During a mental health assessment, a patient laughs manically while describing a recent loss of a loved one. The nurse recognizes this emotional expression as:

Inappropriate affect

Flat affect

Labile affect

Answer and Explanation

The Correct Answer is A

Choice A reason: Inappropriate affect, where emotions like manic laughter mismatch the context of loss, is common in disorders like schizophrenia. It reflects limbic-prefrontal dysregulation, causing emotional responses to be incongruent with the situation, making this the correct choice for the described behavior.

Choice B reason: Flat affect involves minimal or no emotional expression, often in schizophrenia or depression. The patient’s manic laughter is an active, inappropriate response, not a lack of emotion, making this choice incorrect for the scenario described.

Choice C reason: Labile affect involves rapid emotional shifts, such as laughing to crying, seen in bipolar disorder. The scenario describes a single inappropriate response (manic laughter), not shifts, making this choice incorrect for the patient’s presentation.

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Correct Answer is A

Explanation

Choice A reason: A legal guardian, appointed for a patient with advanced dementia, has authority to make healthcare decisions, as the patient lacks capacity due to cognitive impairment. Following the guardian’s decisions ensures legal and ethical compliance, prioritizing the patient’s best interests, making this the correct choice.

Choice B reason: Ignoring the legal guardian violates legal standards, as the guardian is appointed to act in the patient’s best interest. Nurses lack authority to override guardians, and doing so risks unethical care and legal repercussions, making this choice incorrect.

Choice C reason: Consulting a patient with advanced dementia directly disregards their lack of decision-making capacity, as cognitive impairments prevent informed choices. The legal guardian’s role supersedes patient preferences in this context, making this choice incorrect.

Choice D reason: Requiring written consent from a patient with advanced dementia is inappropriate, as they lack capacity to provide informed consent. Legal guardians provide consent for such patients, ensuring care aligns with their best interests, making this choice incorrect.

A. Apply restraints and leave the patient unattended for 2 hours B. Restrain the patient to the bed using all four limbs tightly to limit any movement C. Ensure a provider’s face-to-face evaluation occurs within 1 hour of restraint application D. Document the restraint use once at the end of the shift

Correct Answer is C

Explanation

Choice A reason: Leaving a restrained patient unattended for 2 hours violates safety standards, as restraints pose risks like injury or respiratory compromise. Regular monitoring is required to assess circulation, skin integrity, and psychological distress, ensuring patient safety, making this choice incorrect.

Choice B reason: Restraining all four limbs tightly risks injury, such as nerve damage or impaired circulation, and violates least-restrictive restraint principles. Restraints should allow minimal movement and be applied only as necessary, with regular reassessment, making this choice incorrect.

Choice C reason: A provider’s face-to-face evaluation within 1 hour is required by regulations to ensure restraints are justified and safe. This assesses the patient’s condition, mental status, and need for continued restraint, minimizing harm and ensuring compliance, making this the correct choice.

Choice D reason: Documenting restraint use only at shift’s end is inadequate, as regulations require ongoing documentation of restraint rationale, patient condition, and monitoring. Delayed documentation risks missing critical changes, compromising care and legal compliance, making this choice incorrect.

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During a mental health assessment, a patient laughs manically while describing a recent loss of a loved one. The nurse recognizes this emotional expression as:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for an elderly patient with advanced dementia who is unable to make healthcare decisions independently. The patient’s adult child has been appointed legal guardian. What is the nurse’s best action regarding the patient’s care decisions?

Correct Answer is A

Explanation

A patient becomes agitated and physically aggressive on the unit, requiring the use of restraints. Which of the following actions by the nurse is appropriate when applying and managing restraints?

Correct Answer is C

Explanation

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What is waxy flexibility in psychiatric patients?

The nurse is caring for a patient recently diagnosed with a terminal illness. The patient says, “There’s no way this is right. I’m going to get another opinion—this doctor doesn’t know what they’re talking about.” The nurse recognizes that the patient is in which stage of grief?

A patient diagnosed with schizophrenia tells the nurse, “I hear voices sometimes, but they don’t bother me.” Which of the following is the most appropriate open-ended response by the nurse to further assess the patient’s experience?

A client on a psychiatric unit states, “It’s a waste of time being here. I can’t talk to you or anyone.” Which is the correct nursing response?

The nurse is preparing to perform a psychosocial assessment on a patient. Which of the following should be included in the environment to promote an effective assessment? (Select all that apply)

A nurse observes a patient with bipolar disorder who suddenly shifts from laughing joyfully to crying within minutes during the therapy session. This sudden and intense change in emotional expression is an example of: