saunders mental health study review
The nurse is caring for a client who is at risk for suicide. What is the priority nursing action for this client? 1.Provide authority, action, and participation. 2.Display an attitude of detachment, confrontation, and efficiency. 3.Demonstrate confidence in the client's ability to deal with stressors. 4.Provide hope and reassurance that the problems will resolve themselves.
1 A crisis is an acute, time-limited state of disequilibrium resulting from situational, developmental, or societal sources of stress. A person in this state is temporarily unable to cope with or adapt to the stressor by using previous coping mechanisms. The person who intervenes in this situation (the nurse) "takes over" for the client (authority) who is not in control and devises a plan (action) to secure and maintain the client's safety. When this has occurred, the nurse works collaboratively with the client (participates) in developing new coping and problem-solving strategies
A client with diabetes mellitus is told that amputation of the leg is necessary to sustain life. The client is very upset and tells the nurse, "This is all my primary health care provider's fault. I have done everything I've been asked to do!" Which nursing interpretation is best for this situation? 1.An expected coping mechanism 2.An ineffective defense mechanism 3.A need to notify the hospital lawyer 4.An expression of guilt on the part of the client
1 Rationale:The nurse needs to be aware of the effective and ineffective coping mechanisms that can occur in a client when loss is anticipated. The expression of anger is known to be a normal response to impending loss, and the anger may be directed toward the self, God or other spiritual being, or caregivers. Notifying the hospital lawyer is inappropriate. Guilt may or may not be a component of the client's feelings, and the data in the question do not indicate that guilt is present.
The nurse determines that the wife of an alcoholic client is benefiting from attending an Al-Anon group if the nurse hears the wife make which statement? 1."I no longer feel that I deserve the beatings my husband inflicts on me." 2."My attendance at the meetings has helped me see that I provoke my husband's violence." 3."I enjoy attending the meetings because they get me out of the house and away from my husband." 4."I can tolerate my husband's destructive behaviors now that I know they are common among alcoholics.
1. "I no longer feel that I deserve the beatings my husband inflicts on me." Rationale:Al-Anon support groups are a protected, supportive opportunity for spouses and significant others to learn what to expect and to obtain excellent pointers about successful behavioral changes. The correct option is the healthiest response because it exemplifies an understanding that the alcoholic partner is responsible for his behavior and cannot be allowed to blame family members for loss of control. Option 2 is incorrect, because the nonalcoholic partner should not feel responsible when the spouse loses control. Option 3 indicates that the group is viewed as an escape, not as a place to work on issues. Option 4 indicates that the wife remains codependent
A client is participating in a therapy group and focuses on viewing all team members as equally important in helping the clients meet their goals. The nurse is implementing which therapeutic approach? 1.Milieu therapy 2.Interpersonal therapy 3.Behavior modification 4.Support group therapy
1. Milieu therapy Rationale: All treatment team members are viewed as significant and valuable to the client's successful treatment outcomes in milieu therapy. Interpersonal therapy is based on a one-to-one or group therapy approach in which the therapist-client relationship is often used as a way for the client to examine other relationships in her or his life. Behavior modification is based on rewards and punishment. Support groups are based on the premise that individuals who have experienced and are insightful concerning a problem are able to help others who have a similar problem.
A client is preparing to attend a Gamblers Anonymous meeting for the first time. The nurse should tell the client that which is the first step in this 12-step program? 1.Admitting to having a problem 2.Substituting other activities for gambling 3.Stating that the gambling will be stopped 4.Discontinuing relationships with people who gamble
1.Admitting to having a problem A client is preparing to attend a Gamblers Anonymous meeting for the first time. The nurse should tell the client that which is the first step in this 12-step program? Rationale:The first step in the 12-step program is to admit that a problem exists. Substituting other activities for gambling may be a strategy, but it is not the first step. The remaining options are not realistic strategies for the initial step in a 12-step program.
A client is unwilling to go to his church because his ex-girlfriend goes there and he feels that she will laugh at him if she sees him. Because of this hypersensitivity to a reaction from her, the client remains homebound. The home care nurse develops a plan of care that addresses which personality disorder? 1.Avoidant 2.Borderline 3.Schizotypal 4.Obsessive-compulsive
1.Avoidant Rationale:The avoidant personality disorder is characterized by social withdrawal and extreme sensitivity to potential rejection. The person retreats to social isolation. Borderline personality disorder is characterized by unstable mood and self-image and impulsive and unpredictable behavior. Schizotypal personality disorder is characterized by the display of abnormal thoughts, perceptions, speech, and behaviors. Obsessive-compulsive personality disorder is characterized by perfectionism, the need to control others, and a devotion to work
A hospitalized client with a history of alcohol misuse tells the nurse, "I am leaving now. I have to go. I don't want any more treatment. I have things that I have to do right away." The client has not been discharged and is scheduled for an important diagnostic test to be performed in 1 hour. After the nurse discusses the client's concerns with the client, the client dresses and begins to walk out of the hospital room. What action should the nurse take? 1.Call the nursing supervisor. 2.Call security to block all exit areas. 3.Restrain the client until the primary health care provider (PHCP) can be reached. 4.Tell the client that the client cannot return to this hospital again if the client leaves now.
1.Call the nursing supervisor. Rationale:Most health care facilities have documents that the client is asked to sign relating to the client's responsibilities when the client leaves against medical advice. The client should be asked to wait to speak to the PHCP before leaving and to sign the "against medical advice" document before leaving. If the client refuses to do so, the nurse cannot hold the client against the client's will. Therefore, in this situation, the nurse should call the nursing supervisor. The nurse can be charged with false imprisonment if a client is made to believe wrongfully that she or he cannot leave the hospital. Restraining the client and calling security to block exits constitutes false imprisonment. All clients have a right to health care and cannot be told otherwise.
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 they are not in charge of the nursing unit. 3.Assist the client in identifying ways of setting limits on personal behaviors. 4.Follow through about the consequences of behavior in a nonpunitive manner. 5.Enforce rules by informing the client that he/she will not be allowed to attend therapy groups. 6.Have the client state the consequences for behaving in ways that are viewed as unacceptable.
1.Communicate expected behaviors to the client. 3.Assist the client in identifying ways of setting limits on personal behaviors. 4.Follow through about the consequences of behavior in a nonpunitive manner. 6.Have the client state the consequences for behaving in ways that are viewed as unacceptable. Rationale:Interventions for dealing with the client exhibiting manipulative behavior include setting clear, consistent, and enforceable limits on manipulative behaviors; being clear with the client regarding the consequences of exceeding the limits set; following through with the consequences in a nonpunitive manner; and assisting the client in identifying a means of setting limits on personal behaviors. Ensuring that the client knows that she or he is not in charge of the nursing unit is inappropriate; power struggles need to be avoided. Enforcing rules and informing the client that she or he will not be allowed to attend therapy groups is a violation of a client's rights.
The nurse is preparing to perform an admission assessment on a client with a diagnosis of bulimia nervosa. Which assessment findings should the nurse expect to note? Select all that apply. 1.Dental decay 2.Moist, oily skin 3.Loss of tooth enamel 4.Electrolyte imbalances 5.Body weight well below ideal range
1.Dental decay .Loss of tooth enamel 4.Electrolyte imbalances Rationale:Clients with bulimia nervosa initially may not appear to be physically or emotionally ill. They are often at or slightly below ideal body weight. On further inspection, a client exhibits dental decay and loss of tooth enamel if the client has been inducing vomiting. Electrolyte imbalances are present. Dry, scaly skin (rather than moist, oily skin) is present
The emergency department nurse is caring for an adult client who is a victim of family violence. Which priority information should be included in the discharge instructions? 1.Information regarding shelters 2.Instructions regarding calling the police 3.Instructions regarding self-defense classes 4.Explaining the importance of leaving the violent situation
1.Information regarding shelters Rationale:Tertiary prevention of family violence includes assisting the victim after the abuse has already occurred. The nurse should provide the client with information regarding where to obtain help, including a specific plan for removing the self from the abuser and information regarding escape, hotlines, and the location of shelters. An abused person is usually reluctant to call the police. Teaching the victim to fight back is not the appropriate action for the victim when dealing with a violent person. Explaining the importance of leaving the violent situation is important, but a specific plan is necessary.
When reviewing the admission assessment, the nurse notes that a client was admitted to the mental health unit involuntarily. Based on this type of admission, the nurse should provide which intervention for this client? 1.Monitor closely for harm to self or others. 2.Assist in completing an application for admission. 3.Supply the client with written information about her or his mental health problem. 4.Provide an opportunity for the family to discuss why they felt the admission was needed.
1.Monitor closely for harm to self or others. Rationale:Involuntary admission is necessary when a person is a danger to self or others or is in need of psychiatric treatment regardless of the client's willingness to consent to the hospitalization. A written request is a component of a voluntary admission. Providing written information regarding the mental health problem, is likely premature initially. The family may have had no role to play in the client's admission.
Which interventions are most appropriate for caring for a client in alcohol withdrawal? Select all that apply. 1.Monitor vital signs. 2.Provide a safe environment. 3.Address hallucinations therapeutically. 4.Provide stimulation in the environment. 5.Provide reality orientation as appropriate. 6.Maintain NPO (nothing by mouth) status.
1.Monitor vital signs. 2.Provide a safe environment. 3.Address hallucinations therapeutically. 5.Provide reality orientation as appropriate Rationale:When the client is experiencing withdrawal from alcohol, the priority for care is to prevent the client from harming self or others. The nurse would monitor the vital signs closely and report abnormal findings. The nurse would provide a low-stimulation environment to maintain the client in as calm a state as possible. The nurse would reorient the client to reality frequently and would address hallucinations therapeutically. Adequate nutritional and fluid intake need to be maintained.
The nurse observes that a client is pacing, agitated, and presenting aggressive gestures. The client's speech pattern is rapid, and affect is belligerent. Based on these observations, which is the nurse's immediate priority of care? 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 in which to calm down and gain control
1.Provide safety for the client and other clients on the unit. Rationale:Safety of the client and other clients is the immediate priority. The correct option is the only one that addresses the safety needs of the client as well as those of the other clients.
The nurse in the mental health unit plans to use which therapeutic communication techniques when communicating with a client? Select all that apply. 1.Restating 2.Active listening 3.Asking the client "Why?" 4.Maintaining neutral responses 5.Providing acknowledgment and feedback 6.Giving advice and approval or disapproval
1.Restating 2.Active listening 4.Maintaining neutral responses 5.Providing acknowledgment and feedback Rationale:Therapeutic communication techniques include listening, maintaining silence, maintaining neutral responses, using broad openings and open-ended questions, focusing and refocusing, restating, clarifying and validating, sharing perceptions, reflecting, providing acknowledgment and feedback, giving information, presenting reality, encouraging formulation of a plan of action, providing nonverbal encouragement, and summarizing. Asking "Why" is often interpreted as being accusatory by the client and should also be avoided. Providing advice or giving approval or disapproval are barriers to communication
The nurse is conducting a group therapy session. During the session, a client diagnosed with mania consistently disrupts the group's interactions. Which intervention should the nurse initially implement? 1.Setting limits on the client's behavior 2.Asking the client to leave the group session 3.Asking another nurse to escort the client out of the group session 4.Telling the client that they will not be able to attend any future group sessions
1.Setting limits on the client's behavior Rationale:Manic clients may be talkative and can dominate group meetings or therapy sessions by their excessive talking. If this occurs, the nurse initially would set limits on the client's behavior. Initially, asking the client to leave the session or asking another person to escort the client out of the session is inappropriate. This may agitate the client and escalate the client's behavior further. Barring the client from group sessions is also an inappropriate action because it violates the client's right to receive treatment and is a threatening action.
Which behavior observed by the nurse indicates a suspicion that a depressed adolescent client may be suicidal? 1.The adolescent gives away a DVD and a cherished autographed picture of a performer. 2.The adolescent runs out of the therapy group, swearing at the group leader, and to her room. 3.The adolescent becomes angry while speaking on the telephone and slams down the receiver. 4.The adolescent gets angry with her roommate when the roommate borrows the client's clothes without asking.
1.The adolescent gives away a DVD and a cherished autographed picture of a performer. Rationale: A depressed suicidal client often gives away that which is of value as a way of saying goodbye and wanting to be remembered. Options 2, 3, and 4 deal with anger and acting-out behaviors that are often typical of an adolescent.
The nurse should plan which goals of the termination stage of group development? Select all that apply. 1.The group evaluates the experience. 2.The real work of the group is accomplished. 3.Group interaction involves superficial conversation. 4.Group members become acquainted with one another. 5.Some structuring of group norms, roles, and responsibilities takes place. 6.The group explores members' feelings about the group and the impending separation.
1.The group evaluates the experience. 6.The group explores members' feelings about the group and the impending separation. Rationale:The stages of group development include the initial stage, the working stage, and the termination stage. During the initial stage, the group members become acquainted with one another, and some structuring of group norms, roles, and responsibilities takes place. During the initial stage, group interaction involves superficial conversation. During the working stage, the real work of the group is accomplished. During the termination stage, the group evaluates the experience and explores members' feelings about the group and the impending separation.
he nurse is performing an assessment on a client with dementia. Which piece of data gathered during the assessment indicates a manifestation associated with dementia? 1.Use of confabulation 2.Improvement in sleeping 3.Absence of sundown syndrome 4.Presence of personal hygienic care
1.Use of confabulation Rationale:The clinical picture of dementia ranges from mild cognitive deficits to severe, life-threatening alterations in neurological functioning. For the client to use confabulation or the fabrication of events or experiences to fill in memory gaps is not unusual. Often, lack of inhibitions on the part of the client may constitute the first indication of something being "wrong" to the client's significant others (e.g., the client may undress in front of others, or the formerly well-mannered client may exhibit slovenly table manners). As the dementia progresses, the client will have difficulty sleeping and episodes of wandering or sundowning.
A client experiencing disturbed thought processes believes that his food is being poisoned. Which communication technique should the nurse use to encourage the client to eat? 1.Using open-ended questions and silence 2.Sharing personal preference regarding food choices 3.Documenting reasons why the client does not want to eat 4.Offering opinions about the necessity of adequate nutrition
1.Using open-ended questions and silence ationale:Open-ended questions and silence are strategies used to encourage clients to discuss their problems. Sharing personal food preferences is not a client-centered intervention. The remaining options are not helpful to the client because they do not encourage the client to express feelings. The nurse should not offer opinions and should encourage the client to identify the reasons for the behavior.
The home care nurse is visiting an older client whose spouse died 6 months ago. Which behaviors by the client indicates effective coping? Select all that apply. 1. Neglecting personal grooming 2. Looking at old snapshots of family 3. Participating in a senior citizens program 4. Visiting the spouse's grave once a month 5. Decorating a wall with the spouse's pictures and awards received
2. Looking at old snapshots of family 3. Participating in a senior citizens program 4. Visiting the spouse's grave once a month 5. Decorating a wall with the spouse's pictures and awards received
A client with a diagnosis of anorexia nervosa, who is in a state of starvation, is in a 2-bed room. A newly admitted client will be assigned to this client's room. Which client would be the best choice as a roommate for the client with anorexia nervosa? 1.A client with pneumonia 2.A client undergoing diagnostic tests 3.A client who thrives on managing others 4.A client who could benefit from the client's assistance at mealtime
2. A client undergoing diagnostic tests Rationale:The client undergoing diagnostic tests is an acceptable roommate. The client with anorexia nervosa is most likely experiencing hematological complications, such as leukopenia. Having a roommate with pneumonia would place the client with anorexia nervosa at risk for infection. The client with anorexia nervosa should not be put in a situation in which the client can focus on the nutritional needs of others or be managed by others, because this may contribute to sublimation and suppression of personal hunger.
A client is admitted with a recent history of severe anxiety following a home invasion and robbery. During the initial assessment interview, which statement by the client should indicate to the nurse the possible diagnosis of post-traumatic stress disorder? Select all that apply. 1."I'm afraid of spiders." 2."I keep reliving the robbery." 3."I see his face everywhere I go." 4."I don't want anything to eat now." 5."I might have died over a few dollars in my pocket." 6."I have to wash my hands over and over again many times."
2."I keep reliving the robbery." 3."I see his face everywhere I go." 5."I might have died over a few dollars in my pocket." Rationale:Reliving an event, experiencing emotional numbness (facing possible death), and having flashbacks of the event (seeing the same face everywhere) are all common occurrences with post-traumatic stress disorder. The statement "I'm afraid of spiders" relates more to having a phobia. The statement "I have to wash my hands over and over again many times" describes ritual compulsive behaviors to decrease anxiety for someone with obsessive-compulsive disorder. Stating "I don't want anything to eat now" is vague and could relate to numerous conditions.
The spouse of a client admitted to the mental health unit for alcohol withdrawal says to the nurse, "I should get out of this bad situation." Which is the most helpful response by the nurse? 1."Why don't you tell your spouse about this?" 2."What do you find difficult about this situation?" 3."This is not the best time to make that decision." 4."I agree with you. You should get out of this situation."
2."What do you find difficult about this situation? Rationale:The most helpful response is one that encourages the client to solve problems. Giving advice implies that the nurse knows what is best and can foster dependency. The nurse should not agree with the client, and the nurse should not request that the client provide explanations.
The nurse has been closely observing a client who has been displaying aggressive behaviors. The nurse observes that the behavior displayed by the client is escalating. Which nursing intervention is most helpful to this client at this time? Select all that apply. 1.Initiate confinement measures. 2.Acknowledge the client's behavior. 3.Assist the client to an area that is quiet. 4.Maintain a safe distance from the client. 5.Allow the client to take control of the situation.
2.Acknowledge the client's behavior. 3.Assist the client to an area that is quiet. 4.Maintain a safe distance from the client. Rationale:During the escalation period, the client's behavior is moving toward loss of control. Nursing actions include taking control, maintaining a safe distance, acknowledging behavior, moving the client to a quiet area, and medicating the client if appropriate. To initiate confinement measures during this period is inappropriate. Initiation of confinement measures, if needed, is most appropriate during the crisis period.
The home health nurse visits a client at home and determines that the client is dependent on drugs. During the assessment, which action should the nurse take to plan appropriate nursing care? 1.Ask the client why he started taking illegal drugs. 2.Ask the client about the amount of drug use and its effect. 3.Ask the client how long he thought that he could take drugs without someone finding out. 4.Do not ask any questions for fear that the client is in denial and will throw the nurse out of the home.
2.Ask the client about the amount of drug use and its effect. Rationale:Whenever the nurse carries out an assessment for a client who is dependent on drugs, it is best for the nurse to attempt to elicit information by being nonjudgmental and direct. Option 1 is incorrect because it is judgmental and off-focus, and reflects the nurse's bias. Option 3 is incorrect because it is judgmental, insensitive, and aggressive, which is nontherapeutic. Option 4 is incorrect because it indicates passivity on the nurse's part and uses rationalization to avoid the therapeutic nursing intervention.
The nurse is caring for a client diagnosed with paranoid personality disorder who is experiencing disturbed thought processes. In formulating a nursing plan of care, which best intervention should the nurse include? 1.Increase socialization of the client with peers. 2.Avoid using a whisper voice in front of the client. 3.Begin to educate the client about social supports in the community. 4.Have the client sign a release of information to appropriate parties for assessment purposes.
2.Avoid using a whisper voice in front of the client Rationale: Disturbed thought process related to paranoid personality disorder is the client's problem, and the plan of care must address this problem. The client is distrustful and suspicious of others. The members of the health care team need to establish a rapport and trust with the client. Laughing or whispering in front of the client would be counterproductive. The remaining options ask the client to trust on a multitude of levels. These options are actions that are too intrusive for a client with this disorder.
A client with anorexia nervosa is a member of a predischarge support group. The client verbalizes that she would like to buy some new clothes, but her finances are limited. Group members have brought some used clothes to the client to replace the client's old clothes. The client believes that the new clothes are much too tight and has reduced her calorie intake to 800 calories daily. How should the nurse evaluate this behavior? 1.Normal behavior 2.Evidence of the client's disturbed body image 3.Regression as the client is moving toward the community 4.Indicative of the client's ambivalence about hospital discharge
2.Evidence of the client's disturbed body image Rationale: Disturbed body image is a concern with clients with anorexia nervosa. Although the client may struggle with ambivalence and show regressed behavior, the client's coping pattern relates to the basic issue of disturbed body image. The nurse should address this need in the support group.
When planning the discharge of a client with chronic anxiety, which is the most appropriate maintenance goal? 1.Suppressing feelings of anxiety 2.Identifying anxiety-producing situations 3.Continuing contact with a crisis counselor 4.Eliminating all anxiety from daily situations
2.Identifying anxiety-producing situations Rationale:Recognizing situations that produce anxiety allows the client to prepare to cope with anxiety or avoid a specific stimulus. Counselors will not be available for all anxiety-producing situations, and this option does not encourage the development of internal strengths. Suppressing feelings will not resolve anxiety. Elimination of all anxiety from life is impossible.
The nurse is caring for a female client who was admitted to the mental health unit recently for anorexia nervosa. The nurse enters the client's room and notes that the client is engaged in rigorous push-ups. Which nursing action is most appropriate? 1.Interrupt the client and weigh her immediately. 2.Interrupt the client and offer to take her for a walk. 3.Allow the client to complete her exercise program. 4.Tell the client that she is not allowed to exercise rigorously.
2.Interrupt the client and offer to take her for a walk Clients with anorexia nervosa frequently are preoccupied with rigorous exercise and push themselves beyond normal limits to work off caloric intake. The nurse must provide for appropriate exercise and place limits on rigorous activities. The correct option stops the harmful behavior yet provides the client with an activity to decrease anxiety that is not harmful. Weighing the client immediately reinforces the client's preoccupation with weight. Allowing the client to complete the exercise program can be harmful to the client. Telling the client that she is not allowed to complete the exercise program will increase the client's anxiety.
The nurse is reviewing the assessment data of a client admitted to the mental health unit. The nurse notes that the admission nurse documented the client is experiencing anxiety as a result of a situational crisis. The nurse plans care for the client, determining that this type of crisis could be caused by which event? 1.Witnessing a murder 2.The death of a loved one 3.A fire that destroyed the client's home 4.A recent rape episode experienced by the client
2.The death of a loved one Rationale:A situational crisis arises from external rather than internal sources. External situations that could precipitate a crisis include loss or change of a job, the death of a loved one, abortion, change in financial status, divorce, addition of new family members, pregnancy, and severe illness. Options 1, 3, and 4 identify adventitious crises. An adventitious crisis refers to a crisis of disaster, is not a part of everyday life, and is unplanned and accidental. Adventitious crises may result from a natural disaster (e.g., floods, fires, tornadoes, earthquakes), a national disaster (e.g., war, riots, airplane crashes), or a crime of violence (e.g., rape, assault, murder in the workplace or school, bombings, or spousal or child abuse).
A client diagnosed with delirium becomes disoriented and confused at night. Which intervention should the nurse implement initially? 1.Move the client next to the nurses' station. 2.Use an indirect light source and turn off the television. 3.Keep 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 an indirect light source and turn off the television. Rationale:Provision of a consistent daily routine and a low-stimulating environment is important when a client is disoriented. Noise, including radio and television, may add to the confusion and disorientation. Moving the client next to the nurses' station may become necessary but is not the initial action
The nurse is planning activities for a client diagnosed with bipolar disorder with aggressive social behavior. Which activity would be most appropriate for this client? 1.Chess 2.Writing 3.Board games 4.Group exercise
2.Writing Rationale: Solitary activities that require a short attention span with mild physical exertion are the most appropriate activities for a client who is exhibiting aggressive behavior. Writing (journaling), walks with staff, and finger painting are activities that minimize stimuli and provide a constructive release for tension. The remaining options have a competitive element to them or are group activities and should be avoided because they can stimulate aggression and increase psychomotor activity.
The nurse is caring for a client with anorexia nervosa. Which behavior is characteristic of this disorder and reflects anxiety management? 1.Engaging in immoral acts 2.Always reinforcing self-approval 3.Observing rigid rules and regulations 4.Having the need always to make the right decision
3 Rationale:Clients with anorexia nervosa have the desire to please others. Their need to be correct or perfect interferes with rational decision-making processes. These clients are moralistic. Rules and rituals help these clients manage their anxiety.
A depressed client verbalizes feelings of low self-esteem and self-worth typified by statements such as "I'm such a failure. I can't do anything right." How should the nurse plan to respond to the client's statement? 1.Reassure the client that things will get better. 2.Tell the client that this is not true and that we all have a purpose in life. 3.Identify recent behaviors or accomplishments that demonstrate the client's skills. 4.Remain with the client and sit in silence; this will encourage the client to verbalize feelings.
3 Rationale:Feelings of low self-esteem and worthlessness are common symptoms of a depressed client. An effective plan of care to enhance the client's personal self-esteem is to provide experiences for the client that are challenging but that will not be met with failure. Reminders of the client's past accomplishments or personal successes are ways to interrupt the client's negative self-talk and distorted cognitive view of self. Options 1 and 2 give advice and devalue the client's feelings. Silence may be interpreted as agreement.
The nurse is creating a plan of care for a client who was experiencing anxiety after the loss of a job. The client is now verbalizing concerns regarding the ability to meet role expectations and financial obligations. What is the priority nursing problem for this client? 1.Anxiety 2.Unrealistic outlook 3.Lack of ability to cope effectively 4.Disturbances in thoughts and ideas
3 Rationale:Lack of ability to cope effectively may be evidenced by a client's inability to meet basic needs, inability to meet role expectations, alteration in social participation, use of inappropriate defense mechanisms, or impairment of usual patterns of communication. Anxiety is a broad description and can occur as a result of many triggers; although the client was experiencing anxiety, the client's concern now is the ability to meet role expectations and financial obligations. There is no information in the question that indicates an unrealistic outlook or disturbances in thoughts and ideas.
A client comes to the emergency department after an assault and is extremely agitated, trembling, and hyperventilating. What is the priority nursing action for this client? 1.Begin to teach relaxation techniques. 2.Encourage the client to discuss the assault. 3.Remain with the client until the anxiety decreases. 4.Place the client in a quiet room alone to decrease stimulation
3 Rationale:This client is in a severe state of anxiety. When a client is in a severe or panic state of anxiety, it is crucial for the nurse to remain with the client. The client in a severe state of anxiety would be unable to learn relaxation techniques. Discussing the assault at this point would increase the client's level of anxiety further. Placing the client in a quiet room alone may also increase the anxiety level.
A client is admitted to a medical nursing unit with a diagnosis of acute blindness after being involved in a hit-and-run accident. When diagnostic testing cannot identify any organic reason why this client cannot see, a mental health consult is prescribed. The nurse plans care based on which mental health condition? 1.Psychosis 2.Repression 3.Conversion disorder 4.Dissociative disorder
3. Conversion disorder Rationale:A conversion disorder is the alteration or loss of a physical function that cannot be explained by any known pathophysiological mechanism. A conversion disorder is thought to be an expression of a psychological need or conflict. In this situation, the client witnessed an accident that was so psychologically painful that the client became blind. Psychosis is a state in which a person's mental capacity to recognize reality, communicate, and relate to others is impaired, interfering with the person's ability to deal with life's demands. Repression is a coping mechanism in which unacceptable feelings are kept out of awareness. A dissociative disorder is a disturbance or alteration in the normally integrative functions of identity, memory, or consciousness.
A client says to the nurse, "The federal guards were sent to kill me." Which is the best response by the nurse to the client's concern? 1."I don't believe this is true." 2."The guards are not out to kill you." 3."Do you feel afraid that people are trying to hurt you?" 4."What makes you think the guards were sent to hurt you?"
3."Do you feel afraid that people are trying to hurt you?" A client says to the nurse, "The federal guards were sent to kill me." Which is the best response by the nurse to the client's concern? Rationale:It is most therapeutic for the nurse to empathize with the client's experience. The remaining options lack this connection with the client. Disagreeing with delusions may make the client more defensive, and the client may cling to the delusions even more. Encouraging discussion regarding the delusion is inappropriate
A female victim of a sexual assault is being seen in the crisis center. The client states that she still feels "as though the rape just happened yesterday," even though it has been a few months since the incident. Which is the most appropriate nursing response? 1."You need to try to be realistic. The rape did not just occur." 2."It will take some time to get over these feelings about your rape." 3."Tell me more about the incident that causes you to feel like the rape just occurred." 4."What do you think that you can do to alleviate some of your fears about being raped again?"
3."Tell me more about the incident that causes you to feel like the rape just occurred." Rationale: The correct option allows the client to express her ideas and feelings more fully and portrays a nonhurried, nonjudgmental, supportive attitude on the part of the nurse. Clients need to be reassured that their feelings are normal and that they may express their concerns freely in a safe, caring environment. Option 1 immediately blocks communication. Option 2 places the client's feelings on hold. Option 4 places the problem solving totally on the client.
The nurse is conducting an initial assessment of a client in crisis. When assessing the client's perception of the precipitating event that led to the crisis, which is the most appropriate question? 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?" The nurse is conducting an initial assessment of a client in crisis. When assessing the client's perception of the precipitating event that led to the crisis, which is the most appropriate question? Rationale:The nurse's initial task when assessing a client in crisis is to assess the individual or family and the problem. The more clearly the problem can be defined, the better the chance a solution can be found. The correct option would assist in determining data related to the precipitating event that led to the crisis. Options 1 and 2 assess situational supports. Option 4 assesses personal coping skills.
The nurse is preparing a client with schizophrenia a history of command hallucinations for discharge by providing instructions on interventions for managing hallucinations and anxiety. Which statement in response to these instructions suggests to the nurse that the client has a need for additional information? 1."My medications will help my anxious feelings." 2."I'll go to support group and talk about what I am feeling." 3."When I have command hallucinations, I'll call a friend for help." 4."I need to get enough sleep and eat well to help prevent feeling anxious."
3."When I have command hallucinations, I'll call a friend for help." Rationale:The risk for impulsive and aggressive behavior may increase if a client is receiving command hallucinations to harm self or others. If the client is experiencing a hallucination, the nurse or health care counselor, not a friend, should be contacted to discuss whether the client has intentions to hurt herself or himself or others. Talking about auditory hallucinations can interfere with subvocal muscular activity associated with a hallucination. The client statements in the remaining options will aid in wellness but are not specific interventions for hallucinations, if they occur
The nurse observes that a client with a potential for violence is agitated, pacing up and down the hallway, and making aggressive and belligerent gestures at other clients. Which statement would be most appropriate to make to this client? 1."You need to stop that behavior now." 2."You will need to be placed in seclusion." 3."You seem restless; tell me what is happening." 4."You will need to be restrained if you do not change your behavior."
3."You seem restless; tell me what is happening. Rationale:The most appropriate statement is to ask the client what is causing the agitation. This will assist the client to become aware of the behavior and may assist the nurse in planning appropriate interventions for the client. Option 1 is demanding behavior that could cause increased agitation in the client. Options 2 and 4 are threats to the client and are inappropriate.
A client diagnosed with terminal cancer says to the nurse, "I'm going to die, and I wish my family would stop hoping for a cure! I get so angry when they carry on like this. After all, I'm the one who's dying." Which response by the nurse is therapeutic? 1. "Have you shared your feelings with your family?" 2."I think we should talk more about your anger with your family." 3."You're feeling angry that your family continues to hope for you to be cured?" 4."You are probably very depressed, which is understandable with such a diagnosis."
3."You're feeling angry that your family continues to hope for you to be cured?" Rationale:Restating is a therapeutic communication technique in which the nurse repeats what the client says to show understanding and to review what was said. Although it is appropriate for the nurse to attempt to assess the client's ability to discuss feelings openly with family members, it does not help the client discuss the feelings causing the anger. The nurse's direct attempt to expect the client to talk more about the anger is premature. The nurse would never make a judgment regarding the reason for the client's feeling; this is nontherapeutic in the one-to-one relationship.
The nurse visits a client at home. The client states, "I haven't slept at all the last couple of nights." Which response by the nurse demonstrates therapeutic communication? 1. "I see." 2."Really?" 3."You're having difficulty sleeping?" 4."Sometimes I have trouble sleeping too."
3."You're having difficulty sleeping?" The nurse visits a client at home. The client states, "I haven't slept at all the last couple of nights." Which response by the nurse demonstrates therapeutic communication? Rationale:The correct option uses the therapeutic communication technique of restatement. Although restatement is a technique that has a prompting component to it, it repeats the client's major theme, which assists the nurse to obtain a more specific perception of the problem from the client. The remaining options are not therapeutic responses because none of them encourages the client to expand on the problem. Offering personal experiences moves the focus away from the client and onto the nurse.
A client is admitted to the mental health unit after an attempted suicide by hanging. The nurse can best ensure client safety by which action? 1.Requesting that a peer remain with the client at all times. 2.Removing the client's clothing and placing the client in a hospital gown. 3.Assigning to the client a staff member who will remain with the client at all times. 4.Admitting the client to a seclusion room where all potentially dangerous articles are removed.
3.Assigning to the client a staff member who will remain with the client at all times. Rationale: Hanging is a serious suicide attempt. The plan of care must reflect action that ensures the client's safety. Constant observation status (one-to-one) with a staff member is the best choice. Placing the client in a hospital gown and requesting that a peer remain with the client would not ensure a safe environment. Seclusion should not be the initial intervention, and the least restrictive measure should be used.
A manic client begins to make sexual advances toward visitors in the dayroom. When the nurse firmly states that this is inappropriate and will not be allowed, the client becomes verbally abusive and threatens physical violence to the nurse. Based on the analysis of this situation, which intervention should the nurse implement? 1. Place the client in seclusion for 30 minutes. 2.Tell the client that the behavior is inappropriate. 3.Escort the client to their room, with the assistance of other staff. 4.Tell the client that their telephone privileges are revoked for 24 hours.
3.Escort the client to their room, with the assistance of other staff Rationale:The client is at risk for injury to self and others and should be escorted out of the dayroom. Seclusion is premature in this situation. Telling the client that the behavior is inappropriate has already been attempted by the nurse. Denying privileges may increase the agitation that already exists in this client.
A moderately depressed client who was hospitalized 2 days ago suddenly begins smiling and reporting that the crisis is over. The client says to the nurse, "I'm finally cured." Based on the client's behavior and statement, which intervention should the nurse include in the plan? 1.Suggesting a reduction of medication 2.Allowing increased "in-room" activities 3.Increasing the level of suicide precautions 4.Allowing the client off-unit privileges as needed
3.Increasing the level of suicide precautions Rationale: A client who is moderately depressed and has only been in the hospital 2 days is unlikely to have such a dramatic cure. When a depression suddenly lifts, it is likely that the client may have made the decision to harm herself or himself. Suicide precautions are necessary to keep the client safe. The remaining options are therefore incorrect interpretations.
The emergency department nurse is caring for a client who has been identified as a victim of physical abuse. In planning care for the client, which is the priority nursing action 1.Adhering to the mandatory abuse-reporting laws 2.Notifying the caseworker of the family situation 3.Removing the client from any immediate danger 4.Obtaining treatment for the abusing family member
3.Removing the client from any immediate danger Rationale:Whenever an abused client remains in the abusive environment, priority must be placed on ascertaining whether the client is in any immediate danger. If so, emergency action must be taken to remove the client from the abusing situation. Options 1, 2, and 4 may be appropriate interventions but are not the priority.
The nurse is caring for a client just admitted to the mental health unit and diagnosed with catatonic stupor. The client is lying on the bed in a fetal position. Which is the most appropriate nursing intervention? 1.Ask direct questions to encourage talking. 2.Leave the client alone so as to minimize external stimuli. 3.Sit beside the client in silence with simple open-ended questions. 4.Take the client into the dayroom with other clients to provide stimulation.
3.Sit beside the client in silence with simple open-ended questions.
The nurse assesses a client with the admitting diagnosis of bipolar affective disorder, mania. Which client symptoms require the nurse's immediate action? 1.Incessant talking and sexual innuendoes 2.Grandiose delusions and poor concentration 3.Outlandish behaviors and inappropriate dress 4.Nonstop physical activity and poor nutritional intake 1.Incessant talking and sexual innuendoes 2.Grandiose delusions and poor concentration 3.Outlandish behaviors and inappropriate dress 4.Nonstop physical activity and poor nutritional intake
4 HomeHelpCalculator Study Mode Question 53 of 331 ID: 0872 | 70.xml #872 PreviousGoNext StopBookmark Rationale Strategy Reference Labs Submit The nurse assesses a client with the admitting diagnosis of bipolar affective disorder, mania. Which client symptoms require the nurse's immediate action? Rationale:Mania is a mood characterized by excitement, euphoria, hyperactivity, excessive energy, decreased need for sleep, and impaired ability to concentrate or complete a single train of thought. The client's mood is predominantly elevated, expansive, or irritable. All of the options reflect a client's possible symptoms. However, the correct option clearly presents a problem that compromises physiological integrity and needs to be addressed immediately.
A client experiencing a great deal of stress and anxiety is being taught to use self-control therapy. Which statement by the client indicates a need for further teaching about the therapy? 1."This form of therapy can be applied to new situations." 2."An advantage of this technique is that change is likely to last." 3."Talking to oneself is a basic component of this form of therapy." 4."This form of therapy provides a negative reinforcement when the stimulus is produced."
4 Rationale:Negative reinforcement when the stimulus is produced is descriptive of aversion therapy. Options 1, 2, and 3 are characteristics of self-control therapy.
A client with a diagnosis of depression who has attempted suicide says to the nurse, "I should have died. I've always been a failure. Nothing ever goes right for me." Which response by the nurse demonstrates therapeutic communication? . "You have everything to live for." 2. "Why do you see yourself as a failure?" 3. "Feeling like this is all part of being depressed." 4. "You've been feeling like a failure for a while?"
4. "You've been feeling like a failure for a while?" Responding to the feelings expressed by a client is an effective therapeutic communication technique. The correct option is an example of the use of restating. The remaining options block communication because they minimize the client's experience and do not facilitate exploration of the client's expressed feelings. In addition, use of the word why is nontherapeutic because clients frequently interpret why questions as accusations. Why questions can cause resentment, insecurity and mistrust.
The nurse is creating a plan of care for a client in a crisis state. When developing the plan, the nurse should consider which factor? 1. A crisis state indicates that the client has a mental illness. 2. A crisis state indicates that the client has an emotional illness. 3. Presenting symptoms in a crisis situation are similar for all clients experiencing a crisis. 4. A client's response to a crisis is individualized and what constitutes a crisis for one client may not constitute a crisis for another client.
4. A client's response to a crisis is individualized and what constitutes a crisis for one client may not constitute a crisis for another client. HomeHelpCalculator Study Mode Question 42 of 331 ID: 0830 | 67.xml #830 PreviousGoNext StopBookmark Rationale Strategy Reference Labs Submit The nurse is creating a plan of care for a client in a crisis state. When developing the plan, the nurse should consider which factor? Rationale:Although each crisis response can be described in similar terms as far as presenting symptoms are concerned, what constitutes a crisis for one client may not constitute a crisis for another client, because each is a unique individual. Being in the crisis state does not mean that the client has a mental or emotional illness.
When a client is admitted to an inpatient mental health unit with the diagnosis of anorexia nervosa, a cognitive behavioral approach is used as part of the treatment plan. The nurse plans care based on which purpose of this approach? 1.Providing a supportive environment 2.Examining intrapsychic conflicts and past issues 3.Emphasizing social interaction with clients who withdraw 4.Helping the client to examine dysfunctional thoughts and beliefs
4. Helping the client to examine dysfunctional thoughts and beliefs Rationale:Cognitive behavioral therapy is used to help the client identify and examine dysfunctional thoughts and to identify and examine values and beliefs that maintain these thoughts. The remaining options, while therapeutic in certain situations, are not the focus of cognitive behavioral therapy.
The nurse is assessing a client who was admitted 24 hours ago for a fractured humerus. Which findings should alert the nurse to the potential for alcohol withdrawal delirium? 1.Hypotension, ataxia, hunger 2.Stupor, lethargy, muscular rigidity 3.Hypotension, coarse hand tremors, lethargy 4.Hypertension, changes in level of consciousness, hallucinations
4. Hypertension, changes in level of consciousness, hallucinations Rationale:Symptoms associated with alcohol withdrawal delirium typically include anxiety, insomnia, anorexia, hypertension, disorientation, hallucinations, changes in level of consciousness, agitation, fever, and delusions
A depressed client on an inpatient unit says to the nurse, "My family would be better off without me." Which is the nurse's best response? 1."Have you talked to your family about this?" 2."Everyone feels this way when they are depressed." 3."You will feel better once your medication begins to work." 4."You sound very upset. Are you thinking of hurting yourself?"
4."You sound very upset. Are you thinking of hurting yourself?" Rationale:Clients who are depressed may be at risk for suicide. It is critical for the nurse to assess suicidal ideation and plan. The nurse should ask the client directly whether a plan for self-harm exists. Options 1, 2, and 3 do not deal directly with the client's feelings.
A client is admitted to the mental health unit with a diagnosis of depression. The nurse should develop a plan of care for the client that includes which intervention? 1. Encouraging quiet reading and writing for the first few days 2.Identification of physical activities that will provide exercise 3.No socializing activities until the client asks to participate in milieu 4.A structured program of activities in which the client can participate
4.A structured program of activities in which the client can participate Rationale:A client with depression often is withdrawn while experiencing difficulty concentrating, loss of interest or pleasure, low energy, fatigue, and feelings of worthlessness and poor self-esteem. The plan of care needs to provide successful experiences in a stimulating yet structured environment. The remaining options are either too "restrictive" or offer little or no structure and stimulation.
On review of the client's record, the nurse notes that the admission was voluntary. Based on this information, the nurse plans care anticipating which client behavior? 1.Fearfulness regarding treatment measures 2.Anger and aggressiveness directed toward others 3.An understanding of the pathology and symptoms of the diagnosis 4.A willingness to participate in the planning of the care and treatment plan
4.A willingness to participate in the planning of the care and treatment plan Rationale:In general, clients seek voluntary admission. If a client seeks voluntary admission, the most likely expectation is that the client will participate in the treatment program since she or he is actively seeking help. The remaining options are not characteristics of this type of admission. Fearfulness, anger, and aggressiveness are more characteristic of an involuntary admission. Voluntary admission does not guarantee that a client understands her or his mental health problem, only the client's desire for help.
The nurse is working with a client who, despite making a heroic effort, was unable to rescue a neighbor trapped in a house fire. Which client-focused action should the nurse engage in during the working phase of the nurse-client relationship? 1.Exploring the client's ability to function 2.Exploring the client's potential for self-harm 3.Inquiring about the client's perception or appraisal of why the rescue was unsuccessful 4.Inquiring about and examining the client's feelings for any that may block adaptive coping
4.Inquiring about and examining the client's feelings for any that may block adaptive coping Rationale:The client must first deal with feelings and negative responses before the client can work through the meaning of the crisis. The correct option pertains directly to the client's feelings and is client-focused. The remaining options do not directly focus on or address the client's feelings.
What is the most appropriate nursing action to help manage a manic client who is monopolizing a group therapy session? 1.Ask the client to leave the group for this session only. 2.Refer the client to another group that includes other manic clients. 3.Tell the client to stop monopolizing in a firm but compassionate manner. 4.Thank the client for the input, but inform the client that others now need a chance to contribute.
4.Thank the client for the input, but inform the client that others now need a chance to contribute. Rationale:If a client is monopolizing the group, the nurse must be direct and decisive. The best action is to thank the client and suggest that the client stop talking and try listening to others. Although telling the client to stop monopolizing in a firm but compassionate manner may be a direct response, the correct option is more specific and provides direction for the client. The remaining options are inappropriate because they are not directed toward helping the client in a therapeutic manner.
The nurse in the emergency department is caring for a young female victim of sexual assault. The client's physical assessment is complete, and physical evidence has been collected. The nurse notes that the client is withdrawn, distracted, tremulous, and bewildered at times. How should the nurse interpret these behaviors? 1.Signs of depression 2.Reactions to a devastating event 3.Evidence that the client is a high suicide risk 4.Indicative of the need for hospital admission
Rationale: During the acute phase of the rape crisis, the client can display a wide range of emotional and somatic responses. The symptoms noted indicate an expected reaction. Options 1, 3, and 4 are incorrect interpretations.