Senior Seminar week 7 ch 68-72

the client diagnosed with terminal cancer says to the family nurse, "I'm going to die and I wish my family would stop hoping for a cure! i get so angry when they carry on like this. after all, im the one who's dying" which response is therapeutic?

"youre feeling angry that your family continues to hope for you to be cured?"

The nurse is creating a plan of care for a client in a crisis state. When developing the plan, the nurse should consider which factor?

A client's response to a crisis is individualized and what constitutes a crisis for one client may not constitute a crisis for another client

The nurse has been closely observing a client who has been displaying aggressive behaviors. The nurse observes that the behavior displayed by the client is escalating. Which nursing intervention is most helpful to this client at this time?

Acknowledge the client's behavior Assist the client to an area that is quiet Maintain a safe distance from the client

The police arrive to the ED with a client who has alerted both wrists. Which is the initial nursing action?

Assess and treat the wound site

A client receiving tricyclic antidepressant arrives at the mental health clinic. Which observation would indicate that the client is following the medication plan correctly?

Client arrives at the clinic neat and appropriate in appearance

The nurse is teaching a client who is being started on imipramine about the medication. The nurse should inform the client to expect maximum desired effects at which time period following itinerant of the medication?

In 2-3 weeks

The nurse is planning care for a client being admitted to the nursing unit who attempted suicide. Which priority nursing intervention should the nurse include in the plan of care?

One to one suicide precautions

Which behavior observed by the nurse indicates a suspicion that a depressed adolescent client may be suicidal?

The adolescent gives away a DVD and a cherished autographed picture of a performer

a client is admitted to the mental health unit with a diagnosis of depression. the nurse should develop a plan of care for the client that includes which intervention?

a structured program of activites which the client can participate

on review of the clients record, the nurse notes that the admission was voluntary. based on this information, the nurse plans care anticipating which client behavior?

a willingness to participate in the planning of the care and treatment plan

the nurse is caring for a client diagnosed with paranoid peronality disorder who is experiening disturbed thought processes. in formulating a nursing care plan, which best intvn should the nurse include

avoid using a whisper voice in front of the client

The nurse calls security and has physical restraints applied to a client who was admitted voluntarily when the client becomes verbally abusive, demanding to be discharged from th ehospital. which represents the possible legal ramifications for the nurse associated with these interventions?

battery, assault, false imprisonment

a client admitted voluntarily for txt of an anxiety disorder demands to be released from the hospital. which action should the nurse take initially?

contact the clients HCP

the nurse is preparing to perform an admission assessment on a client with a diagnosis of bulimia nervosa which assessment findings should the nurse expect to note?

dental decay loss of tooth enamel electrolyte imbalances

a client says to the nurse, the federal guards were sent to killl me. which is the best response by the nurse to the clients concern?

do you feel afraid that people are trying to hurt you

the nurse is conducting a group therapy session. during the session, a client diagnosed with mania consistently disrupts the groups interactions. which intervention should the nurse initallly implement?

setting limits on the clients behavior

the nurse employed in a mental health clinic is greeted by a neighbor in a local grocery store. the neighbor sasys to the nurse, how is carol doing? she is mu best friend and is seen at your clinic each week." which is the most appropriate response?

"I cannot discuss any client situation with you"

A client is admitted with a recent history of severe anxiety following a home invasion and robbery. During the initial assessment interview, which statement by the client should indicate to the nurse the possible diagnosis of PTSD?

"I keep reliving the robbery." "I see his face everywhere I go" "I might have died over a few dollars in my pocket"

A female victim of sexual assault is being seen in the crisis center. The client states that she still feels "as though the rape just happened yesterday," even though it has been a few months since the incident. Which is the most appropriate nursing response?

"Tell me more about the incident that causes you to feel like the rape just occurred."

He nurse is conducting an initial assessment of a client in crisis. When assessing the client's perception of the precipitating event that led to the crisis, which is the most appropriate question?

"What leads you to seek help now?"

A depressed client on an inpatient unit says to the nurse, "My family would be better off without me." Which is the nurse's best response?

"You sound very upset. Are you thinking of hurting yourself?"

a client with the diagnosis of depression who has attempted suicide says to the nurse, I should have died. ive always been a failure. nothing ever goes right for me. which response by the nurse demonstrates therapeutic communication?

"You've been feeling like a failure for a while"

A client is admitted to the mental health unit after an attempted suicide by hanging. The nurse can best ensure client safety by which action?

Assigning to the client a staff member who will remain with the client at all times

A client's medication sheet contains a prescription for sertraline. To ensure safe administration of the medication, how should the nurse administer the dose?

At the same time each evening

A hospitalized client is started on phenelzineu for the treatment of depression. The nurse should instruct the client that which foods are acceptable to consume while taking this medication?

Crackers Tossed Salad

The nurse is describing the medication side and adverse effects to a client who is taking oxazepam. Which information should the nurse incorporate in the discussion?

Increase fluids and bulk in the diet

a client with a diagnosis of anorexia nervosa, who is in a state of starvation, is in a 2-bed room. a newly admitted client will be assigned to this clients room. which cleint would be the best choice?

a client undergoing diagnostic tests

a client is preparing to attend a gamblers annonymous meeting for the first time. the nurse should tell the client that which is the first step in this 12 step program?

admitting to having a problem

a client with anorexia nervosa is a member of predischarge support group... the client believes the new clothes are much too tight and has reduced her calorie intake to 800. how should the nurse evaluate this behavior?

evidence of the clients disturbed body image

when a client is admitted to an inpatient mental health unit with the diagnosis of anorexia nervosa, a congnitive behavioral approach is used as part of the txt plan. the nurse plans care based on which purpose of this approach?

helping the client to examine dysfunctional thoughts and beliefs

the nurse determines that the wife of an alcoholic client is benefiting from attending an alc-anon group if the nurse hears the wife make which statement

i no longer feel that I deserve the beatings my husband inflicts on me

when planning the discharge of a client with chronic anxiety, the nurse directs the goals at promoting a safe environment at home. which is the most appropriate maintenance goal?

identifying anxiety-producing situations

a client is participating in a therapy group and focuses on viewing all team members as equally important in helping the clients to meet their goals. the nurse is impelemtning which therapeutic approach?

millieu therapy

when reviewing the admission assessment, the nurse notes that a client was admitted to the mental health unit involuntarily. based on this type of admission, the nurse should provide which intervention for the client?

monitor closely for harm to self or others

which intvns are most appropriate for caring for a client in alcohol withdrawal?

monitor vital signs provide a safe enviornment address hallucinations therapeutically provide reality orientation as appropriate

the nurse observes that a client is pacing, agitated, and presenting aggressive gestures. the clients speech pattern is rapid, and affect is belligerent. based on these observations, which is the nurses immediate priority of care

provide safety for the client an o ther clients on the unit

the nurse in the mental health unit plans to use which therapeutic communication techniques when communicating with a client?

restraining listening maintaining a neutral response providing acknowledgment and feedback

The nurse notes that a client which schizophrenia and receiving an antipsychotic medication is moving her mouth, protruding her tongue, and grimacing as she watches television. The nurse determines that the client is experiencing which medication complication?

tardive dyskinesia

which nursing intv are appropriate for a hospitalized client with mania who is exhibiting manipulative behavior?

-communicate expected behaviors to the client -assist the client in identifying ways of setting limits on personal behaviors -follow through about the consequences of behavior in a nonpunitive manner -have the client state the consequences for behaving in ways that are viewed as unacceptable

The nurse is administering risperidone to a client who is scheduled to be discharged. Before discharge, which instruction should the nurse provide to the client?

Get up slowly when changing positions

A moderately depressed client who was hospitalized 2 days ago suddenly begins smiling and reporting that the crisis is over. The client says to the nurse, "Im officially cured." How should the nurse interpret this behavior as a cue to modify the treatment plan?

increasing the level of suicide precautions

the nurse is working with a client who dispite making a heroic effort was unable to rescue a trapped neighbor in a house fire. which client focused action should the nurse engage in during the working phase of the nurse-client relationship?

inquiring about and examining the clients feelings for any that may block adaptive coping

the nurse is caring for a female clilent who was admitted to the mental health unit recently for anorexia nervosa. the nurse enters the clients room and notes that the client is engaged in rigorous pushups. which nursing action is most appropriate

interrupt the client and offer to take her for a walk

A hospitalized client has begun taking bupropion as an antidepressant agent. The nurse determines that which is an adverse effect, indicating that the client is taking an excessive amount of medication?

seizure activity

a client diagnosed with delirium becomes disoriented and confused at night. which intervention should the nurse implement initially?

use an indirect light source and turn off the television

a client experiencing disturbed thought processes believes that his food is being poisoned. which communication technique should the nurse use to encourage the client to eat?

using open-ended questions and silence

the spouse of a client admitted to the mental health unit for alc withdrawal says to the nurse, i should get out of this bad situation. which is the most helpful response?

what do you find difficult about this situation?

what is the most appropriate nursing action to help manage a manic client who is monopolizing a group therapy session?

thank the client for the input but inform the client that outher now need a chance to contribute

the nurse should plan which goals of the termination stage of group development

the group evaluates the experience the group explores members feelings about the group and impending separation

A client taking lithium reports vomiting, abdominal pain, diarrhea, blurred vision, tinnitus, and tremors. The lithium level is 2.5 mEq/L. The nurse plans care based on which representation of this level?

toxic

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

"You seem restless; tell me what is happening"

the nurse is monitoring a hospitalized client who abuses alcohol. which finding should alert the nurse to the potential for alcohol withdrawal derlium

hypertension, changes in LOC, hallucinations

The ED nurse is caring for an adult client who is a victim of family violence. Which priority instruction should be included in the discharge instructions?

information regarding shelters

A client is scheduled for discharge and will be taking phenobarbital for an extended period. The nurse would place highest priority on teaching the client which point that directly relates to client safety?

Avoid drinking alcohol while taking this medication

A client gives the home health nurse a bottle of clomiprapramine. The nurse notes that the medication has not been taken by the client in 2 months. Which behavior observed in the client would validate noncompliance with this medication?

Frequent hand washing with hot, soapy water

The nurse is performing a follow up teaching session with a client discharged one month ago. The client is taking fluoxetine. Which information would be important for the nurse to obtain during this client visit regarding the side and adverse effects of the medication?

GI dysfunctions

A client who has been taking buspirone for one month returns to the clinic for a follow-up assessment. The nurse determines that the medication is effective if the absence of which manifestation has occurred?

Rapid heartbeat or anxiety

the nurse is preparing a client with a history of command hallucinations for discharge by providing instructions on interventions for managing hallucinations and anxiety. which statement in response to these instructions suggests to the nurse that the client has a need for additional information

when i have command hallucinations, i'll call a friend and ask him what I should do

the nurse is planning activities for a client diagnosed with bipolar disorder with agressive social behavior. which activity would the most appropriate for the client

writing

the nurse visits a client at home. The client states, "I havent slept at all the last couple of nights." which response by the nurse demonstrates therapeutic communication?

youre having difficulty sleeping?

The nurse in the emergency department is caring for a young female victim of sexual assault. The client's physical assessment is complete, and physical evidence has been collected. The nurse notes that the client is withdrawn, confused, and at times physically immobile. How should the nurse interpret these behaviors?

Reactions to a devastating event

The nurse is reviewing the assessment data of a client admitted to the mental health unit. The nurse notes that the admission nurse documented that the client is experiencing anxiety as a result of a situational crisis. The nurse plans care for the client determining that this type of crisis could be cause by which event?

The death of a loved one

A client with schizophrenia has been started on medication therapy with clozapine. The nurse should assess the results of which laboratory study to monitor for adverse effects from this medication?

WBC count

the home health nurse visits a client at home and determines that the client is dependent on drugs. during the assessment, at which action should the nurses take to plan appropriate nursing care

ask the client about the amount of drug use and its effects

a client is unwilling to go to his church b/c his ex girlfirend goes there and he feels that she will laugh at him if she sees him. Because of this hypersensitivity to a reaction from her, the client remains homebound. the home care nurse develops a plan of care that addresses which personality disorder?

avoidant

the nurse provides and educational session on client rights. which statement by a member of the session demonstrates the best understanding of the nurses role regarding enduring that each clients rights are respected?

being respectful and concerned will ensure that im attentive to my clients rights

a hospitalized client with a history of alc abuse tells the nurse "I am leaving now, I have to go, i dont want txt anymore." the client has not been discharged and is scheduled for an important diagnostic test to be performed in 1 hr. after the nurse discussed the clients concerns with the client, the client dresses and begins to walk out of the hospital room. what action should the nurse take?

call the nursing supervisor

a client is admitted to a medical nursing unit with a diangosis of acute blindness after being involved in a hit and run accident. when diagnostic testing cannot identify any organic reason why this clinet cannot see, a mental health consult is prescribed. the nurse plans care based oon which condition that should be the focus of this consult?

conversion disorder

a manic client begins to make sexual advances toward visitors in the dayroom. when the nurse firmly states that this is inappropriate and will not be allowed, the client vecomes verbally abusive and threatens physical violence to the nurse. based on the analysis of this situation, which intervention should the nurse implement?

escort the client to their room, with the assistance of other staff

the nurse is caring for a client just admitted to the mental health unit and diagnosed with catatonic stupor. the client is lying on the bed in a fetal positon. which is the most appropriate nursing intervention

sit beside the client in silence with occasional open ended questions