Capstone Psych

A manic client announces to everyone in the day room that a stripper is coming to perform that evening. when the psychiatric nurse's aide firmly states that the client's behavior is not appropriate, the manic client becomes verbally abusive and threatens physical violence to the nurse's aide. Based on the analysis of this situation, the nurse determines that the appropriate action would be to: 1. Escort the manic client to his or her room 2. Orient the client to time, person, and place 3. Tell the client that the behavior is not appropriate 4. Tell the client that smoking privileges are revoked for 24 hours

1. Escort the manic client to his or her room

A nurse observes that a client is psychotic, pacing, and agitated and is making aggressive gestures. The client's speech pattern is rapid and the client's affect is belligerent. Based on these observations, the nurse's immediate priority of care is to: 1. Provide safety for the client and other clients on the unit 2. Provide the clients on the unit with a sense of comfort and safety 3. Assist the staff in caring for the client in a controlled environment 4. Offer the client a less-stimulating area to calm down and gain control

1. Provide safety for the client and other clients on the unit

The emergency department nurse is assessing a female client who has a laceration on the forehead and a black eye. The nurse asks the man who is with the client to please leave the room. The man refuses to leave the room. Which action should the nurse take first? 1. Tell the man the client needs to go to the x-ray department. 2. Notify hospital security and have the man removed from the room. 3. Explain that the man must leave the room while the nurse checks the client. 4. Give the client a brochure with information about a woman's shelter.

1. Tell the man the client needs to go to the x-ray department. The nurse needs to remove the man from the room so that the nurse can talk to the client and discuss probable abuse. Taking the client to the x-ray department may not arouse suspicion in the man and may allow the client to discuss the situation.

Which task would be most appropriate for the psychiatric nurse to delegate to themental health worker (MHW)? 1. Request the MHW to take the client with lithium toxicity to the emergency room. 2. Have the MHW sit with a client diagnosed with bulimia for 1 hour after the meal. 3. Encourage the MHW to teach the client how to express his or her anger in a positive way. 4. Ask the MHW to sit with the client while the client talks to his mother on the telephone.

2. Have the MHW sit with a client diagnosed with bulimia for 1 hour after the meal. Having someone stay with the client after a meal will prevent the client from inducing vomiting and could be delegated to an MHW. The client diagnosed with bulimia needs someone there to prevent vomiting, which is a sign of this mental health problem.

The nurse is in the middle/working phase of the nurse/client relationship. Which statement is a task in the orientation phase? 1. Identify the client's strengths and weaknesses. 2. Help the client identify problem-solving techniques. 3. Evaluate the client's experience while in the group. 4. Establish the rules for how the meetings will be conducted.

2. Help the client identify problem-solving techniques. Identifying problem-solving techniques is part of the working phase.

A client with delirium becomes agitated and confused at night. The best initial intervention by the nurse is to: 1. Move the client next to the nurse's station 2. Use a night light and turn off the television 3. Keep up the television and a soft light on during the night. 4. Play soft music during the night and maintain a well-lit room

2. Use a night light and turn off the television

Which interventions should the inpatient psychiatric nurse implement for the client experiencing sleepwalking? Select all that apply. 1. Encourage the client to exercise prior to going to bed. 2. Place the client on elopement precautions. 3. Instruct to client to drink decaffeinated beverages. 4. Place an alarm on the bed activated when client gets up. 5. Tell the MHW to be on a 1-to-1 watch during the night.

3, 4 3. Caffeinated beverages are stimulants; therefore, this is an appropriate intervention. 4. An alarm on the bed would help ensure safety for the client because the nurse will know immediately when the client leaves the bed.

The client on the psychiatric unit tells the nurse, "I am so bored. I hate just sitting onthe unit doing nothing." Which intervention should the nurse implement? 1. Explain that with time the client will be able to go to the activity area. 2. Allow the client to vent feelings of being bored on the unit. 3. Notify the psychiatric recreational therapist about the client's concerns. 4. Tell the client that there is nothing that can be done about being bored.

3. Notify the psychiatric recreational therapist about the client's concerns. According to the NCLEX-RN® test blueprint, the nurse must be knowledgeable of the multidisciplinary team. The recreational therapist helps the client to balance work and play in his or her life and provides activities that promote constructive use of leisure or unstructured time.

A woman comes to the emergency department (ED) and tells the triage nurse she was raped by two men. The woman is crying and disheveled, and has bruises on her face. Which action should the triage nurse implement first? 1. Ask the client whether she wants the police department notified. 2. Notify a Sexual Assault Nurse Examiner (SANE) to see the client. 3. Request an ED nurse to take the client to a room and assess for injuries. 4. Assist the client to complete the emergency department admission form.

3. Request an ED nurse to take the client to a room and assess for injuries. The triage nurse's first intervention is to address the client's physiological needs, which means to assess for any type of trauma or injury.

A nurse is caring for an older adult client who has recently lost her husband. The client says, "No one cares about me anymore. All the people I loved are dead." Which response by the nurse is therapeutic? 1. "Right! why not just pack it in?" 2. "That seems rather unlikely to me" 3. "I don't believe that, and neither do you" 4. "You must be feeling all alone at this point"

4. "You must be feeling all alone at this point"

The male client diagnosed with paranoid schizophrenia is yelling, talking to himself,and blocking the view of the television. The other clients in the day room are becoming angry. Which action should the nurse take first? 1. Obtain a restraint order from the HCP. 2. Escort the other clients from the day room. 3. Administer an intramuscular (IM) antipsychotic medication. 4. Approach the client calmly along with two mental health workers (MHWs).

4. Approach the client calmly along with two mental health workers (MHWs). The first intervention is to approach the client calmly and attempt to remove him from the day room. Staff members should not approach the agitated client alone, but should be accompanied by other personnel.

A nurse is planning care for a client who is being hospitalized because the client has been displaying violent behavior and is at risk for potential harm to others. The nurse avoids which intervention in the plan of care? 1. Facing the client when providing care 2. Ensuring that a security officer is within the immediate area 3. Keeping the door to the client's room open when with the client 4. Assigning the client to a room at the end of the hall to prevent disturbing the other clients.

4. Assigning the client to a room at the end of the hall to prevent disturbing the other clients.

The male client diagnosed with major depression is returning to the psychiatric unit froma weekend pass with his family. Which intervention should the nurse implement first? 1. Ask the wife for her opinion of how the visit went. 2. Determine whether the client took his medication. 3. Ask the client for his opinion of how the visit went. 4. Check the client for sharps or dangerous objects.

4. Check the client for sharps or dangerous objects. The nurse's first intervention should be to ensure the client's safety by checking to make sure the client has no sharps or dangerous objects that he could use to hurt himself, since he is diagnosed with major depression

The nurse answers the client's phone in the lobby area and the person asks, "May I speak to Mr. Jones?" Which action should the nurse implement? 1. Ask the caller who is asking for Mr. Jones. 2. Tell the caller Mr. Jones cannot have phone calls. 3. Request the caller to give the access code for information. 4. Find Mr. Jones and tell him he has a phone call.

4. Find Mr. Jones and tell him he has a phone call. The nurse should find Mr. Jones and tell him he has a phone call. The client cannot have rights restricted unless it is a part of the client's individualized care plan. For example, the client may not be able to use the phone if he or she is calling 911 and making false reports. 3. The access code for client information is requested when the caller is asking questions about the client. It is not used when the caller wants to talk directly to the client.

Which task would be inappropriate for the psychiatric charge nurse to delegate to the mental health worker (MHW)? 1. Instruct the MHW to escort the client to the multidisciplinary team meeting. 2. Ask the MHW to stay in the day room and watch the clients. 3. Tell the MHW to take care of the client on a 1-to-1 suicide watch. 4. Request the MHW to draw blood for a serum carbamazepine (Tegretol) level.

4. Request the MHW to draw blood for a serum carbamazepine (Tegretol) level. The MHW does not draw blood, and this would be an inappropriate task to delegate. The laboratory technician draws the client's blood work.

The mental health worker (MHW) reports to the psychiatric nurse that two clients were kissing each other while watching the movie in the lobby area. Which action should the nurse implement? 1. Tell the MHW to tell the clients not to kiss each other again. 2. Discuss the inappropriate behavior at the weekly team meeting. 3. Transfer one of the clients to another psychiatric unit. 4. Talk to the clients about kissing each other in the lobby area.

4. Talk to the clients about kissing each other in the lobby area. The nurse needs to talk to the clients to determine whether the kissing was consensual or under duress. Either way, the behavior is inappropriate, and the clients should be told there is no kissing or sexual activity allowed between clients while they are hospitalized on the psychiatric unit.

The nurse is working in an outpatient mental health clinic and returning phone calls. Which client should the psychiatric nurse call first? 1. The client diagnosed with agoraphobia who is calling to cancel the clinic appointment. 2. The client diagnosed with a somatoform disorder who has numbness in both legs. 3. The client diagnosed with hypochondriasis who is afraid she may have breast cancer. 4. The client diagnosed with post-traumatic stress disorder (PTSD) who is threatening his wife.

4. The client diagnosed with post-traumatic stress disorder (PTSD) who is threatening his wife. Post-traumatic stress disorder is an illness that occurs to someone who has experienced a traumatic event. The client feels a numbing of general responsiveness but has outbursts of anger. The nurse should return this call first and assess the situation to determine whether the client should be seen in the clinic.

The charge nurse responds to an emergency situation on the psychiatric unit in whichthe male client is angry, yelling, and attempting to hit other clients and the staff.Which interventions should the nurse implement? Select all that apply. 1. Notify the operator to initiate a call for emergency responders to assist. 2. Tell the client to sit down and be quiet or he will lose privileges. 3. Have the mental health worker escort the other clients to their rooms. 4. Make sure that the staff speaks loudly and directly to the client. 5. Request the unit secretary to stand by the locked doors to allow emergency responders on the unit.

1, 3, 5 1. Psychiatric units have emergency codes to request assistance for a "take down" procedure when a client is deemed uncontrollable; the charge nurse should request this assistance. 3. The other clients should be removed from possible harm. 5. The psychiatric unit is a locked unit. When the notification is made for assistance, someone must open the door so the emergency responders can enter the unit.

The client diagnosed with anorexia is refusing to eat and is less than 20% of ideal body weight (IBW) for her height and structure. The client has not eaten anything since admission 2 days ago. Which action should the nurse implement? 1. Notify the psychiatrist to request a court order to feed the client. 2. Take no action because the client has the right to refuse treatment. 3. Discharge the client because she is not complying with the treatment. 4. Physically restrain the client and insert a nasogastric tube for feeding.

1. Notify the psychiatrist to request a court order to feed the client. When a person is admitted to a psychiatric unit, the client does not lose any rights. The client has a right to refuse treatment, but if the client is a danger to herself, then the psychiatric team must go to court and obtain an order to force feed the client. This could be with nasogastric tube feedings or total parenteral nutrition.

A nurse is assisting in planning care for a client being admitted to the nursing unit who has attempted suicide. which priority nursing intervention will the nurse include in the plan of care? 1. One to one suicide precautions 2. Suicide precautions, with 30 minute checks 3. Checking the whereabouts of the client every 15 minutes 4. Asking that the client report suicidal thoughts immediately

1. One to one suicide precautions

The charge nurse of the psychiatric unit is making assignments. Which clients should be assigned to the medical-surgical nurse who is working in the psychiatric unit for the day? Select all that apply. 1. The client diagnosed with depression who has attempted suicide four times and now is refusing to go to therapy. 2. The client diagnosed with bipolar disease who has diabetes and requires blood glucose monitoring. 3. The female client diagnosed with dissociative identity disorder (DID) who is complaining that she is being falsely imprisoned. 4. The client diagnosed with schizophrenia who is blocking the screen of the television and refuses to move so other clients can watch the television. 5. The client diagnosed with major depression who started taking anti-depressant medication 2 days ago and who wants to remain in bed.

2, 5 2. The client with diabetes can be monitored by the medical-surgical nurse. The option does not state that any unusual situations are occurring with the client's diagnosed illness. The client wishes to remain in bed and the medications have not had enough time in the client's body to make him or her a suicide risk. 5. A client with major depression who has started anti-depressant medications 2 days ago could be cared for by the medical-surgical nurse. It is expected that this client has not received medication therapy long enough to make a difference in the depression. The medication requires 2 to 3 weeks of administration before showing effectiveness.

A young child, Joey, was admitted to the pediatric unit with a fractured jaw, bruises, and multiple cigarette burns to the arms. The mother reported the father hurt the child. A man comes to the nurse's station saying, "I am Joey's father; can you tell me how he is doing?" Which statement is the nurse's best response? 1. "Your son has a fractured jaw and some bruises but he is doing fine." 2. "I am sorry I cannot give you any information about your son." 3. "You should go talk to your wife about your son's condition." 4. "The social worker can discuss your son's condition with you."

2. "I am sorry I cannot give you any information about your son." The Health Insurance Portability and Accountability Act (HIPAA) considers parents the "personal representative" of the minor child with the right to information. However, there are exceptions to this rule, including when the provider reasonably believes that the minor may be a victim of abuse or neglect by the parents/guardians. This statement is the nurse's best response.

The mother of a client recently diagnosed with schizophrenia says to the nurse, "I was afraid of my son. Will he be all right?" Which response by the psychiatric nurse supports the ethical principal of veracity? 1. "I can see your fear; you are concerned your son will not be all right." 2. "If your son takes medication, the symptoms can be controlled." 3. "Why were you afraid of your son? Did you think he would hurt you?" 4. "Schizophrenia is a mental illness and your son will not be all right."

2. "If your son takes medication, the symptoms can be controlled." Veracity is the ethical principle "to tell the truth." The truth is that schizophrenia is a thought disorder caused by a chemical imbalance of the brain. Antipsychotic medication can control the client's hallucinations and delusions.

The mental health worker (MHW) reports that one of the nurses threatened to force feed the male client diagnosed with schizophrenia if the client did not eat the meal on the lunch tray. Which action should the charge nurse take first? 1. Tell the MHW that this intervention is part of the client's care plan. 2. Request the nurse to come to the office and discuss the MHW's allegation. 3. Ask the client what happened between him and the nurse during lunch. 4. Ask the MHW to write down the situation to submit to the head nurse.

2. Request the nurse to come to the office and discuss the MHW's allegation. This is client abuse, and the charge nurse must investigate the allegation immediately with the nurse. If the allegations are true, they should be documented in writing and reported to the client abuse committee.

A nurse is preparing to care for a dying client, and several family members are at the client's bedside. Which therapeutic techniques should the nurse use when communicating with the family? Select all that apply. 1.Discourage reminiscing 2.make the decisions for the family 3.encourage expression of feelings, concerns, and fears 4.explain everything that is happening to all family members 5.extend touch and hold the client's or family member's hand if appropriate 6.Be honest and truthful and let the client family know that you will not abandon them.

3, 5, 6 3. Encourage expression of feelings, concerns, and fears 5. Extend touch and hold the client's or family member's hand if appropriate 6. Be honest and truthful and let the client family know that you will not abandon them.

The client diagnosed with hypochondriasis is angry and yells at the psychiatric clinic nurse, "No one believes I am sick! Not my family, not my doctor, and not you. "Which statement is the nurse's best response? 1. "Have you discussed your feelings with your family?" 2. "I am sure your doctor believes you are sick." 3. "I can see you are upset. Sit down and let's talk." 4. "We cannot find any physiological reason for your illness."

3. "I can see you are upset. Sit down and let's talk." The nurse must first calm the client, assess the situation, and ensure a therapeutic nurse/client relationship. This response addresses all these issues.

An older client is a victim of elder abuse, and the client's family has been attending weekly counseling sessions. Which statement by the abusive family member would indicate the client has learned positive coping skills? 1. "I will be more careful to make sure that my father's needs are met" 2. "Now that my father is moving into my home, I will need to change my ways" 3. "I feel better able to care for my father now that I know where to obtain assistance" 4. "I am so sorry and embarrassed that the abusive event occurred. It won't happen again."

3. "I feel better able to care for my father now that I know where to obtain assistance"

The psychiatric nurse overhears a mental health worker (MHW) telling a client diagnosed with schizophrenia, "You cannot use the phone while you are here on the unit." Which action should the psychiatric nurse take? 1. Praise the MHW for providing correct information to the client. 2. Tell the MHW this is not correct information in front of the client. 3. Explain to the MHW that the client does not lose any rights. 4. Discuss this situation at the weekly multidisciplinary team meeting.

3. Explain to the MHW that the client does not lose any rights. The nurse should explain to the MHW that the mental health client retains all of the civil rights afforded to all persons, except the right to leave the hospital in the case of involuntary commitments. The client may have phone calls restricted if that is included in the care plan—for example, if the client is calling and threatening the president.

A nurse is preparing for the hospital discharge of a client with a history of command hallucinations to harm self or others. The nurse instructs the client about about interventions for hallucinations and anxiety and determines that the client understands the interventions when the client states: 1. "My medications won't make me anxious" 2. "I'll go to a support group and talk so that I won't hurt anyone." 3. "I won't get anxious or hear things if I get enough sleep and eat well" 4. "I can call my therapist when I'm hallucinating so that I can talk about my feelings and plans and not hurt anyone"

4. "I can call my therapist when I'm hallucinating so that I can talk about my feelings and plans and not hurt anyone"

A client is admitted to the in-patient unit and is being considered for electroconvulsive therapy (ECT). The client appears calm, but the family is hypervigilant and anxious. the client's mother begins to cry and states, "my child's brain will be destroyed. How can the doctor do this?" the nurse makes which therapeutic response? 1. "It sounds as though you need to speak to the psychiatrist." 2. "Perhaps you'd like to see the ECT room and speak to the staff" 3. "Your child has decided to have this treatment. you should be supportive of the decision" 4. "It sounds as though you have some concerns about the ECT procedure. Why don't we sit down together and discuss any concerns you may have?"

4. "It sounds as though you have some concerns about the ECT procedure. Why don't we sit down together and discuss any concerns you may have?"

A nurse is assisting in developing a plan of care for the client in a crisis state. when developing the plan, the nurse will consider which of the following? 1. A crisis state indicates that the individual is suffering from a mental illness 2. A crisis state indicates that the individual is suffering from an emotional illness 3. Presenting symptoms in a crisis situation are similar for all individuals experiencing a crisis. 4. A client's response to a crisis is individualized, and what constitutes a crisis for one person may not constitute a crisis for another person.

4. A client's response to a crisis is individualized, and what constitutes a crisis for one person may not constitute a crisis for another person.

It would be most helpful for the nurse to deal with a client with severe anxiety by: A. Give specific instructions using speak in concise statements. B. Ask the client to identify the cause of her anxiety. C. Explain in detail the plan of care developed. D. Urge the client to focus on what the nurse is saying.

A. Give specific instructions using speak in concise statements. The client has narrowed the perceptual field. Lengthy explanations cannot be followed by the client. Maintain a calm, non-threatening manner while working with the client. Anxiety is contagious and may be transferred from health care provider to client or vice versa. The client develops a feeling of security in presence of a calm staff person. Option B: The client will not be able to identify the cause of anxiety. Establish and maintain a trusting relationship by listening to the client; displaying warmth, answering questions directly, offering unconditional acceptance; being available and respecting the client's use of personal space. Option C: Move the client to a quiet area with minimal stimuli such as a small room or seclusion area (dim lighting, few people, and so on.) Anxious behavior escalates by external stimuli. A smaller or secluded area enhances a sense of security as compared to a large area which can make the client feel lost and panicked. Option D: The client has difficulty concentrating and will not be able to focus. Remain with the client at all times when levels of anxiety are high (severe or panic); reassure the client of his or her safety and security. The client's safety is utmost priority. A highly anxious client should not be left alone as his anxiety will escalate.

The psychiatric nurse uses cognitive-behavioral techniques when working with a client who experiences panic attacks. Which of the following techniques are common to this theoretical framework? Select all that apply. A. Administering anti-anxiety medication as prescribed. B. Encouraging the client to restructure thoughts. C. Helping the client to use controlled relaxation breathing. D. Helping the client examine evidence of stressors. E. Questioning the client about early childhood relationships. F. Teaching the client about anxiety and panic.

B, C, D, F These are all appropriate techniques based on the framework of cognitive-behavioral therapy. The main approaches to the treatment of panic disorder include both psychological and pharmacological interventions. Psychological interventions consist of cognitive-behavioral therapy. As an added benefit in patients with a panic disorder that also has concomitant comorbid medical conditions, there are components of their therapeutic regimens which may also secondarily improve their respective medical illnesses. Option A: Antidepressants and benzodiazepines are the mainstays of pharmacologic treatment. Among the different classes of antidepressants, selective serotonin reuptake inhibitors (SSRIs) are recommended over monoamine oxidase inhibitors and tricyclic antidepressants. SSRIs are considered the first-line treatment option for patients with panic disorder. Option B: Suggest that the client substitute positive thoughts for negative ones. Emotion connected to thought, and changing to a more positive thought can decrease the level of anxiety experienced. This also gives the client an alternative way of looking at the problem. Include the client in making decisions related to selection of alternative coping strategies. Allowing the client choices provides a measure of control and serves to increase feelings of self-worth. Option C: Breathing training is a method of reducing panic symptomatology by utilizing capnometry biofeedback to decrease the number of episodes of hyperventilation. Several of these slow breathing techniques have been shown to benefit patients with asthma and hypertension. Hyperventilation reduction can help patients with cardiovascular disease. Anxiety and stress-reduction techniques can lower adverse outcomes in cardiovascular illness by decreasing sympathetic activity. Option D: Encourage the client to explore underlying feelings that may be contributing to irrational fears. Help the client to understand how facing these feelings, rather than suppressing them, can result in more adaptive coping abilities. Verbalization of feelings in a non threatening environment may help the client come to terms with unresolved issues. Discuss the process of thinking about the feared object/situation before it occurs. Anticipation of a future phobic reaction allows the client to deal with the physical manifestations of fear. Option E: Encourage the client to share the seemingly unnatural fears and feelings with others, especially the nurse therapist. Clients are often reluctant to share feelings for fear of ridicule and may have repeatedly been told to ignore feelings. Once the client begins to acknowledge and talk about these fears, it becomes apparent that the feelings are manageable. Option F: Explore things that may lower fear level and keep it manageable (e.g. singing while dressing, repeating a mantra, practicing positive self-talk while in a fearful situation); provides the client with a sense of control over the fear. Distracts the client so that fear is not totally focused on and allowed to escalate. Educate the patient and/or SO that anxiety. disorders are treatable. Pharmacological therapy is an effective treatment for anxiety disorders; treatment regimen may include antidepressants and anxiolytics.

The client with long-term alcoholism asks the nurse, "How does Alcoholics Anonymous help me quit drinking?" Which statements are the nurse's best responses? Select all that apply. 1. "AA has sponsors whom you can contact if you want to take a drink." 2. "AA discusses medications used to help prevent drinking alcohol." 3. "AA is a support group of alcoholics who have successfully quit drinking." 4. "AA helps you realize the power you have over your addiction to alcohol." 5. "AA has professional guest speakers to address addictive personalities."

1, 3 1. Each member of AA has a sponsor who has successfully quit drinking and is a support to a new member trying to stop drinking. 2. AA does not discuss medications used to help prevent drinking alcohol. 3. AA is a support group made up of recovering alcoholics who help others to stop drinking based on the 12-step approach. 4. AA helps an alcoholic realize he/she is helpless over his or her addiction. He/she has no power over the addiction. 5. Recovering alcoholics speak at the meetings, not professional guest speakers.

Which nursing interventions are appropriate for a hospitalized client with mania who is exhibiting manipulative behavior? Select all that apply. 1. Communicate expected behaviors to the client 2. Ensure that the client knows that he or she is not in charge of the nursing unit 3. Assist the client in developing means of setting limits on personal behavior 4. Follow through about the consequences of behavior in a nonpunitive manner 5. Enforce rules and inform the client that he or she will not be allowed to attend therapy groups. 6. Be clear with the client regarding the consequences of exceeding limits set regarding behavior

1, 3, 4, 6 1. Communicate expected behaviors to the client 3. Assist the client in developing means of setting limits on personal behavior 4. Follow through about the consequences of behavior in a non-punitive manner 6. Be clear with the client regarding the consequences of exceeding limits set regarding behavior

During an interview, the female client tells the psychiatric nurse in a mental health clinic, "Sometimes I feel like life is not worth living. I am going to kill myself." Which interventions should the nurse implement? Select all that apply. 1. Make a no-suicide contract with the client. 2. Place the client on a 1-to-1 supervision. 3. Ask the client whether she has a plan. 4. Commit the client to the psychiatric unit. 5. Assess the client's support system.

1, 3, 5 1. A no-suicide contract is one of the first interventions the nurse implements with the client. It states that if the client feels ANSWERS suicidal, he or she will talk to someone and will not take action on the thoughts. 3. The nurse should ask the client whether she has a plan. The more the specific the plan is, the more seriously the statement should be taken. 5. The nurse should assess the client's support system and the type of help each person or group can give the client, such as hotlines, church groups, and self-help groups, as well as family members.

The client in the psychiatric unit tells the nurse, "Someone just put a bomb under the couch in the lobby." Which action should the nurse implement first? 1. Look under the couch for a bomb. 2. Implement the bomb scare protocol. 3. Have the staff evacuate the unit. 4. Tell the client there is no bomb.

1. Look under the couch for a bomb. The nurse must know the bomb scare policy of the facility, and in many cases the nurse looks for the bomb but does not touch it if it is found. In some instances, the nurse should not attempt to look for a bomb, but because the client is on a psychiatric unit, the nurse should look for a suspicious-looking object before notifying the bomb squad and evacuating the clients.

The psychiatric nurse overhears a mental health worker (MHW) arguing with a client diagnosed with paranoid schizophrenia. Which action should the nurse implement? 1. Ask the MHW to go to the nurse's station. 2. Tell the MHW to quit arguing with the client. 3. Notify the clinical manager of the psychiatric unit. 4. Report this behavior to the client abuse committee.

1. Ask the MHW to go to the nurse's station. The nurse should first separate the MHW from the client; therefore, asking the MHW to go to the nurse's station would be the first intervention.

The mental health worker (MHW) has tried to calm down the client on the psychiatric unit who is angry and attempting to fight with another client. The nurse observes the MHW "taking down" the client to the floor. Which intervention should the nurse implement? 1. Assist the MHW with the "take down" of the client. 2. Call the hospital security to come and assist the MHW. 3. Document the client "take down" in the nurse's notes. 4. Remove the other clients from the day room area.

1. Assist the MHW with the "take down" of the client. All psychiatric staff members are taught how to "take down" a client physically if the client is a danger to him- or herself or to others. The nurse should assist the MHW in subduing the client so that no one is injured.

The nurse is caring for clients in the psychiatric unit. Which task would be mostappropriate for the nurse to delegate to the mental health worker (MHW)? 1. Instruct the MHW to walk with the client who is agitated and anxious. 2. Ask the MHW to clean up the floor where the client has urinated. 3. Tell the MHW to phone the HCP to obtain a PRN medication order. 4. Request the MHW to explain seizure precautions to another staff member.

1. Instruct the MHW to walk with the client who is agitated and anxious. The MHW could walk with the client who is agitated. This may help decrease the client's agitation and anxiety.

A client is admitted to the psychiatric unit after a serious suicidal attempt by hanging. the nurse's most important aspect of care is to maintain client safety and plans to: 1. Request that a peer will remain with the client at all times 2. Remove the client's clothing and place the client in a hospital gown. 3. Assign a staff member to the client who will remain with him or her at all times 4. Admit the client to a seclusion room where all potentially dangerous articles are removed

1. Request that a peer will remain with him or her at all times

The charge nurse is caring for clients in an acute care psychiatric unit. Which client would be most appropriate for the charge nurse to assign to the licensed practical nurse (LPN)? 1. The client diagnosed with dementia who is confused and disoriented. 2. The client diagnosed with schizophrenia who is experiencing tardive dyskinesia. 3. The client diagnosed with bipolar disorder who has a lithium level of 2.0 mEq/L. 4. The client diagnosed with chronic alcoholism who is experiencing delirium tremens.

1. The client diagnosed with dementia who is confused and disoriented. The client diagnosed with dementia would be expected to have confusion and disorientation; therefore, the LPN could be assigned this client. This client is not experiencing any potentially life-threatening complication of dementia.

Which behaviors observed by the nurse might lead to the suspicion that a depressed adolescent client could be suicidal? 1. The client gives away a prized CD and a cherished autographed picture of the performer 2. The client runs out of the therapy group swearing at the group leader and then runs to her room 3. The client gets angry with her roommate when the roommate borrows her clothes without asking 4. The client becomes angry while speaking on the telephone and slams the receiver down on the hook.

1. The client gives away a prized CD and a cherished autographed picture of the performer

A mother of a teenage client with an anxiety disorder is concerned about her daughter's progress on discharge. She states that her daughter "stashes food, eats all the wrong things that make her hyperactive" and "hangs out with the wrong crowd". In helping the mother prepare for her daughter's discharge, the nurse suggests that the mother: 1. Restrict the daughters socializing time with her friends. 2. Restrict the amount of chocolate and caffeine products in the home. 3. Keep her daughter out of school until she can adjust to the school environment. 4. Consider taking time from work to help her daughter readjust to the home environment.

2. Restrict the amount of chocolate and caffeine products in the home.

The male client in the psychiatric unit asks the MHW to mail a letter to his family forhim. Which action would warrant intervention by the psychiatric nurse? 1. The MHW tells the client to place the letter in the mailbox. 2. The MHW informs the client he cannot send mail to his family. 3. The MHW takes the letter and places it in the unit mailbox. 4. The MHW reports the client mailed a letter at the team meeting.

2. The MHW informs the client he cannot send mail to his family. The nurse should explain to the MHW that mental health clients retain all of the civil rights afforded to all persons, except the right to leave the hospital in the case of involuntary commitments. The client has the right to mail and receive letters.

The psychiatric nurse is working in an outpatient mental health clinic. Which clientshould the nurse intervene with first? 1. The client who had a baby 2 months ago and who is sitting alone and looks dejected. 2. The client whose wife just died and who wants to go to heaven to be with her. 3. The client whose mother brought her to the clinic because the mother thinks the client is anorexic. 4. The client who is rocking compulsively back and forth in a chair by the window.

2. The client whose wife just died and who wants to go to heaven to be with her. This client who says he wants to go to heaven to be with his wife may be suicidal and should be assessed first to see whether he has a plan.

A nurse is collecting data on a client who is actively hallucinating. Which nursing statement would be therapeutic at this time? 1. "I know you feel they are out to get you, but its not true" 2. "I can hear the voice and she wants you to come to dinner" 3. "sometimes people hear things or voices others can't hear" 4. "I talked to the voices you're hearing and they won't hurt you now"

3. "Sometimes people hear things or voices others can't hear"

A nurse observes that a client with a potential for violence is agitated, pacing up and down in the hallway, and making aggressive and belligerent gestures at other clients. which statement would be appropriate to make to this client? 1. "You need to stop that behavior now" 2. "You will need to be placed in seclusion" 3. "What is causing you to become agitated" 4. "You will need to be restrained if you do not change your behavior"

3. "What is causing you to become agitated"

A nurse is gathering data from a client in crisis. when determining the client's perception of the precipitating event that led to the crisis, the most appropriate question to ask is: 1. "With whom do you live?" 2. "Who is available to help you?' 3. "What leads you to seek help now?" 4. "What do you usually do to feel better?"

3. "What leads you to seek help now?"

A client who is diagnosed with pedophilia and has been recently paroled as a sex offender says "Im in treatment and I have served my time. Now this group has posters of me all over the neighborhood telling about me with my picture on it" which of the following is an appropriate response by the nurse? 1. "When children are hurt as you hurt them, people want you isolated" 2. "You're lucky it doesn't escalate into something pretty scary after your crime" 3. "You understand that people fear for their children, but you're feeling unfairly treated?" 4. "You seem angry, but you have committed serious crimes against several children, so your neighbors are frightened?"

3. "You understand that people fear for their children, but you're feeling unfairly treated?"

Which situation requires priority intervention on an inpatient psychiatric unit? 1. A client is threatening to throw the television at another client. 2. A male client wants to use the phone to call his spouse. 3. A client sitting in a chair is delusional and hallucinating. 4. A client has refused to eat anything for the last 2 days.

3. A client sitting in a chair is delusional and hallucinating. Safety is priority over a client who is exhibiting behavior common to an inpatient psychiatric unit. 1. On the inpatient psychiatric unit, the priority is maintaining safety for the clients and staff.

The clinical manager assigned the psychiatric nurse a client diagnosed with major depressionwho attempted suicide and is being discharged tomorrow. Which dischargeinstruction by the psychiatric nurse would warrant intervention by the clinical manager? 1. The nurse provides the client with phone numbers to call if needing assistance. 2. The nurse makes the client a follow-up appointment in the psychiatric clinic. 3. The nurse gives the client a prescription for a 1-month supply of antidepressants. 4. The nurse tells the client not to take any over-the-counter medications.

3. The nurse gives the client a prescription for a 1-month supply of antidepressants. The client should be given a 7-day supply of antidepressants because safety of the client is priority. As antidepressant medications become more effective, the client is at a higher risk for suicide; therefore, the nurse should ensure that the client cannot take an overdose of medication. This instruction warrants intervention by the clinical manager.

During a prenatal assessment, the clinic nurse suspects that her client was abused. Which of the following questions would be most appropriate? A. "Are you being threatened or hurt by your partner?" B. "Are you frightened of your partner?" C. "Is something bothering you?" D. "What happens when you and your partner argue?"

A. "Are you being threatened or hurt by your partner?" The use of simple, direct questions, asked in an emphatic manner, is best to validate the presence of an abusive situation. The evaluation should start with a detailed history and physical examination. Clinicians should screen all females for domestic violence, and refer to females who screen positive. This includes females who do not have signs or symptoms of abuse. All healthcare facilities should have a plan in place that provides for assessing, screening, and referring patients for intimate partner violence. Protocols should include referral, documentation, and follow-up. Option B: Typical domestic injury patterns include contusions to the head, face, neck, breast, chest, abdomen, and musculoskeletal injuries. Accidental injuries more commonly involve the extremities of the body. Abuse victims tend to have multiple injuries in various stages of healing from acute to chronic. Although professional and public awareness has increased, many patients and providers are still hesitant to discuss abuse. Option C: Domestic violence victims may have emotional and psychological issues such as anxiety and depression. Complaints may include backaches, stomachaches, headaches, fatigue, restlessness, decreased appetite, and insomnia. Women are more likely to experience asthma, irritable bowel syndrome, and diabetes. Option D: The other questions are indirect and may not lead to the discussion of an abusive situation. Patients that have suffered domestic violence may or may not want a referral. Many are fearful of their lives and financial well-being and hence may be weighing the tradeoff in leaving the abuser leading to loss of support and perhaps the responsibility of caring for children alone. The healthcare provider needs to assure the patient that the decision is voluntary and that the provider will help regardless of the decision. The goal is to make resources accessible, safe, and to enhance support.

A client tells the nurse that people from Mars are going to invade the earth. Which response by the nurse would be most therapeutic? A. "That must be frightening to you. Can you tell me how you feel about it?" B. "There are no people living on Mars." C. "What do you mean when you say they're going to invade the earth?" D. "I know you believe the earth is going to be invaded, but I don't believe that."

A. "That must be frightening to you. Can you tell me how you feel about it?" This response addresses the client's underlying fears without feeding the delusion. Attempt to understand the significance of these beliefs to the client at the time of their presentation. Important clues to underlying fears and issues can be found in the client's seemingly illogical fantasies. Option B: Refuting the client's delusion would increase anxiety and reinforce the delusion. Initially do not argue with the client's beliefs or try to convince the client that the delusions are false and unreal. Arguing will only increase a client's defensive position, thereby reinforcing false beliefs. This will result in the client feeling even more isolated and misunderstood. Option C: Asking the client to elaborate on the delusion would also reinforce it. Interact with clients on the basis of things in the environment. Try to distract the client from their delusions by engaging in reality-based activities (e.g., card games, simple arts and crafts projects, etc). When thinking is focused on reality-based activities, the client is free of delusional thinking during that time. Helps focus attention externally. Option D: Voicing disbelief about the delusion wouldn't help the client deal with underlying fears. Show empathy regarding the client's feelings; reassure the client of your presence and acceptance. The client's delusion can be distressing. Empathy conveys your caring, interest, and acceptance of the client.

The charge nurse of a psychiatric unit is planning the client assignment for the day. The most appropriate staff to be assigned to a client with a potential for violence is which of the following: A. A timid nurse B. A mature, experienced nurse C. An inexperienced nurse D. A soft-spoken nurse

B. A mature, experienced nurse The unstable, aggressive client should be assigned to the most experienced nurse. Maintain a consistent approach, employ consistent expectations, and provide a structured environment. Clear and consistent limits and expectations minimize the potential for the client's manipulation of staff. Option A: The timid nurse may not be able to lay out consistent limits to an angry client. The client can use inconsistencies and value judgments as justification for arguing and escalating mania. Option C: An inexperienced nurse may not know how to handle the situation appropriately. Using a calm and firm approach may provide structure and control for a client who is out of control. Option D: A soft-spoken nurse may feel intimidated by the angry patient. Using short, simple, and brief explanations or statements is appropriate for the client. A short attention span limits understanding of small pieces of information.

A client with a diagnosis of narcissistic personality disorder has been given a day pass from the psychiatric hospital. The client is due to return at 6 pm. At 5 pm the client telephones the nurse in charge of the unit and says "6 o'clock is too early. I feel like coming back at 7:30." The nurse would be most therapeutic by telling the client to: A. Return immediately, to demonstrate control. B. Return on time or restrictions will be imposed. C. Come back at 6:45, as a compromise to set limits. D. Come back as soon as possible or the police will be sent.

B. Return on time or restrictions will be imposed. This sets limits, points out reality, and places responsibility for behavior on the client. Be clear with the client as to the unit/hospital/clinic policies. Give brief concrete reasons for the rules, if asked, and then move on. Institutional policies provide structure and safety. Be very clear about the consequences if policies/limits are not adhered to. Client needs to understand the consequences of breaking the rules. Option A: When limits or policies are not followed, enforce the consequences in a matter-of-fact, nonjudgmental manner. Enforces that the client is responsible for his or her own actions. Option C: If the client becomes seductive, reiterate the therapeutic goals and boundaries of treatment. The client is in the hospital/clinic for a reason. Being taken in by seductive behavior undermines the effectiveness of the treatment. Option D: Approach the client in a consistent manner in all interactions. Enhances feelings of security and provides structure. Exceptions encourage manipulative behavior. If the client becomes hostile or projects blame onto you or staff, project a neutral, calm demeanor, and avoid power struggles. Focus on the client's underlying feelings.

A client with borderline personality disorder becomes angry when he is told that today's psychotherapy session with the nurse will be delayed 30 minutes because of an emergency. When the session finally begins, the client expresses anger. Which response by the nurse would be most helpful in dealing with the client's anger? A. "If it had been your emergency, I would have made the other client wait." B. "I know it's frustrating to wait. I'm sorry this happened." C. "You had to wait. Can we talk about how this is making you feel right now?" D. "I really care about you and I'll never let this happen again."

C. "You had to wait. Can we talk about how this is making you feel right now?" This response may diffuse the client's anger by helping to maintain a therapeutic relationship and addressing the client's feelings. Regardless of the clinical setting, the nurse must provide structure and limit setting in the therapeutic relationship; in a clinic setting, this may mean seeing the client for scheduled appointments of a predetermined length rather than whenever the client appears and demands the nurse's immediate attention. Option A: This wouldn't address the client's anger. Cognitive restructuring is a technique useful in changing patterns of thinking by helping clients to recognize negative thoughts and feelings and to replace them with positive patterns of thinking; thought stopping is a technique to alter the process of negative or self-critical thought patterns. Option B: This is incorrect because the client with a borderline personality disorder blames others for things that happen, so apologizing reinforces the client's misconceptions. Establish boundaries in relationships. The nurse must be quite clear about establishing the boundaries of the therapeutic relationship to ensure that neither the client's nor the nurse's boundaries are violated. Option D: The nurse can't promise that a delay will never occur again because such matters are outside the nurse's control. Help clients to cope and to control emotions. The nurse can help the clients to identify their feelings and learn to tolerate them without exaggerated responses such as destruction of property or self-harm; keeping a journal often helps clients gain awareness of feelings.

The nurse acts as a patient advocate when she does one of the following: A. She encourages the client to express her feelings regarding her experience. B. She assesses the client for injuries. C. She postpones the physical assessment until the client is calm. D. Explains to the client that her reactions are normal.

C. She postpones the physical assessment until the client is calm The nurse acts as a patient advocate as she protects the client from psychological harm. Nurse advocates support the patient's best interests while respecting the family's important role. Advocates become facilitators when patients and family members need to discuss uncomfortable information or explore its implications. Nurses may sometimes need to advocate for patients against their families. Option A: The nurse acts as a counselor. A need for counseling is a clinical judgment made by the nurse, and his/her response will be immediate situational counseling, continuing counseling sessions, or referral. Types of counseling situations that the nursing professional may encounter are outlined, including four escapes utilized by students, such as substance abuse, suicide, fear of AIDS, and anorexia/bulimia. Since students do utilize health services, the nurse counselor with a holistic view of nursing care, which includes health education and counseling, has an opportunity and a responsibility to act upon this knowledge. Option B: The nurse acts as a technician. Nurse technicians are medical care providers who give basic medical care to patients. A nurse tech generally works under the supervision of a Registered Nurse. Also known as nursing attendants or nursing aides, they provide important services to help the registered nurses complete their tasks. Option D: This exemplifies the role of a teacher. Nurse educators are registered nurses with advanced education who are also teachers. Most work for several, if not many, years before deciding to turn to a career teaching future nurses. Most nurse educators have extensive clinical experience, and many continue caring for patients after becoming educators.

Situation: A widow age 28, whose husband died one (1) year ago due to AIDS, has just been told that she has AIDS. Panky says to the nurse, "Why me? How could God do this to me?" The nurse's therapeutic response is: A. "I will refer you to a clergy who can help you understand what is happening to you." B. " It isn't fair that an innocent like you will suffer from AIDS." C. "That is a negative attitude." D. "It must really be frustrating for you. How can I best help you?"

D. "It must really be frustrating for you. How can I best help you?" This response reflects the pain due to loss. A helping relationship can be forged by showing empathy and concern. Communicate therapeutically with patient and family members and allow them to verbalize feelings. Sharing feelings with a healthcare provider may help the patient find significance in the experience of loss. Option A: This is not therapeutic since it passes the buck or responsibility to the clergy. Support the patient and significant others share mutual fears, concerns, plans, and hopes for each other. Keeping secrets won't do any help during this time. These times of stress can be used as an opportunity for growth and family development. Option B: This response is not therapeutic because it gives the client the impression that she is right which prevents the client from reconsidering her thoughts. Help the client accept that the loss is real by providing sensitive, factual information concerning the loss. Option C: This statement passes judgment on the client. Acknowledge the patient's need to review the loss experience. In this way, the patient and family members integrate the event into their experience.

A client with schizotypal personality disorder is sitting in a puddle of urine. She's playing in it, smiling, and softly singing a child's song. Which action would be best? A. Admonish the client for not using the bathroom. B. Firmly tell the client that her behavior is unacceptable. C. Ask the client if she's ready to get cleaned up now. D. Help the client to the shower, and change the bedclothes.

D. Help the client to the shower, and change the bedclothes. A client with schizotypal personality disorder can experience high levels of anxiety and regress to childlike behaviors. This client may require help needing self-care needs. The client may not respond to the other options or those options may generate more anxiety. Option A: Approach the client in a consistent manner in all interactions. Enhances feelings of security and provides structure. Exceptions encourage manipulative behavior. When the client is ready and interested, teach client coping skills to help defuse tension and trouble feelings (e.g., anxiety reduction, assertiveness skills). Option B: Be clear with the client as to the unit/hospital/clinic policies. Give brief concrete reasons for the rules, if asked, and then move on. Institutional policies provide structure and safety. Option C: Give the client positive attention when behaviors are appropriate and productive. Avoid giving any attention (when possible and not dangerous to self or others) when client's behaviors are inappropriate. Reinforcing positive behaviors might increase the likelihood of repetition. Ignoring negative behaviors (when feasible) robs the client of even negative attention.

A nurse is orienting a new client to the unit when another client rushes down the hallway and asks the nurse to sit down and talk. The client requesting the nurse's attention is extremely manipulative and uses socially acting-out behaviors when demands are unmet. The nurse should: A. Suggest that the client requesting attention speak with another staff member. B. Leave the new client and talk with the other client to avoid precipitating acting out behavior. C. Tell the interrupting client to sit down and be patient, stating, "I'll be back as soon as possible." D. Introduce the two clients and suggest that the client join the new client and the nurse on the tour.

C. Tell the interrupting client to sit down and be patient, stating, "I'll be back as soon as possible." This sets realistic limits on behavior without rejecting the client. Identify behavioral limits and behaviors that are expected. Client needs a clear structure. Expect frequent testing of limits initially. Maintaining limits can enhance feelings of safety in the client. Option A: Be clear with the client as to the unit/hospital/clinic policies. Give brief concrete reasons for the rules, if asked, and then move on. Institutional policies provide structure and safety. Be very clear about the consequences if policies/limits are not adhered to. Client needs to understand the consequences of breaking the rules. Option B: When limits or policies are not followed, enforce the consequences in a matter-of-fact, nonjudgmental manner. Enforces that the client is responsible for his or her own actions. Make a clear and concrete written plan of care so other staff can follow. Helps minimize manipulations and might help encourage cooperation. Option D: Some clients might attempt to instill guilt when they do not get what they want. Remain neutral but firm. Nurses often want to be seen as "nice" However, being professional and maintaining limits is the better therapeutic approach.

The nurse is caring for children in a psychiatric unit. Which client requires immediate intervention by the psychiatric nurse? 1. The 10-year-old child diagnosed with oppositional defiant disorder who refuses to follow the directions of the mental health worker (MHW). 2. The 5-year-old child diagnosed with pervasive developmental disorder who refuses to talk to the nurse and will not make eye contact. 3. The 7-year-old child diagnosed with conduct disorder who is throwing furniture against the wall in the day room. 4. The 8-year-old mentally retarded child who is sitting on the playground and eating dirt and sand.

The 7-year-old child diagnosed with conduct disorder who is throwing furniture against the wall in the day room. The child with conduct disorder is aggressive to people and animals, bullies and threatens others, destroys property, and sets fires. Throwing furniture could endanger the child or other clients. This behavior warrants immediate intervention. 1. Oppositional defiant disorder consists of a pattern of uncooperative, defiant, and hostile behavior toward authority figures. Not following the MHW's directions would be expected behavior in a child diagnosed with this disorder and would not require immediate intervention by the nurse. 2. Refusal to talk and/or make eye contact is a sign of autism, the best known of the pervasive developmental disorders; therefore, this client would not require immediate intervention by the nurse. 4. Eating dirt and sand is pica, or the ingestion of non-nutritive substances such as paint, hair, cloth, leaves, sand, clay, or soil. It is commonly seen in mentally retarded children, but it is not life threatening unless a medical complication such as a bowel obstruction, infection, or a toxic condition (e.g., lead poisoning) occurs. This behavior would not require immediate intervention.

Which situation would warrant immediate intervention by the charge nurse on the psychiatric unit after receiving the a.m. shift report? 1. The client diagnosed with paranoid schizophrenia who is delusional. 2. The p.m. shift licensed practical nurse (LPN) called in to say he or she would not be able to work today. 3. The male mental health worker (MHW) reports losing his unit key and identification card. 4. The unit secretary has HCP's orders that need to be co-signed.

3. The male mental health worker (MHW) reports losing his unit key and identification card. The loss of a unit key is priority because the nurse must determine when the MHW last had the key and determine whether it may be lost on the psychiatric unit. If a client finds the key, then the unit is no longer secure.

The charge nurse has assigned the licensed practical nurse (LPN) to administer medications to the clients on an inpatient psychiatric unit. Which client should the LPN force to take the prescribed medications? 1. The client with bipolar disorder who has been declared incompetent in a court of law. 2. The client with major depression who voluntarily admitted herself to the unit. 3. The client with paranoid schizophrenia who was involuntarily admitted to the unit. 4. The client with a borderline personality who has legal charges pending in the court.

1. The client with bipolar disorder who has been declared incompetent in a court of law. When an individual is declared incompetent in a court, a guardian makes decisions for the client. The client loses the right to refuse medication.

The client seeing the psychiatric nurse in the mental health clinic tells the nurse,"If I tell you something very important, will you promise not to tell anyone?" Whichstatement is the nurse's best response? 1. "I promise I will not tell anyone if you don't want me to." 2. "If it affects your care I will have to tell someone who can help." 3. "If you don't want me to tell anyone, then please don't tell me." 4. "Why do you not want me to tell anyone if it is so important?"

2. "If it affects your care I will have to tell someone who can help." This is the nurse's best response. The nurse is being honest with the client but will keep the information confidential if it does not affect the client's care.

The nurse in the outpatient psychiatric unit is returning phone calls. Which client should the psychiatric nurse call first? 1. The female client diagnosed with histrionic personality disorder who needs to talk to the nurse about something very important. 2. The male client diagnosed with schizophrenia who is hearing voices telling him to hurt his mother. 3. The male client diagnosed with major depression whose wife called and said he was talking about killing himself. 4. The client diagnosed with bipolar disorder who is manic and has not slept for the last 2 days.

2. The male client diagnosed with schizophrenia who is hearing voices telling him to hurt his mother. The nurse should contact this client first because the client realizes the voices are telling him to hurt his mother. The nurse should inform this client to come to the clinic immediately, and he should be admitted to a psychiatric unit. 1. The client with a histrionic personality has excessive emotionality and seeks attention. Her saying "something important" must be understood within this context and would not warrant calling this client first. 3. Because the wife called the clinic, the client is being watched and should be safe from killing himself. The nurse should call this client immediately but not before a client who made the phone call himself and who may be alone and hearing voices. 4. The nurse should expect the client who is manic not to be sleeping; therefore, this is expected behavior. The nurse should call this client immediately but not before the client who is hearing voices telling him to hurt his mother. Content - Mental Health: Category of Health

The psychiatric charge nurse is making shift assignments for the admission unit. The staff includes one registered nurse (RN), two licensed practical nurses (LPNs), four mental health workers (MHWs), and a unit secretary. Which task would be most appropriate to assign to the LPNs? 1. Update the clients' individualized care plans. 2. Stay in the lobby area and watch the clients. 3. Administer routine medications to the clients. 4. Transcribe the admission orders for a client.

3. Administer routine medications to the clients. The LPNs' scope of practice allows the administration of medication. This is an appropriate assignment. 4. The LPNs can transcribe an HCP's orders, but the unit secretary can also transcribe orders, which the RN/LPN can co-sign. This would not be the most appropriate assignment for the LPNs.

The client diagnosed with bipolar disorder is admitted to the psychiatric unit in an acute manic state. The nurse needs to complete the admission assessment, but the client is restless, very energetic, and agitated. Which intervention should the nurse implement? 1. In a very firm voice, ask the client to sit down. 2. Administer lithium (Eskalith), an antimania medication. 3. Ask questions while walking and pacing with the client. 4. Do not complete the admission assessment at this time.

3. Ask questions while walking and pacing with the client. Walking or pacing with the client will allow the client to work off energy and may decrease restlessness and agitation. The nurse should implement this intervention to obtain information for the admission assessment.

The nurse is working in an outpatient psychiatric clinic. The male client tells the nurse, "I am going to kill my wife if she files for divorce. I know I can't live without her." Which action should the nurse implement? 1. Take no action because this is confidential information. 2. Document the statement in the client's nurse's notes. 3. Inform the client's psychiatric healthcare provider (HCP) of the comment. 4. Encourage the client to talk to his wife about the divorce.

3. Inform the client's psychiatric healthcare provider (HCP) of the comment. Mental health clinicians have a duty to warn identifiable third parties of threats made by a person even if these threats were discussed during a therapy session (Tarasoff v. Regents of the University of California, 1976). The nurse should notify the client's psychiatric HCP so that the wife can be notified of the threat.

The client on the psychiatric unit is yelling at other clients, throwing furniture, and threatening the staff members. The charge nurse determines the client is at imminent risk for harming the staff/clients and instructs the staff to place the client in seclusion. Which intervention should the charge nurse implement first? 1. Document the client's behavior in the nurse's notes. 2. Instruct the MHWs to clean up the day room area. 3. Obtain a restraint/seclusion order from the HCP. 4. Ensure that none of the other clients were injured.

3. Obtain a restraint/seclusion order from the HCP. The use of restraints and seclusion requires an HCP's order every 24 hours. The nurse must obtain this order first after placing the client in the seclusion room. The nurse can place the client in seclusion for the safety of the client/ staff/other clients, but the nurse must then immediately obtain a HCP's order.

A nurse is caring for a client diagnosed with catatonic stupor. the client is lying on the bed, with the body pulled into a fetal position. the appropriate nursing intervention is which of the following? 1. Ask direct questions to encourage talking. 2. Leave the client alone and intermittently check on him. 3. Sit beside the client in silence and verbalize occasional open-ended questions. 4. Take the client into the dayroom with other clients so they can help watch him.

3. Sit beside the client in silence and verbalize occasional open-ended questions.

Which client should the psychiatric charge nurse assign to the nurse from the surgicalunit who was assigned to the psychiatric unit for the shift? 1. The client diagnosed with schizophrenia who is hallucinating and delusional. 2. The client with bipolar disorder who is manic and aggressive toward staff and clients. 3. The client who is diagnosed with chronic depression and will not talk to anyone. 4. The client with schizophrenia and an Axis 2 antisocial personality.

3. The client who is diagnosed with chronic depression and will not talk to anyone. The client who is chronically depressed should be assigned to the surgical nurse who is being floated to the psychiatric unit. The client is not identified as suicidal in the option.

he head nurse in a psychiatric unit in the county emergency department is assigning clients to the staff nurses. Which client should be assigned to the most experienced nurse? 1. The client who is crying and upset because she was raped. 2. The client diagnosed with bipolar disorder who is agitated. 3. The client who was found wandering the streets in a daze. 4. The client diagnosed with schizophrenia who is hallucinating.

3. The client who was found wandering the streets in a daze. The client who was found wandering in a daze has no diagnosis and requires an indepth assessment. This client should be assigned to the most experienced nurse.

When a client with a personality disorder begins demonstrating manipulative behavior, which of the following nursing actions are most appropriate? Select all that apply. A. Ask the client to think about the consequences of behavior. B. Allow the client time to perform specific rituals. C. Develop a consistent team approach to handle the client's behaviors. D. Help the client to express anxiety verbally rather than with specific symptoms. E. Provide immediate feedback concerning the client's specific behaviors. F. Set limits in a clear, direct manner.

A, C, E, F These interventions allow the nurse to immediately confront the client's manipulative behavior and provide consistent structure (through limit-setting and team approach). Option A: Be very clear about the consequences if policies/limits are not adhered to. The client needs to understand the consequences of breaking the rules. Option B: This is appropriate for the client with obsessive-compulsive behavior. During the beginning of treatment, allow plenty of time for rituals. Do not be judgmental or verbalize disapproval of the behavior to deny the client this activity can precipitate panic level of anxiety. Option C: Make a clear and concrete written plan of care so other staff can follow. Helps minimize manipulations and might help encourage cooperation. Option D: For someone with somatization problems. Encourage the client to explore feelings and concerns (e.g., identify fears, loneliness, self-hate). Client is used to acting out feelings. Option E: Give the client positive attention when behaviors are appropriate and productive. Avoid giving any attention (when possible and not dangerous to self or others) when the client's behaviors are inappropriate. Option F: Use assertiveness when setting limits on the client's unreasonable demands for attention and time. Firm, clear, nonjudgmental limits give the client structure.

What would be the best approach for a wife who is still living with her abusive husband? A. "Here's the number of a crisis center that you can call for help ." B. "It's best to leave your husband." C. "Did you discuss this with your family?" D. " Why do you allow yourself to be treated this way."

A. "Here's the number of a crisis center that you can call for help ." Protection is a priority concern in abuse. Help the victim to develop a plan to ensure safety. The world for many domestic abuse victims can be lonely, isolated, and filled with fear. Sometimes reaching out and letting them know that someone is there for them can provide tremendous relief. Option B: Do not give advice to leave the abuser. Making decisions for the victim further erodes her esteem. However, discuss options available. If you want to help, it is important that you validate her feelings by letting her know that having these conflicting thoughts is normal. But it is also important that you confirm that violence is not okay, and it isn't normal to live in fear of being physically attacked. Option C: The victim tends to isolate from friends and family. Help the victim find support and resources. Look up telephone numbers for shelters, social services, attorneys, counselors, or support groups. If available, offer brochures or pamphlets about domestic violence. Option D: This is judgmental. Avoid in any way implying that she is at fault. If the person does decide to talk, listen to the story without being judgmental, offering advice, or suggesting solutions. Chances are if you actively listen, the person will tell you exactly what they need. Just give the person the full opportunity to talk. You can ask clarifying questions, but mainly just let the person vent their feelings and fears. You may be the first person in which the victim has confided.

A client with paranoid personality disorder is admitted to a psychiatric facility. Which remark by the nurse would best establish rapport and encourage the client to confide in the nurse? A. "I get upset once in a while, too." B. "I know just how you feel. I'd feel the same way in your situation." C. "I worry, too, when I think people are talking about me." D. "At times, it's normal not to trust anyone."

A. "I get upset once in a while, too." Sharing a benign, non-threatening, personal fact or feeling helps the nurse establish rapport and encourages the client to confide in the nurse. The nurse can't know how the client feels. Identify with the client symptoms he experiences when he or she begins to feel anxious around others. Increased anxiety can intensify agitation, aggressiveness, and suspiciousness. If a client is found to be very paranoid, solitary or one-on-one activities that require concentration are appropriate. The client is free to choose his level of interaction; however, concentration can help minimize distressing paranoid thoughts or voices. Option B: Telling the client otherwise would justify the suspicions of a paranoid client; furthermore, the client relies on the nurse to interpret reality. Attempt to understand the significance of these beliefs to the client at the time of their presentation. Important clues to underlying fears and issues can be found in the client's seemingly illogical fantasies. Initially do not argue with the client's beliefs or try to convince the client that the delusions are false and unreal. Option C: This is incorrect because it focuses on the nurse's feelings, not the client's. Recognize the client's delusions as the client's perception of the environment. Recognizing the client's perception can help you understand the feelings he or she is experiencing. Option D: This wouldn't help establish rapport or encourage the client to confide in the nurse. Show empathy regarding the client's feelings; reassure the client of your presence and acceptance. The client's delusion can be distressing. Empathy conveys your caring, interest, and acceptance of the client. Interact with clients on the basis of things in the environment. Try to distract the client from their delusions by engaging in reality-based activities (e.g., card games, simple arts and crafts projects etc).

Which of these statements by the nurse reflects the best use of therapeutic interaction techniques? A. "You look upset. Would you like to talk about it?" B. "I'd like to know more about your family. Tell me about them." C. "I understand that you lost your partner. I don't think I could go on if that happened to me." D. "You look very sad. How long have you been this way?"

A. "You look upset. Would you like to talk about it?" Giving broad opening statements and making observations are examples of therapeutic communication. The other options are too specific or focused on being therapeutic. Therapeutic communication is often most effective when patients direct the flow of conversation and decide what to talk about. To that end, giving patients a broad opening such as "What's on your mind today?" or "What would you like to talk about?" can be a good way to allow patients an opportunity to discuss what's on their mind. Option B: Observations about the appearance, demeanor, or behavior of patients can help draw attention to areas that might pose a problem for them. Observing that they look tired may prompt patients to explain why they haven't been getting much sleep lately; making an observation that they haven't been eating much may lead to the discovery of a new symptom. Option C: Nurses provide patients with support and information while maintaining a level of professional distance and objectivity. With therapeutic communication, nurses often use open-ended statements and questions, repeat information, or use silence to prompt patients to work through problems on their own. Option D: Sometimes during a conversation, patients mention something particularly important. When this happens, nurses can focus on their statement, prompting patients to discuss it further. Patients don't always have an objective perspective on what is relevant to their case; as impartial observers, nurses can more easily pick out the topics to focus on.

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 a movie with the peer group.

A. Art therapy in a small group Art therapy provides a non-threatening vehicle for the expression of feelings, and use of a small group will help the client become comfortable with peers in a group setting. Initially, provide activities that require minimal concentration (e.g., drawing, playing simple board games). Depressed people lack concentration and memory. Activities that have no "right or wrong" or "winner or loser" minimizes opportunities for the client to put himself/herself down. Option B: Basketball is a competitive game that requires energy; the client with major depression is not likely to participate in this activity. Involve the client in gross motor activities that call for very little concentration (e.g., walking). Such activities will aid in relieving tensions and might help in elevating the mood. Option C: Recommending that the client read a self-help book may increase, not decrease his isolation. When the client is in the most depressed state, Involve the client in one-to-one activity; maximizes the potential for interactions while minimizing anxiety levels. Option D: Watching a movie with a peer group does not guarantee that interaction will occur; therefore, the client may remain isolated. Eventually, involve the client in group activities (e.g., group discussions, art therapy, dance therapy). Socialization minimizes feelings of isolation. Genuine regard for others can increase feelings of self-worth.

A client with avoidant personality disorder says occupational therapy is boring and doesn't want to go. Which action would be best? A. State firmly that you'll escort him to OT. B. Arrange with OT for the client to do a project on the unit. C. Ask the client to talk about why OT is boring. D. Arrange for the client not to attend OT until he is feeling better.

A. State firmly that you'll escort him to OT. If given the chance, a client with avoidant personality disorder typically elects to remain immobilized. The nurse should insist that the client participates in OT. Expand limits by clarifying expectations for clients in a number of settings. When time is taken in initial meetings to clarify expectations, confrontations, and power struggles with clients can be minimized and even avoided. Option B: In a respectful, neutral manner, explain expected client behaviors, limits, and responsibilities during sessions with nurse clinician. Clearly state the rules and regulations of the institution, and the consequences when these rules are not adhered to. From the beginning, clients need to have explicit guidelines and boundaries for expected behaviors on their part, as well as what the client can expect from the nurse. Clients need to be fully aware that they will be held responsible for their behaviors. Option C: Addressing an invalid issue such as the client's perceived boredom avoids the real issue: the client's need for therapy. Understand that PD clients, in particular, will be resistant to change and that this is symptomatic of PDs. This is particularly true in the beginning phases of therapy. Option D: Arranging for the client to do a project on the unit validates and reinforces the client's desire to avoid getting to OT. Responding to client's resistance and seeming lack of change in a neutral manner is part of the foundation for trust. In other words, the nurse does not have a vested interest in the client "getting better.". The nurse remains focused on the client's needs and issues in any event.

Situation: Knowledge and skills in the care of violent clients is vital in the psychiatric unit. A nurse observes that a client with a potential for violence is agitated, pacing up and down the hallway and making aggressive remarks. Which of the following statements is most appropriate to make to this patient? A. What is causing you to become agitated? B. You need to stop that behavior now. C. You will need to be restrained if you do not change your behavior. D. You will need to be placed in seclusion.

A. What is causing you to become agitated? In a non-violent aggressive behavior, help the client identify the stressor or the true object of hostility. This helps reveal unresolved issues so that they may be confronted. Frequently assess client's behavior for signs of increased agitation and hyperactivity. Early detection and intervention of escalating mania will prevent the possibility of harm to self or others, and decrease the need for seclusions. Option B: Pacing is a tension-relieving measure for an agitated client. Remain neutral as possible; Do not argue with the client. The client can use inconsistencies and value judgments as justification for arguing and escalating mania. Option C: This is a threatening statement that can heighten the client's tension. Use short, simple, and brief explanations or statements. A short attention span limits understanding of small pieces of information. Option D: Seclusion is used when less restrictive measures have failed. If nursing interventions (quiet environment and firm limit setting) and chemical restraints (tranquilizers-e.g., haloperidol [Haldol]) have not helped dampen escalating manic behaviors, then seclusion might be warranted.

A client with a diagnosis of paranoid schizophrenia comments to the nurse, "How do I know what is really in those pills?" Which of the following is the best response? A. Say, "You know it's your medicine." B. Allow him to open the individual wrappers of the medication. C. Say, "Don't worry about what is in the pills. It's what is ordered." D. Ignore the comment because it's probably a joke.

B. Allow him to open the individual wrappers of the medication. This is correct because allowing a paranoid client to open his medication can help reduce suspiciousness. Talk openly with the client about their beliefs and thoughts, showing empathy and support. Help build trust and rapport with clients. Paranoid clients may be more reluctant to trust anyone, but open communication generally offers more cooperation. Explain all procedures clearly and carefully, and their purpose, before starting them. Prevents aggressive behavior and suspicion. Promotes cooperation and compliance. Helps develop trust. Option A: This is incorrect because the client doesn't know that it's his medication and he's obviously suspicious. Discuss feelings and help the client identify behaviors that cause conflict or alienate others. Helping clients see the reality of their behaviors can help treatment progress and lead to more appropriate behaviors and interactions. Option C: Discuss and have the client demonstrate (through role-play if appropriate) more acceptable responses and reactions to behaviors and stressors. Helps the client develop more positive coping skills for dealing with delusions, suspicions, and fears. Provide reorientation as appropriate, but avoid confrontation of the delusions. The client may need to be refocused to reality at times, but avoid confrontation that may be interpreted as argumentative to avoid non-compliance and uncooperative behaviors. Option D: Telling the client not to worry or ignoring the comment isn't supportive and doesn't offer reassurance. Set behavior boundaries and enforce per facility protocols with medications or restraints as necessary. Promote the safety of clients during agitated moments and the safety of others from aggressive behaviors. Follow your facility's specific protocol regarding supervision, restraint, and documentation.

Barbara is a client with a borderline personality disorder. She is defensive and emotionally labile and often becomes suddenly and explosively angry. When interacting with her, you as a nurse would: A. Point out how angry Barbara is becoming, and confront the behavior. B. Take a calm, quiet, and non-confrontational approach, and avoid arguing with Barbara. C. Tell Barbara to calm down and to avoid becoming explosive or restraints will be used. D. Use a gentle touch and a caring approach to calm Barbara.

B. Take a calm, quiet, and non-confrontational approach, and avoid arguing with Barbara. The best way to respond to the client with angry behavior is a calm, non-confrontational, non-argumentative approach. This will avoid further escalating the client's behavior. Use a calm and firm approach. Provides structure and control for a client who is out of control. Option A: Confronting the client's behavior could exacerbate anger and trigger explosive behavior. Remain neutral as possible; Do not argue with the client. The client can use inconsistencies and value judgments as justification for arguing and escalating mania. Option C: Telling the client to calm down minimizes the client's problems, and the mention of restraints may be perceived as threatening to the client. Redirect agitation and potentially violent behaviors with physical outlets in an area of low stimulation (e.g., punching bag). Option D: Touch may also be perceived as threatening; it is not recommended for a client who may become explosive. Maintain a consistent approach, employ consistent expectations, and provide a structured environment.

The client says " the FBI is out to get me." The nurse's best response is: A. "The FBI is not out to catch you." B. "I don't believe that." C. "I don't know anything about that. You are afraid of being harmed." D. " What made you think of that."

C. "I don't know anything about that. You are afraid of being harmed." This presents reality and acknowledges the client's feelings. Interact with clients on the basis of things in the environment. Try to distract the client from their delusions by engaging in reality-based activities (e.g., card games, simple arts and crafts projects etc). When thinking is focused on reality-based activities, the client is free of delusional thinking during that time. Helps focus attention externally. Option A: Initially do not argue with the client's beliefs or try to convince the client that the delusions are false and unreal. Arguing will only increase a client's defensive position, thereby reinforcing false beliefs. This will result in the client feeling even more isolated and misunderstood. Option B: This statement is not a therapeutic response because these disagree with the client's false belief and makes the client feel challenged. Attempt to understand the significance of these beliefs to the client at the time of their presentation. Important clues to underlying fears and issues can be found in the client's seemingly illogical fantasies. Option D: This statement is an unnecessary exploration of the false. Identify feelings related to delusions. If a client believes someone is going to harm him/her, the client is experiencing fear. When people believe that they are understood, anxiety might lessen.

Every day for the past 2 weeks, a client with schizophrenia stands up during group therapy and screams, "Get out of here right now! The elevator bombs are going to explode in 3 minutes!" The next time this happens, how should the nurse respond? A. "Why do you think there is a bomb in the elevator?" B. "That is the same thing you said in yesterday's session." C. "I know you think there are bombs in the elevator, but there aren't." D. "If you have something to say, you must do it according to our group rules."

C. "I know you think there are bombs in the elevator, but there aren't." This is the most therapeutic response because it orients the client to reality. Identify feelings related to delusions. If a client believes someone is going to harm him/her, the client is experiencing fear. When people believe that they are understood, anxiety might lessen. Option A: Interact with clients on the basis of things in the environment. Try to distract the client from their delusions by engaging in reality-based activities (e.g., card games, simple arts and crafts projects etc). When thinking is focused on reality-based activities, the client is free of delusional thinking during that time. Helps focus attention externally. Option B: These are condescending. Attempt to understand the significance of these beliefs to the client at the time of their presentation. Important clues to underlying fears and issues can be found in the client's seemingly illogical fantasies. Recognize the client's delusions as the client's perception of the environment. Recognizing the client's perception can help you understand the feelings he or she is experiencing. Option D: This sounds punitive and could embarrass the client. Initially do not argue with the client's beliefs or try to convince the client that the delusions are false and unreal. Arguing will only increase a client's defensive position, thereby reinforcing false beliefs. This will result in the client feeling even more isolated and misunderstood.

A young, handsome man with a diagnosis of antisocial personality disorder is being discharged from the hospital next week. He asks the nurse for her phone number so that he can call her for a date. The nurse's best response would be: A. "We are not permitted to date clients." B. "No, you are a client and I am a nurse." C. "I like you, but our relationship is professional." D. "It's against my professional ethics to date clients."

C. "I like you, but our relationship is professional." This accepts the client as a person of worth rather than being cold or implying rejection. However, the nurse maintains a professional rather than a social role. Maintain a neutral, calm, and respectful manner, although with some clients this is easier said than done. Helps a client see himself or herself as respected as a person even when behavior might not be appropriate. Option A: Keep in mind clients with personality disorders might defend against feelings of low-self-esteem through blaming, projection, anger, passivity, and demanding behaviors. Many behaviors seen in PD clients cover a fragile sense of self. Often these behaviors are the crux of clients' interpersonal difficulties in all their relationships. Option B: Focus questions in a positive and active light; helps client refocus on the present and look to the future. For example, "What can you do differently now?" or "What have you learned from that experience?". Allows the client to look at past behaviors differently, and gives the client a sense that he or she has choices in the future. Option D: Give the client honest and genuine feedback regarding your observations as to his or her strengths, and areas that could use additional skills. Feedback helps give clients a more accurate view of self, strengths, areas to work on, as well as a sense that someone is trying to understand them.

A client with antisocial personality disorder was admitted in a unit at Nurseslabs Hospital. The newly admitted client stole money from an elderly in the unit. Which of the following is the most appropriate for the nurse to say to this client? A. "Why did you take the money?" B. "Let's talk about how you felt when you took the money." C. "The consequences of stealing are a loss of privileges." D. "This client is defenseless against you."

C. "The consequences of stealing are loss of privileges." The most appropriate response is to reinforce the consequences of behavior that disregard the rights of others. Be very clear about the consequences if policies/limits are not adhered to. Client needs to understand the consequences of breaking the rules. Option A: This client is likely to rationalize and excuse the behavior. Approach the client in a consistent manner in all interactions. Enhances feelings of security and provides structure. Exceptions encourage manipulative behavior. Option B: The nurse should not encourage the client to provide excuses or explanations of behaviors that are clearly against the rules. Be clear with the client as to the unit/hospital/clinic policies. Give brief concrete reasons for the rules, if asked, and then move on. Option D: A client with antisocial personality disorder is unlikely to have compassion for others and typically lacks respect for the rights of others. When limits or policies are not followed, enforce the consequences in a matter-of-fact, nonjudgmental manner. Helps minimize manipulations and might help encourage cooperation.

A client with antisocial personality is trying to convince a nurse that he deserves special privileges and that an exception to the rules should be made for him. Which of the following responses is the most appropriate? A. "I believe we need to sit down and talk about this." B. "Don't you know better than to try to bend the rules?" C. "What you're asking me to do is unacceptable." D. "Why don't you bring this request to the community meeting?"

C. "What you're asking me to do is unacceptable." These clients often try to manipulate the nurse to get special privileges or make exceptions to the rules on their behalf. By informing the client directly when actions are inappropriate, the nurse helps the client learn to control unacceptable behaviors by setting limits. The nurse must be quite clear about establishing the boundaries of the therapeutic relationship to ensure that neither the client's nor the nurse's boundaries are violated. Option A: By sitting down to talk about the request, the nurse is telling the client there's room for negotiating when there is none. Be aware of flattery as an attempt to feed into your needs to feel special. Giving into the client's thinking that you are "the best" or "the only one" can pit you against other staff and undermine the client's need for limits. Option B: Regardless of the clinical setting, the nurse must provide structure and limit setting in the therapeutic relationship; in a clinic setting, this may mean seeing the client for scheduled appointments of a predetermined length rather than whenever the client appears and demands the nurse's immediate attention. Option D: Be clear with the client as to the unit/hospital/clinic policies. Give brief concrete reasons for the rules, if asked, and then move on. Institutional policies provide structure and safety.

The client is concerned about his coming discharge, manifested by being unusually sad. Which is the most therapeutic approach by the nurse? A. "You are much better than when you were admitted so there's no reason to worry." B. "What would you like to do now that you're about to go home?" C. "You seem to have concerns about going home." D. "Aren't you glad that you're going home soon?"

C. "You seem to have concerns about going home." This statement reflects how the client feels. Showing empathy can encourage the client to talk which is important as an alternative more adaptive way of coping with stressors. Patients often ask nurses for advice about what they should do about particular problems or in specific situations. Nurses can ask patients what they think they should do, which encourages patients to be accountable for their own actions and helps them come up with solutions themselves. Option A: Giving false reassurance is not therapeutic. It's frequently useful for nurses to summarize what patients have said after the fact. This demonstrates to patients that the nurse was listening and allows the nurse to document conversations. Ending a summary with a phrase like "Does that sound correct?" gives patients explicit permission to make corrections if they're necessary. Option B: While this technique explores plans after discharge, it does not focus on the expression of feelings. Sometimes during a conversation, patients mention something particularly important. When this happens, nurses can focus on their statement, prompting patients to discuss it further. Patients don't always have an objective perspective on what is relevant to their case; as impartial observers, nurses can more easily pick out the topics to focus on. Option D: This close-ended question does not encourage verbalization of feelings. Therapeutic communication is often most effective when patients direct the flow of conversation and decide what to talk about. To that end, giving patients a broad opening such as "What's on your mind today?" or "What would you like to talk about?" can be a good way to allow patients an opportunity to discuss what's on their mind.

A nurse discusses job possibilities with a client with schizoid personality disorder. Which suggestion by the nurse would be helpful? A. "You can work in a family restaurant part-time on the weekend and holidays." B. "Maybe your friend could get you that customer service job where you work only on the weekends." C. "Your idea of applying for the position of filing and organizing records is worth pursuing." D. "Being an introvert limits the employment opportunities you can pursue."

C. "Your idea of applying for the position of filing and organizing records is worth pursuing." Clients with schizoid personality disorder prefer solitary activities, such as filing, to working with others. Working as a cashier or in customer service would involve interacting with many people. They're often described as eccentric or bizarre. They may be suspicious and paranoid of others. They come across as "stiff" and don't seem to fit in anywhere they go. Option A: Individuals with schizotypal personality disorders experience extreme discomfort during interpersonal interactions. Unlike in social anxiety disorder, where an individual is likely to grow more comfortable with time, individuals with schizotypal personality disorder remain uncomfortable even when they're interacting with the same people in the same environment over and over again. Option B: The disorder also involves distorted thinking and eccentric behavior—which tends to push people away and create even more isolation. Sometimes, individuals with schizotypal personality disorder are superstitious or preoccupied with paranormal phenomena that are outside what would be expected in their culture. Option D: They might also appear constricted and show little emotion during their interactions. They may have unusual mannerisms, such as an unkempt manner of dress. They may occasionally express sadness over their lack of close relationships but their behavior suggests they have little desire for close connections. They often interact with people when they have to but prefer to keep to themselves.

An adult client with a borderline personality disorder become nauseated and vomits immediately after drinking 2 ounces of shampoo as a suicide gesture. The most appropriate initial response by the nurse would be to: A. Promptly notify the attending physician. B. Immediately initiate suicide precautions. C. Sit quietly with the client until nausea and vomiting subsides. D. Assess the client's vital signs and administer syrup of ipecac.

C. Sit quietly with the client until nausea and vomiting subside. This intervention demonstrates the nurse's caring presence which is vital for this client. Identify feelings experienced before and around the act of self-mutilation. Feelings are a guideline for future intervention (e.g., rage at feeling left out or abandoned). Option A: Although the treatment team does need to know about the event, notification is not the immediate concern. Set and maintain limits on acceptable behavior and make clear client's responsibilities. If the client is hospitalized at the time, be clear regarding the unit rules. Clear and non punitive limit setting is essential for decreasing negative behaviors. Option B: This is premature and it reinforces the client's predisposition to manipulative behavior. Secure a written or verbal no-harm contract with the client. Identify specific steps (e.g., persons to call upon when prompted to self-mutilate). The client is encouraged to take responsibility for healthier behavior. Talking to others and learning alternative coping skills can reduce frequency and severity until such behavior ceases. Option D: This medication is inappropriate in this situation; vomiting would be expected after the ingestion of shampoo. After the treatment, discuss what happened right before, and the thoughts and feelings that the client had immediately before self-mutilating. identify dynamics for both client and clinician. Allows the identification of less harmful responses to help relieve intense tensions.

A client was admitted to the psychiatric unit for severe depression. After several days, the client continues to withdraw from other clients. Which of the following would be the most appropriate statement by the nurse to promote interaction with other clients? A. "Your doctor thinks it's good for you to spend time with others." B. "It is important for you to participate in group activities." C. "Painting this picture will help you feel better." D. "Come play Chinese Checkers with Gerry and me."

D. "Come play Chinese Checkers with Gerry and me." This gradually engages the client in interactions with others and uses positive behavioral expectation. Initially, provide activities that require minimal concentration (e.g., drawing, playing simple board games). Depressed people lack concentration and memory. Activities that have no "right or wrong" or "winner or loser" minimizes opportunities for the client to put himself/herself down. Option A: When the client is at the most depressed state, Involve the client in one-to-one activity. Maximizes the potential for interactions while minimizing anxiety levels. Involve the client in gross motor activities that call for very little concentration (e.g., walking). Such activities will aid in relieving tensions and might help in elevating the mood. Option B: Eventually involve the client in group activities (e.g., group discussions, art therapy, dance therapy). Socialization minimizes feelings of isolation. Genuine regard for others can increase feelings of self-worth. Eventually maximize the client's contacts with others (first one other, then two others, etc.). Contact with others distracts the client from self-preoccupation. Option C: Allow the patient to engage in simple recreational activities, advancing to more complex activities in a group environment. The patient may feel overwhelmed at the start when participating in a group setting. Encourage the client to participate in a group therapy where the members share the same situations/feelings that they have to minimize the feelings of isolation and provide an atmosphere where positive feedback and a more realistic appraisal of self are available.

The nurse asks a client to roll up his sleeves so she can take his blood pressure. The client replies "If you want I can go naked for you." The most therapeutic response by the nurse is: A. "You're attractive, but I'm not interested." B. "You wouldn't be the first that I will see naked." C. "I will report you to the guard if you don't control yourself." D. "I only need access to your arm. Putting up your sleeve is fine."

D. "I only need access to your arm. Putting up your sleeve is fine." The nurse needs to deal with the client with sexually connotative behavior in a casual, matter of fact way. Stay calm and be patient. Gently but firmly tell the person that the behavior is inappropriate. Option A: Maintain consistent, firm boundaries. Don't accidentally encourage inappropriate behavior by sending mixed signals, like briefly allowing the behavior one time and then reacting negatively the next time. Be consistently firm every time, saying "No, stop. I don't like that." or "Stop, that's not right." Option B: These responses are not therapeutic because they are challenging and rejecting. Distract them and redirect to a positive activity. To distract, ask a question, turn on the TV, or offer a snack. To redirect, turn on some music they like, go for a walk, bring out their favorite hobby. Option C: Threatening the client is not therapeutic. Recommendations for such interventions include redirection, same-sex caregivers, clothing that closes or fastens in the back, and patient and caregiver counseling and education. Most often the limiting factor of effectiveness in employing these strategies is the degree of the patient's cognitive impairment.