Mental health questions (ch 6, 7, 8) exam 1

A client states "That nurse never seems comfortable being with me." The nurse can be described as

not seeming genuine to the client.

A 17-year-old patient confides to the nurse that they have been thinking of ways to kill a peer. What response should the nurse give when the patient states, "you have to keep it a secret because its confidential information"?

"Issues of this kind have to be shared with the treatment team and your parents."

A nurse on the psychiatric unit has a past history of alcoholism and has regular meetings with a mentor. Which statement made to the nurse's mentor would indicate the presence of countertransference?

"My patient has been abusing alcohol. I told her that the only way to recover was to go 'cold turkey' and to get away from her dysfunctional family and to do it now!"

Consider the nurse-patient relationship on an inpatient psychiatric unit. Which of the following statements made by the nurse reflects an accurate understanding of when the issue of termination should first be discussed?

"Now that we've discussed your reasons for being here and how often we will meet, I'd like to talk about what we will do at the time of your discharge."

When considering the duty to warn and protect third parties, which client statement should the nurse report to the treatment team members?

"That judge is going to really regret putting me in here."

A patient who recently loss a parent begins crying during a one-to-one session with the nurse. Which of the following responses by the nurse illustrates empathy?

"That must have been such a hard situation for you to deal with."

Which response should the nurse provide a client who asks, "Why you need to conduct an assessment interview"?

"We will be able to form a relationship together where we can discuss the current problems and come up with goals and a plan for treatment."

The nurse best assesses the client's spiritual life by asking which question?

"What role does religion play in your life?"

A 26-year-old patient is brought to the emergency room by a friend. The patient is unable to give any coherent history. Which response should the nurse provide when the patient's friend offers to provide information regarding the patient?

"Yes, I will be happy to get any information and history that you can provide."

A client has been admitted to your inpatient psychiatric unit with suicidal ideation. In a one-to-one session with the nurse, he shares the terrible guilt he feels over sexually abusing his stepdaughter and wanting to die because of it. Which of the following responses you could make reflects a helpful trait in a therapeutic relationship?

"You are suffering with guilt over what you did. Let's talk about some goals we could work on that may make you want to keep living."

A nurse is about to interview an older client whose glasses and hearing aid were placed in the bedside drawer for safe keeping. Before beginning the interview, which nursing intervention that will best facilitate data collection?

Assist the client in putting on glasses and hearing aid.

A term is a synonym for the characteristic of genuineness?

Authentic

The use of seclusion or restraint to control the behavior of a client who is at risk of harming self or others gives rise to conflict between which ethical principles?

Autonomy and beneficence

The outcome of the nurse's expressions of sympathy instead of empathy toward the client often leads to which outcome?

Decreased client communication

If a client is placed in seclusion and held there for 24 hours without a written order or examination by a physician, the client has experienced which illegal act?

False imprisonment

If a nurse is charged with leaving a suicidal client unattended, it is being suggested that the nurse's behavior has violated which ethical principle?

Fidelity

The nurse would address which of the following goals in attempting to establish a therapeutic nurse-client relationship?

Helping patients examine self-defeating behaviors and test alternatives Promoting self-care and independence Assisting patients with problem solving to help facilitate activities of daily living Facilitating communication of distressing thoughts and feelings

Which nursing diagnosis for a psychiatric client is correctly structured and worded?

Imbalanced nutrition: less than body requirements related to poor self-concept as evidenced by reporting "I'm not worthy of eating"

What principle forms the basis of nursing outcome planning?

Individuals have the right to outcomes that is reflective of their abilities.

After the death of a client, what rule of confidentiality should be followed by nurses who provided care for the individual?

Nothing may be disclosed that would have been kept confidential before death.

Which tool can the novice nurse might refer to when writing nursing outcomes?

Nursing Outcomes Classification (NOC)

The mental status examination aids in the collection of what type of data?

Objective

What three structural components comprise a nursing diagnosis?

Problem, related factors, defining characteristics

The client's priority nursing diagnosis has been established as risk for self-directed violence: suicide related to multiple losses. What is the priority outcome for this client?

Refrain from attempting suicide.

A client reports to the nurse that once he is released he will make sure his wife will never again be able to have him committed to a psychiatric hospital. What action should the nurse take?

Report the incident to the client's therapist.

The nurse is caring for an admitted client with a history of becoming aggressive when angry and has caused physical injury to another client and two staff members. When this client begins to demonstrate signs of anger while in the day room what intervention should the nurse implement to address the safety of the milieu?

Request that the client accompany the nurse to the client's room

A 43-year-old client being seen in the mental health clinic states, "I have always been a practicing Jew, but in the past few months I am questioning everything. I just don't know if I believe in it anymore." Which of the following nursing diagnoses best describes the client's comment?

Spiritual distress

Which phase of the nurse-client relationship may cause client anxieties to reappear and past losses to be reviewed?

Termination phase

What assumption can be made about the client who has been admitted on an involuntary basis?

The client has failed to agree to fully participate in treatment and care planning. The client is a danger to self or others or unable to meet basic needs. The commitment was court ordered.

When considering client rights, which client can be legally medicated against his or her wishes?

The client may cause imminent harm to himself or others.

When a nurse and client meet informally or have an otherwise limited but helpful relationship, what term is used to identify this relationship?

Therapeutic encounter

When considering the civil rights of persons diagnosed with mental illness and hospitalized for treatment, which statement is true?

They are assured the same as those for any other citizen.

What is the primary difference between a social and a therapeutic relationship?

Type of responsibility involved

The nurse reads the medical record and learns that a client has asked for treatment, agreed to receive treatment, and to abide by hospital rules. The nurse may correctly assume that the client has met the criteria for which type of admission?

Voluntarily

What nursing action supports a client's right to autonomy?

Witnessing the informed consent for electroconvulsive therapy from a client

Which ethical principle refers to the individual's right to make his or her own decisions?

autonomy

A client who presents no danger to himself or to others is forced to take medication against his will. This situation represents

battery

During what stage of the therapeutic nurse-client relationship is a formal or informal contract between the nurse and client established?

orientation

Which right of the client has been violated if he is medicated without being asked for his permission?

right to informed consent

Which criterion is essential when the nurse plans nursing interventions designed to meet a specific goal?

safe evidence based practice individualized realistic

Which of the following statements are true regarding the differences between a social relationship and a therapeutic relationship?

~In a social relationship, both parties come up with solutions to problems and solutions may be implemented by both (a friend may lend the other money, etc.); in a therapeutic relationship, solutions are discussed but are only implemented by the patient. ~Giving advice is done in social relationships; in therapeutic relationships giving advice is not usually therapeutic. ~In a social relationship, both parties' needs are met; in a therapeutic relationship, only the patient's needs are to be considered.

The nurse is finding it difficult to provide structure and set limits for a client. The nurse should self-evaluate for which characteristic of a dysfunctional nurse-patient relationship?

Boundary blurring

Which hospitalized patient should the nurse identify as being a candidate for the appropriate use of a release from hospitalization known as against medical advice (AMA)?

A 37-year-old patient scheduled for discharge in 24 hours wishes to be discharged immediately

Which scenarios describe a HIPAA violation associated with a nurse's behavior?

A nurse on the cardiac unit gives report to the nurse on the step-down unit while transporting a client in the staff elevator.

The nurse is conducting an admission interview with a client who was raped 2 weeks ago. When asked about the rape, the client becomes very anxious and upset and begins to sob. What should be the nurse's response to the client's reaction?

Acknowledge that the topic of the rape is upsetting and reassure the client that it can be discussed at another time when she feels more comfortable.

A client tells the nurse "I really feel close to you. You are like the friend I never had." The nurse can assess this statement as indicating the client may be experiencing which unconscious emotion?

Positive transference

The primary source for data collection during a psychiatric nursing assessment is the

client's own words and actions.