Review_Mental

A licensed practical nurse (LPN) is caring for a client with a diagnosis of schizophrenia. The LPN observes behaviors indicative of paranoia and reports these observations to the registered nurse (RN). The LPN assists the RN in developing a plan of care for the client and suggests inclusion of which intervention in the plan of care?

Rationale: A client with paranoia is distrustful and suspicious of others. Joking, laughing, or whispering in front of the client would increase these feelings in the client. Options 1, 2, and 3 are not appropriate or helpful interventions for the client with paranoia.

A nurse is preparing to admit a client diagnosed with obsessive-compulsive disorder (OCD) to the mental health unit. The nurse observes this client for behavioral characteristic(s) of one who is:

Rationale: Rigidity and inflexibility are behavioral characteristics of the client with OCD. Clients are not usually hostile unless they are prevented from performing the obsession or compulsion, because that is what decreases the anxiety. The other options are incorrect because they are not characteristics of OCD.

nurse observes that a client with a potential for violence is agitated, pacing up and down in the hallway, and making aggressive and belligerent gestures at other clients. Which statement would be appropriate to make to this client?

Rationale: The best statement is to ask the client what is causing the agitation. This will assist the client to become aware of the behavior and will assist the nurse in planning appropriate interventions for the client. Option 1 is demanding behavior, which could cause increased agitation in the client. Options 2 and 4 are threats to the client and are inappropriate.

A client was admitted to a medical unit because the client suddenly experienced total deafness. The client undergoes numerous testing to determine the cause of the deafness. All test results are negative, and there seems to be no organic reason why this client cannot hear. On further review of the client's record, the nurse notes that the client became deaf after witnessing a murder. Based on this information and the results of the diagnostic tests, the nurse suspects that the client may be experiencing:

Rationale: A conversion disorder is the alteration or loss of a physical function that cannot be explained by any known pathophysiological mechanism. It is thought to be an expression of a psychological need or conflict. In this scenario, the client witnessed a murder that was so psychologically painful, the client became deaf. Psychosis is a state in which a person's mental capacity to recognize reality, communicate, and relate to others is impaired, thus interfering with the person's capacity to deal with life demands. A dissociative disorder is a disturbance or alteration in the normally integrative functions of identity, memory, or consciousness. Repression is a coping mechanism in which unacceptable feelings are kept out of awareness

A 15-year-old client who is pregnant and unwed, says, "My life was unbearable before I met Johnny. My mother beats me up every day and my dad has been sleeping with me since I was ten years old!" Which response is appropriate for the nurse to make?

Rationale: Adolescent pregnancy outside of marriage can arise from female low self-esteem, fears of inadequacy, and desperation to escape from an abusive and dysfunctional family. The most therapeutic communication technique is the one that uses restatement and repeats the main thought that the client expressed. This assures the client that the nurse is listening and is attempting to validate what the client has said. Options 1, 2, and 3 are nontherapeutic. Option 1 reflects knowledge deficit on the nurse's part. Option 2 is insensitive and makes assumptions. Option 3 makes connections that are assumed and imply judgmental bias.

The wife of a client who abuses alcohol tells the nurse she cannot "do it alone" any longer and asks the nurse about the availability of any free support services for "people like me." The nurse refers the client's wife to which of the following community groups?

Rationale: Al-Anon is a support group for families of alcoholics. Families Anonymous is a support group for parents of children who abuse substances. Fresh Start is a self-help group for those with addiction to nicotine. Alcoholics Anonymous is a major self-help organization for those who suffer from alcoholism.

A nurse is preparing a client who was hospitalized for depression for discharge. In evaluating the coping strategies learned during hospitalization, the nurse would recognize which statement by the client as an indication that further teaching is needed?

Rationale: Depression may be a recurring illness for some people. The client needs to understand the symptoms and recognize when or if treatment needs to begin again. Options 1, 3, and 4 identify that the client has learned some coping skills, such as setting limits and taking medications.

A nurse is caring for a client who has bipolar disorder with aggressive social behavior. Which of the following activities would be most appropriate initially for this client?

Rationale: Solitary activities that require a short attention span with mild physical exertion are the most appropriate activities initially for a client who is aggressive. Writing (journaling), walks with staff, and finger painting are activities that minimize stimuli and provide a constructive release for tension. Competitive games (options 1, 3, and 4) should be avoided because they can stimulate aggression and increase psychomotor activity.

While a nurse is providing care, a client angrily reports to the nurse that the health care provider purposefully provided wrong information about her diagnosis and states, "The doctor lied to me." Which of the following nursing responses would likely be a barrier to further communication with the client?

Rationale: The response in option 1 could make the client defensive and block further communication because it expresses disagreement with the client's statement. Options 2 and 3 attempt to clarify the client's comment. Option 4 attempts to explore whether the client is comfortable talking to the health care provider about this subject and encourages direct confrontation.

A nurse is collecting data on a client diagnosed with mild depression. The client says to the nurse, "I haven't had an appetite at all for the last few weeks." Which of the following responses by the nurse would be therapeutic?

Rationale: The therapeutic nursing communication technique is restatement. Although it is a technique that has a prompting component to it, it repeats the client's major theme, which helps the nurse obtain a more specific perception of the problem from the client. Options 1 and 2 block the communication process. Option 3 focuses on the number of weeks that the lack of appetite has been present rather than the specific problem

A client says to the home care nurse, "I can't believe that my wife died yesterday. I keep expecting to see her everywhere I go in this house, ready to plan our activities for the day." Which of the following is the therapeutic nursing response?

Rationale: The therapeutic nursing response is the one that recognizes the difficulties of grieving the loss of a loved one and facilitates expression of feelings. Options 2, 3, and 4 are not therapeutic and do not encourage expression of feelings.

A nursing student is developing a plan of care for the hospitalized client with bulimia nervosa. The nursing instructor intervenes if the student documents which incorrect intervention in the plan?

Rationale: Excessive exercise is a characteristic of anorexia nervosa, not bulimia nervosa. Frequent vomiting, in addition to laxative and diuretic abuse, may lead to dehydration and electrolyte imbalance. Monitoring for dehydration and electrolyte imbalance are important nursing actions. Option 3 is the only option that is not associated with care of the client with bulimia.

A mental health nurse is assigned to care for a client with a diagnosis of schizophrenia, acute phase. The nurse should use which of the following approaches when planning care for this client?

Rationale: In the acute phase of schizophrenia, the nurse must assume responsibility for planning the client's basic human needs, such as nutrition, hygiene, sleep, and activities of daily living. As the nurse plans care for the schizophrenic client, it is important to understand the client's developmental stage and ability to accept the disease. The client lacks insight and may not be aware of the illness because of the severe decompensation in thinking. Option 1 is a nontherapeutic communication technique. Options 2 and 3 are incorrect, because these actions do not provide a structured routine.

During the termination phase of the nurse-client relationship, the clinic nurse observes that the client continuously demonstrates bursts of anger. The appropriate interpretation of the behavior is that the client:

Rationale: In the termination phase of a relationship, it is normal for a client to demonstrate a number of regressive behaviors. Typical behaviors include return of symptoms, anger, withdrawal, and minimizing the relationship. The anger that the client is experiencing is a normal behavior during the termination phase and does not necessarily indicate the need for hospitalization or treatment.

A hospitalized client with a history of alcohol abuse tells a nurse, "I am leaving now. I don't want help. I have other things to attend to that are more important." The nurse attempts to discuss the client's concerns, but the client dresses and begins to walk out of the hospital room. The nurse should take which action at this time?

Rationale: The nurse should call the nursing supervisor. When clients leave AMA, most health care facilities have documents relating to the client's responsibilities, which the client is asked to sign before leaving. The nurse should request that the client speak to the health care provider before leaving, but if the client refuses, the nurse cannot hold the client against his or her will. Any client has a right to health care and cannot be told otherwise (option 1). A nurse can be charged with false imprisonment if a client is made to wrongfully believe that he or she cannot leave the hospital (options 3 and 4).