MH Exam 3 evolve
A nurse is discussing the possible existence of abuse related to a 4 year old currently being treated in the emergency department. Which statement by the nurse requires immediate intervention? "We don't need physical proof of injury to report this situation." "A 4 year old can be an unreliable source since they have such wonderful imaginations." "It's up to the state's child protection agency to determine if our fears are valid." "I'm absolutely sure every state requires that we report our concerns."
"A 4 year old can be an unreliable source since they have such wonderful imaginations." When child abuse is suspected, persons in authority including nurses, teachers, spiritual leaders, coaches, counselors, and child care providers are legally responsible for reporting to the appropriate child protective agency. Each state mandates that a report must be filed when suspected abuse or neglect is encountered. It is not necessary to have proof of the abuse. If there is a suspicion or the child says something is happening, that is enough grounds to report. It is then up to the CPS agency to investigate and make a determination.
Which question demonstrates the nurse's understanding of the need to assess a client who has been physically abused for additional forms of trauma? "What types of injuries have you received as a result of the physical abuse?" "Do you know what triggers the physical abuse?" "Did your abuser ever intimidate or threaten you with physical harm?" "Can you tell me when the physical abuse began?"
"Can you tell me when the physical abuse began?" The physical damage caused by physical abuse is usually accompanied by emotional abuse. Emotional abuse includes threats and intimidation. The remaining options focus on the physical abuse/trauma.
A client, being cared for in the emergency department (ED) after a sexual assault, asks that a friend be allowed to stay in the examination room while waiting for the SANE nurse to arrive. The client is observably anxious and states, "I don't want to be alone." What response will the ED nurse make in order to best assure the client's safety and emotional health? "I understand. I'll stay with you." "Are you thinking about hurting yourself?" "Certainly; whatever makes you feel safe." "Do you want to talk to a psychiatrist?"
"Certainly; whatever makes you feel safe." Having someone stay with the patient (friend, neighbor, sexual assault advocate, or staff member) while waiting to be treated is a priority intervention. People in high levels of anxiety need someone with them until their anxiety level is down to moderate. Never leave the individual alone. While the remaining options may become appropriate, the client has not yet demonstrated behaviors to warrant implementing either one.
Recognizing that grief and mourning are different processes, which statement reflects a client's progress toward completing the mourning process? "I've discovered who I can rely upon since he died." "It's only been 2 years since he died but it seems so much longer." "He had his faults but I know he loved me." "My love of gardening has given me pleasure since losing him."
"He had his faults but I know he loved me." The work of mourning is complete when the bereaved person or persons can remember realistically both the pleasures and the disappointments of the lost relationship. Grief work is successful when the relationship to the deceased person has been restructured and energy is available for new relationships and life pursuits. Brief periods of intense emotions may still occur at significant times, such as holidays and anniversaries, but the person or family members have energy to reinvest in new relationships that bring shared joys, security, satisfaction, and comfort. If, after a normal period (12 to 18 months), a person has not been able to find pleasure, satisfaction, and comfort in his or her life, then reassessment and re-evaluation are indicated.
Which assessment question will provide the nurse with information concerning the client's perception of the situational crisis of losing their job? "Do you have a plan for meeting your financial obligations while unemployed?" "Have you ever been out of a job before?" "How much will being unemployed for several months affect your life?" "Who can you rely upon for help while you are looking for a job?"
"How much will being unemployed for several months affect your life?" Whether an event is perceived as a crisis is, in part, dependent on the outlook and strengths of the patient. Therefore it is important to view the event through the eyes of the patient. The nurse's initial task is to assess the individual's and possibly the family's perception of the problem. The correct option directly assesses the client's perception of the crisis. While the other options are not inappropriate, they don't focus on perception.
A client is currently expressing suicidal ideations. Which statement made by the client demonstrates knowledge of appropriate crisis management techniques that are focused on safety? "I know the thoughts will likely go away." "I need you to stay with me." "I have survived the urge to kill myself before." "I trust the staff here to help."
"I need you to stay with me." During a suicidal crisis, it is important that the client understand that the crisis is temporary; unbearable pain can be survived; that help is available; and he or she is not alone. The knowledge most relevant to the client's safety is that he or she is not alone. Being attended to by another demonstrates that he or she is important and cared about. These are the feelings necessary to resist following through on his or her suicidal ideations.
A client has been receiving treatment for posttraumatic stress disorder (PTSD) after experiencing a sexual assault. Which statement supports that the client is able to resume pre-trauma function? "I really like my therapist." "I'm hopeful that life will get back to normal." "I'm being considered for a promotion at work." "I'm feeling less anxious among strangers."
"I'm being considered for a promotion at work." Most patients will be able to eventually resume their previous lives after supportive services and crisis counseling or therapy. If survivors are relatively free of signs of PTSD and their lifestyles are close to their lifestyles before the rape, the recovery is considered successful. Being considered for a promotion indicates the client is able to effectively work and engage in areas of interest. The remaining options, while positive statements, lack tangible proof of resuming pre-trauma levels of functioning.
Which statement by the terminally ill client demonstrates an understanding of the concept of palliative care? "Palliative care will focus on the management of my cancer pain." "When I'm ready to die, I'll certainly consider palliative care." "The focus of hospice and palliative care are the same." "I'm dying and palliative care will help preserve my quality of life."
"I'm dying and palliative care will help preserve my quality of life." Palliative care provides holistic interdisciplinary care for people with serious life-limiting illness. This form of care emphasizes collaborative and coordinated care by an interdisciplinary team. It also provides services that are available concurrently or independent of curative or life-prolonging care as well as support of the patient and family, hope for peace, and dignity until death. Hospice is a model of care designed to help patients and family members during the last 6 months of life.
Grief therapy was prescribed for a client who recently experienced tremendous grief upon the death of a parent. Which statement best demonstrates that a client is moving toward the healthy resolution of that grief? "I've enjoyed going to the book club my sister suggested." "My mother would want me to get back to living my life again." "I'm going to stop being sad and rely on my faith to support me." "I'm considering it's time to go back to work."
"I've enjoyed going to the book club my sister suggested." Ongoing evaluation will be performed until the crisis has resolved sufficiently to allow a return to normal pre-crisis functioning. As the patient's anxiety level reduces from severe to moderate to mild through successful interventions, the patient will need less support and return to independence. The correct option demonstrates independence, social engagement, and a return of enjoyment to one's life. The remaining options demonstrate consideration associated with returning to the familiar life situations (work, faith-based comfort).
Which statement best demonstrates a client's understanding of how years of addiction have affected their ability to mature normally? "My years of addiction allowed me to avoid being a mature person." "Taking on grown up responsibilities is certainly a challenge." "I don't think I've ever had to think like an adult before." "I've got to learn how to address my problems like an adult would."
"I've got to learn how to address my problems like an adult would." Alcohol and drug addiction will interrupt an individual's progression through the maturational stages. As the patient escapes from stressors through the use of substances, he or she is not practicing communication and coping skills that contribute to maturity. When the individual gets clean and sober, he or she will discover that his or her maturation has been halted at about the age he or she began using drugs or alcohol. The good news is that the developmental process can resume and progress through supportive treatment. The correct option demonstrates an understanding of personal deficits and a need to address them, while the other options are statements of facts.
Which statement, by a client diagnosed with poor impulse control, indicates an improved prognosis? "My children will stop loving me if I continue to act this way." "I feel so badly when I act on my anger." "I've learned to walk away when I start feeling angry." "Being angry is ruining my life."
"I've learned to walk away when I start feeling angry." An improved prognosis requires proof the behaviors are being managed or eliminated. The patient will recognize when anger and aggressive tendencies begin to escalate and employ at least one new tension-reducing behavior at that time (time outs, deep breathing, talking to a previously designated person, employing an exercise such as jogging). While the remaining options demonstrate self-awareness, they lack a strategy to manage the behavior.
Which statement made by a community leader demonstrates a common stigma associated with the serious and persistent mentally ill (SPMI)? "It's difficult to use government money to support people who are unemployable." "Establishing a community treatment center for the mentally ill will be very expensive." "It's a serious obligation to commit city funds to provide shelter for the mentally ill." "The city will contribute a sum equal to the money donated by private citizens."
"It's difficult to use government money to support people who are unemployable." Stigma is perpetuated by stereotypical images or language in the media, thoughtless comments by everyday people or celebrities, and misperceptions of mental illness. It can cause people to assume that those with SPMI are less capable, responsible for their own illness, and even dangerous. To state that the mentally ill are unemployable is a stigmatic statement. The remaining options are true but are not verbalizing untruths about the mentally ill community.
Which client statement reflects resiliency associated with a situational crisis he or she is experiencing? "I wasn't planning on another pregnancy but I would never consider an abortion." "Losing my son is so hard but when my father died, grief counseling really helped." "Retirement is something I had always dreaded but so far it's been pretty enjoyable." "When my son died in the flood, I depended on my family and friends for support."
"Losing my son is so hard but when my father died, grief counseling really helped." Situational crises are somewhat common, and at least some of them, like experiencing a loss through death, will be experienced by all individuals during their lifetime. Response to the situation depends in part upon the degree of support available. The existence of caring friends, family members, and groups as well as previous success in navigating life events (resiliency), and the overall physical and emotional health of the individual all contribute to an individual's resiliency. The correct option represents both a situational crisis and resiliency based in a past experience. Retirement is a maturational crisis, and the option demonstrates acceptance but not resiliency. While the pregnancy is a situational crisis, the option demonstrates a value but not resilience. The death of a loved one in a flood is an example of an adventitious crisis and the option doesn't demonstrate a past experience upon which to rely.
Which statement, by a child who recently lost "Sammy" a beloved pet, best demonstrates the parent's role in nurturing the child's resiliency? "It's sad but Dad said that pets die every day." "Mom, Dad, and I talk about how much fun we had with Sammy." "Dad gave me a picture of Sammy when he was just a puppy." "Mom promised that I can get another pet really soon."
"Mom, Dad, and I talk about how much fun we had with Sammy." Resiliency helps protect children and adolescents in a stressful situation. Temperament, problem-solving skills, and the support of a nurturing adult contribute to resiliency and successful navigation of stressful events. The correct option shows the parents helping the child through the grieving process. While the remaining options are not inappropriate, they are not focused on successfully managing the grief associated with the death of a loved one.
A client became angry with a staff member and began throwing objects at others in the unit. Which question will the nurse manager ask the staff in order to address the goals of the debriefing of the incident that focuses on client care? "What injuries resulted from the violence?" "Were the unit's policies on managing violence followed?" "What was the client's reasoning for the violent behaviors?" "When did the violence begin?"
"Were the unit's policies on managing violence followed?" Staff analysis of an episode of violence, referred to as critical incident debriefing, is crucial for a number of reasons. First, a review is necessary to ensure that quality care was provided to the patient. Staff members need to critically examine their response to the patient and so identifying policy-driven responses is a part of the process. While the remaining questions are appropriate, they are not associated with the debriefing process.
A client has expressed great concern over "feeling like I'm going crazy" since experiencing anxiety, depression, and nightmares after being sexually assaulted. What response will the nurse make initially to address the client's concerns? "What you are experiencing is common among assault victims. It's not a result of going crazy." "Let's talk about how these symptoms are making you feel and especially how they are making you feel crazy." "These are common feelings after being assaulted. Fortunately you are not going crazy so try not to worry." "What you are experiencing must be frightening. These symptoms are shared by many who have been sexually assaulted."
"What you are experiencing must be frightening. These symptoms are shared by many who have been sexually assaulted." Many individuals think they are going crazy and are not aware that this is a process that many people in their situation have experienced. Explain to the patient that the signs and symptoms that many people experience during the long-term phase include nightmares, anxiety, and depression. The correct option is the only one that gives the client the needed information while also acknowledging his or her feelings.
Which client-focused change will the nurse identify as a sign of possible escalation of anger? An impulsive client demonstrates introspection. A depressed client begins to cry. A quiet client becomes talkative and loud. A manic client becomes withdrawn.
A quiet client becomes talkative and loud. Anger involves an increase in energy. Signs and symptoms of anger may involve changes in mood and behavior from quiet to talkative and loud, from talkative to silent and withdrawn, from calm to angry, or from depressed to elated. The remaining options lack the demonstration of increased energy.
Which client will likely have a history of intermittent explosive disorder? A young adult diagnosed with kleptomania who has been arrested five times for stealing. An older adult found guilty of assault stemming from an incidence of road rage. An adolescent diagnosed with conduct disorder who has been expelled three times. A middle-aged client diagnosed with pathological gambling who is $800,000 in debt.
An older adult found guilty of assault stemming from an incidence of road rage. Intermittent explosive disorder involves recurrent, unpremeditated episodes of marked verbal or behavioral aggression or rage. The acts are often severe enough to hurt people or destroy significant property and occur in otherwise normal individuals. The acts are disproportionate to the perceived provocation and can occur in response to ordinarily minor events such as traffic delays. The distractors describe kleptomania, conduct disorder, and pathological gambling.
How will the nurse best assess a client for the current presence of suicidal ideations? Carefully observe the client's nonverbal behaviors. Determine whether the client has ever acknowledged suicidal ideations. Ask the client directly, "Are you thinking of killing yourself?" Place the client on one-on-one suicide observation.
Ask the client directly, "Are you thinking of killing yourself?" If suicidal ideations are suspected, always ask directly, "Are you thinking of killing yourself?" None of the other options effectively assess the client for currently suicidal thoughts/ideations.
Which actions are associated with addressing the needs of health care providers who are frequently involved in the compassionate care of grieving clients? (Select all that apply.) Select all that apply. Consciously making the effort to encourage staff members Advocating for facility-sponsored exercise program Attending the weekly scheduled debriefing and support session Changing unit assignments on a regular basis Earning a certification associated with grief counseling
Consciously making the effort to encourage staff members Advocating for facility-sponsored exercise program Changing unit assignments on a regular basis Earning a certification associated with grief counseling to balance a work life that centers on others, create habits that reconnect you with your own life, your well-being, your commitment to work, and your enjoyment of the larger world. Find people you can trust at work and support each other. Accept each other's failings, successes, vulnerabilities, and intentions. Work for systemic changes at your place of employment that will enhance self-care, such as exercise programs and periodic debriefings and memorials when patients die. Continue to increase your knowledge base and seek professional certifications. Ask your supervisor to email inspiring or appreciative messages to the staff. Take a few moments to thank and appreciate each other. Changing units is appropriate only in the event that burnout and compassion fatigue are unavoidable. The timing and frequency of these interventions vary from person-to-person.
Which assessment data best establishes that the client has demonstrated the ability to meet a challenge commonly faced by someone diagnosed with a serious mental illness (SMI)? Attends regular church services Medication adherent Currently employed Is willing to attend AA meetings
Currently employed Stigma and chronicity present many challenges to coping with a SMI and contribute to a variety of other social, physical health, and mental health problems including poverty and unemployment. While positive, none of the other options demonstrate such achievement.
When considering oppositional defiance disorder (ODD), which behavior will be viewed as a mandatory diagnostic criteria? Ran away from home twice in the last 6 weeks. Was discovered attempting to drown the neighbor's cat. Hid the backpack of a classmate who refused to give up answers to a test. Repeatedly refuses to follow family rules about completing chores.
Hid the backpack of a classmate who refused to give up answers to a test. While all children will test limits or have tantrums, ODD goes beyond the normal scope of these behaviors. Symptoms must be displayed with at least one person who is not a sibling and include at least four of the criteria: often loses temper, easily annoyed, angry, argues with authority figures, defies or refuses rules, deliberately annoys others, blames others for mistakes or misbehavior, vindictive. The remaining options are associated with the more severe diagnosis of conduct disorder.
A widow is demonstrating signs of complicated grief after the death of her spouse 18 months ago. Which information included in her mental health assessment should the nurse identify as requiring further investigation? They had been happily married for over 50 years. The couple lost a child when she was 4 years old. Her husband was an insulin-dependent diabetic. His death was a result of a failed robbery attempt.
His death was a result of a failed robbery attempt. Indicators of the potential for complicated or unresolved grief include social isolation, extensive dependency on the deceased person, unresolved interpersonal conflicts, loss of a child, a catastrophic loss, or a violent and senseless death like that of her husband. While the loss of a child is considered a possible trigger, this client's current loss was not associated with a child. The remaining options are not recognized triggers for complicated grief.
When considering signs of risk for an adult client diagnosed with a serious and persistent mental illness, which characteristic presents the greatest threat? Poor social skills Impaired judgment Substance abuse Depression
Impaired judgment Impaired judgment, paranoia, and psychosis increase the risk of dangerous behavior; such persons may engage in behaviors that lack reflection and attention to consequences. The remaining options are less associated with impaired judgment and so while considered potentially a risk do not have the degree of risk associated with poor/impaired judgment
After the admission interview and assessment, the emergency department nurse has reason to believe that a child is being abused physically. Which intervention will the nurse implement to best determine if the child has been abused? Insist that the child be further assessed without the parents being present. Delay the assessment until the appropriate child protection authorities are present. Allow the child to pick one parent to be present during the remaining examination. Provide the child with suggestions of other possible examples of abuse.
Insist that the child be further assessed without the parents being present. In the case of suspected child abuse, after the initial interview with the parents, the child should be seen alone giving him or her a chance to disclose mistreatment. The child should not be prompted about possible abuse nor should the examination be delayed since these actions can affect the outcome of the assessment.
A client is diagnosed as a child with attention-deficit/hyperactivity disorder (ADHD). Achieving which long-term goal will best indicate personal effective condition management as an adult? Demonstrates effective time management and organizational skills. Absence of classic fidgety physical activity. Mental focus that allows for completion of tasks. Medication therapy discontinued by health care provider.
Medication therapy discontinued by health care provider. Nonstimulant (atomoxetine, guanfacine) and stimulant medications (methylphenidate, d-, l-amphetamine, lisdexamfetamine) may be needed during elementary and high school. Some individuals learn to compensate and no longer need medication in adulthood. This would be the best demonstration of effective condition management by the client. The remaining options, while demonstrating effective treatment, all are reliant upon medication therapy adherence.
There is reason to believe that a client unknowingly ingested flunitrazepam prior to being sexually assaulted. Which intervention will the nurse implement in order to confirm this suspicion? Obtain a bedside electrocardiogram. Obtain a urine sample. Assess what the client drank before the assault. Assess the client's pupils.
Obtain a urine sample. Assessment for "date rape" drugs like flunitrazepam should be included if description of the event indicates that possibility (loss of consciousness, vomiting). In such a case, a urine sample may be obtained. The remaining options are not directly associated with such an assessment.
A nurse is managing the care of a 19-year-old adult diagnosed with Level 1 autism spectrum disorder. Which intervention will the nurse include in the client's plan of care? Organization and planning strategies Boundary setting to manage aggressive behavior Group therapy that focuses on social skills Techniques to help manage repetitive ritualistic behaviors
Organization and planning strategiesThe severity of autism spectrum disorder is categorized into levels based on functional ability. In Level 1, there is noticeable social deficit, but language and speech are normal. Individuals have difficulty switching between activities, and they struggle with organization and planning. In Level 2, there is noticeable deficit in both verbal and nonverbal social and communication skills. Social impairment and repetitive behaviors are obvious to others. These individuals do not tend to initiate social interactions, and change in routine causes distress. In Level 3, social deficits are severe, with communication being limited and needs-based. Individuals may be nonverbal, speak in few-word sentences, be difficult to understand, make odd noises, echo a word or sentence over and over, or use overly literal language. Repetitive and restrictive behaviors markedly interfere with functioning in all spheres. Changing focus, action, or routine causes great distress. Aggression toward self or others is more common at this level.
Which nursing intervention is believed to have the greatest effect on antipsychotic medication therapy adherence? Arranging for the client to receive medication at an outpatient center Hospitalizing clients until their symptoms are significantly lessened Advocating for first-generation medications at lower cost Patient education regarding management of side effects
Patient education regarding management of side effects Medication side effects can produce a wide range of distressing effects. Addressing side effects is essential because they may impair one's quality of life or lead to treatment nonadherence. Patient education is important because some side effects respond to treatment or can be counteracted by lifestyle or behavior changes. While cost is a factor, its effect is not as dramatic as are the side effects. The remaining options are not realistic to implement.
A client is seeking treatment in the emergency department (ED) after a sexual assault. Which notation made by the ED nurse demonstrates appropriate nonjudgmental documentation? An alleged sexually assaulted inside a local parking garage was made by the client. Physical evidence supports that vaginal penetration occurred. Treatment for facial abrasions was refused. No acute emotional distress during assessment was noted.
Physical evidence supports that vaginal penetration occurred. Pejorative terms often reflect old myths and a lack of knowledge and understanding regarding the rape victim's experience and need for immediate intervention. Words and phrase like "alleged," "refused," "intercourse," and "no acute distress" all minimize the devastation of the event. Penetration is the preferred term when describing the sexual aspects of the assault.
Which intervention will the nurse identify for the care plan of a client diagnosed with a moderate form of intellectual disability? Discussing options for vocational training Providing choices for independent living Re-enforcing the concepts of money management Discussing the choices related with buying a home
Re-enforcing the concepts of money management The moderate form of intellectual disability constitutes 10% of the cases. These children develop communication, social, and academic skills slowly. Conceptual domain is at an elementary school level, with reading commonly at a first to third grade level. Although able to perform activities of daily living, ongoing assistance is needed for conceptual tasks of daily life. They may have long-term intimate relationships and friends but may not interpret social cues accurately. Support is needed to obtain success in employment, in areas such as transportation and money management skills. The client with the mild form of intellectual disability is able to perform self-care and may be capable of vocational training and independent living. More than half of these individuals will own a home, marry, and have children.
A client is engaged in short-term therapy to assist in resolving complicated grieving over the loss of a child. Which intervention is directed toward encouraging the parent to fully express emotions regarding the child's death? Role-playing in order to describe how much the loss has affected life Talking to a friend about how life has changed since the loss Engaging in a discussion about the changes that losing a child will create Identifying strategies to help manage life without her child
Role-playing in order to describe how much the loss has affected life Encouragement of full expression of emotions and effect may include writing letters to deceased, role-playing, and looking at pictures. The remaining options, while appropriate, are focused on education and achieving peace in the post-death life of the client.
Which action is an example of anger? Setting fire to the business that hires illegal immigrants Proposing radical changes to the way police manage public protesters at a town meeting Slapping a spouse in the face during an argument about the family budget Writing a scathing letter to the local newspaper regarding corrupt local politicians
Slapping a spouse in the face during an argument about the family budget Anger is an unplanned reaction to a stressor. Although we are all familiar with the feelings of anger, not everyone responds to anger with aggression or violence in the same way. Anger becomes unhealthy if it gets in the way of a person's functioning or relationships or puts others at risk. Slapping in the midst of an argument is usually unplanned and an example of anger. The remaining options include planned expressions of frustration and/or aggression.
A client has recently lost all his or her possessions in a fire a month ago. Which assessment data suggests that hospitalization should be considered? Has gained 10 pounds since the fire. Drinks a six pack of beer daily. States, "The fire made my life so hopeless." Reports, "I really do need someone to talk to."
States, "The fire made my life so hopeless." In crisis situations, it is important to evaluate the person's level of anxiety. Common coping mechanisms may be overeating, drinking, smoking, withdrawing, seeking out someone to talk to, crying, yelling, sleeping too much, praying, or engaging in other physical activity. The potential for suicide or homicide must be assessed. If the patient is thinking of harming themself or someone else, or is unable to take care of personal needs, hospitalization should be considered. The correct option demonstrates a potential risk for suicide.DIF: Cognitive Level: Analysis (Analyzing)
A client with a history of being bullied has been admitted to the hospital for treatment of anger issues. Which classic reaction will the nurse address in the client's plan of care? Suicidal ideations Hallucinations Somatic pain Paranoia
Suicidal ideations Those who are bullied are prone to negative feelings about self, humiliation, poor self-concept, and great emotional pain, and many can suffer severe reactions that may last a lifetime, such as depression, posttraumatic stress disorder (PTSD), anxiety disorders, and even attempted or completed suicide. The remaining options are not necessarily associated with the client's diagnosis.
An older adult has experienced both physical and emotional abuse while living with a family member. The family member has been adherent with required therapy and at the client's request the two will again be living together. Which intervention will best assure that both the client and the family member's needs are being met? The family member is informed that criminal charges will be filed if any abuse occurs. The client agrees to report any incidences of abuse by the family member immediately. Initially, 7 days a week, 24-hour home aides are provided. The home will have regular but unscheduled visits by adult protective services agents.
The home will have regular but unscheduled visits by adult protective services agents. Follow-up is crucial in ensuring ongoing safety of the elderly patient and support of the caregiving system. None of the other options provide long-term support and supervision.
A nurse is conducting a family assessment to identify possible triggers for abusive behaviors. Which family characteristic will the nurse identify as such a trigger? The father is the "stay-at-home parent." The parents are of different ethnic and religious backgrounds. The parents were teenagers when the children were born. The family only socializes with other immigrant families.
The parents were teenagers when the children were born. The classic frustration-aggression hypothesis proposes that when frustration is high in response to negative societal situations, frustration may lead to aggression. Early parenthood is considered such a stressor. None of the other options are recognized as triggers for possible family-centered abuse.
When considering an individual's risk for suicide, which client will the nurse consider the priority? The older transgender female who has been repeatedly assaulted The resent Middle Eastern immigrant from a war torn country The teenager recovering from a self-inflicted gunshot wound The gay male who has been diagnosed with HIV
The teenager recovering from a self-inflicted gunshot wound By far the strongest risk factor for suicide is a previous suicide attempt but there is growing concern over the high suicide rates globally among vulnerable groups who experience discrimination, such as refugees and migrants; indigenous peoples; and lesbian, gay, bisexual, transgender, and intersex (LGBTI) persons. Higher suicide rates are also seen among those who are incarcerated and those who live through war.
When considering the lethality of a client's suicide plan, what is the basic principle the nurse will consider? If the action is reversible, the plan is less lethal. A gun can easily deliver a fatal wound. Ingesting pills is a slow method of self-harm. Any suicide plan has the potential to be lethal.
if the action is reversible, the plan is less lethal. A plan that doesn't allow for a last minute reversal of the action is consider more lethal. While all suicide plans should be taken seriously, not all plans are considered lethal. The remaining options are true statements but not the guiding principle concerning determining a plan's lethality.
A client has made a successful suicide attempt while hospitalized on a unit that specializes on the treatment of depression. When considering both milieu control and crisis management, which intervention will the nursing staff implement? All group therapy sessions will be held on the unit for at least a 72-hour period. Suicide precautions for a full 24 hours will be implemented for all clients. Every client will be questioned concerning the impact the suicide had on him or her personally. A client-focused psychological postmortem assessment will be conducted immediately.
uicide precautions for a full 24 hours will be implemented for all clients. A successful suicide attempt is a crisis situation for the unit. The safety of the milieu and of the individual clients are of primary importance. Since the unit focuses on clients diagnosed with depression, all the patients on the unit need to be closely monitored for suicidal ideations. The first 24 hours after inpatient suicide is crucial for both safety and crisis management reasons. A postmortem assessment is conducted by staff and administrators to review policies and procedures that would be relevant to preventing such an occurrence. The remaining options are not therapeutic in this situation.