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Part (3): matching

Benha University

Faculty of nursing
Fourth year final exam- second semester

Course title: psychiatric and mental health nursing
Time allowed: 3 hours Multiple-choice questions Define the following Fill in the blanks Part (1): Read the following Multiple-choice and circle the
best answer: (15 marks)
Which of the following matches the definition of: "response to
severe emotion stress resulting in involuntary disturbance of
physical functions"
A. . Conversion disorder B. Depressive reaction C. Bipolar disorder D. Alzheimer's disease 2- Which of the following describes a person using words that have
no known meaning?
A. Neologisms D. Delusional blocking 3-Freud stresses out that the ego is the part of personality which:
A. Distinguishes between things in the mind and things in the B. Moral arm of the personality that strives for perfection than C. Reservoir of instincts and drives D. Controls the physical needs instincts. 4- All of the following are examples of alteration of perception

A. Ideas of reference B. Flight of ideas C. Illusion D. Hallucination
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. 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 7. 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 8. When teaching Mario with atypical depression about foods to
avoid while taking pheneizine (Nardil), which of the following the
nurse is charge include?

A. Aroasted chicken B. fresh fish C. Salami D. hamburger 9. The nurse is caring for a client who is suicidal. When
accompanying the client to the bathroom, the nurse should:

A. Give him privacy in the bathroom B. Allow him to shave C. Open the window and allow him to get some fresh air D. Observe him 10-After 3 days of taking haloperidol, the client shows an inability to
sit still, is restless and fidgety, and paces around the unit. Of the
following Extrapyramidal adverse reactions, the client is showing
signs of:

A. Dystonia B. Akathisia C. Parkinsonism. D. Tardive dyskinesia.
11-A client tells the nurse that the television newscaster is sending a
secret message to her. The nurse suspects the client is experiencing:

A. A delusion. B. Flight of ideas. C. Ideas of reference. D. A hallucination. 12. The nurse is caring for a client with manic depression. The care
plan for a client in a manic state would include:

A. Offering high-calorie meals and strongly encouraging the client to finish all food. B. Insisting that the clients remain active throughout the day so That he'll sleep at night. C. Allowing the client to exhibit hyperactive, demanding, manipulative behavior without setting limits. D. Listening attentively with a neutral attitude and avoiding power struggles. 13. A 22-year-old client is diagnosed with dependent personality
disorder. Which behavior is most likely evidence of ineffective
individual coping?

A. Inability to make choices and decisions without advice B. Showing interest only in solitary activities C. Avoiding developing relationships D. Recurrent self-destructive behavior with history of depression 14. A client with bipolar disorder is being treated with lithium for the
first time. The nurse should observe the client for which common
adverse effect of lithium?

A. Sexual dysfunction B. Constipation C. Polyuria D. Seizures
15. The client is taking fluoxetine (Prozac) 20 mg at bedtime. He
states that Prozac is not helping him to sleep. The nurse recognizes:

A. That the client should take Prozac in the morning. B. That dose is too high. C. That the client's symptoms of depression seem to be getting worse. D. That the client is on the wrong medication.
Part (2): True and false: (15 marks)
II -Read each statement carefully and circle (T) if the statement is
true and (F) if statement false
1. Drug-induced parkinsonism is used for the patient with T
2. Classical depression is characterized by retardation of thinking T
3. Dementia is one of the side effect of ECT F
4. Child develops psychologically and grows normally by passing T
through more positive experiences than negative ones 5. The condition of waxy flexibility is encountered during the T
physical examination of patients with schizophrenia 6. The speaker is more important than the listener in the T
communication process 7. During a crisis one may regress to a stage provoking less anxiety T
in an attempt to cope with an un acceptable l situation 8. Buspirone is considered anti psychotic agent T
9. Provides assistance for family as a whole focuses on assisting T
members of family improve adaptive functioning 10. Nurse Tony should first discuss terminating the nurse-client T
relationship with a client during the working phase 11. Patient receiving Mono-Amino Oxidase Inhibitors and eating milk T
12. Grace is exhibiting withdrawn patterns of behavior. nurse Johnny T
is a ware that this type of behavior eventually produces feeling of 13. One of the main nursing roles regarding chronically schizophrenia T
client is to assist him to enjoy dependence on staff. 14. You will have bipolar symptoms if bipolar runs in your family F
15. Autistic thinking is a preoccupation with inner, private world, T
egocentric (self –centred) fantasy.
Part (3): Define the following:

1- Personality disorder
Personality Disorders describe persistently maladaptive ways of perceiving, thinking, and relating to the world and other people that greatly differs from the expectations of the individual's culture. It has an onset in adolescence or early adulthood. 2- Cognition
Is the brains ability to process, retain and use information. Cognitive comprehension, and memory. These cognitive abilities are essential for many important tasks including making decision, solving problems, interpreting the environment, and learning new information 3- Milieu therapy
Milieu therapy, or therapeutic community, is defined as "a scientific structuring of the environment to effect behavioral changes and to improve the psychological health and functioning of the individual." Within the therapeutic community setting, the patient is expected to learn adaptive coping, interaction, and relationship skills that can be generalized to other aspects of his or her life. 4- Stigma
Negative attitude, misunderstanding, and associated fears about mental Stigma creates financial, employment, social barrier to accessing care 5- Concrete thinking
When the patient use literal thinking with out understanding the implicit meaning behind sentence &it is verse abstract
Part (4): Fill the blanks
1-The criteria of the person with anorexia nervosa

a- refusal to maintain weight above a safe level B-Fear of becoming obese c- Distortion of body image d- The age of onset is usually late adolescent 2-Contraindications of seclusion and restraints are:
a-don't use as punishment b- Free staff member from having to observe the client c- Don't use on the patient who is actively suicidal ,highly aggressive and /or combative, who strikes &endangers himself or others unless they receive constant monitoring D-Potentially suicidal patients when left alone may harm themselves. 3-Side effects of the mood stabilizer are
A -Nausea, vomiting, diarrhea, thrust, polyuria b- Slurred speech, muscle weakness, hand tremor.
c- Advanced toxicity:
d- Decreased BP, EEG change
4-Waring signs of the suicide patient are
a-Change in eating and sleeping habits b- Withdrawal from friends, family, lack of energy C-Drug and alcohol abuse. d-Unusal neglect of personal appearance 5-Symptoms of neuroleptic malignant syndrome
a- Altered level of consciousness B-Hyperthermia up to 108f c- Autonomic dysfunction:-hypertension, tachycardia, diaphoresis, and D-Muscular rigidity 6- The main principles in creating a therapeutic relationship are
a-To follow the principles of psychiatric nursing b-To understand the patient c-To understand her self d-To benefit from her previous experiences with mental patients 7- Community mental health resources in Egypt
A-General and private hospital b- Psychiatric unit in general hospitals C-Out patient clinics 8- Criteria for mixed episode: a- Criteria are met both for a manic episode and for a major depressive episode during at least a 1-week period b- Causes functional impairment, necessitates hospitalisation, or there are psychotic features c- Symptoms are not due to substance abuse, a general medical condition, or somatic antidepressant therapy. Part (5): Essay
List (5) the principles of psychiatric nursing and explain one (10
(1)- Patient Accepted exactly as he is:  Acceptance conveys the feeling of being loved and cared for. Acceptance provides the patient with an experience which is emotionally natural, where he finds unlearning of his sick behavior less threatening before he can relearn the art of living with himself  Acceptance does not mean complete permissiveness but acceptance means setting of positive behavior to convey to him respect as an individual human being acceptance is expressed in the following A - Be non judgmental and non -punitive : -  We don't judge patient's behavior as right or wrong, good or bad, patient is not punished for his undesired behavior. All direct and indirect methods of punishing must be avoided. B- Show interest in the patient as a person by:  Study patient's behavior pattern.  Listing to him.  Making the patient aware in a suitable manner that you are interested  Seeking out a patient.  Using time spent with him on those things he is interested in.  Being aware of his likes and dislikes.  Explain when his demands cannot be met.  Dealing with his comments, complaints and expressions of approval  Accepting his fears as real to him.  Avoiding subjects on which he feels sensitive. C - Recognize and reflect on feeling which patient may express:  Nurse acts as a sounding board for patient's negative feeling. The nurse- develops skill in identifying the feelings actually expressed, (example of patient's words "I would like to break some one's neck" (anger)," I am a dead person" (feeling of worthlessness. etc.)  When patient talk, it is not the content but the feelings a skilled observer notices. D - Talk with a purpose:  Nurse's conversation with a patient must revolve around his need, wants and interest's .Nurse's responses must guide her to understand  Indirect approaches like reflection, open - end questions, focusing on a point, presenting reality, are more effective when the problems are  Avoid evaluative, hostile, probing responses and use the understanding responses which may help the patient to explore his E - Permit patient to express strongly held feeling:  Strong emotions bottled up are potentially explosive and dangerous. It is better to permit the patient to express his strong feeling without disapproval or punishment.  Feeling of anxiety, fear, hostility, hatred or anger should be expected, tolerated and allowed expression.  Expression of these negative feeling may be encouraged in verbal or symbolic manner.  Nurse must accept the expression of patient's strong, negative feeling quietly and calmly.  In other words a nurse makes the patient as comfortable with his illness as possible. II - Self understanding as a therapeutic tool:  Self understanding leads to understanding of others. Knowing how one ought to feel or act is important to understand why one behaves the way she does is vital.  A patient's behavior can produce a lot of anxiety or fear in the nurse and she ought to understand why she is anxious or frightened. How can a nurse understand herself better?
 Exchange personal experience freely and frankly with your  Discuss your personal reaction with on experienced person.  Participate in group conference regarding your patient care.  Keep reflecting on why you feel or act way you do III Consistency is used to contribute to patient's security A -Why  Not knowing what to expect, or fear of unknown produces anxiety. A. Patient must feel that he can depend on the people working in ward.
B. Areas where consistency must operate:-
1. Attitude of the staff. 2. Ward routine. 3. Define the limitation placed on the patient. C. How should consistency operate :-
 Patient to be constantly and continuously exposed to an atmosphere of quiet acceptance.  Consistency must to be maintained from nurse to nurse and shift which must be planned properly.  Permissiveness to be limited e.g. with patient's who are homicidal, suicidal, hyperactive and suspicious.  Patient is allowed to feel as he does but limitations are put on his  Limit and its reinforcement requires a great deal of tact and understanding, and should be done in a quiet and matter of fact way.  The attempt to win patient's liking (favoritism) is most disastrous for IV-Reassurance must to be given in suitable and acceptable  Reassurance building Patient's confidence or restoring his confidence, understand the meaning of experience to the patient A nurse must have an ability to see how a situation appears to the patient. B- How to give reassurance?
 Be truly interested in patient's problems.  Pay attention to the matter that is important to the patient - no matter however insignificant it may be.  Allow him to be as sick as he needs' to be.  Be aware and accept how the patient really feels  Do things for the patient without asking anything of the patient in return such as improved behavior or show of appreciation.  Sit beside patient even when he does not want to talk.  Accepting patient's silence and your physical presence can be very reassurance to the patient  Listen to personal without showing surprise or disapproval.  Agree that patient has a problem and think along with him to solve  Provide patient with acceptable outlet of anxiety. C- Avoid saying to the patient:
 You will get well"  Your fears are groundless"  You are a nice person "  All will end well"  No thing to worry " V-Patient's behavior is changed through emotional experience not by rational interpretation.  Major focus is on feeling aspect and not intellectual aspect. Telling and advising patients are not effective in changing behavior.  Patient's defensive behavior against anxiety producing stress or his beliefs is based on strong emotional needs.  The more beliefs are challenged the more the patient becomes  Corrective emotional experience can bring about behavior change.  Help the patient feel emotionally secure to enable him to develop and use understanding of own behavior  Understanding cannot be forced; insight and understanding of ones own behavior is painful.  Interpretation is only done when patient is ready for it i.e. secure enough to tolerate it and able to apply it to alter his behavior  Attitude are also not identified for the patient, when he is ready to tolerate them, he will identify them himself. VI-Unnecessary increase in patient's anxiety should be avoided A- What's anxiety?  It is a threat to biological integrity of the self system (ego) of the B- What factors, situation, topics or approaches that increase anxiety?  This may differ from patient to patient, but some general types of situation which increased anxiety are: - 1. Direct contradiction of patient's psychotic ideas. 2. Demands on patient which he obviously cannot meet. 4. Indiscriminate use of professional terms. 5. Careless conversation within patient's hearing. 6. Calling attention to patient's defects. 8. Lack of proper orientation. 9. Threats, sharp command and indifference. 10. Asking question about family, work friends, and home which are not good for the first phase of patient - nurse relationship. Best rule is to follow patient's lead 11. Nurse's own anxiety VII. Observation of mentally ill patient is directed toward why of  Everything patient does or says is observed and analyzed, to seek its motivation and to understand what he is trying to accomplish.  Continuous prediction of patient's behavior improves skills of  Try to learn patient's basic problem and then guess what he will do, if your prediction is right, ask yourself why? If prediction is wrong again. Ask yourself why? Keep asking yourself what is the goal of the patient? Why did he behave and the way did he behaves? (Be B- What do you mean by objectivity?  Objectivity is an ability to evaluate exactly what a patient what's to say and not mix up your own reeling, opinion or judgment  Objectivity is not coldness. Indifference and absence of feeling, but it is an ability not to let your own judgment get confused with emotional warmth. C- How can you be objective?  One important way is to keep indulging in introspection make sure that your own emotional needs don't take precedence care of D- What is the situation of lack of objectivity? 1. Nurse is critical of patient. 2. Defending or justifying herself. 3. Demanding that patient should treat her in a certain way 4. Evaluating patient's behavior as right or wrong.  Nurse needs to be honest with her. This honesty can be painful but  Ability to accept the faults one cannot change and personal limitations of herself are as important as her ability to accept her VIII - Maintain realistic nurse – patient relationship  A realistic or professional relationship focuses on the personal and emotional needs of the patient's and not on nurse's needs such a relationship is therapeutically oriented and planned. It always based on patient's needs. Nurse keeps analyzing the interaction between herself arid the patient to prepare herself to guide the patient towards  Nurse must differentiate between patient's demands and actual needs- (For discussion) what is the difference between social and professional relationships?  What do we mean by an intimate relationship? Is it therapeutic? IX- Verbal and physical force must be avoided if possible  Any kind of force applied on patient results in psychological trauma should be avoided, unless it is a patient-who-needs and welcome  If the nurse is knowledgeable in predicting patient's behavior, she can prevent an onset of undesirable behavior.  If at all force needs to be used the following steps must be applied. 1. Carry out the procedure quickly, firmly and efficiently with 2. Anger or annoyance should not be shown. 3. No verbal comments should be made during the procedure except to tell the patient in a matter - of - fact - tone the reason for the procedure and, also that he will be allowed to mix with others when he has more control of himself. 4. Never let the patient feel that he is being .punished, attend to his 5. Never remind a patient again about the incidence. 6. Nursing team must nave self control and understanding in carry out the procedure? X - Nursing care centered on patient as a person, not on control symptoms:  Every behavior is meaningful and behavior is reflected in the symptoms a patient presents, two patients showing the same symptom may be expressing different needs , analysis and study of symptoms are necessary to reveal their meaning and their significance to the patient.  List three characteristics of the histrionic personality disorder (5
Constantly seeking attention, Uncomfortable when not the center of attention Excessively emotional; they are dramatic, flamboyant, and extroverted but are unable to form long-lasting, meaningful relationships. Extreme sensitivity to others' approval Easily influenced by others or situation Excessive concern with physical appearance to draw attention to self Perceives relationships as more intimate than they actually are Inappropriately seductive or provocative behavior Often use defense mechanism of regression—they revert to childlike behaviors.
Discuss the phases of crisis (5 grades)
a-First phase: - the first phase is increased anxiety in response to
trauma, a persons tries to use familiar mechanisms are effective, there B-Second phase: - if coping mechanisms are ineffective, person
enters the second stage of crisis which is marked by further increased anxiety from the failure of coping mechanism. C - Third phase:- in the third phase , anxiety continues to (escalate
person usually feels compelled to reach out for assistance or seek out counseling.
D - Fourth phase:- if person cannot bring his anxiety control he enter 4
phase of crisis and anxiety reach to panic level of anxiety  State one of nursing diagnoses for generalized anxiety disorder and your response as a psychiatric mental health nurse (5 grades) Assessment phase:
1- People with (GAD) are chronic worries. Decision-making is difficult because poor concentration and the fear making mistakes 2- Restlessness, inability to relax and fatigue 3- Autonomic hyperactivity e.g. palpitations, cold clammy hands, urinary frequency, pallor, pulse rate and rapid respiration. 4- Apprehensiveness 5- Sleep disturbance, muscle tension 6- The symptoms have, existed 6 months or longer. With no history of medical causes or substance abuse. Nursing diagnosis, goals, and interventions:
1- Ineffective individual coping related to anxiety- it is
evidenced by increased muscle tension and restlessness,
apprehensive, sweating, frequent urination, pulse,
elevated, skin pale.

Goals: The patient will recognize his own anxiety and cope effectively
with associated with anxiety.
1- Stay with patient and listen to him 2- Acknowledge patient's anxiety 3- Speak slowly and calmly, use short simple words 4- Assure patient that you are available and can assists him or her 5- Give brief directions 6- Decrease excessive stimuli and approved quiet environment. 7- Walk with pacing patient to give him support 8- Increase level of supervision for acutely patient to minimize self- injury or loss control 9- Allow patient to use defenses as long as physical well-being is not 10-Teach the sign and symptoms of anxiety 11-Give positive reinforcement for use of health behavior 12-Help the patient to know the life situation that can control or not help to identify his or her in ability.
2- Sleep pattern disturbance related to physiologic
disturbances caused by anxiety. it is evidenced by
difficulty getting in sleep.

Goals: The patient will achieve adequate sleep
1-Encourage verbalization of problems associated with anxiety 2-Provide measures appropriate reduce insomnia:- 3-Quite, secure environment 4-Relaxation techniques 5- Night light decrease 6-Number of distraction e.g. taking temperature during night 7-Structured bedtime routine for the patient e.g. bath, reading, warm milk, 8-Consistent structured day time activities include physical exercise as 9-Discourages napping

Source: http://fnur.bu.edu.eg/fnur/images/namazeg/2-2013/4/Copy%20of%20final%20exam.doc2012-2013%202trem.pdf


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