause life-threatening hypertensive crisis. It’s imperative that a client checks with his physician and pharmacist before taking any other medications.
19. B. Panic is the most severe level of anxiety. During panic attack, the client experiences a decrease in the perceptual field, becoming more focused on self, less aware of surroundings and unable to process information from the environment. The decreased perceptual field contributes to impaired attention andinability to concentrate.
20. A. The emergency nurse must establish rapport and trust with the anxious client before using therapeutic touch. Touching an anxious client may actually increase anxiety.
21. D. Diarrhea is a common physiological response to stress and anxiety.
22. B. The parasympathetic nervous system would produce incomplete G.I. motility resulting in hyperactive bowel sounds, possibly leading to diarrhea.
23. C. The antidepressants fluvoxamine and clomipramine have been effective in the treatment of OCD.
24. A. Phobias cause severe anxiety (such as panic attack) that is out of proportion to the threat of the feared object or situation. Physical signs and symptoms of phobias include profuse sweating, poor motor control, tachycardia and elevated B.P.
25. D. In many instances, the nurse can diffuse impending violence by helping the client identify and express feelings of anger and anxiety. Such statement as “What happened to get you this angry?” may help the client verbalizes feelings rather than act on them.
26. B. When speaking to a client with Alzheimer’s disease, the nurse should use close-ended questions.Those that the client can answer with “yes” or “no” whenever possible and avoid questions that require the client to make choices. Repeating the question aids comprehension.
27. A. The nurse should prepare a client for ECT in a manner similar to that for general anesthesia.
28. C. Aged cheese and Chianti wine contain high concentrations of tyramine.
29. D. ECT commonly causes transitory short and long term memory loss and confusion, especially in geriatric clients. It rarely results in permanent short and long term memory loss.
30. A. Polyuria commonly occurs early in the treatment with lithium and could result in fluid volume deficit.
31. D. Signs of anxiety agent overdose include emotional lability, euphoria and impaired memory.
32. B. Drinking alcohol can potentiate the sedating action of tricyclic antidepressants. Dry mouth and blurred vision are normal adverse effects of tricyclic antidepressants.
33. C. Women may experience amenorrhea, which is reversible, while taking antipsychotics. Amenorrhea doesn’t indicate cessation of ovulation thus, the client can still be pregnant.
34. D. The first are for assessment would be the client’s reason for refusing medication. The client may not understand the purpose for the medication, may be experiencing distressing side effects, or may be concerned about the cost of medicine. In any case, the nurse cannot provide appropriate intervention before assessing the client’s problem with the medication. The patient’s income level, living arrangements, and involvement of family and support systems are relevant issues following determination of the client’s reason for refusing medication. The nurse providing follow-up care would have access to the client’s medical record and should already know the reason for inpatient admission.
35. A. Excess dopamine is thought to be the chemical cause for psychotic thinking. The typical antipsychotics act to block dopamine receptors and therefore decrease the amount of neurotransmitter at the synapses. The typical antipsychotics do not increase acetylcholine, stabilize serotonin, stimulate GABA.
36. B. The TCAs affect norepinephrine as well as other neurotransmitters, and thus have significant cardiovascular side effects. Therefore, they are used with caution in elderly clients who may have increased risk factors for cardiac problems because of their age and other medical conditions. The remaining side effects would apply to any client taking a TCA and are not particular to an elderly person.
37. B. Cognitive thinking therapy focuses on the client’s misperceptions about self, others and the world that impact functioning and contribute to symptoms. Using medications to alter neurotransmitter activity is a psychobiologic approach to treatment. The other answer choices are frameworks for care, but hey are not applicable to this situation.
38. C. The concept that behavior is motivated and has meaning comes from the psychodynamic framework. According to this perspective, behavior arises from internal wishes or needs. Much of what motivates behavior comes from the unconscious. The remaining responses do not address the internal forces thought to motivate behavior.
39. C. The client is demonstrating faulty thought processes that are negative and that govern his behavior in his work situation – issues that are typically examined using a cognitive theory approach. Issues involving learned behavior are best explored through behavior theory, not cognitive theory. Issues involving ego development are the focus of psychoanalytic theory. Option 4 is incorrect because there is no evidence in this situation that the client has conflictual relationships in the work environment.
40. D. Anxiety is a response to a threat arising from internal or external stimuli.
41. A. Systematic desensitization is a behavioral therapy technique that helps clients with irrational fears and avoidance behavior to face the thing they fear, without experiencing anxiety. There is no attempt to promote insight with this procedure, and the client will not be taught to substitute one fear for another. Although the client’s anxiety may decrease with successful confrontation of irrational fears, the purpose of the procedure is specifically related to performing activities that typically are avoided as part of the phobic response.
42. B. A client with antisocial personality disorder typically has frequent episodes of acting impulsively with poor ability to delay self-gratification. Therefore, decreased frequency of impulsive behaviors would be evidence of improvement. Charming behavior when around authority figures and statements indicating no remorse are examples of symptoms typical of someone with this disorder and would not indicate successful treatment. Self-satisfaction would be viewed as a positive change if the client expresses low self-esteem; however this is not a characteristic of a client with antisocial personality disorder.
43. D. In autoimmune disorders, stress and the response to stress can exacerbate symptoms. Stress management techniques can help the client reduce the psychological response to stress, which in turn will help reduce the physiologic stress response. This will afford the client an increased sense of control over his symptoms. The nurse can address the remaining answer choices in her teaching about the client’s disease and treatment; however, knowledge alone will not help the client to manage his stress effectively enough to control symptoms.
44. D. Disregard for established rules of society is the most common characteristic of a client with antisocial personality disorder. Attention to detail and order is characteristic of someone with obsessive compulsive disorder. Bizarre mannerisms and thoughts are characteristics of a client with schizoid or schizotypal disorder. Submissive and dependent behaviors are characteristic of someone with a dependent personality.
45. D. The client with anorexia typically feels powerless, with a sense of having little control over any aspect of life besides eating behavior. Often, parental expectations and standards are quite high and lead to the clients’ sense of guilt over not measuring up.
46. A. One of the core issues concerning the family of a client with anorexia is control. The family’s acceptance of the client’s ability to make independent decisions is key to successful family intervention. Although the remaining options may occur during the process of therapy, they would not necessarily indicate a successful outcome; the central family issues of dependence and independence are not addresses on these responses.
47. B. Use of cognitive techniques allows the nurse to help the client recognize that this negative beliefs may be distortions and that, by changing his thinking, he can adopt more positive beliefs that are realistic and hopeful. Agreeing with the client’s feelings and presenting a cheerful attitude are not consistent with a cognitive approach and would not be helpful in this situation. Denying the client’s feelings is belittling and may convey that the nurse does not understand the depth of the client’s distress.
48. A. Art therapy provides a nonthreatening vehicle for the expression of feelings, and use of a small group will help the client become comfortable with peers in a group setting. Basketball is a competitive game that requires energy; the client with major depression is not likely to participate in this activity. Recommending that the client read a self-help book may increase, not decrease his isolation. Watching movie with a peer group does not guarantee that interaction will occur; therefore, the client may remain isolated.
49. C. Day treatment programs provide clients with chronic, persistent mental illness training in social skills, such as meeting and greeting people, asking questions or directions, placing an order in a restaurant, taking turns in a group setting activity. Although management of hallucinations and medication teaching may also be part of the program offered in a day treatment, the nurse is referring the client in this situation because of his need for socialization skills. Vocational training generally takes place in a rehabilitation facility; the client described in this situation would not be a candidate for this service.
50. A. The best approach with a withdrawn client is to initiate brief, nondemanding activities on a one-to-one basis. This approach gives the nurse an opportunity to establish a trusting relationship with the client. A board game with a group clients or playing a team sport in the gym may overwhelm a severely withdrawn client. Watching TV is a solitary activity that will reinforce the client’s withdrawal from others.

psych: common manifestations

 Assessment of Motor Ability
 Automatism: repeated, purposeless behaviors often indicative of anxiety such as drumming
 fingers, twisting locks of hair, or tapping the foot
 Psychomotor retardation: overall slowed movements
 Waxy flexibility: maintenance of posture or position over time even when it is awkward or uncomfortable



 Assessment of Mood and Affect
 Blunted affect: showing little or a slow-to respond facial expression
 Broad affect: displaying a full range of emotional expressions
 Flat affect: showing no facial expression
 Inappropriate affect: displaying a facial expression that is incongruent with mood or situation; often silly or giddy regardless of circumstances
 Restricted affect: displaying one type of expression, usually serious or somber
 Labile mood – mood that is unpredictable and rapidly changing


 Assessment of thought process and content
 Circumstantial thinking: term used when a client eventually answers a question but only after giving excessive unnecessary detail
 Flight of ideas: excessive amount and rate of speech composed of fragmented or unrelated ideas
 Loose associations: disorganized thinking that jumps from one idea to another with little or no evident relation between the thoughts
 Tangential thinking: wandering off the topic and never providing the information requested
 Thought blocking: stopping abruptly in the middle of a sentence or train of thought; sometimes unable to continue the idea
 Thought broadcasting: a delusional belief that others can hear or know what the client is thinking
 Thought insertion: a delusional belief that others are putting ideas or thoughts into the client’s head—that is, the ideas are not those of the client
 Thought withdrawal: a delusional belief that others are taking the client’s thoughts away and the client is powerless to stop it
 Word salad: flow of unconnected words that convey no meaning to the listener
 Hallucination-
 Illusions-
 Delusion: a fixed, false belief not based in reality
o Somatic delusion- false belief involving functioning of the body
o Delusion of grandeur- a person’s exaggerated conception of his importance, power or identity (ex: I am Napoleon)

psych: aggressive client

Anger

- A normal human behavior or emotion
- A strong and uncomfortable emotional response to a real or perceived provocation
- Positive force leading to problem solving and productive change when appropriately handled
- Potentially destructive and life-threatening when inappropriately channeled (denial, suppression)

• Catharsis
o Expression of anger through aggressive but safe means like hitting a punching bag and yelling
o Increases anger rather than alleviating

• Assertive Communication
o Use of word “I” in accepting one’s anger
 Example
• I am angry about your constant nagging.

Anger Control versus Anger Suppression

Anger Control
• Utilizing Assertive communication
• Use of non-aggressive means like walking or talking

Anger Suppression
• Common in women
• Prevents the expression of anger and keeping it
• Prone to somatic and psychological complications


Hostility

- Also known as verbal aggression
- An emotion expressed through verbal abuse, uncooperativeness, threatening behaviors, and lack of concern for laws and norms
- Expressed when threatened or powerless
- Intended to intimidate


Passive Aggressiveness/ Passivity

- Indirect and subtle expression of anger toward others
- People who are afraid of rejection or punishment


Intermittent Explosive Disorder

- Aggression as its main symptom
- An impulse control disorder
- Failure to resist aggressive impulses
- Aggressive episodes are out of proportion
- Behavior is not caused by a physiologic effect or drugs


Etiology

- Serotonin, GABA, and Dopamine derangements
- Brain Damages and trauma
- Alzheimer’s
- Hormonal Imbalances
- Dementia
- Alcohol or Drug Abuse
- Nutritional Deficiencies
- Medication Non-Compliance


Best Predictors of Potential Violent Behavior:
1. Excessive alcohol intake
2. History of violent acts, with arrests or criminal activity
3. History of childhood abuse.

Signs of Impending Violence:
1. Recent acts of violence inc. property violence
2. Verbal and physical threats.
3. Carrying weapons or other objects that may be used as weapons.
4. Progressive psychomotor agitation.
5. Alcohol or other substance intoxication.
6. Paranoid features in a psychotic patient.
7. Command violent auditory hallucinations.
8. Brain diseases
9. Catatonic excitement
10. Certain manic episodes
11. Certain agitated depressive episodes
12. Personality disorders

PSYCHOTHERAPY

 Empathy is critical to healing.
 Note vulnerability of selected close relatives.
 No single approach is appropriate for all persons in similar situations.


When you don’t know what to say, the best approach is to LISTEN.
PHARMACOTHERAPY

 Major indications for the use of psychotropic medication:
1. violent and assaultive behavior
2. massive anxiety/panic

Onset and Clinical Course

- Sudden and explosive
- Often in 5 stages known as the assault or aggression cycle
- Triggering and Escalation Phases are the most critical stages for preventing physical aggression


Use of Restraints:
 Preferably five or a minimum of four persons should be used to restrain the patient. Leather restraints are the safest and surest type of restraint.
 Explain to the patient why he or she is going into restraints.
 A staff member should always be visible and reassuring the patient who is being restrained.
 Patients should be restrained with legs spread-eagled and one arm restrained to one side and the other arm restrained over the patient's head.
 Restraints should be placed so that intravenous fluids can be given, if necessary.
 The patient's head is raised slightly to decrease the patient's feelings of vulnerability and to reduce the possibility of aspiration.
 The restraints should be checked periodically for safety and comfort.
After the patient is in restraints, the clinician begins treatment, using verbal intervention.
 Even in restraints, most patients still take antipsychotic medication in concentrated form.
 After the patient is under control, one restraint at a time should be removed at 5-minute intervals until the patient has only two restraints on. Both of the remaining restraints should be removed at the same time, because it is inadvisable to keep a patient in only one restraint.
 Always thoroughly document the reason for the restraints, the course of treatment, and the patient's response to treatment while in restraints.

psych: communication

THERAPEUTIC COMMUNICATION

Communication

- Interaction between two or more people involving exchange of information between the sender and receiver
- The product of communication is message interpreted by the receiver
- Channels of communication: Verbal and Nonverbal


Verbal Communication

- Use of words. Content and context of words should be assessed
1. Written – ex: documents, mail, e-mail, records, text messaging
- Considerations: language, grammar, legibility of hand writing,
2. Spoken – consider: timbre and tone, rate and emphasis of speech, body language, mannerisms, emotion


Nonverbal Communication

- Monitor if congruent and incongruent to spoken words.
1. Kinesthetic/ gestures
2. Proxemics -
Distance zones (Hall 1966)
• Intimate zone: 0-18 inches
• Personal zone: 18-36 inches
• Social zone: 4-12 feet, therapeutic relationship happens
• Public zone:12-25 feet, sender and receiver remains strangers
3. Touch
5 types of touch (Knapp 1980)
• Functional professional
• Social polite
• Friendship warmth
• Love intimacy
• Sexual arousal

4. Cultural artifacts
5. Position – sitting position, posture
6. Physical appearance
7. Facial expressions
8. Vocal cues



Therapeutic Communication

- Focuses on the client needs and problems
- It is planned and directed
- Confidentiality is respected but information the professional nurse must share information to the treatment team



How to develop therapeutic communication skills?

1. Know yourself
2. Be honest
3. Be secure in ability to relate to people- don’t let behavior of others threaten or intimidate you
4. Be sensitive to the needs of others
5. Be consistent
6. Recognize symptoms of anxiety
7. Watch your nonverbal movements
8. Use words carefully
9. Recognize differences
10. Recognize and evaluate your actions and responses

Psych: nurse-cclient relationship

The Therapeutic Nurse-Client Relationship (NCR)

-essential for attaining positive behavioral change

Characteristics

• Goal Directed
• Focused on the need of the patient
• Planned
• Time limited
• Professional


Components of Therapeutic Relationships

• Trust
• Friendliness
• Caring
• Interest
• Understanding
• Consistency
• Treating the client as a human being
• Suggesting without telling
• Approachability
• Listening
• Keeping promises
• Providing schedules of activities
• Honesty

• Genuine interest
• Empathy
• Acceptance
• Positive regards


Self Awareness and Therapeutic Use of Self

- To be able to use self as a therapeutic agent, nurses should be aware of their own self.
- This includes values, beliefs, attitudes, motivations, prejudice, strengths and weaknesses
- A nurse who successfully evaluated and accepted self will have better relationship with clients
- One tool that is useful in learning oneself is Johari’s Window



PHASES OF NURSE- CLIENT RELATIONSHIP (NCR)


A. Pre-interaction/Pre-orientation (For the Nurse)

- the core value and major goal of a nurse is self awareness
- begins when the client is assigned to the nurse
- includes gathering of data, planning for interaction
- nurse may feel little anxiety like in planning an interview


B. ORIENTATION (INITIATION)

- Begins when the nurse meets the client
- The nurse establish roles, the purpose of the meeting, the parameters of the subsequent meeting, assess/identifies the client’s problem, needs and clarifies expectations
- Levels of anxiety of both the nurse and client are identified
- The major goal in this stage is establishing rapport
- Set goals of relationship. –Contracts-
- Define responsibilities of nurse and client. Stage of testing.
- Establish boundaries of relationship. Stress confidentiality.
- The start of termination phase: “Good morning, full name, RN, shift, session, date start & end.”

ESSENTIAL ELEMENTS OF A NURSE- CLIENT CONTRACT
1. Names of RN and patient 5. Purpose of a relationship
2. Roles of RN and patient 6. Meeting location / time
3. Responsibilities of RN and patient 7. Condition for termination
4. Goals / Expectations 8. Confidentiality




C. WORKING PHASE

 Highly individualize
 The most difficult and the longest phase
 Promote acceptance of each other
 Major task is identification and resolution of the client’s problem
 Accept client as having value and worth as a unique individual.
 Most problems encountered are resistance, transference and counter transference
 NCP is a continuing process
- Identification of the problem/exploration
- The Core Value is Consistency especially for manipulative patients
Be consistent to patient with: BAAAM COPS
B orderline C onduct d/o
A ntisocial O ral/eating disorder
A lzheimer’s P aranoid
A utistic S uicidal
M anic

TASK:

1. Maintaining the professional, therapeutic relationship
2. Gathering more data- recognize blocks to communications
3. Exploring perceptions of reality and keeping interactions reality oriented
4. Developing positive coping skills
5. Promoting positive self concept -reflection of feelings
6. Encouraging verbalization of feelings- by active listening
7. Facilitating behavior change
8. Working through resistance
9. Evaluating progress
10. Practice new coping behaviors
11. Promoting independence


D. TERMINATION
 Plan for termination of relationship: orientation phase
 Begins when problems are solved
 It is a weaning process
 Major task is to assist the client in reviewing what has learned and applying it to interpersonal relationships
- Separation Anxiety:
S/Sx: Regression: Temper tantrums, thumb sucking, apathy, fetal position when crying.

- Evaluation
 Maintain boundaries do not give address and telephone numbers
 Be firm and professional
 Don’t promise that relationship will continue
 Anticipate problems of termination:
 Dependency on the nurse
 Recalling of past negative experiences like rejection, depression, abandonment,
 Regressive behaviors may surface

psych: legal issues

Legal Issues

Commitment Issues

- Concerns with the admission in the hospital

1. Voluntary commitment

• client seeks help or requests the admission voluntarily
• signs consent for treatment
• may refuse any treatment prescribed
• if ready, they may also sign themselves out of the facility
• AMA or involuntary confinement may be issued if the client is assessed to still be needing further treatment


2. Involuntary commitment

• Client has legal capacity to consent to treatment but refuses to do so
• Client is unable to determine the need for examination
• Greatly disabled
• Impose threat to himself or others
• Common categories:
(1) Evaluation and emergency care – 48 to 72 hrs
(2) Certification for observation and treatment
(3) Extended or indeterminate care- needs prolonged psychiatric care typically for 60-180 days

Conservatorship

 Also called guardianship
 Conservators are legally obligated to act in the best interest of their conservatee
 Included are signing of informed consent, contracts, writing of checks, deciding on treatment modalities
 Nurse must gain consent from conservator to prevent legal consequences
 Criteria for having a conservator:
• Gravely disabled
• Unable to provide basic needs although resources exists
• Cannot act in their best own interest
• Incompetent



Patient’s Rights
1. Right to treatment using the least restrictive alternative/environment
• means that the client does not have to hospitalized if they are able to be treated in outpatient basis
2. Right to confidentiality
3. Right to freedom from restrain and seclusion
• restrain- direct application of physical force against will to restrict freedom
• Human or mechanical restrain
• seclusion- involuntary confinement to a specially constructed room with lock, window or camera
• short term use of restrain and seclusion are used only if the client becomes aggressive to himself or environment
• requires physician’s order every 12 hours
• assessed by nurses every 2-4 hours
• checks every 10-15 minutes for skin condition, blood circulation, side effects of medications and emotion
• nurse can approve seclusion and restrain in emergency situations if no physician is available but the client must be seen within 4hours
• document everything especially:
a. type of restraint
b. reason of restraint
c. length of restraint
d. observation to maintain safety
4. Right to give or refuse consent to treatment
5. Right to access to personal belongings
6. Right to daily exercise
7. Right to have visitors
8. Right to use writing materials and uncensored mail
9. Right to use the telephone
10. Right to access courts and attorneys
11. Right to employment compensation
12. Right to be informed of rights
13. Right to refuse electroconvulsive therapy or psychotherapy


Nursing Liability
 Nurses are expected to met the standards of care
 Torts – is a wrongful act which results to injury, damages or losses
 Two types of torts: unintentional and intentional
A. Unintentional – failure to do reasonable and prudent person would do in similar situation
• Negligence - involves causing of harm by failing to do what a reasonable and prudent person would do in a similar condition.
• Elements: 1. duty to care, 2. An obligation of reasonable care, 3. Breach of duty, 4. Actual injury resulting from breach of duty
• Malpractice – is negligence that refers specifically to professionals like nurses and physicians
B. Intentional – voluntary act that cause harm to client
• Assault- involves any action that causes a person to fear being touched in a way that is offensive, insulting, or physically injurious without consent or authority
• Battery- involves harmful or not consented contact with the client wherein harm or injury may or may not have happened
• False Imprisonment- defined as the unjustifiable detention of a person examples are inappropriate use of restraint and seclusion

o Ethical Issues
• Important aspects in caring for any client. This may cause conflicts between clients and the medical team
• Ethical issues includes:
a. Utilitarianism
b. Beneficence
c. Nonmaleficence
d. Justice
e. Fidelity
f. Veracity



o Duty to Warn

• Includes threat to self and others
• Tarasoff vs the reagents of University of California
• Nurse should warn the significant others if client’s is seen to have plans of committing suicide
• Also nurses have the responsibility to warn individuals that the client threats to hurt



o Insanity Defense
• M’Naghten rule
• Is an argument that a person accused of a crime is not guilty because that person cannot understand the nature and implications of their actions and is not able to determine between right and wrong
• Upon meeting the criteria, a person may have a verdict of “guilty by reason of insanity”


Patient’s Bill of Rights
1. The patient has the right to considerate and respectful care.
2. The patient has the right and is encouraged to obtain from physicians and other direct caregivers relevant, current, and understandable information concerning diagnosis, treatment, and prognosis.
3. The patient has the right to make decisions about the plan of care prior to and during the course of treatment and to refuse a recommended treatment or plan of care to the extent permitted by law and hospital policy and to be informed of medical consequences of this action. In case of such refusal, the patient is entitled to other appropriate care and services that the hospital provides, or transfer to another hospital. The hospital should notify patients of any policy that might affect patient choice within the institution.
4. The patient has the right to have an advance directive (such as a living will, health care proxy, or durable power of attorney for health care) concerning treatment, with the expectation that the hospital will honor the intent of that directive to the extent permitted by law and hospital policy.
5. The patient has the right to every consideration of privacy. Case discussion, consultation, examination, and treatment should be conducted so as to protect each patient’s privacy.
6. The patient has the right to expect that all communications and records pertaining to his or her care will be treated as confidential by the hospital, except in cases such as suspected abuse and public health hazards, when reporting is permitted or required by law. The patient has the right to expect that the hospital will emphasize the confidentiality of this information when it releases it to any other parties entitled to review information in these records.
7. The patient has the right to review the records pertaining to his or her medical care and to have the information explained or interpreted as necessary, except when restricted by law.
8. The patient has the right to expect that, within its capacities and policies, a hospital will make a reasonable response to the request of a patient for appropriate and medically indicated care and services.
9. The patient has the right to ask and be informed of the existence of business relationships among the hospital, educational institutions, other health care providers, or payers that may influence the patient’s treatment and care.
10. The patient has the right to consent or decline to participate in proposed research studies or human experimentation affecting care and treatment or requiring direct patient involvement, and to have those studies fully explained prior to consent. A patient who declines to participate in research or experimentation is entitled to the most effective care that the hospital can otherwise provide.
11. The patient has the right to expect reasonable continuity of care when appropriate and to be informed by physicians and other caregivers of available and realistic patient care options when hospital care is no longer appropriate.
12. The patient has the right to be informed of hospital policies and practices that relate to patient care, treatment, and responsibilities. The patient has the right to be informed of available resources for resolving disputes, grievances, and conflicts, such as ethics committees, patient representatives, or other mechanisms available in the institution. The patient has the right to be informed of the hospital’s charges for services and available payment methods.
 American Hospital Association. (1992). A patient’s bill of rights. Chicago: AHA

American Nurses Association Code of Ethics for Nurses
1. The nurse, in all professional relationships, practices with compassion and respect for the inherent dignity, worth, and uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems.
2. The nurse’s primary commitment is to the patient, whether an individual, family, group, or community.
3. The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient.
4. The nurse is responsible and accountable for individual nursing practice and determines the appropriate delegation of tasks consistent with the nurse’s obligation to provide optimum patient care.
5. The nurse owes the same duties to self as to others, including the responsibility to preserve integrity and safety, to maintain competence, and to continue personal and professional growth.
6. The nurse participates in establishing, maintaining, and improving health care environments and conditions of employment conducive to the provision of quality health care and consistent with the values of the profession through individual and collective action.
7. The nurse participates in the advancement of the profession through contributions to practice, education, administration, and knowledge development.
8. The nurse collaborates with other health professionals and the public in promoting community, national, and international efforts to meet health needs.
9. The profession of nursing, as represented by associations and their members, is responsible for articulating nursing values, for maintaining the integrity of the profession and its practice, and for shaping social policy.

psych:mental health

MENTAL HEALTH AND MENTAL ILLNESS


Mental Health

 World Health Organization defines mental health as "a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community”

 in contact with reality and the environment in ways that are in accord with oneself and possess the ability to love, work and resolve conflicts within a framework of reasonability

 A state of emotional, psychological and social wellness evidenced by satisfying interpersonal relationships, effective behavior and coping, positive self concept and emotional stability

 Simultaneous success at working, loving and creating with the capacity for mature and flexible resolutions of conflicts between instincts, conscience and important other people and reality (American Psychiatric Association, 1980)


Mental Illness

 State of imbalance characterized by a disturbance in the persons thoughts, feelings, and behavior.

 A clinically significant behavioral or psychological syndrome or pattern the occurs in an individual and that is associated with present distress or disability or with a significantly increased risk of suffering, death, pain, disability or important loss of freedom

 Not limited to relations between person and society


Incidence and Prevalence of Mental Health
• 5.7% of American adults over the age of 18 have a serious mental disorder in any 12 month period
• 25% of Americans are affected by mental and addictive disorders each year
• Anxiety disorders accounts as having the highest percentages of mental illness
Elements of Mental Health


1. self-acceptance/self-esteem
2. perceives reality accurately
3. personal growth / achieves a unifying, integrated outlook in life
4. sense purpose and meaning- maximizes one’s potential
5. positive relations with others
6. environmental mastery
7. autonomy or self-determination



Factors that Influence Mental Health


1. inherited characteristics
2. nurturing during childhood
3. life circumstances
4. interpersonal
5. sociocultural



General Causes of Mental Disorders

1. Biological
a. Genetic theory- temperament
b. Neurotransmitter- dopamine is associated with schizophrenia
c. Brain abnormality- post traumatic stress syndrome
d. Age
e. Gender
f. Physical illness

2. Psychological
a. Coping skills, interpersonal relationships
b. Early childhood experiences

3. Psychosocial / sociocultural
a. Poverty and deprivation
b. role overload
c. relocation and culture shock

Diagnosis of Mental Illness
• Health History
o current symptoms and previous history or mental disturbances
o current and previous role and social functioning
o suicide
o history from significant others

• Physical Examination
o History and PE should be comprehensive to rule out treatable physical illness
o Includes neurologic assessment

• Diagnostics
o No specific diagnostic tests for diagnosing a specific mental illness
o Therapeutic drug levels may be ordered throughout the course of treatment
o Brain Imaging, CT scan, MRI, Electrocephalogram may be acquired


 DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS 4TH EDITION

• DSM-IV-TR
• Published by the American Psychiatric Association
• Provides a common language for mental health professionals
• Lists of specific criteria necessary for assignment of a special mental disorder diagnosis

psych: aggressive

Anger

- A normal human behavior or emotion

- A strong and uncomfortable emotional response to a real or perceived provocation

- Positive force leading to problem solving and productive change when appropriately handled

- Potentially destructive and life-threatening when inappropriately channeled (denial, suppression)

· Catharsis

o Expression of anger through aggressive but safe means like hitting a punching bag and yelling

o Increases anger rather than alleviating

· Assertive Communication

o Use of word “I” in accepting one’s anger

§ Example

· I am angry about your constant nagging.

Anger Control versus Anger Suppression

Anger Control

· Utilizing Assertive communication

· Use of non-aggressive means like walking or talking

Anger Suppression

· Common in women

· Prevents the expression of anger and keeping it

· Prone to somatic and psychological complications

Hostility

- Also known as verbal aggression

- An emotion expressed through verbal abuse, uncooperativeness, threatening behaviors, and lack of concern for laws and norms

- Expressed when threatened or powerless

- Intended to intimidate

Passive Aggressiveness/ Passivity

- Indirect and subtle expression of anger toward others

- People who are afraid of rejection or punishment

Intermittent Explosive Disorder

- Aggression as its main symptom

- An impulse control disorder

- Failure to resist aggressive impulses

- Aggressive episodes are out of proportion

- Behavior is not caused by a physiologic effect or drugs

Etiology

- Serotonin, GABA, and Dopamine derangements

- Brain Damages and trauma

- Alzheimer’s

- Hormonal Imbalances

- Dementia

- Alcohol or Drug Abuse

- Nutritional Deficiencies

- Medication Non-Compliance

Best Predictors of Potential Violent Behavior:

1. Excessive alcohol intake
2. History of violent acts, with arrests or criminal activity
3. History of childhood abuse.

Signs of Impending Violence:

1. Recent acts of violence inc. property violence
2. Verbal and physical threats.
3. Carrying weapons or other objects that may be used as weapons.
4. Progressive psychomotor agitation.
5. Alcohol or other substance intoxication.
6. Paranoid features in a psychotic patient.
7. Command violent auditory hallucinations.
8. Brain diseases
9. Catatonic excitement
10. Certain manic episodes
11. Certain agitated depressive episodes
12. Personality disorders

PSYCHOTHERAPY

l Empathy is critical to healing.

l Note vulnerability of selected close relatives.

l No single approach is appropriate for all persons in similar situations.

When you don’t know what to say, the best approach is to LISTEN.

PHARMACOTHERAPY

l Major indications for the use of psychotropic medication:

1. violent and assaultive behavior

2. massive anxiety/panic

Onset and Clinical Course

- Sudden and explosive

- Often in 5 stages known as the assault or aggression cycle

- Triggering and Escalation Phases are the most critical stages for preventing physical aggression

Use of Restraints:

Ø Preferably five or a minimum of four persons should be used to restrain the patient. Leather restraints are the safest and surest type of restraint.

Ø Explain to the patient why he or she is going into restraints.

Ø A staff member should always be visible and reassuring the patient who is being restrained.

Ø Patients should be restrained with legs spread-eagled and one arm restrained to one side and the other arm restrained over the patient's head.

Ø Restraints should be placed so that intravenous fluids can be given, if necessary.

Ø The patient's head is raised slightly to decrease the patient's feelings of vulnerability and to reduce the possibility of aspiration.

Ø The restraints should be checked periodically for safety and comfort.
After the patient is in restraints, the clinician begins treatment, using verbal intervention.

Ø Even in restraints, most patients still take antipsychotic medication in concentrated form.

Ø After the patient is under control, one restraint at a time should be removed at 5-minute intervals until the patient has only two restraints on. Both of the remaining restraints should be removed at the same time, because it is inadvisable to keep a patient in only one restraint.

Ø Always thoroughly document the reason for the restraints, the course of treatment, and the patient's response to treatment while in restraints.