PMH-BC study guide: four domains at RN scope

A client with paranoid delusions believes his roommate is poisoning him. He clenches his fists and says, "If he comes near me tonight, he'll regret it." Which nursing diagnosis has priority?

Each of the 4 choices opens onto the reasoning behind it.

1. ARisk for self-directed violence

   Why A is wrong. Nothing in his words or behavior points at self-directed harm; the threat is aimed at the roommate.
2. BImpaired social interaction

   Why B is wrong. His suspicion does strain relationships, but a social problem ranks below an imminent safety risk to another client.
3. CRisk for other-directed violence

   Why C is right. A fixed persecutory belief about the roommate, a clenched fist, and a threat for tonight signal risk of violence toward another person, so this diagnosis comes first.
4. DAnxiety

   Why D is wrong. Fear may drive the delusion, yet labeling it anxiety misses the explicit threat that sets the priority.

A mother says her 9-month-old son now cries whenever she leaves the room, although a few months ago he went happily to anyone. The nurse explains that this behavior is:

1. AA reaction to inconsistent caregiving

   Why A is wrong. Crying when the mother leaves shows attachment to her, not inconsistent or erratic caregiving.
2. BAn insecure attachment pattern

   Why B is wrong. Insecure attachment is judged by how the infant responds to reunion and comfort, not by protest when the parent leaves.
3. CA normal developmental milestone

   Why C is right. Distress at separation from the main caregiver typically emerges around 8 to 9 months; this normal developmental milestone shows that a specific attachment has formed.
4. DAn early sign of anxiety disorder

   Why D is wrong. Separation distress at this age is expected; an anxiety disorder would need fear well beyond what is typical for the child's age.

A college student with ADHD is setting goals with the nurse. Which client-stated goal is most therapeutic?

1. A"I want better grades this semester."

   Why A is wrong. Grades are an outcome rather than a behavior, so this wish gives no step to practice.
2. B"I'll split each paper into steps in my planner."

   Why B is right. This goal names a concrete action the student controls and can check off, which suits the planning problems typical of ADHD.
3. C"I'll try my best to focus a lot better in my classes."

   Why C is wrong. Trying to focus 'a lot better' cannot be observed or counted, and it does not say what the student will do differently.
4. D"I should stop procrastinating so much."

   Why D is wrong. Saying 'I should stop procrastinating' states a criticism rather than an action, and 'so much' gives no way to tell when the goal is met.

A 55-year-old farmer brought in by his wife denies being "depressed" and says, "Real men handle their own problems." He admits he is not sleeping and has lost interest in work. Which approach is most likely to engage him?

1. AAsk his wife to describe his feelings for him

   Why A is wrong. Having his wife describe his feelings for him undercuts his autonomy and pride, the very values driving his denial.
2. BFrame the talk around his stress and poor rest

   Why B is right. Framing the talk around stress and rest uses his own terms and avoids a label he rejects, so a man who values self-reliance can admit to symptoms without losing face.
3. CHand him a pamphlet on depression and suicide

   Why C is wrong. A pamphlet built around the word he rejects is easy to set aside, and it skips the conversation needed to engage him.
4. DInsist he accept the diagnosis of depression first

   Why D is wrong. Requiring him to accept the label before anything else sets up a power struggle and is likely to end the visit.

A client on a surgical unit becomes withdrawn and tearful after an amputation, and staff are unsure how to approach him. Which resource should the charge nurse request?

1. AThe psychiatric liaison nurse

   Why A is right. A consultation-liaison psychiatric nurse assesses mood after a loss and coaches the medical staff on how to approach the client.
2. BThe hospital's risk manager

   Why B is wrong. Risk management handles incidents and liability; nothing here is an incident.
3. CA security officer on standby nearby

   Why C is wrong. Withdrawal and tears show no threat to anyone, so posting security would be unnecessary and stigmatizing.
4. DThe wound care nurse

   Why D is wrong. The wound care nurse manages the residual limb and dressings, not the grief and low mood the staff are unsure how to approach.

A client says, "I lost my job, my wife left, and then I started drinking—or maybe it was the other way around." Which nurse response places the events in sequence?

1. A"What do you think you should do about the drinking?"

   Why A is wrong. Jumping to what to do about the drinking moves to problem-solving before the sequence of events is understood.
2. B"You must feel very alone right now with all that."

   Why B is wrong. Saying the client must feel alone guesses at a feeling the client has not named and does nothing to order the events.
3. C"That sounds like a lot to happen to one person."

   Why C is wrong. This comment acknowledges that a lot has happened but leaves the order of events unclear.
4. D"Which came first: the drinking or the job loss?"

   Why D is right. Asking which came first, the drinking or the job loss, helps the client sort out cause and effect in a jumbled account, which is what placing events in sequence means.

A client receives an injection of olanzapine pamoate, a long-acting form of olanzapine. Which nursing action is required after the injection?

1. AObserve the client in the facility for at least 3 hours

   Why A is right. The labeling requires at least 3 hours of observation after every injection because of post-injection delirium/sedation syndrome, which looks like an olanzapine overdose.
2. BLet the client drive home and call if drowsy

   Why B is wrong. Driving is unsafe on the day of the injection; the client should go home accompanied once the observation period ends.
3. CDischarge after at least 15 minutes if vital signs are stable

   Why C is wrong. Fifteen minutes is far too short: the delirium/sedation reaction can begin later within the 3-hour window, even when early vital signs are normal.
4. DMassage the injection site well afterward

   Why D is wrong. Massaging a deep depot injection is not done and does nothing to prevent the post-injection reaction.

A client with major depressive disorder has been in treatment for 8 weeks. Which finding most urgently indicates the need to revise the care plan?

1. AStill has low energy despite better sleep

   Why A is wrong. Energy often lags behind sleep in recovery from depression, so partial improvement at 8 weeks is not urgent.
2. BWants to stop over sexual side effects

   Why B is wrong. Sexual side effects do threaten adherence and need follow-up, but they are less urgent than a sign of suicidal planning.
3. CCries when talking about a recent divorce

   Why C is wrong. Crying about a recent divorce is an expected response to a real loss and does not by itself show the plan is failing.
4. DHas begun looking up lethal medication doses

   Why D is right. Researching lethal doses is preparation for suicide, a warning sign that calls for an immediate safety reassessment and a change in the plan.

A client is receiving a course of ECT for severe depression. Which finding should the nurse report to the treatment team before the next session?

1. AConfusion that lingers until the following treatment

   Why A is right. Confusion that has not cleared before the next session suggests cumulative cognitive effects, which the team may address by changing the schedule or technique.
2. BBrief confusion on waking that clears within an hour

   Why B is wrong. Short confusion on emergence from anesthesia and the seizure is expected and resolves on its own.
3. CTrouble recalling events from the morning of treatment

   Why C is wrong. Patchy memory for events close to each session is an expected effect of ECT and usually improves after the course ends.
4. DHeadache and jaw soreness on the afternoon after treatment

   Why D is wrong. Headache and jaw soreness are common, short-lived after-effects that are treated with comfort measures.