ch 10 behavioral health

A client's nursing diagnosis of "risk for self-directed violence" has been identified because of her recent history of cutting and self-mutilation. Which of the following expected outcomes is most appropriate for this client's plan of care during inpatient treatment?

"The client will refrain from cutting or self-mutilation."

The nurse is performing a cultural assessment on a client admitted with depression. What question would obtain the most detailed assessment information?

"What is your definition of health?"

The psychiatric nurse is interviewing a new client. The psychiatric nurse teaches the client to reflect on one's own personal-identity. Which client statement reflects that the client is determining personal-identity?

"What words would I use to describe who I am?"

A client describes the recent breakup of a dating relationship when being interviewed by the nurse. Which finding will the nurse determine is the client's affect?

An emotionless tone and flat facial expression

The nurse is performing an assessment to determine the client's ability to concentrate. Which task will the nurse have the client perform to obtain this information?

Ask the client to list the days of the week in reverse order.

The nurse is performing a mental-health assessment for a client. Which will the nurse have the client do to best assess judgment?

Discussing hypothetical situations

A client states, "I don't want to eat anything because I am afraid that my food is poisoned." Which intervention is best for the nurse to perform to encourage the client to eat?

Encourage the client to help with meal preparation.

A client is showing no facial expression when engaging in a game with peers during an outing at a park. How will the nurse document the client's affect?

Flat affect

The client has an elevated serum thyroxine concentration. This finding indicates which disease processes?

Hyperthyroidism

A nurse develops a plan of care for a client with an eating disorder. The plan includes developing a contract with the client to modify behavior. What is the next step?

Implement nursing actions that have been identified

A nurse awaits the arrival of a client who is being transferred from a nursing home. The client has a history of schizophrenia and has been behaving bizarrely. The nurse begins preparing the plan of care by outlining expected outcomes. The nurse's actions are which of the following?

Inconsistent with the nursing process, because assessment always comes first

A client reported to the nurse that on the client's way to the clinic, a police officer in a patrol car turned on the car's lights and pulled the client over. When asked what the client did next, the client stated, "I pulled over, of course." Which was the nurse trying to assess?

Judgment

In the space of five minutes, the client has been laughing and euphoric, then angry, and then crying for no reason that is apparent to the nurse. This behavior would be best described as ...

Labile mood

During an assessment, which would be the most important question topic?

Suicidal ideation

When conducting a psycho-social assessment, the nurse inquires about the client's social supports. In order to effectively do this, which does the nurse need to explore?

The length and quality of relationships

Which intervention uses the reading of written materials to express feelings or gain insight?

bibliotherapy

A client is yelling, pacing, and becoming violent toward staff members. What technique should be tried first to control the situation initially?

deescalation

A client is admitted to the psychiatric unit and states, "I am president of the largest corporation in the world. Everyone comes to me for advice." Which behavior does the nurse document the client is exhibiting?

delusion

A nurse is completing an assessment interview, and is attempting to bring the conversation back to the questions at hand when the client goes off on a tangent. Which assessment interview behavior is the nurse using?

focusing

How should the nurse describe the mood and effect of a client who has a mask-like facial expression but states, "I'm really happy?"

incongruent

What is a nursing intervention used in the social domain?

milieu therapy

The nurse encourages an older adult client to write a letter to an old friend. What therapy is the nurse utilizing as an intervention?

reminiscence

After assessing a client, a nurse noted: "The client was tearful, tried to commit suicide, had no immediate plan for another suicide attempt, was unable to concentrate, and reported having trouble sleeping and having little or no appetite." The nurse also noted that the client's appearance was unkempt, and the client spoke with a low monotone voice and was unable to establish and maintain eye contact. Based on this information, which nursing diagnosis would be the most appropriate?

risk for suicide