med surg example 1

What is the most appropriate nursing intervention for clients who exhibit mild cognitive impairment?

Reality orientation

A nurse is counseling a client who has had an angry episode that subsided after several minutes. What is the most important short-term objective for the client?

Talking about situations that cause angry outbursts

A client with a history of violence is becoming increasingly agitated. Which nursing intervention will most likely increase the risk of acting-out behavior?

Teaching relaxation

While caring for a client who is demonstrating bizarre behavior, impaired communication, delusions, illusions, and hallucinations, a nurse tries to establish a therapeutic relationship with the client. Which actions on the part of the nurse are appropriate efforts in establishing a therapeutic relationship? Select all that apply.

-Using simple and clear statements -Being available and actively listening

A nurse moves into the working phase of a therapeutic relationship with a depressed client who has a history of suicide attempts. What question should the nurse ask the client when exploring alternative coping strategies?

"How will you manage the next time your problems start piling up?"

A nurse enters a client's room and notes that the client appears preoccupied. Turning to the nurse, the client says, "They're saying terrible things about me. Can't you hear them?" What is the most therapeutic response by the nurse?

"I don't hear anyone else talking, but I can see that you're upset."

A client with a diagnosis of antisocial personality disorder is being discharged from the hospital. The client asks the nurse, "Can I have your phone number so I can call you for a date?" What is the best response by the nurse?

"Our relationship is professional; therefore I will not see you socially."

An older widower who is sitting by himself in a lounge in the nursing home, says, "I'm all alone; no one has any use for me." Which response by the nurse is most therapeutic?

"You seem upset. Let's talk about what's bothering you."

Before a treatment requiring informed consent can be performed, what information must the client be given? Select all that apply.

-Alternative treatment options - The risks and benefits of the treatment -The risks involved in refusing the treatment -The nature of the problem requiring the treatment

A health care provider writes a prescription of "Restraints PRN" for a client who has a history of violent behavior. What is the nurse's responsibility in regard to this order?

Recognizing that PRN orders for restraints are unacceptable

When communicating with a client with a psychiatric diagnosis, the nurse uses silence. How should clients feel when silence is used in therapeutic communication?

Unhurried to answer

At times a client's anxiety level is so high that it blocks attempts at communication and the nurse is unsure of what is being said. To clarify understanding, the nurse says, "Let's see whether we mean the same thing." What communication technique is being used by the nurse?

Seeking consensual validation

The nurse is explaining the Client Bill of Rights to a female client whose psychiatrist has admitted her to an inpatient facility. Her admission is voluntary. The statement that is not a client right is the right to what?

Select health team members

It is the first day of the psychiatric clinical rotation for a group of nursing students. During the morning, a client with bipolar disorder, manic episode, seeks out a small group of the students and tells them, "I'm being held against my will, and I plan to escape during the evening shift." What is the best action by the nursing students?

Informing the primary nurse of the client's behavior and plan

What is an initial client objective in relation to anger management?

Taking responsibility for the hostile behavior

Which goal specific to a client with impaired verbal communication related to a psychological barrier should be documented in the client's clinical record?

Interacting appropriately with others in the therapeutic milieu

An adult client with schizophrenia is involuntarily admitted to the psychiatric unit. While off the unit for needed testing, the client runs away. Legally, who should the nurse notify immediately?

Law enforcement officer

Which nursing intervention involves providing, structuring, and maintaining a safe and therapeutic environment in collaboration with patients, families, and other health care providers?

Milieu therapy

A client is presented with the treatment option of electroconvulsive therapy (ECT). After discussion with staff members, the client requests that a family member be called to help make the decision about this treatment. What ethical principle does the nurse consider when supporting the client's request?

Autonomy

A primary health-care provider wants to assess the presence of stressors that could affect the mental health diagnosis in a client. In which axis of the Diagnostic and Statistical Manual of Psychiatric Disorders (DSM-V) is this assessment finding made?

Axis IV

A client has had repeated hospitalizations for aggressive, violent behavior. While on the mental health service, the client becomes very angry, starts screaming at the nurse, and pounds the table. What is the priority nursing assessment at this time?

Degree of control over the behavior

What is the nurse's specific responsibility when the rights of a client on a mental health unit are restricted by the use of seclusion?

Documenting both the client's behavior and the reason that specific rights were denied

A disturbed male client, unprovoked, attacks another client. What should a short-term initial plan for this client include?

Having the client sit with a staff member in whom he trusts

A psychiatric nurse is hired to work in the psychiatric emergency department of a large teaching hospital. While reviewing the manuals, the nurse reads, "People with mental health emergencies shall be triaged within 5 minutes of entering the emergency department." What does the nurse consider this statement to represent?

Hospital policy

An older adult is brought to the clinic by a family member because of increasing confusion over the past week. What can the nurse ask the client to do to determine orientation to place?

Identify the name of the clinic's town

Which tool is used to standardize and measure nursing treatments?

Nursing Interventions Classification (NIC)