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A hospitalized psychiatric client with the diagnosis of histrionic personality disorder demands a sleeping pill before going to bed. After being refused the sleeping pill, the client throws a book at the nurse. What does the nurse recognize this behavior to be? Exploitive Acting out Manipulative Reaction formation
b- Acting out is the process of expressing feelings behaviorally. The action is not exploitive, because no evidence is provided to demonstrate that anyone has been used to get what the client wants. The action is not manipulative, because no evidence is provided to demonstrate that anyone has been influenced against his or her wishes. The action is not disguising unacceptable feelings by expressing opposite emotions (reaction formation).
A nurse may best assist abusive parents in altering behavior toward their toddler by helping them do what? Recognize what behavior is normal for a toddler. Learn suitable ways of punishing a toddler's undesirable behavior. Identify the specific ways that the toddler's behavior provokes frustration. Ignore the toddler's adverse nondestructive behavior while supporting acceptable behavior.
By learning how the toddler's behavior provokes frustration, parents can develop more constructive ways of responding to undesirable behavior. Although these parents do need to learn what behavior is normal for a particular age level, it is most important that they learn how to respond more effectively to their toddler's behavior. Learning suitable ways of correcting undesirable behavior is helpful only when the parents are first able to identify how the toddler's behavior provokes their frustration and how to develop a strategy for responding constructively to that frustration. The toddler's adverse behavior cannot be ignored and should be handled thoughtfully.
A nurse has been assigned to care for a client with the diagnosis of obsessive-compulsive disorder (OCD). Before providing care for this client, what should the nurse remember about clients with OCD? Are unaware that the ritual serves no purpose Can alter the ritual depending on the situation Should be prevented from performing the ritual Do not want to repeat the ritual but feel compelled to do so
The repeated thought or act defends the client against even higher, more severe levels of anxiety. Clients usually do recognize that the ritual serves little or no purpose. Rituals are usually followed rigidly; setting limits on or altering a ritual increases anxiety. Preventing the client from performing the ritual may precipitate a panic level of anxiety.
What is the best room assignment for a 5-year-old child admitted with injuries that may be related to abuse? <p>What is the <b>best</b> room assignment for a 5-year-old child admitted with injuries that may be related to abuse?</p> In an isolation room With a friendly older child With a child of the same age In a room near the nurses' desk
A child who exhibits signs of abuse needs close supervision, especially when members of the family visit. The child requires close monitoring and should not be left alone. There is no indication that this child needs to be placed in an isolation room for the sake of infection control. An older child who exhibits signs of friendliness may be threatening to this child. Placement with a child of the same age may be desirable from a developmental level, but it does not meet the child's safety needs.
A single mother of two children who recently lost her job because her company is downsizing comes to the emergency department. The woman does not know what to do and is in crisis. The most critical factor for the nurse to determine during crisis intervention is the client's what? <p>A single mother of two children who recently lost her job because her company is downsizing comes to the emergency department. The woman does not know what to do and is in crisis. The <b>most</b> critical factor for the nurse to determine during crisis intervention is the client's what?</p> Developmental history Available situational supports Underlying unconscious conflict Willingness to restructure the personality
Personal internal strengths and supportive individuals are critical to the development of a crisis intervention plan; they must be explored with the client. Although developmental history information may be helpful, it is not essential; factors concerning the current situation are paramount. Identifying unconscious conflicts takes a long time and is inappropriate for crisis intervention. Willingness to restructure the personality is a goal of psychotherapy, not crisis intervention.
An older client is treated in the emergency department for soft-tissue injuries that the medical team suspects might be caused by physical abuse. An adult child states that the client is forgetful and confused and falls all the time. A mini-mental examination indicates that the client is oriented to person, place, and time, and the client does not comment when asked directly how the bruises and abrasions occurred. What is the next appropriate nursing action? Interview the client without the presence of family members. Report the abuse to the appropriate state agency for investigation. Accept the adult child's explanation until more data can be collected. Refer the client's clinical record to the hospital ethics committee for review.
Privacy may provide an environment that is conducive to the client sharing information about the situation. The client needs to be kept safe; this action ensures additional time for assessment to rule out the possibility of abuse. Reporting the abuse to the appropriate state agency for investigation is premature; further assessment is needed to determine if it is necessary to notify the appropriate agency. Accepting the adult child's explanation until more data can be collected will form a separate relationship with the adult child, which is not in the client's best interest. Referring the client's clinical record to the hospital ethics committee for review is inappropriate; this situation presents a legal, not ethical, issue.
The nurse teaches a client methods of coping with anger. The nurse concludes that the client has learned the most effective method when the client states that the client will do what when angry? Go for a long jog. Talk about the anger. Go to the basement to scream. Concentrate on what caused the anger.
Talking about angry feelings is better than acting them out; this response indicates that the client has learned a positive coping method. Although taking a long jog or going to the basement to scream may help, it is an isolated activity that does not permit sharing of feelings and may not always be possible. Concentrating on what made the client angry may result in an escalation of angry feelings.
A client comes to a trauma center reporting that she has been raped. She is disheveled, pale, and staring blankly. The nurse asks the client to describe what happened. What is the nurse's rationale for doing this? It will help the nursing staff give legal advice and provide counseling. Talking about the assault will help the client see how her behavior may have led to the event. It will let the victim put the event in better perspective and help begin the resolution process. Discussing the details will keep the victim from concealing the intimate happenings during the assault.
Talking about what actually happened helps the client sort out the truth from confused thoughts and helps the client begin to accept what has happened as a part of her history. Legal counsel should come from a legal authority, not the nurse; the victim should be told of the legal services available. Sexual assaults are often planned. They are violent acts, and the perpetrators are responsible for their behavior. If the client does not want to discuss intimate details, this wish should be respected.
A client with the diagnosis of obsessive-compulsive disorder who has a need to wash his hands 50 to 60 times a day tearfully tells the nurse, "I know that my hands aren't dirty, but I just can't stop washing them." What is the best response by the nurse? "Let's talk about why you feel that you have to wash your hands." "I think you're getting better; you're beginning to understand your problem." "Don't worry about it; these actions are part of your illness, and the feelings will pass." "I understand that—maybe we can work together to limit the number of times you wash them."
The nurse shows an understanding of the client's needs by not totally restricting the handwashing and by working with the client to set limits on the behavior. At this time the client is still too anxious to be capable of coping with the reasons for handwashing. Continued handwashing does not reveal an understanding of the underlying problem, nor is it a sign of progress. Telling the client not to worry denies the client's feelings and may close off communication.
A 3-year-old child is brought to the emergency department by the mother, who reports that her child fell down the stairs and sustained injuries to the right arm and leg. During the physical assessment the nurse identifies a number of old bruises on the child's back, buttocks, and upper arms. What should the nurse say to the child to obtain additional information? <p>A 3-year-old child is brought to the emergency department by the mother, who reports that her child fell down the stairs and sustained injuries to the right arm and leg. During the physical assessment the nurse identifies a number of old bruises on the child's back, buttocks, and upper arms. What should the nurse say to the child to obtain additional information?</p> "Why did you fall down the stairs?" "Did you really fall down those stairs?" "Show me how you fell down the stairs." "Your mommy must have told you to say you fell down the stairs."
The response "Show me how you fell down the stairs" will allow the child to show what happened; it removes the pressure of verbalization. Children have difficulty answering "why" questions; asking why the child fell may add to the guilty feelings of the abused child. Asking, "Did you really fall down those stairs?" will confuse the child because it might become necessary to verify a lie. The response "Your mommy must have told you to say you fell down the stairs" will confuse the child because of his or her dependence on the mother; the child may be afraid of contradicting the mother.
A client is admitted to the psychiatric hospital after many self-inflicted nonlethal injuries over the preceding month. Of which level of suicidal behavior is the client's behavior reflective? Threats Ideation Gestures Attempts
A suicidal gesture involves superficial, nonlethal injuries; the client has no intent to die as a result of the injuries. A suicidal threat is a person's verbal statement of intent to commit suicide; there is no action. Suicidal ideation is a person's thoughts regarding suicide; there is no definitive intent or action expressed. A suicide attempt is an actual implementation of a severe self-injurious act; there is an attempt to cause serious self-harm or death.
A teenager with a diagnosis of osteosarcoma is to have the affected leg amputated. What should the nurse do to promote psychologic adjustment and early function immediately after surgery? Allow the client to change the first dressing. Help the client adjust to the temporary prosthesis. Assign the client to a room with another adolescent. Have the client meet with a member of a cancer survivor organization.
A temporary prosthesis attached to a cast with a metal extension can be applied immediately after surgery. This will allow the adolescent to walk within several hours and helps start the adjustment process. The first dressing change is usually done by a member of the surgical team; also, this is too early to expect the adolescent to be ready to look at the surgical site. Assigning the adolescent to a particular room is usually done out of necessity rather than to promote psychologic adjustment. It is too early to have another cancer survivor visit, but this may be done later in the recovery process.
A married woman is brought to the emergency department of a local hospital. Her eyes are swollen shut, and she has a bruise on her neck. She reports that she is being beaten by her husband. How does the nurse expect the husband to behave when he arrives at the emergency department? Fearful Confused Charming Indifferent
Abusers are often extremely charming to mask their abusive tendencies and convince the abused mate and others that change is possible. After an abusive episode there is often a "honeymoon" period because the tensions of the abuser have been released. Abusers mask their fears by becoming angry and aggressive. Abusers are not confused; they are manipulative of others. Abusers are rarely indifferent; they tend to be opinionated and demanding.
A primary healthcare 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 prescription? Asking that the prescription indicate the type of restraint Recognizing that PRN prescriptions for restraints are unacceptable Implementing the restraint prescription when the client begins to act out Ensuring that the entire staff is aware of the prescription for the restraints
A new prescription must be written each time a client requires restraints. When a client is acting out, the nurse may use restraints or a seclusion room and then obtain the necessary prescription. Less restrictive interventions should be used when the client begins to act out; restraints are used as a last resort.
The nurse would recognize which behavior as being characteristic of the panic phase of crisis behavior? Being physically immobile Sobbing for no apparent reason Reporting great difficulties falling asleep Startling easily to loud noises and being touched
A- Being unable to physically move is a psychomotor characteristic of extreme panic, which is a characteristic of crisis behavior. Sobbing for no apparent reason, reporting great difficulties falling asleep, and startling easily to loud noises and being touched are behaviors seen in lesser degrees of anxiety.
A teenager is being discharged with a cast. What should the nurse recommend if the client experiences pruritus around the cast edges? "Scratch the itchy area gently." "Put an ice pack on the affected area." "Sprinkle a layer of powder around the itchy spots." "Ask your doctor for a prescription for an antihistamine."
An ice pack numbs the area and may temporarily diminish the discomfort. Scratching stimulates the release of histamine, which worsens the pruritus; also, scratching may break the skin and open an avenue for infection. Powder may become caked and slip under the cast, causing additional discomfort. Also, powder should be avoided because it is toxic if inhaled. Antihistamines are not prescribed unless all other measures have failed.
The emergency department nurse is conducting an interview and assisting with the physical examination of a female sexual assault victim. What is most important for the nurse to document on this client's record? Observations about the client's reaction to male staff members Statements by the client about the sexual assault and the rapist Information about the client's previous knowledge of the rapist Summary statement about the client's description of the assault and the rapist
B- Statements by the client about the sexual assault and the rapist eliminate the nurse's subjectivity from the report. Observations about the client's reaction to male staff members is unrelated to the sexual assault itself and are subjective. Eliciting information about the client's previous knowledge of the rapist is not the responsibility of the nurse. A summary statement about the client's description of the sexual assault and the rapist may invite subjectivity.
A nurse is teaching a class about child abuse. What defense mechanism most often used by the physically abusive individual should the nurse include? Repression Manipulation Transference Displacement
Displacement is a defense mechanism in which one's pent-up feelings toward a threatening person are discharged on those who are less threatening. Repression is the unintentional putting out of the mind unacceptable or troubling thoughts, desires, or experiences. Transference is a mechanism by which affects or emotional tones are shifted from one individual to another; it is unrelated to child abuse. Manipulation is a mechanism by which individuals attempt to manage, control, or use others to suit their own purpose or to gain an advantage; it is unrelated to child abuse.
A client arrives at the clinic and tells the nurse about various aches and pains since her spouse's death 3 months ago. The client appears depressed and tense. What is the initial nursing intervention? <p>A client arrives at the clinic and tells the nurse about various aches and pains since her spouse's death 3 months ago. The client appears depressed and tense. What is the initial nursing intervention?</p> Facilitating a discussion of the spouse's death Focusing on teaching the client relaxation exercises Asking the practitioner for a psychiatric consultation Helping the client recognize ambivalence toward the spouse
Facilitating a discussion of the spouse's death will encourage the client to speak about the spouse and begin moving toward resolving the loss. Although relaxation exercises may be beneficial, the focus should be on the expression of feelings. A psychiatric consultation is not indicated by the data at this time. The data do not indicate ambivalence toward the spouse.
A client in the mental health clinic who has been seeing a therapist for more than 6 months begins to talk and act like a therapist who is analyzing coworkers. What defense mechanism does the nurse identify? Undoing Projection Introjection Intellectualization
Introjection is treating something outside the self as if it is actually inside the self; it is unconsciously incorporating the wishes, values, and attitudes of another as if they were one's own. Undoing is taking some action to counteract or make up for a wrongdoing. Projection is attributing to another person or group one's own unacceptable attitudes or characteristics. Intellectualization is using logical explanations without feelings or an affective component.
A child would be demonstrating outwardly focused anger or aggression in an overt manner when engaging in which behavior? Dominating a class discussion Intentionally forgetting to do homework Scribbling on a classmate's art assignment Crying when told he or she must wait his or her turn
Overt anger is demonstrated obviously or in an unconcealed manner that is hurtful, such as in damaging the artwork of another student. Examples of passive outwardly focused anger would be in dominating conversations or intentionally forgetting to do something that is required. Crying is a demonstration of inwardly focused anger that is objectively displayed.
Besides providing reassurance, what should nursing interventions for a client who is hyperventilating be focused on? Administering oxygen Using an incentive spirometer Having the client breathe into a paper bag Administering an IV containing bicarbonate ions
Reassurance decreases anxiety and slows respirations; the bag is used so that exhaled carbon dioxide can be rebreathed to resolve respiratory alkalosis and return the client to an acid-base balance. Administering oxygen is not necessary because there is no evidence of hypoxia. Using an incentive spirometer is used to prevent atelectasis. The client is already alkalotic; bicarbonate ions will increase the problem.
An older depressed person at an independent living facility constantly complains about her health problems to anyone who will listen. One day the client says, "I'm not going to any more activities. All these old crabby people do is talk about their problems." What defense mechanism does the nurse conclude that the client is using? Projection Introjection Somatization Rationalization
The client is assigning to others those feelings and emotions that are unacceptable to herself. Introjection is treating something outside the self as if it is inside the self. Somatization is the unconscious transformation of anxiety into a physical symptom that has no organic cause. Rationalization is the use of a socially acceptable logical explanation to justify personally unacceptable material.
While being admitted for a lumpectomy the client begins to cry and says, "I found the lump a few months ago, but I didn't go to the doctor because of what it could be." How should the nurse reply? <p>While being admitted for a lumpectomy the client begins to cry and says, "I found the lump a few months ago, but I didn’t go to the doctor because of what it could be." How should the nurse reply?</p> "This has been frightening for you." "About 80% of breast lumps are benign." "Cry as long as you like and get it out of your system." "More than 95% of breast lumps are discovered by the woman herself."
Saying "This has been frightening for you" involves the use of a reflective technique to acknowledge the client's feelings. Providing statistics does not acknowledge the client's feelings and may cut off communication. Providing false reassurance that crying will ease her concerns is inappropriate.
An executive busy at work receives a phone call from a friend relating bad news. The executive makes a conscious effort to put this information out of mind and continues to work at the task at hand. The next day executive remembers that the friend telephoned but is unable to recall the message. Which defense mechanism does this behavior represent? Regression Suppression Reaction formation Passive aggression
Suppression is the voluntary exclusion from awareness of anxiety-producing feelings, ideas, and situations. In regression, a person returns to an earlier and more comfortable developmental level. Passive aggression is the use of behaviors such as passivity, procrastination, and inefficiency that negatively affect others. Reaction formation is a conscious behavior that is the opposite of an unconscious feeling.
A nurse in the emergency department is assessing a client who has been physically and sexually assaulted. What is the nurse's priority during assessment? The family's feelings about the attack The client's feelings of social isolation The client's ability to cope with the situation Disturbance in the client's thought processes
The situation is so traumatic that the individual may be unable to use past coping behaviors to comprehend what has occurred. Assessing emotions that occur in response to news of the attack will occur later. The client should be the focus of care at this time. Social isolation is not an immediate concern. Coping skills, not thought processes, are challenged at this time.
A nurse is considering Erikson's stages of psychosocial development while caring for a client. Which behavior is consistent with a problem involving trust versus mistrust? Woman in an abusive relationship who refuses to leave the abuser Man with paranoid schizophrenia who demands placement in a private room Woman whose parents were chronic alcoholics and who has problems making friends Man with borderline personality disorder who has been caught stealing from other clients
Trust is learned in infancy. Being parented by individuals who were not able to consistently meet the client's basic physiologic and safety needs is likely to result in an inability to engage in healthy interpersonal relationships as an adult. The response of the client in an abusive relationship is based not on events that occurred during infancy but rather on events in adulthood. The responses of the clients with paranoid schizophrenia and borderline personality disorder are symptoms of a psychiatric disorder rather than of an event that occurred during infancy.
A 7-year-old child must remain quietly in bed while undergoing peritoneal dialysis. What activity is most appropriate for the nurse to plan for this child? <p>A 7-year-old child must remain quietly in bed while undergoing peritoneal dialysis. What activity is <b>most </b>appropriate for the nurse to plan for this child?</p> Learning to play chess Constructing a model airplane Working multiple-piece puzzles with another child Using a large sponge ball to play catch with a roommate
Working puzzles is a quiet activity that will not jeopardize placement of the peritoneal catheter and is appropriate for the child's cognitive level and allows social interaction with a peer. Chess requires cognitive abilities beyond the scope of a 7-year-old child. Although constructing a model airplane is a quiet activity, it is probably too difficult for a 7-year-old to do without help from an adult. Playing catch could result in displacement of the peritoneal catheter.
While assessing an older adult during a regular health checkup, a nurse finds signs of elder abuse. Which physical findings would further confirm the nurse's suspicion? Select all that apply. Presence of hyoid bone damage Presence of cognitive impairment Presence of burns from cigarettes Presence of bed sores. Presence of unexplained bruises on the wrist(s)
cde- A physical finding of abuse in older adults can be the presence of burns from cigarettes. The physical presence of bed sores also indicates client abuse. Unexplained bruises on the wrist(s) may also be an indication of abuse in older adults. The presence of hyoid bone damage is an indication of intimate partner violence. The presence of cognitive impairment is a behavioral finding in older adult abuse.
Nurses on a psychiatric unit have secluded a client who has the diagnosis of bipolar I disorder, manic episode, and who has been losing control and throwing objects while in the dayroom. What is the most important intervention for the client who is given an as-needed (PRN) medication and confined to involuntary seclusion? Continue intensive nursing interactions. Evaluate the client's progress toward self-control. Determine whether any staff member has been injured. Observe the client for side effects of the medication given to the client.
For the safety of the client and everyone on the unit, improvement in a client's level of self-control is essential before the degree of restraint and seclusion is progressively reduced. Continuing intensive interaction at this time would not be productive and could cause the client's behavior to escalate. The nurse's prime responsibility should be the client; staff members can assess other staff members. Observing the client for side effects of medications is only one of the many factors in determining the client's level of self-control.
One afternoon the nurse on the unit overhears a young female client having an argument with her boyfriend. A while later the client complains to the nurse that dinner is always late and the meals are terrible. The nurse identifies the defense mechanism that the client is using as what? Projection Dissociation Displacement Intellectualization
Displacement reduces anxiety by transferring the emotions associated with an object or person to another emotionally safer object or person. Projection is the attempt to deal with unacceptable feelings by attributing them to another. Dissociation is an attempt to detach emotional involvement or the self from an interaction or the environment. Intellectualization is the use of facts or other logical reasoning rather than feelings to deal with the emotional effect of a problem.
When presenting a workshop on adolescent suicide, a community health nurse identifies which risk factors? Select all that apply Victim of family violence Limited or strained family finances Member of a single-parent household Dependence on alcohol, drugs, or both Uncertainty related to sexual orientation Repeated demonstration of poor impulse control
adef- Being a victim of family violence of any kind increases the risk of suicide. Alcohol or drug abuse is a significant factor in adolescent suicide. A concern about sexual orientation or being accepted as homosexual is a risk factor for suicide, especially among adolescents. Poor impulse control can lead to an increased tendency toward risk taking, which is a factor in suicide, especially among adolescents. Although economic problems and absence of a parent can both stress a family and its members, there is no research to support that either is a major factor in adolescent suicide.
