Mental Health Treatment #34
The night nurse reports that a young client with paranoid schizophrenia has been awake for several nights. The day nurse reviews the client's record and finds that this client did not have an interrupted sleep pattern disorder before transfer from a private room to a four-bed room 3 days ago. What factor should the nurse identify as most likely related to the client's sleeplessness? 1. Fear of the other clients 2. Concern about family at home 3. Watching for an opportunity to escape 4. Trying to work out emotional problems
1. Fear of the other clients Because the client has paranoid feelings that other people are out to do harm, assignment to a four-bed room may be threatening. Concern about family at home seems unlikely, because the disruption appears to have started with the transfer to a four-bed room. Watching for an opportunity to escape is possible but unlikely; planning an escape is usually not part of a schizophrenic pattern of behavior. Trying to work out emotional problems is possible but not likely; clients with schizophrenia have difficulty solving problems.
A client who was involved in a near-fatal automobile collision arrives at the mental health clinic with complaints of insomnia, anxiety, and flashbacks. The nurse determines that the client is experiencing symptoms of crisis. What is the nurse's initial intervention? 1. Focusing on the present 2. Identifying past stressors 3. Discussing a referral for psychotherapy 4. Exploring the client's history of mental health problems
1. Focusing on the present Crisis intervention deals with the here and now; the past is not important except in building on client strengths. The client is anxious and uncomfortable because of the current situation; the focus is on the present, not the past. Psychotherapy is not appropriate for crisis intervention; psychotherapy focuses on the causes of current feelings and behavior and may be provided long term. Exploring the client's history of mental health problems is not significant to crisis intervention.
A nurse is caring for a young, hyperactive child with attention deficit-hyperactivity disorder who engages in self-destructive behavior. What is the most important nursing objective in the planning of care for this child? 1. Keeping the child from inflicting any self-injury 2. Helping the child improve communication skills 3. Helping the child formulate realistic ego boundaries 4. Providing the child with opportunities to discharge energy
1. Keeping the child from inflicting any self-injury All nursing care should be directed toward preventing injury, particularly with a self-destructive child. Although improved communication skills, formulation of realistic ego boundaries, and opportunities to discharge energy are all important, prevention of injury is the priority.
While watching television in the dayroom, a client who has demonstrated withdrawn, regressed behavior suddenly screams, bursts into tears, and runs from the room to the far end of the hallway. What is the most therapeutic intervention by the nurse? 1. Walking to the end of the hallway where the client is standing 2. Accepting the action as the impulsive behavior of a sick person 3. Asking another client in the dayroom why the client acted in this way 4. Documenting the incident in the client's record while the memory is fresh
1. Walking to the end of the hallway where the client is standing Walking to the end of the hallway where the client is standing lets the client know that the nurse is available. It also demonstrates an acceptance of the client. Accepting the action as the impulsive behavior of a sick person is an avoidance technique; it shows a lack of acceptance of the client as a person. Another client's perception of the incident may or may not be valid. Although it is important to document the incident in the client's record, this does not take precedence over letting the client know the nurse is available if needed.
A client who uses a complex ritual says to the nurse, "I feel so guilty. None of this makes any sense. Everyone must really think I'm crazy." What is the most therapeutic response by the nurse? 1. "Your behavior is bizarre, but it serves a useful purpose." 2. "You're concerned about what other people are thinking about you." 3. "I am sure people understand that you can't help this behavior right now." 4. "Guilt serves no useful purpose. It just helps you stay stuck where you are."
2. "You're concerned about what other people are thinking about you." Paraphrasing encourages further ventilation of feelings and concerns by the client. Telling the client that the behavior is bizarre but that it serves a useful purpose is a negative response that may increase the client's fears about being "crazy." Saying "I'm sure people understand that you can't help this behavior right now" provides false reassurance and implies that the client is out of control, which may increase the fears. Telling the client that guilt serves no useful purpose and just helps the client stay stuck denies the client's feelings.
A nurse is monitoring a client with the diagnosis of schizophrenia who is experiencing opposing emotions simultaneously. When providing a change-of-shift report, how should the nurse refer to this emotional experience of the client? 1. Double bind 2. Ambivalence 3. Loose association 4. Inappropriate affect
2. Ambivalence Ambivalence is the existence of two conflicting emotions, impulses, or desires. Double bind is two conflicting messages, not emotions, in a single communication. Loose associations are not two conflicting emotions but instead the loosening of connections between thoughts. Inappropriate affect is the inappropriate expression of emotions.
A client with a borderline personality disorder is admitted to the mental health unit. What should the nurse do to maintain a therapeutic relationship with the client? 1. Provide an unstructured environment to promote self-expression. 2. Be firm, consistent, and understanding and focus on specific target behaviors. 3. Use an authoritarian approach, because this type of client needs to learn to conform to the rules of society. 4. Record but ignore marked shifts in mood, suicidal threats, and temper displays, because these last only a few hours.
2. Be firm, consistent, and understanding and focus on specific target behaviors. Consistency, limit-setting, and supportive confrontation are essential nursing interventions designed to provide a secure, therapeutic environment for clients with borderline personality disorder. To be therapeutic, the environment needs structure, and the staff must help the client set short-term goals for behavioral changes. The use of an authoritarian approach will increase anxiety in this type of client, resulting in feelings of rejection and withdrawal. Ignoring the client's behavior is nontherapeutic and may reinforce underlying fears of abandonment.
A client who was hospitalized with severe anxiety is ready to be discharged. What priority outcome has been met? 1. Follows rules of the milieu 2. Maintains anxiety at a manageable level 3. Verbalizes positive aspects about the self 4. Recognizes that hallucinations can be controlled
2. Maintains anxiety at a manageable level Maintenance of anxiety at a manageable level results from teaching the client to recognize situations that provoke anxiety and how to institute measures to control its development. Following the rules of the milieu and verbalizing positive aspects about the self are not priorities; the client has probably had little difficulty in these areas. No evidence was presented to indicate that the client is hallucinating.
On the afternoon of admission to a psychiatric unit, an adolescent boy with the diagnosis of schizophrenia exposes his genitals to a female nurse. What should the nurse's immediate therapeutic response be? 1. Ignoring the client at this time 2. Stating that this behavior is unacceptable 3. Moving him to his room for a short time-out 4. Telling the client to come to the office later to discuss the behavior
2. Stating that this behavior is unacceptable When clients enter a new milieu, limits should be set on unacceptable behavior and acceptable behavior should be reinforced. Neither clients nor unacceptable behavior should ever be ignored. Moving the client to his room for a short time-out is punishment. Unacceptable attention-getting behavior must be addressed immediately; also, the focus should be on appropriate behavior.
What is the priority when a nurse is formulating a plan of care for a client with a diagnosis of dementia of the Alzheimer type? 1. Implementing remotivational therapy 2. Structuring the environment for safety 3. Arranging for long-term custodial care 4. Stimulating thinking with new experiences
2. Structuring the environment for safety Structuring the environment for safety supports the client's ability to function in a protected, safe milieu. Attempting to remotivate the client is not the priority; also, it is not always possible to remotivate a client with organic brain damage. There are no data to indicate the client needs long-term care at this time. Structure and routines will decrease anxiety and increase performance of activities of daily living. Cognitive maintenance should be part of the focus of care.
A client scheduled to begin electroconvulsive therapy (ECT) to treat severe depression that has not responded to any of the antidepressant medications tells the nurse, "I'm scared that I'll lose my memory forever after the treatment." What is the most therapeutic response by the nurse? 1. "Your memory loss may be permanent, but usually it's just temporary." 2. "You won't experience a permanent memory loss, so there's no need to be frightened." 3. "You'll experience a temporary loss of memory, and feeling frightened about it is expected." 4. "Your memory loss will be temporary, and it will help block out many of your painful past experiences."
3. "You'll experience a temporary loss of memory, and feeling frightened about it is expected." Giving the client simple facts and assuring the client that being frightened is expected may help ease the client's fears. Memory loss affects recently learned information such as the ECT experience; the response that it may be permanent may unnecessarily worry the client. Although it is a true statement that memory loss is not permanent and there is no need to worry, this response negates the client's feelings. ECT does not selectively block out painful experiences.
A client is experiencing feelings of sadness and is having difficulty concentrating and sleeping. What are additional common signs and symptoms of depression that the nurse should expect when performing an assessment of this client? 1. Rigidity and a narrowing of perception 2. Alternating episodes of fatigue and high energy 3. Diminished pleasure in activities and alteration in appetite 4. Excessive socialization and interest in activities of daily living
3. Diminished pleasure in activities and alteration in appetite Depression is characterized by feelings of hopelessness, helplessness, and despair, leaving little room for any pleasure; alteration in appetite (either decreased or increased) is common in depressed clients. Although there is a narrowing of perception, rigidity is uncommon with depression. Fatigue is continually present and does not alternate with a high energy level. There is a loss of interest in socialization and little participation in activities of daily living.
An older adult is brought to the clinic by a family member because of increasing confusion over the past week. What can the nurse ask the client to do to assess orientation to place? 1. Explain a proverb. 2. Give the state where the client was born. 3. Identify the name of the clinic's town. 4. Recall what the client ate for breakfast
3. Identify the name of the clinic's town. Orientation to place refers to an individual's awareness of the objective world in its relation to the self; orientation to time, place, and person is part of the assessment of cerebral functioning. Asking the client the name of the town the clinic is in assesses this. Explaining a proverb requires abstract thinking, which involves a higher integrative function than does orientation to place. Having the client state where the client was born helps the nurse assess remote memory, not orientation. Having the client recall what was eaten for breakfast helps assess recent memory, not orientation.
What should the nurse include in the plan of care for a client with dementia of the Alzheimer type, stage 2 (moderate dementia)? 1. Discuss recent current events. 2. Teach the client new social skills. 3. Maintain a daily routine of living. 4. Encourage the client to talk about past experiences
3. Maintain a daily routine of living. The client with this disorder will be most comfortable with a familiar and repetitive daily routine because it will produce less anxiety. Cognitive changes probably make a discussion of current events unrealistic. It probably is beyond the client's capability to develop new social skills. Memory impairment may make talking about past events impossible.
A client with the diagnosis of schizophrenia refuses to get out of bed and becomes upset. What is the nurse's initial therapeutic response? 1. Requiring the client to get out of bed at once 2. Allowing the client to stay in bed for a while 3. Staying at the bedside until the client calms down 4. Giving the prescribed as-needed tranquilizer to the client
3. Staying at the bedside until the client calms down Staying at the bedside until the client calms down provides support and security without rejecting the client or placing value judgments on behavior. Eventually limits will have to be set, but this is not the immediate nursing action. Allowing the client to stay in bed for the time being ignores the problem, and isolation may imply punishment. Although medication will calm the client, it does not address the problem.
A nurse has been assigned to work with a depressed client on a one-on-one basis. The next morning the client refuses to get out of bed, saying, "I'm too sick to be helped, and I don't want to be bothered." What is the best response by the nurse? 1. "You won't feel better unless you make the effort to get up and get dressed." 2. "I know you'll feel better again if you just make an attempt to help yourself." 3. "Everyone feels this way in the beginning as they confront their feelings. I'll sit with you." 4. "I know you don't feel like getting up, but you might feel better if you did. Let me help you get started."
4. "I know you don't feel like getting up, but you might feel better if you did. Let me help you get started." The statement "I know you don't feel like getting up, but you might feel better if you did. Let me help you get started" acknowledges the client's feelings, offers hope, and helps the client to a higher level of function. The statement "You won't feel better unless you make the effort to get up and get dressed" ignores the client's feelings and may not be true. The statement "I know you'll feel better again if you just make an attempt to help yourself" denies the client's feelings, and feeling better cannot be guaranteed. The statement "Everyone feels this way in the beginning as they confront their feelings. I'll sit with you" minimizes the client's feelings; also the client is not interested in how others feel.
At night an older client with dementia sleeps very little and becomes more disoriented. How can the nurse best limit this confusion resulting from sleep deprivation? 1. Shutting the client's door during the night 2. Applying a vest restraint when the client is in bed 3. Leaving a dim light on in the client's room at night 4. Administering the client's prescribed as-needed sedative medication
4. Administering the client's prescribed as-needed sedative medication A small light in the room may prevent misinterpretation of shadows, which can heighten fear and alter the client's perception of the environment. A disoriented and confused client should be closely observed, not isolated. Restraints are a last resort; less restrictive interventions should be used first. Sedatives should be used sparingly in older adults, because they may cause further confusion and agitation.
A client with an obsessive-compulsive disorder continually walks up and down the hall, touching every other chair. When unable to do this, the client becomes upset. What should the nurse do? 1. Distract the client, which will help the client forget about touching the chairs 2. Encourage the client to continue touching the chairs as long as the client wants until fatigue sets in 3. Remove chairs from the hall, thereby relieving the client of the necessity of touching every other one 4. Allow the behavior to continue for a specified time, letting the client help set the time limits to be imposed
4. Allow the behavior to continue for a specified time, letting the client help set the time limits to be imposed It is important to set limits on the behavior, but it is also important to involve the client in the decision-making. Distracting the client, which will help the client forget about touching the chairs, is nontherapeutic; rarely can a client be distracted from a ritual when anxiety is high. Encouraging the client to continue touching the chairs for as long he desires until fatigue sets in is a nontherapeutic approach; some limits must be set by the client and nurse together. Removing chairs from the hall, thereby relieving the client of the necessity of touching every other one, will increase the client's anxiety because the client uses the ritual as a defense against anxiety.
A client is admitted to the mental health unit because of a progressively increasing depression over the past month. What clinical finding does a nurse expect during the initial assessment of the client? 1. Elated affect related to reaction formation 2. Loose associations related to thought disorder 3. Physical exhaustion resulting from decreased physical activity 4. Diminished verbal expression caused by a slowed thought process
4. Diminished verbal expression caused by a slowed thought process As depression increases, the thought process becomes slower and verbal expression decreases. The affect of the depressed person is usually one of sadness, or it may be blank. Loose associations are characteristic of clients with schizophrenia, not depressed clients. Decreased physical activity does not produce physical exhaustion.
An older adult with a diagnosis of delirium on the mental health unit begins acting out while in the dayroom. What is the initial nursing intervention? 1. Instructing the client to be quiet 2. Allowing the client to act out until fatigue sets in 3. Guiding the client from the room by gently holding the client's arm 4. Giving the client one simple direction at a time in a firm, low-pitched voice
4. Giving the client one simple direction at a time in a firm, low-pitched voice Clients who are out of control are seeking control and typically respond to simple directions stated in a firm voice. "Be quiet" is a nontherapeutic order; furthermore, it is demeaning to the client. Allowing the client to act out until fatigue sets in will not help the client gain control and might be frightening to other clients in the dayroom. Guiding the client from the room by gently holding the client's arm is done only after an attempt at calming the client has failed.
A nurse is preparing to care for a client who engages in ritualistic behavior. What is the most appropriate intervention to include in the plan of care? 1. Redirecting the client's energy into activities to help others 2. Teaching the client that the behavior is not serving a realistic purpose 3. Administering antianxiety medications that block out the memory of internal fears 4. Helping the client understand that the behavior is caused by maladaptive coping with increased anxiety
4. Helping the client understand that the behavior is caused by maladaptive coping with increased anxiety Helping clients understand that a behavior is being used to control anxiety usually makes them more amenable to psychotherapy. Treatment includes activities to help the client, not others. The client usually understands already that the behavior is not serving a realistic purpose. Administering antianxiety medications that block out the memory of internal fears will only mask symptoms and will not get at the root of what is bothering the client.
A 16-year-old high school student who has anorexia nervosa tells the school nurse that she thinks she is pregnant even though she has had intercourse only once, more than a year ago. What is the most appropriate inference for the nurse to make about the student? 1. Using magical thinking 2. Submitting to peer pressure 3. Lying about the last time she had intercourse 4. Lacking knowledge that anorexia can cause amenorrhea
4. Lacking knowledge that anorexia can cause amenorrhea The loss of body fat from anorexia can cause amenorrhea; the client needs information. No data are available to support the fact that the client is using magical thinking, which is characterized by the belief that thinking or wishing something can cause it to occur; in light of the client's diagnosis of anorexia, this is not the first conclusion. Submitting to peer pressure is not related to this type of concern. Although the nurse should question the timeline again, the client's nutritional status should be explored first.
A school nurse knows that school-aged children often use defense mechanisms to cope with situations that might negatively affect their self-esteem. The nurse hears a child who was not invited to a sleepover say, "I don't have time to go to that sleepover. I have better things to do." The nurse concludes that the student is using which defense mechanism? 1. Denial 2. Projection 3. Regression 4. Rationalization
4. Rationalization Rationalization is the offering of an explanation to one's self or others to allay anxiety. Denial involves avoiding the reality of a situation. Projection is blaming others for one's shortcomings. Regression is returning to an earlier more familiar mode of behavior.
A client is found to have generalized anxiety disorder. For what behavior should the nurse assess the client to determine the effectiveness of therapy? 1. Participating in activities 2. Learning how to avoid anxiety 3. Taking medications as prescribed 4. Recognizing when anxiety is developing
4. Recognizing when anxiety is developing Recognition of anxiety or symptoms of increasing anxiety is an indication that the client is improving. Avoidance of anxiety is not a good indication of improvement; there is no guarantee that anxiety can always be avoided. Participating in activities and taking medications as prescribed do not indicate improvement or recognition of feelings; the client may be doing what others expect.