Foundations of Psychiatric Nursing
A client is to be discharged from an alcohol rehabilitation program. What should the nurse emphasize in the discharge plan as a priority? supportive friends a list of goals returning to work follow-up care
follow-up care
Erikson described the psychosocial tasks of the developing person in his theoretical model. He proposed that the primary developmental task of the young adult (ages 18 to 25) is: intimacy versus isolation. industry versus inferiority. generativity versus stagnation. trust versus mistrust.
intimacy versus isolation.
Which client behavior indicates the nurse-client relationship is in the working phase? The client: attempts to familiarize themself with the nurse. makes an effort to describe their problems in detail. tries to summarize his or her progress in the relationship. starts to challenge the boundaries or outer limits of the relationship.
makes an effort to describe their problems in detail.
The nurse meets with a client in the outpatient clinic who is suicidal and refuses to participate in creating a suicide safety plan. What action should the nurse take next? Arrange for the client to be sent back to the group home. Refer the client to a partial program until the client is no longer suicidal. Arrange for immediate hospitalization on a locked unit. Arrange for admission to a subacute unit for 2 weeks.
Arrange for immediate hospitalization on a locked unit.
The nurse plans care for a client who is being abused. Which measure is most important to include? being compassionate and empathetic teaching the client about abuse and the cycle of violence explaining to the client their personal and legal rights helping the client develop a safety plan
helping the client develop a safety plan
A client is admitted to the hospital because of threatening, aggressive behavior toward his family. In the first group meeting after the client is admitted, another client sits near the nurse and says loudly, "I'm sitting here because I'm afraid of Ted. He's so big, and I heard him talk about hitting people." The nurse should say to the client: "Everyone is here for different problems. You know you don't have to worry." "Ted is new to the group. Let's go around and introduce ourselves to him." "You don't know Ted yet. Once you get to know him, I'm sure you won't be afraid." "It's frightening to have new people on the unit. We're here to talk about things like being afraid."
"It's frightening to have new people on the unit. We're here to talk about things like being afraid."
A client with psychosis is prescribed quetiapine 400 mg by mouth daily in two divided doses. The pharmacy dispenses 200-mg tablets. How many tablets should the nurse administer with each dose? Record your answer using a whole number.
1 tablet
A client with a personality disorder is upset and calls the nurse a "stupid cow." Which is the most effective initial response by the nurse to this client's behavior? Demonstrate empathy by reaching out to touch the client. Calmly discuss the inappropriateness of displacing anger to others. Report the behavior to the physician so that consistency and consequences can be followed. Walk away from the client.
Calmly discuss the inappropriateness of displacing anger to others.
A client doesn't make eye contact with the nurse during an interview. The nurse suspects that the client's behavior has a cultural basis. What should the nurse do first? Read several articles about the client's culture. Ask staff members of a similar culture about the client's behavior. Observe how the client and the client's family and friends interact with one another and with other staff members. Accept the client's behavior because it's probably culturally based.
Observe how the client and the client's family and friends interact with one another and with other staff members.
A psychiatric treatment team is planning care for a client who was involuntarily admitted for treatment of depression and suicide ideation. When planning the client's care, what legal parameters of care should the nurse be aware of? The client is able to refuse medications. The client is able to obtain release against medical advice. The client is in need of a public guardian. The client is considered to be incompetent.
The client is able to refuse medications.
Which finding most indicates that a client who has been raped will have future adjustment problems and need additional counseling? The client becomes upset when talking about the rape to anyone. The client seeks support from formerly ignored relatives and friends. The parents show shame and suspicion about the client's part in the rape. The client's life becomes focused on helping other people who have experienced rape.
The parents show shame and suspicion about the client's part in the rape.
A client who has experienced the loss of their spouse through divorce, the loss of their job and apartment, and the development of drug dependency is experiencing situational low self-esteem. Which outcome is most appropriate initially? The client will: discuss their feelings related to their losses. identify two positive qualities. explore their strengths. prioritize problems.
discuss their feelings related to their losses.
An older adult experiences short-term memory problems and occasional disorientation a few weeks after their spouse's death. The client also is not sleeping, has urinary frequency and burning, and sees rats in the kitchen. The home care nurse calls the client's health care provider to discuss the client's situation and background, assess, and give recommendations. The nurse concludes that the client most likely has which problem? the onset of Alzheimer disease trouble adjusting to living alone without their spouse delayed grieving related to their Alzheimer disease delirium and a urinary tract infection (UTI)
delirium and a urinary tract infection (UTI)
A client who comes to the emergency department with multiple bruises on the face and arms, a black eye, and a broken nose says that these injuries occurred when they fell down the stairs. The nurse suspects that the client may have been physically assaulted. What should the nurse do next? Ask the client directly about the possibility of physical abuse. Tell the client that it is difficult to believe that such injuries resulted from a fall. Ask the client what they did to make someone beat them so badly. Discuss with the client what they can do to deescalate the situation next time.
Ask the client directly about the possibility of physical abuse.
A client with a diagnosis of depression is started on imipramine, 75 mg by mouth at bedtime. Which evaluation would indicate that there has been a therapeutic response to this drug? Client reports weight gain on 10 lb in 6 weeks. Assessment reveals heart rate = 104, respiratory rate = 20, and blood pressure = 132/82 mm Hg. Client reports excessive daytime sleepiness. Client makes eye contact and is well groomed.
Client makes eye contact and is well groomed.
In closed or locked units, the nurse judges the milieu as therapeutic when priorities are given to which factors? socialization and self-understanding recreation and vocation counseling safety, structure, and support communication, social, and leisure skills
safety, structure, and support
A client was experiencing marital discord with a spouse of 4 years. When the spouse walked out, the client became angry and began to throw things and break dishes. A friend talked the client into seeking help at the local mental health center. Which of these questions should the nurse ask initially to begin to assess this client's immediate problem? "Do you feel in control of yourself at this time?" "What did you do to cause your spouse to leave?" "In hindsight, how might you have managed this situation differently?" "What led you to come in for help today?"
"What led you to come in for help today?"
A client has a history of violence toward others and an inability to cope with anger. What should the nurse use as the most important indicator of goal achievement before discharge? acknowledgment of the client's angry feelings ability to describe situations that provoke angry feelings development of a list of how anger has been handled in the past verbalization of feelings in an appropriate manner
verbalization of feelings in an appropriate manner
A client who is neatly dressed and clutching a leather briefcase tightly in their arms scans the adult inpatient unit on their arrival at the hospital and backs away from the window. The client requests that the nurse move away from the window. The nurse recognizes that doing as the client requested is contraindicated for which reason? The action will make the client feel that the nurse is humoring them. The action indicates nonverbal agreement with the client's false ideas. The client will then think they can have their way when whenever they wish. The nurse will be demonstrating a lack of composure over the situation.
The action indicates nonverbal agreement with the client's false ideas.
The nurse is planning an education for new nurses on psychiatric units. Which topic should be given priority? assault battery neglect breach of confidentiality
breach of confidentiality
A client in group therapy is restless. The client's face is flushed and the client makes sarcastic remarks to group members. The nurse responds by saying, "You look angry." The nurse is using which technique? a broad, opening statement reassurance clarification observation
observation
Which term refers to the primary unconscious defense mechanism that blocks intense, anxiety-producing situations from a person's conscious awareness? introjection regression repression denial
repression
A client lives in a group home and visits the community mental health center regularly. During one visit with the nurse, the client states, "The voices are telling me to hurt myself again." Which question by the nurse is most important to ask? "When do you hear the voices?" "Are you going to hurt yourself?" "How long have you heard the voices?" "Why are the voices starting again?"
"Are you going to hurt yourself?"
During a conversation with the nurse, a client who has experienced intimate partner violence says, "Let me try to explain why I stay with my spouse." Which response would the nurse find inconsistent with the profile of a victim of intimate partner violence? "I'm responsible for keeping my family together." "The abuse adds spice to our relationship." "I love my spouse and will help them." "I'm not sure I could get a job that pays even minimum wage."
"The abuse adds spice to our relationship."
An older client was brought into the emergency department in a confused state, incoherent, and agitated after reportedly spray-painting their lawn furniture with metal paint earlier that day. The client has no history of illness and is not on any medication. Which intervention would be most important for the nurse to make? Complete a baseline mental status exam. Moderate the amount of sensory stimulation. Communicate with the physician about the client's condition. Assess for depression related to aging.
Complete a baseline mental status exam.
Despite education and role-play practice of restraint procedures, a staff member is injured when actually restraining a client. When helping the other staff members deal with the incident, the nurse should address which factor? The emotional responses may be similar to those of other crime victims. The team member is likely to resign after experiencing such an injury. Legal action against the client will take time and energy. The team member must debrief with the assaultive client before returning.
The emotional responses may be similar to those of other crime victims.
A nurse and a nursing student are leading a group counseling session for clients with depression who have attempted suicide in the past. Which topic, if selected by the student, would indicate to the nurse that the student needs further education on this group's discussion topics? community resources including phone numbers for mental health centers and hotlines appropriate coping measures dramatization of suicidal behavior in society national statistics and books about suicide
dramatization of suicidal behavior in society
A client changes topics quickly while relating past psychiatric history. This client's pattern of thinking is called: looseness of association. flight of ideas. tangential thinking. circumstantial thinking.
flight of ideas.
A client brought to the clinic after being arrested for harassing and stalking their former spouse denies any other symptoms or problems except anger about being arrested. The former spouse reports to the police, "They're fine except for this irrational belief that we'll remarry." When collaborating with the health care provider about a plan of care, which intervention would be most effective for the client at this time? prescription for olanzapine 10 mg daily joint session with the client and the former spouse prescription for fluoxetine 20 mg every morning referral to an outpatient therapist
referral to an outpatient therapist
The nurse is performing an assessment on a client after the client's third electroconvulsive therapy (ECT). Which finding should the nurse anticipate most frequently? a cardiac arrhythmia a prolonged seizure a headache short-term memory loss
short-term memory loss
The nurse is performing an assessment on a client with a history of a dysfunctional family. Which findings should the nurse anticipate? Select all that apply. unhealthy personal boundaries supportive parents abuse and neglect direction and attention structured limit setting
unhealthy personal boundaries abuse and neglect
The nurse is caring for a client who has been physically abused. Which statement by the nurse expresses empathy for this client? "Our staff will do the best they can to make you feel comfortable." "Do you have questions about what is happening?" "I am so sad to see you going through so much pain." "It must be difficult what you have been going through."
"It must be difficult what you have been going through."
A client who is dying from AIDS is admitted to the inpatient psychiatric unit because they attempted suicide. Their close friend recently died from AIDS. The client states to the nurse, "What's the use of living? My time's running out." What is the nurse's best response? "Let's talk about making some good use of that time." "Don't give up. There could be a cure for AIDS tomorrow." "You're in a lot of pain. What are you feeling?" "Life is precious and worth living."
"You're in a lot of pain. What are you feeling?"
A novice nurse is caring for clients in a psychiatric unit. Which action(s) by the novice nurse would require the nurse supervisor to intervene? Select all that apply. Telling a cousin on the phone that a client has been admitted to the psychiatric unit with mania. Informing a police officer with a court-ordered warrant about a client's prescribed medications. Sharing information with the local news regarding a client who has recently died. Telling the parent of an emancipated minor how substance use disorder therapy is going for the child. Accessing a friend's electronic medical record to see if the friend has an appointment today.
Telling a cousin on the phone that a client has been admitted to the psychiatric unit with mania. Sharing information with the local news regarding a client who has recently died. Telling the parent of an emancipated minor how substance use disorder therapy is going for the child. Accessing a friend's electronic medical record to see if the friend has an appointment today.
The most common reason given by mentally ill clients for noncompliance with medications is their uncomfortable adverse effects. When teaching families, the nurse should identify which need as the greatest? alternative ways to manage the adverse effects home visits to set up a week's supply of medications family monitoring of the administration of medication outpatient monitoring of medication compliance
alternative ways to manage the adverse effects
Which approach by the nurse would most likely foster a therapeutic relationship with a client who tries to manipulate people? strictness sympathy aloofness consistency
consistency
The nurse manager of a psychiatric unit notices that one of the nurses commonly avoids a 75-year-old client's company. Which factor should the nurse manager identify as being the most likely cause of this nurse's discomfort with older adult clients? fear and conflict about aging dislike of physical contact with older people a desire to be surrounded by beauty and youth recent experiences with their parents' older adult friends
fear and conflict about aging
A nurse is teaching a client stress management. Which techniques would be considered adaptive coping skills? Select all that apply. maintain control of my life set realistic goals for each day practice relaxation techniques balance sleep, rest, and exercise try to eliminate total anxiety
set realistic goals for each day practice relaxation techniques balance sleep, rest, and exercise
Assertive behavior involves: saying what is on one's mind at the expense of others. expressing an air of superiority. avoiding unpleasant situations and circumstances. standing up for one's rights while respecting the rights of others.
standing up for one's rights while respecting the rights of others.
A 74-year-old client receiving fluphenazine decanoate therapy develops pseudoparkinsonism, and is ordered amantadine hydrochloride. With the addition of this medication, the client reports feeling dizzy when standing. Which response by the nurse is best? "When you change positions, do so slowly." "I will talk to your doctor about taking you off of one of these medications." "Do you have any slurred speech or weakness in one extremity?" "If this happens just after taking the medicine, consider taking the medication at bedtime."
"When you change positions, do so slowly."
As the nurse stands near the window in the client's room, the client shouts, "Come away from the window! They will see you!" Which response by the nurse would be best? "Who are 'they'?" "No one will see me." "You have no reason to be afraid." "What will happen if they do see me?"
"Who are 'they'?"
A psychiatric nurse in the emergency department is assigned to care for a group of clients. Which client should the nurse see first? A client who states she was sexually assaulted an hour ago. A client with a panic disorder with symptoms of nausea and hand trembling. A client with obsessive-compulsive disorder who has not taken their medication for 2 days. A client with depression who has been experiencing a marked diminished interest in day-to-day activities.
A client who states she was sexually assaulted an hour ago.
A client has chronic low self-esteem related to self-doubt as evidenced by self-deprecatory statements. What goal should the nurse establish for the client? Identify positive aspects of self. Demonstrate reality-based thinking. Use relaxation exercises. Set attainable goals.
Identify positive aspects of self.
A nurse is counseling a client at a crisis center after the client's house burned down and the client's daughter was killed. Which action by the nurse is a priority? solving the client's problems assisting in psychological resolution of the immediate crisis establishing a basis for long-term therapy providing a basis for admission to an acute care facility
assisting in psychological resolution of the immediate crisis
A client with a chronic mental illness who does not always take their medications is separated from their spouse and receives public assistance funds. The client lives with their parent and older sibling and manages their own medication. The client's parent is in poor health and also receives public assistance benefits. The client's sibling works outside the home, and the client's other parent is dead. Which issue should the nurse address first? family support marital communication financial concerns medication compliance
medication compliance
A client with schizophrenia started risperidone 2 weeks ago. Today, the client reports feeling flu-like symptoms. The nurse's assessment reveals the following: temperature 104.4° F (40.2° C), respirations 24 breaths/minute, blood pressure 130/102 mm Hg, pulse rate 120 beats/minute. The nurse also notes muscle stiffness and pain, excessive sweating and salivation, and changes in mental status. The nurse suspects the client is experiencing: the flu. malignant hyperthermia. neuroleptic malignant syndrome. septicemia.
neuroleptic malignant syndrome.
A client is irritable and hostile. They become agitated and verbally lash out when their personal needs are not immediately met by the staff. When the client's request for a pass is refused by the health care provider, they utter a stream of profanities. Which statement best describes the client's behavior? The client's anger is: not intended personally. a reliable sign of serious pathology. an intended attack on the health care provider's skills. a sign that their condition is improving.
not intended personally.
A client with acute stress disorder is telling the nurse about the tornado that leveled his house and killed his wife and baby while he was out of town on business. He states, "If only I had been at home, I could've saved them." Which response would be most appropriate? "Don't blame yourself; you'll only feel worse." "It's not your fault, so stop feeling so guilty." "You might not have been at home." "You couldn't have prevented the tornado; it just happened."
"You couldn't have prevented the tornado; it just happened."
A client was admitted to the psychiatric unit yesterday evening. In the morning, the client approaches the nurse and states, "The psychiatrist and all of you nurses are conspiring against me. I've been warned and I know it's true. You know what I mean." Which response by the nurse would be most therapeutic? "That simply isn't true. Just stay calm." "I'll see if I can find your psychiatrist for you." "I don't know what you mean, but you're secure here." "You must feel very frightened. You're safe here."
"You must feel very frightened. You're safe here."
A 5-year-old child exhibits signs of extreme restlessness, short attention span, and impulsiveness. Which intervention by the nurse would be therapeutic for this child? Increase the child's sensory stimulation. Limit the child's opportunities to verbalize anger and frustration. Define behaviors that are acceptable and behaviors that are not permitted. Restrict the child's participation in physical activities.
Define behaviors that are acceptable and behaviors that are not permitted.
The nurse notes that a client is too busy investigating the unit and overseeing the activities of other clients to eat dinner. To help the client obtain sufficient nourishment, which plan would be best? Serve foods that the client can carry with them. Allow the client to send out for their favorite foods. Serve the client food in small, attractively arranged portions. Allow the client to enter the unit kitchen for extra food as necessary.
Serve foods that the client can carry with them.
The health care provider (HCP) refers a client diagnosed with somatization disorder to the outpatient clinic because of problems with nausea. The client's past symptoms involved back pain, chest pain, and problems with urination. The client tells the nurse that the nausea began when their spouse asked for a divorce. Which intervention is most appropriate? asking the client to describe their problem with nausea directing the client to describe their feelings about the impending divorce allowing the client to talk about the HCPs they have seen and the medications they have taken informing the client about a different medication for their nausea
directing the client to describe their feelings about the impending divorce
The nurse is working with a client with depression in a mental health clinic. During the interaction, the nurse uses the technique of self-disclosure. In order for this technique to be therapeutic, which step must be a priority for the nurse? discussing the nurse's experience in detail asking for the client's perception of what the nurse has revealed ensuring relevance to, and quickly refocusing upon, the client's experience allowing the client time to ask questions about the nurse's experience
ensuring relevance to, and quickly refocusing upon, the client's experience
The nurse in a psychiatric unit has formed a therapeutic relationship with a client with a borderline personality disorder. When the client is readmitted to the unit for a suicide attempt, the nurse exclaims to another staff nurse, "Why? Everything was going well. How could they do this to me?" What response by the staff nurse reflects an understanding of the client's borderline disorder? "I know what you mean. You put a lot of energy into working with our client. It must be disappointing to have the client do something like this." "I could have told you this would happen. A client like this one always gets you in the end." "Clients with borderline disorder act out to relieve anxiety, and something must have provoked a great deal of anxiety." "I know what you mean. I hope this will teach you not to get so involved with a client's welfare."
"Clients with borderline disorder act out to relieve anxiety, and something must have provoked a great deal of anxiety."
A client in a group home is very dependent on the staff but is able to make simple decisions. The client asks, "Would you do my laundry? I don't know how the machine works." Which response would be best? "Sure, I have time; I can do it for you." "You'll have to wait; I don't have time now." "Can your family do it for you?" "Get your laundry; I'll show you how the machine works."
"Get your laundry; I'll show you how the machine works."
A nurse is assessing military personnel who have experienced combat and are diagnosed with posttraumatic stress disorder. Which client statement requires immediate intervention? "I cannot stop the nightmares, even the extra oxycodone pills I take do not work. It is not worth it." "I have been increasing my lorazepam, but I am so tired I take naps every afternoon," "I have seen my therapist every week, but the therapist wants me to come twice a week now." "I had one glass of wine with my family during supper last night."
"I cannot stop the nightmares, even the extra oxycodone pills I take do not work. It is not worth it."
A nurse is teaching self-esteem to a client. Which statements by the client would indicate understanding of the concept? Select all that apply. "I need to have consistent limits." "Living in a critical environment is not good for me." "I need to have healthy boundaries." "Physical discipline does not affect my self-esteem." "I do not like to make decisions."
"I need to have consistent limits." "Living in a critical environment is not good for me." "I need to have healthy boundaries."
A client is admitted to the psychiatric unit following a suicide attempt. The client experienced identity theft through the internet and states, "My savings, checking, and retirement accounts are empty. I have nothing left to pay my bills or buy food and medicines. The only thing left is to die." After 1 week, the nurse would conclude that the client's condition has improved upon hearing which statement(s)? Select all that apply. "I realize that I still can get monthly public assistance benefits." "I filed identity theft claims with the bank, my retirement account, and the government authorities." "I know all the actions I can take, but they take so much time and energy. I'm so tired." "With all the help I got here, I think I may be able to survive after all." "The staff has given me a lot of options, but I'm not sure they are even possible."
"I realize that I still can get monthly public assistance benefits." "I filed identity theft claims with the bank, my retirement account, and the government authorities." "With all the help I got here, I think I may be able to survive after all."
A client on short-term mental health disability leave undergoes required psychiatric evaluation and counseling. The client requests that their evaluation and counseling records be e-mailed to the client's Human Resources representative. How should the nurse respond? "We need to review our administrative policy with the agency director before we can release records." "It's best not to e-mail your personal records because doing so might put your privacy at risk." "Think about whether you want us to release your entire counseling record to the company that employs you." "The treatment team must review disability-related records before we release them."
"It's best not to e-mail your personal records because doing so might put your privacy at risk."
An older adult client is brought to the outpatient clinic by their caregiver for a routine medication evaluation. The caregiver reports that the client is quite stable and has no adverse effects from the risperidone they are taking. Then, the caregiver says, "I just think the client could be even better if they were on a larger dosage. My son takes 1 mg of risperidone every day and the client is only on 0.5 mg." What is the most helpful response by the nurse? "Maybe your son is sicker than the client." "We could increase the client's dosage if you want." "Older clients generally need a lesser dose than younger people." "I am not seeing any symptoms of illness in the client. Let's wait until the next visit."
"Older clients generally need a lesser dose than younger people."
A client, who is unknown to the clinic staff, walks into the community mental health clinic stating, "I've had it. I can't go on any longer. You've got to help me." Which reply by the nurse would be most therapeutic? "The staff here is going to take care of you." "Tell me what brought you into the clinic today." "Give me the names and phone numbers of family and friends so I may contact them about your history." "Where else have you been seen for your mental health needs?"
"Tell me what brought you into the clinic today."
A client with severe and persistent depression is debating undergoing electroconvulsive therapy (ECT). The client's family asks a nurse to convince the client that this treatment would be beneficial. In educating the family about the client's situation, what statement about client rights should the nurse make? "In a situation like this, I recommend family obtain legal counsel for the client." "The client, treatment team, and family can meet to discuss this treatment option." "If the client declines treatment after learning the pros and cons, there is a form to sign." "You must make the client aware of the moral aspects of refusing treatment."
"The client, treatment team, and family can meet to discuss this treatment option."
A nurse is assessing the family of a 10-year-old child brought into the emergency department with severe injuries. Which statement made by the parents could indicate child abuse? "You should ask my child about his injuries. They will know best what happened." "My child fell off his bike and into the street." "I don't know what I will do if something happens to my child." "The injury happened a few days ago but I didn't think it was bad."
"The injury happened a few days ago but I didn't think it was bad."
As the nurse helps a client prepare for discharge, the client says, "You know, I've been in lots of hospitals, and I know when I'm sick enough to be there. I'm not that sick now. You don't need to worry about me." What would be the most therapeutic response by the nurse? "We're concerned about you. How can we help you before you leave?" "We could have helped you more if you had told us more." "Is there any information you need before you leave the hospital?" "Okay, you know what you need better than I do."
"We're concerned about you. How can we help you before you leave?"
A client with bipolar disorder is taking lithium carbonate 300 mg t.i.d. The client's lithium level is 2.7 mEq/L. In assessing the client, the nurse finds no evidence of lithium toxicity. The first assessment question the nurse should ask before ordering another blood test is: "Are you embarrassed or afraid to report medication problems?" "Are you experiencing depression and suicidal ideation?" "Do you understand why you are taking this medication?" "When did you take your last dose of lithium?"
"When did you take your last dose of lithium?"
A client presents to the emergency department confused and disoriented after being pulled out of a house fire. The client is mumbling incoherently. Which statement by the nurse exemplifies therapeutic communication? "You are at the hospital now, and you are safe." "You must talk so I can figure out what is going on with you." "I understand how you feel. I lost my parents in a fire." "Has anything like this happened to you before?"
"You are at the hospital now, and you are safe."
A client tells the nurse at the outpatient clinic that they do not need to attend groups because they are "not a regular like these other people here." How should the nurse respond to the client? "Because you're not a regular client, sit in the hall when the others are in group." "Your family wants you to attend, and they'll be very disappointed if you don't." "I'll have to mark you absent from the clinic today and speak to the health care provider about it." "You say you're not a regular here, but you're experiencing what others are experiencing."
"You say you're not a regular here, but you're experiencing what others are experiencing."
A hospital nurse is conducting a psychiatric assessment for a client being discharged the next day. Which nursing intervention(s) is appropriate when conducting this assessment? Allow the client to direct the conversation and provide redirection as necessary. Choose a public location in the hospital that is well-populated. Sit at an angle toward the client and provide undivided attention. Ask the client to clarify any unclear or ambiguous statement. Stop the assessment if the client reports feeling uneasy.
Allow the client to direct the conversation and provide redirection as necessary. Sit at an angle toward the client and provide undivided attention. Ask the client to clarify any unclear or ambiguous statement. Stop the assessment if the client reports feeling uneasy.
A client scans the adult inpatient unit on arrival at the hospital. The client is neatly dressed and clutches a leather briefcase. The client refuses to let the nurse touch the briefcase to check it for valuables or contraband. Which action by the nurse would be best? Obtain help to take the briefcase away from the client. Ask the client to open the briefcase and describe its contents. Inspect the briefcase when the client is temporarily out of the room. Tell the client that they must follow hospital policy if they wish to stay.
Ask the client to open the briefcase and describe its contents.
While listening to an audio recording of a report at shift change, one of the other team members remarks, "My mother lives near this client, and his yard is always full of junk." What should the nurse assigned to provide care to this client do in this situation? Ask the team member to be quiet. Include the information in the report for the next shift. Ask the team member what the purpose was in sharing the information. Ignore the comment.
Ask the team member what the purpose was in sharing the information.
When creating an educational program about safety, what information should the nurse include about sexual predators? Select all that apply. Child molesters pick children or teens over which they have some authority, making it easier for them to manipulate the child with special favors or attention. Child molesters resort to molestation because they have bad childhoods, so understanding that can help them decrease their molesting. Child molesters gain the child's trust before making sexual advances so the child feels obligated to comply with sex. Child molesters often choose children whose parents must work long hours, making the extra attention initially welcomed by the child. Child molesters maintain the secrecy of their actions by making threats if offering attention and favors fail or if the child is close to revealing the secret.
Child molesters pick children or teens over which they have some authority, making it easier for them to manipulate the child with special favors or attention. Child molesters gain the child's trust before making sexual advances so the child feels obligated to comply with sex. Child molesters often choose children whose parents must work long hours, making the extra attention initially welcomed by the child. Child molesters maintain the secrecy of their actions by making threats if offering attention and favors fail or if the child is close to revealing the secret.
The stigma related to having a mental illness, especially a chronic illness, persists despite improvements in the management of illnesses and an increase in public education. Which view most perpetuates the stigma? Mental illness is hereditary. Mental illnesses have biochemical bases. Clients cannot prevent mental illness if they want to do so. Clients can recover from mental illness if they have willpower.
Clients can recover from mental illness if they have willpower.
A client is admitted to the psychiatric inpatient unit after being found walking on a highway at night talking to themself. The client is unkempt and appears thin and dirty. What would be the best way to assess the client's nutritional status and changes significant to mental health status? Compare current weight with past weight in chart. Discuss recent dietary intake. Arrange for a medical consult. Observe at mealtimes.
Compare current weight with past weight in chart.
A teenage client is a high school wrestler who fasts before every wrestling tournament and then binges immediately after the tournament. On the way to each tournament, the client walks rapidly up and down the bus aisle and spits repeatedly into a cup. Which is the best initial intervention for this client? Teach the client's parent about nutritional requirements of teenagers. Discuss secondary gains that are unconsciously driving the client's behavior. Ask the physician for medication to treat the eating disorder. Call the high school principal to report the wrestling coach for not stopping this behavior.
Discuss secondary gains that are unconsciously driving the client's behavior.
The nurse is caring for a client with a panic disorder who is experiencing difficulty sleeping and is lingering at the nurses' station late at night. What nursing action is best? Suggest the client play pool in the day area until the client is tired. Tell the client to talk to other clients who are up and pacing the halls. Encourage the use of relaxation exercises or techniques. Administer zolpidem 5 mg orally as prescribed.
Encourage the use of relaxation exercises or techniques.
Parents tell a nurse that they have not met their goal of home management of their child with schizoaffective disorder. They report that the client poses a threat to their safety. Based on this information, what recommendation should the nurse make? Evaluate the client for voluntary admission to a mental health facility. Discuss what the family can do to chemically restrain the client at home. Tell the parents that the client's behavior releases them from the duty of care. Arrange for respite care; family members could be aggravating the client's condition.
Evaluate the client for voluntary admission to a mental health facility.
A client is escorted to the psychiatric unit from the emergency department (ED) by staff and a security officer. The client's shoulder is bandaged, and their arm is in a sling because of a self-inflicted gunshot wound to the shoulder. Later, the client's spouse follows with a bag of the client's belongings. Which nursing action is most appropriate at this time? Tell the spouse to take the items home because the client is suicidal. Instruct the spouse to unpack the bag and put the client's things in the dresser. Ask the spouse whether the bag contains anything dangerous. Inspect the bag and its contents in the presence of the client and spouse.
Inspect the bag and its contents in the presence of the client and spouse.
A nurse is evaluating a family in which chronic child abuse has occurred and the parents have experienced chronic alcohol and drug abuse. Significant social supports have been established by social services and the parents have both received drug and alcohol treatment and parenting classes. Which indicates that the parents have progressed in their treatment?? The parents report continued use of spanking as discipline. The parents report high expectations for the young children to manage the household tasks. The parents report an understanding of normal growth and development. The parents say they hope to attend parenting classes.
The parents report an understanding of normal growth and development.
At an emergency shelter, a client who has experienced an earthquake that damaged their home tells the nurse that they are going to spend the night in their own bed at home. Which defense mechanism is the client exhibiting? intellectualization denial rationalization undoing
denial
A client approaches various staff with numerous requests and needs to the point of disrupting the staff's work with other clients. The nurse meets with the staff to decide on a consistent, therapeutic approach for this client. Which approach will be most effective? telling the client to stay in the their room until staff approach limiting the client to the dayroom and dining area giving the client a list of permissible requests having the client discuss needs with the staff person assigned
having the client discuss needs with the staff person assigned
A client who is suspicious of others, including staff, is brought to the hospital wearing a wrinkled dress with stains on the front. The assessment also reveals a flat affect, confusion, and slow movements. Which goal should the nurse identify as the initial priority when planning this client's care? helping the client feel safe and accepted introducing the client to other clients giving the client information about the program providing the client with clean, comfortable clothes
helping the client feel safe and accepted
A client refuses the evening dose of haloperidol and then becomes extremely agitated in the day room while other clients are watching television. The client begins cursing and throwing furniture. The nurse's first action is to: check the client's medical record for an order for an as-needed dose of medication for agitation. place the client in full leather restraints. call the physician and report the behavior. remove all other clients from the day room.
remove all other clients from the day room.
A client with suspected abuse describes their spouse as a good person who works hard and provides well for their family. The client does not work outside the home and states that they are proud to be a spouse and parent just like their own parents. The nurse interprets the family pattern described by the client as best illustrating which characteristic of abusive families? tight, impermeable boundaries unbalanced power ratio role stereotyping learned helplessness
role stereotyping
A client has been involuntarily committed to a hospital after being assessed as being dangerous to self or others. The client has lost which right? the right to refuse medications and treatments the right to send and receive uncensored mail freedom from seclusion and restraints the right to leave the hospital against medical advice
the right to leave the hospital against medical advice
The nurse is developing a discharge plan with a client who has had a lobectomy for treatment of lung cancer. To evaluate the client's understanding of the plan, what should the nurse ask the client to identify? the support available to assist the client at home the distance the client lives from the hospital the client's ability to do home blood pressure monitoring the client's knowledge of the causes of lung cancer
the support available to assist the client at home
