Psychosocial integrity
A client is admitted to a psychiatric unit after a suicide attempt. The client is withdrawn, has poor hygiene, and appears underweight. What is the priority for a nurse in keeping a therapeutic milieu for this client? Give the client structure and support until the client is able to function. Manage the client's spiritual needs. Encourage the client to participate in group therapy sessions. Validate a client's worth and respect for life.
Give the client structure and support until the client is able to function. The nurse's priority for a client who has just entered the milieu of the psychiatric unit is to provide a client with safety and security. As the client progresses and displays less destructive behavior, the nurse will encourage the client to participate in group therapy. Validation is part of the actions of a nurse to establish the therapeutic milieu. The nurse will begin validation by giving the client respect and showing the client worth through the nurse's actions. Management of the client's spiritual needs is continuous within the therapeutic milieu; however, the client's physical environment and physical needs are the priority.
A pediatric nurse is caring for a child suspected of having been sexually abused. Which finding would best support the nurse's suspicions? fear of parents swelling of the genitals poor eye contact poor hygiene
swelling of the genitals The most likely finding for suspected sexual abuse would be difficulty walking or sitting; pain, swelling, or itching in the genitals; or bruises, bleeding, or lacerations of the genital area. Poor hygiene is a sign of physical neglect. Poor eye contact and fear of parents are common signs of physical, not sexual, abuse.
Which factors should be the primary factor in a nurse's decision whether to pray with a client? the client's openness to being prayed for the nurse's familiarity with the prayer traditions of different faiths the nature and course of the client's current diagnosis the availability of a hospital chaplain or other spiritual counselor
the client's openness to being prayed for Many factors influence the nurse's decision to pray with a client. Central among these, however, is the question of whether the client is open to this possibility. This factor is more important than the nurse's familiarity with specific prayer traditions, the patient's medical condition, or the presence or absence of a chaplain.
The nurse is caring for a client who recently lost an infant to sudden infant death syndrome (SIDS). The client talks about how going back to work last week and that the couple want to become pregnant again soon to have another baby. The client reports feeling sad sometimes, but also feeling happy sometimes. What stage of grief does this client demonstrate? Acceptance Delusion Denial Bargaining
Acceptance This client demonstrates acceptance of the new reality. The client shows both dealing with the grief and resuming a more normal life again, such as going back to work and planning another pregnancy. It is normal for the client to still experience times of happiness and sadness, but this shows the client has moved into the acceptance stage and is accepting the loss of the baby without trying to change it. Denial would be characterized by refusing to admit the loss of the baby was real, such as believing that the baby was not really dead. Delusion is not a stage of grief, but rather a false or irrational belief that a person holds strongly to despite proof to the contrary. Bargaining would be characterized by trying to make deals to change the outcome, such as "Take me instead and let my baby live."
A nurse is caring for a client undergoing opiate withdrawal, which causes severe physical discomfort and can be life-threatening. To minimize these effects, opiate users are commonly detoxified with: amphetamines. barbiturates. benzodiazepines. methadone.
Methadone Methadone is used to detoxify opiate users because it binds with opioid receptors at many sites in the central nervous system but doesn't have the same deleterious effects as opiates such as heroin and morphine or stimulants such as cocaine. Barbiturates, amphetamines, and benzodiazepines are highly addictive and using these drugs would make further detoxification treatment necessary.
The nurse is working with a client with depression in a mental health clinic. During the interaction, the nurse uses the technique of self-disclosure. In order for this technique to be therapeutic, which step must be a priority for the nurse? discussing the nurse's experience in detail asking for the client's perception of what the nurse has revealed ensuring relevance to, and quickly refocusing upon, the client's experience allowing the client time to ask questions about the nurse's experience
ensuring relevance to, and quickly refocusing upon, the client's experience The nurse's self-disclosure should be brief and to the point so that the interaction can be refocused on the client's experience. Because the client is the focus of the nurse-client relationship, the discussion should not dwell on the nurse's own experience.
A nurse notices that a depressed client who has been taking amitriptyline hydrochloride for 2 weeks has become very outgoing, cheerful, and talkative. The nurse suspects that the client: is responding appropriately to the antipsychotic. may be experiencing increased energy and is at increased risk for suicide. is ready to be discharged from treatment. is experiencing a split personality.
may be experiencing increased energy and is at increased risk for suicide. As antidepressants take effect, an individual suffering from depression may begin to feel energetic enough to mobilize a suicide plan. Amitriptyline is an antidepressant, not an antipsychotic. The client shouldn't be discharged until the risk of suicide has diminished. The client's elevated mood is a response to the antidepressant, not an indication of a split personality.
The nurse observes that a client is very sad and dejected after a myocardial infarction. What is the best response to the statement, "Life will never be the same"? "This heart attack really saddens you." "I don't understand. You have survived this heart attack. Why do you think life will never be the same?" "Hope has important healing powers. You need to be a little more hopeful of your recovery from this heart attack." "You're very concerned when you think about how this will change your life."
"You're very concerned when you think about how this will change your life." The response should be attuned to the feelings of sadness and dejection the client is experiencing and should allow concerns to be shared. This response also addresses the content of the client's statement, namely how life will change. "This really saddens you." addresses the feelings but does not attend to the feelings about life. "Why" questions are nontherapeutic, and telling the client to be more hopeful negates what the feelings are.
Which nursing intervention will be most effective when caring for a client experiencing powerlessness? Make certain that all staff members focus only on the client's capabilities. Encourage family members to become more responsible for the client's care. Request a referral to a psychologist. Include the client in decision making whenever possible.
Include the client in decision making whenever possible. Focusing on the client's physical capabilities is important, but powerlessness reflects a perceived lack of control over the current situation and the belief that one's actions will not affect the outcome. Participation in decision making is key to getting the client involved and feeling more in control of his own care. Apathy and dependence on others are characteristics of powerlessness. Encouraging others to take responsibility for the client's care will increase his feelings of powerlessness. A referral to a psychologist is not necessarily indicated. The nurse should implement strategies to involve the client in decisions about his care and evaluate the response to this intervention before suggesting a referral.
A nurse assesses an 82-year-old for depression. Because of the client's age, the nurse's assessment should be guided by which factor? Sadness of mood is usually present, but it is masked by other symptoms. Psychosomatic tendencies do not tend to dominate. Impairment of cognition usually is not present. Antidepressant therapies are less effective in older adults.
Sadness of mood is usually present, but it is masked by other symptoms. Older adult clients are a high-risk group for depression. The classic symptoms of depression frequently are masked, and depression presents differently in the aging population. Depression in late life is underdiagnosed because the symptoms are incorrectly attributed to aging or medical problems. Impairment of cognition in a previously healthy older adult client or psychosomatic problems may be the presenting symptom of depression. Antidepressant therapy is usually effective.
A nurse is caring for a client during barbiturate therapy. The client receiving this drug should be evaluated for which condition? hepatotoxicity prolonged bleeding time poor drug absorption physical dependence
physical dependence Clients can become dependent on barbiturates, especially with prolonged use. Barbiturates do not cause increased bleeding time, but may be combined with aspirin, which would be contraindicated in a client with prolonged bleeding time. Barbiturates are absorbed well and do not cause hepatotoxicity, but because barbiturates are metabolized in the liver, existing hepatic damage does require cautious use of these drugs.
A nurse counsels a mother with young children after leaving her abusive husband 6 months ago. The mother says, "My 6-year-old is starting to act just like his father. I just don't know how to handle this." Which response by the nurse is most appropriate? "You'll have to limit your son's contact with his father." "Counseling for your son would be helpful." "Most boys outgrow these behaviors." "Setting limits on his behavior is all you need to do now."
"Counseling for your son would be helpful." Children who witness domestic violence commonly grow up to be victims or abusers. Counseling helps interrupt the pattern of violence in families. Limiting contact between the father and child does not address the child's behavior, and outgrowing violent behaviors is not likely without other interventions. Setting limits on violent behaviors alone does not address the child's feelings and needs.
A male client reports little or no sexual desire, causing marital discord over the past year. What priority questions will the nurse ask the client to explore lack of sexual desire? Select all that apply. "What are the current medications you are taking?" "Did you experience this decreased desire before?" "How long have you been married?" "What are your past sexual practices?" "Do you have any medical conditions?"
"Did you experience this decreased desire before?" "What are the current medications you are taking?" "Do you have any medical conditions?" "How long have you been married?" Clarifying the symptoms and their onset will provide an opportunity to gather useful information about the client's current condition. Many medications can have a profound effect on sexual desire as can some medical conditions. The client's sexual practices and marital history have no direct bearing on the client's lack of desire.
A client is being treated for alcoholism. After a family meeting, the client's spouse asks a nurse about ways to help the family deal with the effects of the spouse's alcoholism. The nurse should suggest that the family join which organization? Al-Anon Make Today Count Emotions Anonymous Alcoholics Anonymous
Al-Anon Al-Anon is an organization that assists family members in sharing common experiences and increasing their understanding of alcoholism. Make Today Count is a support group for people with life-threatening or chronic illnesses. Emotions Anonymous is a support group for people experiencing depression, anxiety, or similar conditions. Alcoholics Anonymous is an organization that helps alcoholics recover by using a 12-step program.
A client tells the nurse about experiencing "spiritual distress." What should the nurse do first? Make a referral to a member of the clergy. Determine what spiritual distress means to the client. Ask the client if having prayers would be helpful. Refer the client to a support group.
Determine what spiritual distress means to the client. The nurse must first allow the client to clarify the meaning of spiritual distress and explore his or her own beliefs and values before making referrals to clergy or a support group. The nurse should allow the client to indicate if praying would be helpful after helping the client clarify the meaning of spiritual distress.
A client's husband expresses concern that his dying wife keeps saying, "I have to go to the store." Which statement by the nurse will be most effective in assisting the husband to understand the dying process? "Many dying clients are restless and can be treated with sedatives." "The client may be fighting death, and you should leave her alone." "Comments related to going somewhere or leaving on a trip are common in dying clients." "You can tell your wife that you will take her to the store."
"Comments related to going somewhere or leaving on a trip are common in dying clients." Mental changes and decreased level of consciousness are common in the dying process, and the client may talk about travel, trips, or going somewhere. Suggesting that the client be sedated ignores the husband's question about what his wife is experiencing. Suggesting that the client is fighting death and that the husband should leave her alone is inappropriate and denies the husband time to spend with his wife. The husband should not make misleading statements to his wife.
A client is being admitted to the psychiatric unit. She responds to some of the nurse's questions with one-word answers. Her eyes are downcast and her movements are very slow. Later that morning, the nurse approaches the client and asks how she feels about being in the hospital. The client does not respond verbally and continues to gaze at the floor. Which action should the nurse take first? Ask another staff member to include the client in an informal group discussion. Spend time sitting in silence with the client. Introduce another client to her and ask him to join you. Leave the client alone and tell her that you will be back later to talk.
Spend time sitting in silence with the client. Sitting in silence with the client shows that the nurse accepts and cares about her. It also will help the client to get to know the nurse, initiate a feeling of comfort with the nurse, and lead to development of trust. Telling the client that the nurse will be back to talk later will only burden the client with the nurse's expectation to talk, which the client may not be likely to meet. Introducing another client and asking him to join you and the client will overwhelm the client and increase her anxiety. The client needs to first interact with one person, the nurse, before progressing to interactions with others. Including the client in group discussion will increase her discomfort and anxiety and will not be therapeutic at this time.
In closed or locked units, the nurse judges the milieu as therapeutic when priorities are given to which factors? socialization and self-understanding recreation and vocation counseling safety, structure, and support communication, social, and leisure skills
safety, structure, and support Clients on a closed or locked inpatient psychiatric unit are typically acutely ill. Providing safety, structure, and support are immediate priorities in the therapeutic milieu for clients with cognitive and mood impairment and inability to handle stress. Socialization and self-understanding are not the priorities of treatment in the milieu on a locked unit. Recreation and vocational counseling will be addressed when the client is discharged from inpatient status and referrals are made along the continuum of care. Developing leisure, social, and communication skills is important, but not the priority. As clients improve, they become better organized in their thinking and more capable of tolerating stress. They would then be more apt to benefit from such groups and therapies at that time. These activities are part of the therapeutic milieu.
After a prescription change from olanzapine to ziprasidone, the client tells the nurse, "I don't want to take this ziprasidone either. I don't like the side effects, and I can't gain any more weight." Which response(s) by the nurse are appropriate for this client? Select all that apply.
"Ziprasidone causes less weight gain than do the other atypical antipsychotics." "I can request a referral for dietary counseling to help you manage the weight gain risk." Most clients experience less weight gain when taking ziprasidone. Dietary counseling, exercise programs, and cognitive and behavioral strategies prevention and intervention strategies have been shown to have modest effects on weight. Although ziprasidone can be administered intramuscularly, it can be used only on an as-needed basis by this route. Ziprasidone has fewer extrapyramidal side effects, but that is not this client's major concern. Ziprasidone is better absorbed when taken with food, so a bedtime snack is needed.
A preadolescent client diagnosed with oppositional defiant disorder is verbally lashing out at other clients and threatening violence. What intervention should the nurse include when planning the care for a child? Take away privileges on the unit. Act as a mediator between the client and the other clients to reduce tension. Assist the client to find ways to deal with their anger. Seclude the client when they threaten violence
Assist the client to find ways to deal with their anger. Assisting the client in dealing with feelings is a behavior modification technique that is quite effective for children and adolescents with defiance and oppositional behaviors. By assisting the client to find ways to deal with anger, the nurse sets limits on the child's behavior and emphasizes appropriate behavior. Taking away privileges and secluding the client misses the opportunity to help the client learn ways to manage their anger. It is not the role of the nurse to go between this client and the other clients and mediate issues.
A 17-year-old high school student was referred to the outpatient mental health clinic in a situational crisis after learning that she is 5 months pregnant. Despite her decision to keep the baby after it is born, she wants to start college next fall. Her parents have offered no financial or emotional support, and her boyfriend broke up with her after learning of her pregnancy. Which action should the nurse take to help the client deal with this crisis? Call the client's parents and suggest they attend a family therapy session. Give the client information about homes for unwed mothers and adoption agencies. Explore with the client different options available to her and the possible consequences of each. Encourage the client to attend classes to get her high school equivalent after the baby is born.
Explore with the client different options available to her and the possible consequences of each. Exploring options available and possible consequences of each is correct because it encourages the client to begin the problem-solving process during this crisis The nurse should not propose family therapy or take over and make decisions for the client unless the client is suicidal. Providing information about adoption or homes for unwed mothers does not respect the choice the client has already made to keep the baby.
A client with impulsive behavior, unstable yet intense interpersonal relationships, and substance use disorder expresses anger to staff and other clients in a psychiatric unit. What is the priority action by the nurse? Inform the client how one's anger and behaviors affect others in the unit. De-escalate the situation by walking away when the client displays anger. Give positive reinforcement when the client uses appropriate ways to express anger. Medicate the client with prescribed haloperidol and lorazepam.
Give positive reinforcement when the client uses appropriate ways to express anger. Impulsive behavior and unstable but intense personal relationships are signs of borderline personality disorder. The client has impaired social interaction, and helping the client better understand how behaviors can impact others is important. The best way to impact the client's anger is to use positive reinforcement. This technique will increase the client's self-esteem and encourage further practice of the behavior. Walking away from the situation or sedating the client with haloperidol and lorazepam is not warranted and would not be therapeutic. Informing the client how one's anger affects others places the focus on other clients in the psychiatric unit. Therapeutic responses require the nurse to focus on the client. The use of positive reinforcement will help the client incorporate acceptable ways to express anger.
The nurse is admitting a client with Borderline Personality Disorder. When planning care for this client, the nurse should give priority to which item? safety splitting empathy manipulation
Safety Persons with Borderline Personality Disorder have a variety of difficult characteristics. Their impulsivity leads them to self-mutilation and sudden suicide attempts. This is the correct answer, as safety is always paramount. In splitting the client categorizes people as good or bad and tries to keep the bad from contaminating the good. Such a client may view a staff member as ideal and later devalue that person. Empathy is the nurse's attempt to understand and respond to a client's needs and feelings. In manipulation a person attempts to obtain needs in unacceptable ways.
A nurse is caring for a client diagnosed with bulimia nervosa. The most appropriate initial goal for this client is to: avoid shopping for large amounts of food. control eating impulses. identify a connection between anxiety and eating behaviors. restrict eating to three meals per day.
identify a connection between anxiety and eating behaviors. Bulimic behavior is generally a maladaptive coping response to stress and underlying issues. The client must identify anxiety-causing situations that stimulate the bulimic behavior and then learn new ways of coping with the anxiety. Controlling shopping for large amounts of food isn't a goal early in treatment. Managing eating impulses and replacing them with adaptive coping mechanisms can be integrated into the care plan after initially addressing stress and underlying issues. Eating three meals per day isn't a realistic goal early in treatment.
