Week 12 - Jensen - Ch. 9 Mental Health, Violence, and Substance Abuse

The nurse is performing a comprehensive health assessment on a client. The nurse would use the SBIRT tool when the client makes which of the following statements? "I have difficulty sleeping." "I feel tired most days." "I have become very forgetful." "I drink most days of the week."

"I drink most days of the week."

The nurse is performing an initial mental status examination on a client with depression. To obtain subjective data, what is the best question made by the nurse? "Tell me how you are feeling right now?" "How long have you felt this way?" "Do you have a history of alcohol or drug use?" "Why are you here?"

"Tell me how you are feeling right now?"

Which factor would alert the nurse to the risk of suicide in the client? Select all that apply. Alcohol abuse Depression Lack of social support Being married Rational though process

Alcohol abuse Depression Lack of social support

A client demonstrates nervousness and fear with a worsening loss of memory. Which nursing diagnosis should the nurse select to help guide this client's care? Risk for powerlessness related to prolonged disability Anxiety related to awareness of increasing memory loss Impaired memory related to dementia Impaired verbal communication related to hearing loss

Anxiety related to awareness of increasing memory loss

A screening tool used to identify whether alcohol use is problematic includes which of the following? CAGE Questionnaire Global Assess of Functioning Scale The Beck Depression Inventory Abnormal Involuntary Movement Scale

CAGE Questionnaire

The nurse is admitting a client with substance abuse. What screening tool would be best to use if this client is in denial about his substance abuse? Mini-Cog exam Mini-mental status examination SAD PERSONAS CAGE questionnaire

CAGE questionnaire

A client states, "I'm worthless and I don't deserve to live." This theme in the client's expressed thought may signal unhealthy responses to which disorder? Mania Delirium tremens Depression ADHD

Depression

A nurse is admitting a 30-year-old female client and recognizes the need to screen the client for abuse. What would the nurse do next? Obtain informed consent. Perform a physical assessment. Teach the client signs of abuse. Ensure a private setting.

Ensure a private setting.

A nurse asks a client the following question: "What do you do if you have pain?" The nurse is assessing which of the following? Judgment Orientation Abstract reasoning Memory

Judgment

A client opens the eyes and answers questions however falls back asleep within seconds. How should the nurse document this assessment finding? Obtunded Stupor Lethargy Coma

Lethargy

A victim of intimate partner violence tells a nurse, "I don't know how I'd live if I left my husband. And what about my children? I have no skills and haven't worked since I was a teenager." When developing the plan of care for this client, which nursing diagnosis would be best? Risk for violence related to inadequate coping abilities Impaired parenting related to family violence Anxiety related to the physical escalation of the violence Low self-esteem related to lack of confidence in ability

Low self-esteem related to lack of confidence in ability

The nurse documents findings from the client's Mini-Mental State Examination. The following information will be documented as a result of this test. Orientation, memory, and cognitive function. Mood, feelings, expressions, and perceptions. Energy level, satisfaction, and social participation. Appropriateness of dress, grooming, and eye contact.

Orientation, memory, and cognitive function.

A female client and her partner come to the emergency department. The client has bruising on both upper extremities and a fracture of the left arm. The client states that she fell down the stairs. What finding would lead the nurse to suspect that the client is a victim of violence? Partner states that client is very clumsy and accident prone Partner leaves the examination room when asked Client holds partner's hand when arm is being examined Client freely answers questions asked about the injury

Partner states that client is very clumsy and accident prone

Healthy People identifies a goal of reducing the annual rate of rape or attempted rape, and other sexual assaults. What action best facilitates this goal? Reducing wage gaps between men and women Teaching children about healthy touch Teaching women about the danger of men Increased electronic surveillance

Teaching children about healthy touch

Which nursing action is essential in caring for the victim of violence? Minimizing confidentiality Normalizing victimization Validating the abuse experience Trivializing the abuse

Validating the abuse experience

A nurse is counseling a woman who has been abused by her husband and who is at risk for serious injury and even death. The woman has two school-aged children at home. Which of the following should the nurse tell the woman to make sure her children know? Select all that apply. How and when to call 911 How they should intervene during abuse to make it stop That it is their job to keep their mother safe Who is safe to tell when they are unsafe A safe place to go when abuse of the client occurs

Who is safe to tell when they are unsafe A safe place to go when abuse of the client occurs How and when to call 911

The client's daughter asks the nurse why the nurse is asking her mother depression-related questions. The nurse explains that even though the client has symptoms of dementia, the Geriatric Depression Scale is being used because it is the most accurate tool to determine the stage of dementia. finding out why she is depressed will help determine the cause of her dementia. depression and dementia are one in the same disorder. depression often mimics signs and symptoms of dementia.

depression often mimics signs and symptoms of dementia.

The nurse is teaching a class in the community to promote protective factors against intimate partner violence. What will the nurse include in the teaching? Select all that apply. young age mutual trust in one's neighborhood high friendship quality social support emotional dependence

high friendship quality social support mutual trust in one's neighborhood.

When assessing for human violence in clients, it is important for the nurse to prioritize the assessment of female clients. become familiar with research on immigrants. assess only older adults. reexamine assumptions and stereotypes.

reexamine assumptions and stereotypes.

The nurse is caring for a client who is a victim of intimate partner violence. The nurse determines the client has successfully developed a safety plan when the client makes which of the following statements? "I will find a safe place to go if things get worse." "I haven't told my neighbors about my abuse." "I have a packed bag ready, just in case." "I will make arrangements for my children if I have to leave."

"I have a packed bag ready, just in case."

The nursing instructor is educating her students on the important of assessing for victims of abuse and violence. What statement by the students indicate an understanding of when to assess for abuse and violence? "It is not necessary to assess every client. Some clients get offended when you ask them those questions." "I will assess a client for abuse and violence only when they present with bruises or a broken limb." "I will assess pregnant clients who come to the clinic." "I will assess a client for abuse and violence with every client encounter."

"I will assess a client for abuse and violence with every client encounter."

A nurse is assessing a client's spirituality. Which question would be most appropriate to ask? "How do you define good and evil?" "Have you every tried to harm yourself?" "How important is your family to you?" "What gives your life meaning?"

"What gives your life meaning?"

Which clients are most at risk for depressive symptoms? (Select all that apply.) Chronically ill clients Females Divorced clients Married clients Males

Chronically ill clients Females Divorced clients

A nurse is interviewing a client who has been abused by her partner. Which of the following should the nurse do? Screen the client regardless of any safety concerns for self Convey a concerned and nonjudgmental attitude Avoid discussion of legal issues at the start Allow the partner to be present with the client

Convey a concerned and nonjudgmental attitude.

When assessing a client for human violence, what basic technique would the nurse need to apply? Using a close family member of the client as an interpreter Demonstrating compassion Positioning self below the client's eye level Speaking slowly and softly, but with authority

Demonstrating compassion

A 29-year-old woman comes to the office. During history taking, the nurse notices that the client is speaking very quickly and jumping from topic to topic so rapidly that it is difficult to follow her. The nurse can find some connections between ideas, but it is difficult. Which word best describes this thought process? Derailment Flight of ideas Circumstantiality Incoherence

Flight of ideas

The client states, "I don't know why God as abandoned me; I am a good person." Which tool would be most appropriate for the nurse to administer? Mini-Cog CAGE HOPE MMSE

HOPE

The client states, "I just know I have cancer. My doctor has run every test in the book and says there is nothing wrong with me. I don't believe any test. I know how sick I am!" This client is exhibiting what type of thought process disturbance? Hypochondriasis Loose association Psychosis Delusion

Hypochondriasis

During the health-history interview, which of the following components of cognitive function can the nurse quickly assess? Memory and attention Calculation and language Judgment and behavior Abstract thinking and perceptions

Memory and attention

The client is brought to the clinic by his son, who states, "My father just doesn't seem to be able to function as well as he used to." When assessing this client the nurse is aware that she will be a what? Surrogate decision maker Diagnostician Patient advocate Family liaison

Patient advocate

A middle-school child tells his parents that he does not want to go back to school. He states that a group of boys are taking his clothes and towel when he is in the shower after gym class and making fun of his genitals. What type of violence is this Hate crime Coercion Punking Human trafficking

Punking

When compared with pregnant women who have not experienced intimate partner violence (IPV), pregnant women who have experienced IPV are at increased risk for what? High-birth-weight infants Gestational diabetes Increased maternal weight gain Risk for alcohol, tobacco, and street drug use

Risk for alcohol, tobacco, and street drug use

Which aspects of the mental status exam refer to data about how thoughts connect to one another? Behavior Thought process Orientation Mood

Thought process

Which of the following would the nurse identify as indicating psychological or emotional abuse? Select all that apply. Throwing things at a victim Threatening to hit the victim Forcing the victim to perform a degrading or humiliating act Controlling how the family's money is spent Calling the victim names Not allowing the victim to seek care for an injury

Threatening to hit the victim Forcing the victim to perform a degrading or humiliating act Calling the victim names

A nurse is educating a victim of intimate partner violence about a safety plan. The nurse should include which of the following? "Do not tell people about the abuse; it will only anger the abuser." "Contact your neighbors to arrange for a place to go should a disruption occur." "Do not remove weapons in the house; this will only upset the abuser." "Have a code word to use with your children, family, and friends that indicates you need help."

"Have a code word to use with your children, family, and friends that indicates you need help."

A nurse is assessing a survivor of intimate partner violence. During the interview, the nurse determines that the survivor's partner is using power and control over the client through coercion and threats. Which client statement would lead the nurse to suspect this? "He tells me that he'll tell child services I'm a bad mother." "He always tells me that the abuse never happened." "He tells me that who I can and cannot see." "He acts like he's the master of his castle and I'm his servant."

"He tells me that he'll tell child services I'm a bad mother."

A 22-year-old man is brought to the office by his father. The client was diagnosed with schizophrenia 6 months ago and has been taking medication since. The father states that his son's dose isn't high enough and needs to be increased. He states that his son has been hearing things that don't exist. The nurse asks the young man what is going on. He says that his father is just jealous because his sister only talks to him. His father turns to him and says, "Son, you know your sister died 2 years ago!" His son replies "Well, she still talks to me in my head all the time!" Which best describes this client's abnormality of perception? Fugue state Perseveration Illusion Hallucination

Hallucination

A middle-aged client with a periorbital hematoma admits to the nurse that the injury occurred when her husband punched her in a rage. Following assessment and treatment, the client expresses her intention to return home to her husband. How should the nurse best respond? Inform the client that a social worker must grant permission for her to return home. Remind the client that she waives her right to press charges if she willingly returns home. Inform the client that she will not be permitted to return to a known unsafe setting. Remind the client of the threat to her safety and of her options for shelter.

Remind the client of the threat to her safety and of her options for shelter.