HESI Prep 1 - NC3
What is the nurse's specific responsibility when the rights of a client on a mental health unit are restricted by the use of seclusion? - Informing the client's family - Monitoring pharmacologic interventions - Completing a denial-of-rights form and forwarding it to the administrative officer - Documenting both the client's behavior and the reason that specific rights were denied
- Documenting both the client's behavior and the reason that specific rights were denied Rationale Seclusion and restraints are special procedures for dealing with aggressive acting-out behavior for the protection of the client and others; clear documentation is essential when the client's rights are restricted. Informing the client's family is not necessary because the use of seclusion or restraints is included in the general consent form that is signed on admission. Pharmacologic intervention should be monitored for all clients. There is not a typical form; however, documentation is required to justify the need for seclusion or the use of restraints.
Which of these is a one-on-one communication between a nurse and another person? - Small-group communication - Intrapersonal communication - Interpersonal communication - Transpersonal communication
- interpersonal communication Rationale Interpersonal communication is a one-on-one interaction between a nurse and another person that often occurs face to face. Small-group communication is interaction that occurs when a small number of people meet. Intrapersonal communication is a form of communication that occurs within an individual. Transpersonal communication is an interaction that occurs within a person's spiritual domain.
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
- acting out Rationale 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 is teaching a client about false imprisonment. What information should the nurse provide? Select all that apply. - "False imprisonment is an example of an intentional tort." - "False imprisonment refers to any intentional touching without consent." - "False imprisonment involves restraining a person unjustly without any legal warrant." - "A falsely imprisoned client should be aware of his or her confinement." - "An unconscious client in restraints is considered to be falsely imprisoned."
- "False imprisonment is an example of an intentional tort" - "False imprisonment involves restraining a person unjustly without any legal warrant" - "A falsely imprisoned client should be aware of his or her confinement" Rationale Intentional torts are willful acts that violate the rights of other individuals. False imprisonment is an example of an intentional tort. Restraining a person unjustly without any legal warrant is called false imprisonment. Falsely imprisoned clients should be aware of their confinement. Any intentional touching without obtaining consent is called battery. An unconscious client in restraints is not considered to be falsely imprisoned.
The registered nurse is teaching a group of student nurses about preventing post-traumatic stress disorder (PTSD) during a mass casualty event. Which statement made by the student nurse indicates effective learning? - "I should take a break whenever needed." - "I should not work more than 18 hours per day." - "I should monitor my own stress level and performance." - "I should avoid talking about my feelings with managers or staff."
- "I should take a break whenever needed" Rationale During a mass casualty event nurses in charge of clients may develop PTSD due to the emotional impact of the incident. Therefore, the nurse should take breaks whenever needed. The nurse should not work more than 12 hours per day. The nurses should monitor each other's stress levels and performance. The nurse should talk about feelings with managers and staff.
The nurse is having difficulty understanding a client's decision to have hospice care rather than an extensive surgical procedure. Which ethical principle does the client's behavior illustrate? - Justice - Veracity - Autonomy - Beneficence
- Autonomy Rationale The client is exhibiting the freedom to make a personal decision, and this reflects the concept of autonomy. Justice refers to fairness. Veracity refers to truthfulness. Beneficence refers to implementing actions that benefit others.
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? - 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
- do not want to repeat the ritual but feel compelled to do so Rationale 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.
A registered nurse is educating a nursing student about nursing malpractice. What information should the nurse provide? Select all that apply. - "Nursing malpractice includes willful acts that violate a client's rights." - "Nursing malpractice takes place when nursing care falls below the standards of care." - "Nursing malpractice may be prevented by developing a caring rapport with the client." - "Nursing malpractice may occur even when the nurses do not intend to harm the clients." - "Nursing malpractice refers to the publication of false statements to damage a person's reputation."
- "Nursing malpractice takes place when nursing care falls below the standards of care." - "Nursing malpractice may be prevented by developing a caring rapport with the client." - "Nursing malpractice may occur even when the nurses do not intend to harm the clients." Rationale Nursing malpractice is also known as professional negligence. This takes place if the nursing care provided to the client falls below the expected standards of care. A nurse may avoid malpractice by developing a caring rapport with the client and communicating about treatment plans and tests. Nursing malpractice may take place even when nurses do not intend to harm clients, but are unable to maintain proper standards of care. Nursing malpractice is an unintentional tort. Intentional torts are willful acts that violate a person's rights. Publishing false statements to damage a person's reputation is called defamation of character.
Which statement accurately demonstrates an act of nursing negligence? - A nurse enters false information in the client's electronic health record to prolong treatment. - A nurse threatens to initiate intravenous therapy by force because the client refuses to give consent. - A nurse instructs the nursing assistive personnel to administer medication through an intravenous line. - A nurse informs the client's family about a surgical procedure despite the client's instructions against doing so.
- A nurse instructs the nursing assistive personnel to administer medication through an intravenous line Rationale Negligence refers to any conduct on the nurse's part that falls below the expected standards of care. A nurse directing the nursing assistive personnel to perform a task that requires specialized skills and knowledge is an act of nursing negligence. The publication of false statements that damage a person's reputation is defamation of character. Libel is the written form of defamation. Entering false information in the client's charts or records is an example of libel. Any act that places a person in a position of apprehension of offensive contact without consent is considered to be assault. Threatening to initiate intravenous therapy to a client without his or her consent is assault. Revealing a client's confidential medical information to family members without obtaining proper consent is an invasion of privacy.
Which nursing intervention will help the toddler-age client diagnosed with a chronic illness develop autonomy? - Bringing finger paints to the child's room - Allowing the child to dress independently - Encouraging play dates with other children of the same age - Providing a choice between a book or movie prior to bedtime
- Allowing the child to dress independently Rationale The toddler-age client diagnosed with a chronic illness may have issues developing autonomy, especially during hospital stays. The nurse should allow the child to dress independently in order to promote the development of autonomy. Finger painting will enhance development of sensorimotor skills. Encouraging play dates with children of the same age is more appropriate for the preschool-age child with a chronic illness, rather than for a toddler with a chronic illness. Providing choices to the toddler with a chronic illness promotes the development of preoperational thought.
A nurse who promotes freedom of choice for clients in decision-making best supports which principle? - Justice - Autonomy - Beneficence - Paternalism
- Autonomy Rationale The principle of autonomy relates to the freedom of a person to form his or her own judgments and actions. The nurse promotes autonomy nonjudgmentally so as not to infringe on the decisions or actions of others. Justice means to be righteous, equitable, and to act or treat fairly. Beneficence relates to the state or act of doing good and being kind and charitable. It also includes promotion of well-being and abstaining from injuring others. Paternalism encompasses the practice of governing people in a fatherly manner, especially by providing for their needs without infringing on their rights or responsibilities.
How is the term "beneficence" in health ethics different from "nonmaleficence"? - Beneficence refers to fairness, whereas nonmaleficence refers to the agreement to keep promises. - Beneficence involves taking positive actions to help others whereas nonmaleficence is the avoidance of harm or hurt. - Beneficence stands for all health care professionals, whereas nonmaleficence stands for nursing professionals. - Beneficence refers to the support of a particular cause, whereas nonmaleficence refers to a willingness to respect one's professional obligations.
- Beneficence involves taking positive actions to help others wereas nonmaleficence is the avoidance of harm or hurt Rationale Beneficence is the act of taking positive actions to help others; nonmaleficence is the avoidance of harm or hurt. Justice refers to fairness; fidelity refers to the agreement to keep promises. Both beneficence and nonmaleficence stand for all healthcare professionals. Advocacy refers to the support of a particular cause; responsibility refers to a willingness to respect one's professional obligations.
A nurse fails to act in a reasonable, prudent manner. Which legal principle is most likely to be applied? - Malice - Tort law - Malpractice - Case law
- Malpractice Rationale Malpractice is the unskilled or faulty treatment by a professional that causes injury or harm to a client. It can result from a lack of professional knowledge or skill that can be expected in others in the profession, or from a failure to exercise reasonable care or judgment in the application of professional knowledge, experience, or skill. Malice is the desire or intent to inflict injury, harm, or suffering. Tort law is a wrongful act, not including a breach of contract of trust, that results in injury to another person and for which the injured person is entitled to compensation. Case law is law established by judicial decisions in particular cases instead of by legislative action.
What should a nurse do in order to comply with the ethic of nonmaleficence in the healthcare setting? - The nurse should focus on doing no harm. - The nurse should keep promises made to clients. - The nurse should respect the autonomy of clients. - The nurse should keep the best interests of the client in mind.
- The nurse should focus on doing no harm Rationale To comply with the ethic of nonmaleficence, the nurse should focus on doing no harm. The healthcare ethic fidelity requires the nurse to keep promises made to the client by following through on the plan of care. To comply with the ethic of autonomy, the nurse should include the client in the decision-making process when developing a care plan. To comply with the healthcare ethic of beneficence, the nurse is required to keep the best interests of the client in mind when providing care.
The nurse is caring for a client with bulimia nervosa. Which outcome criteria are important to discuss with the client? Select all that apply. - Resuming menstruation - Achieving 85% of ideal body weight - Abstaining from binge-purge behaviors - Describing a realistic perception of body shape - Demonstrating three learned skills for managing stress
- abstaining from binge-purge behaviors - describing a realistic perception of body shape - demonstrating three learned skills for managing stress Rationale Abstaining from binge-purge behaviors is an appropriate goal for a client with bulimia nervosa. A realistic perception of body shape is an appropriate goal for clients with bulimia nervosa, because they have an obsessive and persistent concern with body shape and weight and experience a distortion of body image. Demonstration of three learned skills for managing stress is an appropriate goal for clients with bulimia nervosa, because they experience stress and anxiety and have limited impulse control. Although clients with bulimia may have menstrual dysfunction, amenorrhea is not expected. This outcome is appropriate for clients with anorexia nervosa. Clients with bulimia may be slightly overweight or slightly below weight for their height. Achievement of 85% of ideal body weight is not an appropriate goal for clients with bulimia nervosa.
A client is admitted to the mental health unit with the diagnosis of anorexia nervosa. What typical signs and symptoms of anorexia nervosa does the nurse expect the client to exhibit? - Slow pulse, mild weight loss, and alopecia - Compulsive behaviors, excessive fears, and nausea - Amenorrhea, excessive weight loss, and abdominal distention - Excessive activity, memory lapses, and an increase in the pulse rate
- amenorrhea, excessive weight loss, and abdominal distention Rationale In anorexia nervosa, weight loss is excessive (15% of expected weight); nutritional deficiencies result in amenorrhea and a distended abdomen. Although pulse irregularities and alopecia are associated with anorexia, weight loss is excessive, not mild. Although compulsive behaviors are common, excessive fears and nausea are not associated with anorexia nervosa. Memory lapses are not associated with anorexia nervosa; excessive exercising and pulse irregularities are.
Suicide precautions are prescribed for a newly admitted client. What is the most therapeutic way to provide these precautions? - Keeping the client in the lounge during the daytime - Encouraging the client to express feelings frequently - Assigning a staff member to be with the client at all times - Having a nursing aide observe the client every half hour at night
- assigning a staff member to be with the client at all times Rationale Emotional support and close surveillance can demonstrate the staff's caring and their attempt to prevent the client from acting on suicidal ideation. Although surveillance may meet the client's safety needs, it does not meet the client's emotional needs. Also, the client would still have the opportunity to attempt suicide at night. Encouraging the client to express feelings frequently is not a suicide precaution. Having a nursing aide check the client every half hour at night is unsafe; the client could still find a way to carry out a suicide attempt in the room.
A nurse in an outpatient mental health setting has been assigned to care for a new client who has been found to have an antisocial personality disorder. What does the nurse expect to observe in the client during the assessment? - Pays great attention to detail and demonstrates a high level of anxiety - Has scars from self-mutilation and a history of many negative relationships - Displays charm, has an above-average intelligence, and tends to manipulate others - Demonstrates suspiciousness, avoids eye contact, and engages in limited conversation
- displays charm, has an above-average intelligence, and tends to manipulate others Rationale A client with an antisocial personality disorder is charming on first contact, but this charm is a manipulative ploy. These clients usually are bright and use their intelligence for self-gain. Paying great attention to detail and demonstrating a high level of anxiety are traits of an individual with an obsessive-compulsive personality disorder. The client with a borderline personality disorder self-mutilates when under stress; there is a fear of abandonment so that any relationship is better than no relationship. Demonstrating suspiciousness, avoiding eye contact, and engaging in limited conversation resembles the behavior of an individual with a paranoid personality, which includes suspiciousness and lack of trust.
The nursing staff is discussing the best way to develop a relationship with a new client who has antisocial personality disorder. What characteristic of clients with antisocial personality should the nurses consider when planning care? - Engages in many rituals - Independence of others - Exhibits lack of empathy for others - Possesses limited communication skills
- exhibits lack of empathy for others Rationale Self-motivation and self-satisfaction are of paramount concern to people with antisocial personality disorder, and they have little or no concern for others. Clients with obsessive-compulsive disorder, not antisocial personality disorder, engage in rituals. Individuals with antisocial personality disorder are extremely dependent on others; they count on others to extricate them from their problems. They are usually charming on the surface and can easily con people into doing what they want.
A client is admitted to a psychiatric hospital with the diagnosis of schizoid personality disorder. Which initial nursing intervention is a priority for this client? - Helping the client enter into group recreational activities - Convincing the client that the hospital staff is trying to help - Helping the client learn to trust the staff through selected experiences - Limiting the client's contact with others while in the hospital
- helping the client learn to trust the staff through selected experiences Rationale Demonstrating that the staff can be trusted is a vital initial step in the therapy program. The client is not ready to enter group activities yet and will not be until trust is established. Even proof will not convince the client with a schizoid personality that feelings of distrust are false. Arranging the client's contact with others is not realistic even if it is possible; limiting contact with other clients will not enhance trust.
A nurse has been caring for a suicidal client for 3 weeks on an inpatient unit. One morning the client greets the nurse cheerfully and states, "Everything is looking up. I'm not going to have problems for very long." What does the client's behavior and statement indicate? - Increased risk of suicide - Increased level of anxiety - Positive response to treatment - Resolution of suicidal ideation
- increased risk of suicide Rationale A sudden lifting of mood may indicate an increased risk for suicide; the client may now have the emotional energy to make the decision to act on suicidal ideas or, having decided to commit suicide, feels that the problems will soon be gone. The anxiety level usually decreases when the client makes a decision; this may indicate that the decision is to commit suicide. The client's statement "I'm not going to have problems for very long" may indicate continuing suicidal thoughts, not a positive response to treatment or resolution of suicidal ideation.
An adult is found to have schizotypal personality disorder. How should a nurse describe the client's behavior? - Rigid and controlling - Submissive and immature - Arrogant and attention-seeking - Introverted and emotionally withdrawn
- introverted and emotionally withdrawn Rationale These clients usually display social inadequacy and lack of emotional contact with others. Rigid and controlling behaviors reflect an obsessive-compulsive personality disorder. Submissive and immature behaviors reflect a dependent personality disorder. Arrogant and attention-seeking behaviors probably reflect a narcissistic personality disorder.
A nurse working on a mental health unit is caring for several clients who are at risk for suicide. Which client is at the greatest risk for successful suicide? - Young adult who is acutely psychotic - Adolescent who was recently sexually abused - Older single man just found to have pancreatic cancer - Middle-age woman experiencing dysfunctional grieving
- older single man just found to have pancreatic cancer Rationale Older single men with chronic health problems are at the highest risk of suicide. This is because men have fewer social supports than women do. (Men are less social then women in general.) Less social support at times of stress can increase the risk of suicide. Also, chronic health problems can lead to learned helplessness, which can lead to depression. People who are acutely psychotic as a group are at higher risk for suicide, but they do not have the suicide rate of older single adult men with chronic health problems. An adolescent who was recently sexually abused, although severely traumatized, does not have the risk of suicide of an older single man with chronic health problems. Dysfunctional grieving is prolonged grieving that is characterized by greater disability and dysfunctional patterns of behavior. Although people with complicated dysfunctional grieving may be at risk for self-directed violence, they do not have the suicide risk of older single men with chronic health problems.
An older adult client is talking to the nurse about his Vietnam experiences and shares that he still has flashbacks. While assessing him the nurse notes that he is jumpy and exhibits startle reactions and poor concentration. With which mental health disorder does the nurse associate these symptoms? - Delusions - Hallucinations - Posttraumatic stress disorder (PTSD) - Obsessive-compulsive disorder (OCD)
- posttraumatic stress disorder (PTSD) Rationale PTSD is a syndrome characterized by the development of symptoms after an extremely traumatic event. Symptoms include helplessness, flashbacks, intrusive thoughts, memories, images, emotional numbing, loss of interest, avoidance of any place that reminds the affected person of the traumatic event, poor concentration, irritability, startle reactions, jumpiness, and hypervigilance. Delusions are beliefs that guide one's interpretation of events and help make sense of disorder. Common delusions among older adults involve being poisoned, having their assets taken by their children, being held prisoner, and being deceived by a spouse or lover. Hallucinations are visual or auditory perceptions of nonexistent objects and sounds. Older adults with hearing and vision deficits may hear voices or see people who are not actually present. OCD is characterized by recurrent and persistent thoughts, impulses, and urges of ritualistic behaviors that improve the affected person's comfort level.
What is the priority nursing intervention in the planning of nursing care for an adolescent client with anorexia nervosa? - Rewarding weight gain by increasing privileges - Discussing the importance of eating a balanced diet - Encouraging the client to include high-calorie foods in the diet - Family therapy focusing on the influence of the client's behavior on the family
- rewarding weight gain by increasing privileges Rationale Behavior modification[1][2][3] programs are helpful treatment modes for many clients with anorexia nervosa. Discussing the importance of eating a balanced diet is ineffective. The person with anorexia nervosa is more concerned with losing weight than with eating a balanced diet. A well-balanced diet should be encouraged, but actual weight gain is critical and must be reinforced. Although family therapy may be helpful, emphasis on the anorexia may reinforce the negative behavior. Also, family therapy will not be a priority until the client gains weight.
A nurse suggests a crisis intervention group to a client experiencing a developmental crisis. The nurse knows that these groups are successful because of what? - The client is encouraged to talk about personal problems. - The crisis group supplies a workable solution to the client's problems. - The client is assisted in investigating alternative approaches to solving the identified problem. - The crisis intervention worker is a psychologist who understands common patterns of behavior.
- the client is assisted in investigating alternative approaches to solving the identified problem Rationale A crisis intervention group helps clients re-establish psychological equilibrium by assisting them in exploring new alternatives for coping; it considers realistic situations through the use of rational and flexible problem-solving methods. Talking about personal problems is not an immediate goal of crisis intervention. Clients are never given a solution; they are helped to arrive at their own acceptable, workable solutions. It is not necessary for crisis intervention workers to be psychologists.
What is the most important tool a nurse brings to the therapeutic nurse-client relationship? - The self and a desire to help - Knowledge of psychopathology - Advanced communication skills - Years of experience in psychiatric nursing
- the self and a desire to help Rationale The nurse brings to a therapeutic relationship the understanding of self and basic principles of therapeutic communication; this is the unique aspect of the helping relationship. Knowledge of psychopathology, advanced communication skills, and years of experience in the field all support the psychotherapeutic management model, but none is the most important tool used by the nurse in a therapeutic relationship.
A nurse is in the process of developing a therapeutic relationship with a client who has an addiction problem. What client communication permits the nurse to conclude that they are making progress in the working stage of the relationship? Select all that apply. - Describes how others have caused the addiction - Verbalizes difficulty identifying personal strengths - Expresses uncertainty about meeting with the nurse - Acknowledges the effects of the addiction on the family - Addresses how the addiction has contributed to family distress
- verbalizes difficulty identifying personal strengths - acknowledges the effects of the addiction on the family - addresses how the addiction has contributed to family distress Rationale Looking at one's strengths in addition to areas that need growth is difficult work, and sharing this difficulty demonstrates that the client is willing to work with the nurse to address personal issues. When he is willing to address cause and effect issues of personal behavior, the client is in the working phase of a therapeutic relationship. When people in a therapeutic relationship are able to address how their behavior affects others, they are taking the first step toward taking responsibility for their actions. The use of projection is a defense from taking responsibility for the addiction; this will impair the effectiveness of a working therapeutic relationship. Ambivalence about working with the nurse usually occurs during the introductory phase of the nurse-client relationship.
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
- victim of family violence - dependence on alcohol, drugs, or both - uncertainty related to sexual orientation - repeated demonstration of poor impulse control Rationale 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.
