Foundations of Psychiatric Nursing

A client with psychosis is prescribed quetiapine 400 mg by mouth daily in two divided doses. The pharmacy dispenses 200-mg tablets. How many tablets should the nurse administer with each dose? Record your answer using a whole number.

1 The prescribed dosage is 400 mg by mouth daily in two divided doses. 400 mg divided by 2 doses equals 200 mg per dose. The nurse should give one tablet with each dose.

The nurse understands that with the right help at the right time, a client can successfully resolve a crisis and function better than before the crisis, based primarily on which factor? relinquishment of dysfunctional coping gain of crisis prevention knowledge acquisition of new coping skills reestablishment of lost support systems

acquisition of new coping skills Learning new coping skills is the major factor necessary for higher functioning. Better coping is likely to lead to regaining support systems, giving up dysfunctional coping, and awareness of how to prevent future crises.

As the nurse stands near the window in the client's room, the client shouts, "Come away from the window! They will see you!" Which response by the nurse would be best? "No one will see me." "What will happen if they do see me?" "You have no reason to be afraid." "Who are 'they'?"

"Who are 'they'?" Asking the client who "they" are when he is fearful helps the nurse understand his behavior and is least demanding of the client.The client is unlikely to accept statements that indicate that no one will see the nurse. The client is unlikely to accept statements that there is no reason to be afraid.Asking the client what will happen if someone sees the nurse is also unlikely to be acceptable and validates the client's delusion.

Nursing implications for a client taking central nervous system (CNS) stimulants include monitoring the client for which conditions? hyperpyrexia, slow pulse, and weight gain increased appetite, slowing of sensorium, and arrhythmias hypotension, weight gain, and listlessness tachycardia, weight loss, and mood swings

tachycardia, weight loss, and mood swings Stimulants produce mood swings, anorexia and weight loss, and tachycardia. Hyperpyrexia, slow pulse, weight gain, hypotension, listlessness, increased appetite, slowing of sensorium, and arrhythmias indicate CNS depression.

A client becomes angry and belligerent toward the nurse after speaking on the phone with the client's mother. The nurse recognizes this as what defense mechanism? suppression repression rationalization displacement

displacement Displacement is a defense mechanism in which the client transfers feelings for one person to another person who is less threatening. Rationalization is a defense mechanism in which the client makes excuses to justify unacceptable feelings or behaviors. Repression is characterized by an involuntary blocking of unpleasant experiences from one's consciousness. Suppression is the conscious blocking of unpleasant experiences from one's awareness.

A client is being discharged after 3 days of hospitalization for a suicide attempt that followed the receipt of a divorce notice. Which client finding indicates to the nurse that the client is ready for discharge? displays emotional stability expresses a readiness for discharge has the names and phone numbers of two divorce lawyers has a list of support persons and community resources

has a list of support persons and community resources The risk of suicide can persist for 2 to 3 months even after a crisis has abated. Therefore, it is important for the client to be able to verbalize information about appropriate support persons and community resources and to have this information readily available. Although the client may state feeling ready to be discharged, this is not the most reliable indicator. A divorce lawyer may not be appropriate at this point. At 3 days after a suicide attempt, emotional stability is not likely.

A client who has had AIDS for years is being treated for a serious episode of pneumonia. A psychiatric nurse consult was arranged after the client stated, "I'm tired of being in and out of the hospital. I'm not coming in here anymore. I have other options." The nurse would evaluate the psychiatric nurse consult as helpful if the client makes which statements? "I would probably screw up suicide anyway." "I realize that I really do have more time to enjoy my friends and family." "Nobody wants me to commit suicide." "If I talk about suicide, I'll be transferred to the psychiatric unit."

"I realize that I really do have more time to enjoy my friends and family." Focusing on enjoying time with family and friends conveys a renewal of hope for the future and a decreased risk of suicide. Simply saying that no one wants the client to commit suicide does not say the client does not want to do it. Avoiding a transfer to a psychiatric unit does not mean the client is no longer suicidal. Fear of not being successful with suicide usually is not a deterrent.

A client is taking clozapine and complains of a sore throat. This symptom may be an indication of which adverse reaction? agranulocytosis extrapyramidal reaction tardive dyskinesia Reye's syndrome

agranulocytosis The complaint of a sore throat may indicate an infection caused by agranulocytosis, a depletion of white blood cells. Although extrapyramidal reaction and tardive dyskinesia may occur, a sore throat isn't an indication of these conditions. Reye's syndrome is caused by a virus unrelated to clozapine.

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? ensuring relevance to, and quickly refocusing upon, the client's experience allowing the client time to ask questions about the nurse's experience 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 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.

The nurse manager of a psychiatric unit notices that one of the nurses commonly avoids a 75-year-old client's company. Which factor should the nurse manager identify as being the most likely cause of this nurse's discomfort with older adult clients? recent experiences with her mother's older adult friends a desire to be surrounded by beauty and youth fears and conflicts about aging dislike of physical contact with older people

fears and conflicts about aging The most common reason for a nurse's discomfort with older adult clients is that the nurse has not conducted a self-examination of fears and conflicts about aging. Until nurses resolve their fears, it is unlikely that they will feel comfortable with older adult clients. A dislike of physical contact with older people, a desire to be surrounded by beauty and youth, and recent experiences with a parent's older adult friends are possible explanations, but not common or likely.

The most effective way for a nurse to set limits for a newly admitted client who puts out cigarettes on the floor of the designated smoking room is to: encourage other clients to speak with this client about dirtying the floor. ask if the client puts out cigarettes on the floor at home. restrict the client's smoking to times when a staff member can supervise closely. hand the client an ashtray and state that the client must use it or the client will not be allowed to smoke.

hand the client an ashtray and state that the client must use it or the client will not be allowed to smoke. Setting limits is necessary to help clients behave in socially acceptable ways. By handing the client an ashtray and stating objectively that the client won't be allowed to smoke if the client doesn't use the ashtray, the nurse is setting limits on the client's behavior. Because this client is newly admitted, the nurse may need to restate these limits in a manner that shows disapproval of the behavior but doesn't reject the client as a person. A matter-of-fact, nonpunitive tone of voice is important. The nurse must stress that noncompliance will have consequences - in this case, a prohibition against smoking. The nurse can't bend the rules to accommodate the client. Encouraging other clients to deal with a new client isn't advisable. Asking if the client puts out cigarettes on the floor at home has no bearing on whether this behavior is acceptable in the hospital.

A nurse is caring for a client admitted to the psychiatric unit with anxiety and depression. The client refused to take the prescribed fluoxetine and bupropion. Which statement by the nurse is best? "I will contact your provider and request different medications." "These medications upset my stomach too, I will get you crackers first." "Have you taken fluoxetine and bupropion before?" "Can you tell me why you do not want to take these mediations?

"Can you tell me why you do not want to take these mediations? The nurse is required to assess before acting. In this circumstance, the nurse is required to assess why the client is refusing to take the medications before acting. By asking an open-ended question the nurse will encourage the client to express concerns. Asking a yes or no question will not elicit a detailed response. Before the nurse contacts the health care provider, the nurse should first assess why the client is refusing the medications. A therapeutic response should focus on the client, not the nurse. Additionally, the nurse should not assume the client is refusing the medications because of abdominal discomfort.

The nurse manager on a psychiatric unit is reviewing the outcomes of staff participation in an aggression management program. What indicator would the nurse use to evaluate the effectiveness of such a program? fewer client injuries during restraint procedures fewer staff injuries during restraint procedures a reduction in the number of complaints by clients' relatives a reduction in the total number of restraint procedures

a reduction in the total number of restraint procedures The primary goal of an aggression management program is to prevent violence. This goal is evidenced by a reduction in the total number of restraint procedures used or needed. Although fewer client and staff injuries are important, these goals are secondary to prevention. Reduction in the number of complaints by clients' relatives is affected by more variables than just restraint procedures.

The nurse is performing an assessment on a client with a history of a dysfunctional family. Which findings should the nurse anticipate? Select all that apply. structured limit setting direction and attention unhealthy personal boundaries supportive parents abuse and neglect

unhealthy personal boundaries abuse and neglect Healthy boundaries setting limits are established in childhood when parents provide consistent, supportive limits, and attention. In a dysfunctional family, the parents are unable to give the support, attention, care, discipline, and direction that children need in order to develop into mature adults. Often they are abused, emotionally or otherwise, or neglected. This leads to a poor self-concept and role confusion, the basis for unhealthy personal boundaries.

Which statement indicates to the nurse that the client is progressing toward recovery from a somatoform disorder? "I need to find a health care provider who understands what my pain is like." "My headache feels better when I time my medication dose." "I understand my pain will feel worse when I am worried about my divorce." "My stomach pain will go away once I get properly diagnosed."

"I understand my pain will feel worse when I am worried about my divorce." The client who states, "I understand my pain will feel worse when I am worried about my divorce" recognizes the connection between his pain and the divorce and indicates developing insight into his problem. The nurse should then be able to assist the client with developing adaptive coping strategies. The other statements indicate a lack of insight into his disorder and lack of progress toward recovery. The client is still searching for the "right" diagnosis, medication, and health care provider (HCP).

A woman who was raped in her home was brought to the emergency department by her husband. After being interviewed by the police, the husband talks to the nurse. "I don't know why she didn't keep the doors locked like I told her. I can't believe she's had sex with another man now." How should the nurse respond? "Maybe the doors were locked, but the man broke in anyway." "Your wife needs your support right now, not your criticism." "Let's talk about how you feel. Maybe it would help to talk to other men who have been through this." "It wasn't consensual sex. Let's see if your wife was physically injured."

"Let's talk about how you feel. Maybe it would help to talk to other men who have been through this." The nurse should respond to the husband's needs and concerns and should offer support. Protecting or defending the wife against his criticism ignores the husband's needs.

A client is admitted for a surgical biopsy of a suspicious lump in the right breast. At the time the nurse arrives to take the client to surgery, the client is finishing a letter to the client's children. The client tearfully tells the nurse, "I just want to leave this for my children in case anything goes wrong in the surgery." Which nursing response will be most therapeutic? "I will call the doctor to answer any questions you may have about the biopsy." "What are you concerned about right now?" "This really is a minor procedure, so don't let it upset you." "It sounds like you are more worried about the biopsy than about your chances for having cancer."

"What are you concerned about right now?" The most therapeutic response is one in which the nurse reflects back to the client what the client has said and asks the client to reflect further. Making light of the client's worries about the biopsy does not help the client process their feelings or concerns. The client did not express questions about the biopsy; therefore calling the doctor is not appropriate at this time. Confronting the client about what the nurse feels is misplaced anxiety of the biopsy versus cancer would not be beneficial to the client and not therapeutic in these circumstances.

A nurse is working with an adolescent who has reported low self-esteem. When developing a plan of care, the nurse considers the adolescent's psychosocial needs. Which question will best assist the nurse in assessing the adolescent's psychosocial development? "How did you come to understand your feelings about yourself?" "Do you know your ethnic background and customs?" "What makes you think the things you do?" "What is your religion?"

"How did you come to understand your feelings about yourself?" According to Erik Erikson, the primary psychosocial task during adolescence is to establish a personal identity while overcoming role or identity confusion. The adolescent strives to attain a personal identity by becoming more independent from the client's family. Asking the adolescent client about their religious beliefs and ethnic background would not establish identity. Asking the teen what makes them think the things they do could make the teen defensive. An open-ended question that allows the adolescent to explore their thoughts and feelings is the best way to assist the teen in building identity.

A client is admitted to the hospital because of threatening, aggressive behavior toward his family. In the first group meeting after the client is admitted, another client sits near the nurse and says loudly, "I'm sitting here because I'm afraid of Ted. He's so big, and I heard him talk about hitting people." The nurse should say to the client: "Everyone is here for different problems. You know you don't have to worry." "Ted is new to the group. Let's go around and introduce ourselves to him." "You don't know Ted yet. Once you get to know him, I'm sure you won't be afraid." "It's frightening to have new people on the unit. We're here to talk about things like being afraid."

"It's frightening to have new people on the unit. We're here to talk about things like being afraid." The nurse needs to acknowledge the client's feelings. In doing so, the nurse helps the group accept a new member. Focusing on "everyone" and telling the client not to worry ignores the client's fears. Having the other group members introduce themselves places the focus on the other clients in the group and does not address the client's fears. Implying that getting to know someone will reduce the fear is false reassurance.

Which principle of the psychoanalytic model is particularly useful to psychiatric nurses? The first 6 years of a person's life determine personality. Behavioral deviations result from an incongruence between verbal and nonverbal communication. All behavior has meaning. Behavior that is reinforced will be perpetuated.

All behavior has meaning. The principle that all behavior has meaning is of particular importance to the psychiatric nurse. It serves as the basis for the nurse's assessment and analysis of the client's behavior, which reflects the client's needs. Psychoanalytic theory also proposes that the first 6 years of a person's life determine personality; these early influences are difficult, if not impossible, to counteract. However, this assumption is less useful to the nurse in planning interventions that meet the client's current needs. Reinforcement as a means of perpetuating behavior is associated with behavioral theory — not the psychoanalytic model. Incongruence between verbal and nonverbal communications is an element of communications theory.

A nurse assesses a client with psychotic symptoms and determines that the client likely poses a safety threat and needs vest restraints. The client is adamantly opposed to this. What would be the best nursing action? Restrain the client with vest restraints. Apply wrist restraints instead of vest restraints. Ask a family member to come in to supervise the client. Contact the physician and obtain necessary orders.

Contact the physician and obtain necessary orders. If a nurse feels that a client needs to be restrained, the nurse should inform the physician and obtain necessary orders. The nurse should also discuss this with the client's family members and ask their opinion. Applying a wrist restraint instead of a vest restraint is inappropriate if a vest restraint is genuinely necessary. It would be inappropriate to delegate this aspect of care to a family member.

The nurse teaches a client about the benefits of participation in self-help groups. What information does the nurse include in the teaching plan? Select all that apply. It increases the client's sense of well-being. It is more cost-effective than hospitalization. It facilitates the development of advocacy skills. It increases knowledge about mental illness. It develops stronger social networks and support.

It increases knowledge about mental illness. It develops stronger social networks and support. It increases the client's sense of well-being. Participation in self-help groups has been shown to increase knowledge, coping skills, self-esteem, confidence, sense of well-being and a sense of being in control. Improving social and support networks is also a common outcome of client engagement in self-help groups. If symptoms are severe and/or life-threatening hospitalization may be the most appropriate and as a result potentially more cost effective. Development of personal advocacy skills is not a primary outcome of client participation in self-help groups.

During an appointment with the nurse, a client says, "I could hate God for that flood." The nurse responds, "Oh, don't feel that way. We're making progress in these sessions." The nurse's statement demonstrates a failure to do what? Explain to the client why he may think as he does. Give the client credit for solving his own problems. Add to the strength of the client's support system. Look for meaning in what the client says.

Look for meaning in what the client says. The nurse's response fails to identify the meaning in what the client has said. The nurse needs to explore the client's statement about hating God for that flood because the meaning of the client's statement is unclear. Also, statements such as "Don't feel that way" are not helpful because they ignore the client's feelings and his interpretation of the situation in which he finds himself. Explaining to the client why he may think as he does (offering a rationale) is inappropriate. The nurse's response fails to identify the meaning in what the client has said and is not supportive. There is no evidence that the client is solving his problems.

A nurse is evaluating a family in which chronic child abuse has occurred and the parents have experienced chronic alcohol and drug abuse. Significant social supports have been established by social services and the parents have both received drug and alcohol treatment and parenting classes. Which indicates that the parents have progressed in their treatment? The parents report high expectations for the young children to manage the household tasks. The parents report continued use of spanking as discipline. The parents say they hope to attend parenting classes. The parents report an understanding of normal growth and development.

The parents report an understanding of normal growth and development. Understanding normal growth and development helps the parents have more reasonable expectations of their children. Spanking indicates the parents have not learned other forms of discipline. Expecting hyper-responsible behavior is not healthy, and merely hoping to attend parenting classes does not indicate an understanding of the concepts.

What is a crucial goal of therapeutic communication when helping the client deal with personal issues and painful feelings? communicating empathy through gentle touch guaranteeing total confidentiality and anonymity for the client conveying client respect and acceptance even if not all of the client's behaviors are tolerated mutual sharing of information, spontaneity, emotions, and intimacy

conveying client respect and acceptance even if not all of the client's behaviors are tolerated The nurse is required to set limits on inappropriate behavior while conveying respect and acceptance of that person. Doing so conveys that the client is worthy without posing any harm or embarrassment to the client. Touch is a complex issue that must be used cautiously. Touch may be misinterpreted or misperceived by a client who has been abused or who has perceptual or thought disturbances. Mutual sharing reflects a social friendship, not a therapeutic one. Total confidentiality is not desirable. For example, treatment team members and insurance companies need selected information to ensure quality services.

A client who is suspicious of others, including staff, is brought to the hospital wearing a wrinkled dress with stains on the front. Assessment also reveals a flat affect, confusion, and slow movements. Which goal should the nurse identify as the initial priority when planning this client's care? helping the client feel safe and accepted providing the client with clean, comfortable clothes introducing the client to other clients giving the client information about the program.

helping the client feel safe and accepted The initial priority for this client is to help her overcome suspiciousness of others, including staff, and thereby feel safe and accepted. Introducing the client to others, giving the client information about the program, and providing clean clothes are important, but these are of lower priority than helping the client feel safe and accepted.

The nurse correctly judges that the danger of a suicide attempt is greatest with which client behavior? increase in energy level at the point of deepest despair willingness to visit with an estranged brother resumption of former lifestyle

increase in energy level The client's energy level is related to the danger involved. Suicide attempts are more likely carried out when the client has more energy to act on thoughts and impulses. A client may not have the energy to commit suicide during times of severe depression.Resuming a former lifestyle is usually a sign of improvement unless the lifestyle places the client in danger.Visiting an estranged sibling does not indicate that a suicide attempt is imminent.

A client with suspected abuse describes her husband as a good man who works hard and provides well for his family. She does not work outside the home and states that she is proud to be a wife and mother just like her own mother. The nurse interprets the family pattern described by the client as best illustrating which characteristic of abusive families? dysfunctional feeling tone role stereotyping unbalanced power ratio tight, impermeable boundaries

role stereotyping The traditional and rigid gender roles described by the client are examples of role stereotyping. Impermeable boundaries, unbalanced power ratio, and dysfunctional feeling tone are also common in abusive families.

Which factor is a priority for the nurse to evaluate when completing discharge planning for a client who has had a lobectomy for treatment of lung cancer? the distance the client lives from the hospital the support available to assist the client at home the client's knowledge of the causes of lung cancer the client's ability to do home blood pressure monitoring

the support available to assist the client at home Because clients are discharged as soon as possible from the hospital, it is essential to evaluate the support they have to assist them with self-care at home. The distance the client lives from the hospital is not a critical factor in discharge planning. There are no data indicating that home blood pressure monitoring is needed. Knowledge of the causes of lung cancer, although important, is not the most essential area to evaluate given the client's postoperative status.

Which client statement indicates that the client has gained insight into his use of the defense mechanism of displacement? "Now when I am mad at my wife, I talk to her instead of taking it out on the kids." "I can't think about the weekend right now. I've got to study for the exam." "I know I'm not good in sports, but I feel good about my grades." "For years I couldn't remember being molested; now I know I have to face it."

"Now when I am mad at my wife, I talk to her instead of taking it out on the kids." Displacement refers to a defense mechanism that involves taking feelings out on a less-threatening object or person instead of tackling the issue or problem directly. Talking to his wife directly reflects insight into the client's use of the defense mechanism and his ability to overcome it. Not thinking about the weekend is suppression. Here, the client is focusing on the issue with the highest priority. Focusing on academic rather than athletic achievement is compensation, highlighting one's strengths instead of weaknesses. Not remembering the molestation is repression.

A client presents to the emergency department confused and disoriented after being pulled out of a house fire. The client is mumbling incoherently. Which statement by the nurse exemplifies therapeutic communication? "Has anything like this happened to you before?" "You are at the hospital now, and you are safe." "You must talk so I can figure out what is going on with you." "I understand how you feel. I lost my parents in a fire."

"You are at the hospital now, and you are safe." Communicating with a client experiencing a crisis can be difficult. A therapeutic statement is compassionate, focuses on the client and the here and now, and contains truthful information. By telling the client he or she is safe, the nurse is being a source of stability and providing reassurance. Demanding the client talk is considered confrontational and may increase the client's stress level. A therapeutic statement focuses on the client, not the nurse. Additionally, a therapeutic response focuses on the here and now, not the past. Asking if the client has experienced this before does not help the client's present situation.

While listening to a taped-report at shift change, one of the other team members remarks that "My mother lives near this client, and his yard is always full of junk." What should the nurse assigned to provide care to this client do in this situation? Ask the team member to be quiet. Include the information in report for the next shift. Ask the team member what the purpose was in sharing the information. Ignore the comment.

Ask the team member what the purpose was in sharing the information. The assigned nurse should determine if the comment has any relevance to the care of this client. Ignoring the comment or asking the team member to be quiet does not help determine if the comment was appropriate. Only information that has therapeutic value should be shared with other team members.

A client who is neatly dressed and clutching a leather briefcase tightly in his arms scans the adult inpatient unit on his arrival at the hospital and backs away from the window. The client requests that the nurse move away from the window. The nurse recognizes that doing as the client requested is contraindicated for which reason? The action indicates nonverbal agreement with the client's false ideas. The nurse will be demonstrating a lack of composure over the situation. The client will then think that he will have his way when he wishes. The action will make the client feel that the nurse is humoring him.

The action indicates nonverbal agreement with the client's false ideas. The nurse's nonverbal behavior, moving away from the window as the client requests, indicates agreement with the client's false ideas. The client's behavior is likely to be reinforced if the nurse takes steps to agree with the false ideas the client holds.

In terminating the relationship with the nurse, which client reaction should be considered the healthiest? a lack of response an attempt at humor an expression of grief a display of anger

an expression of grief Grief is a direct and appropriate response to termination of a positive relationship. Grief indicates acceptance of termination.A lack of response may be interpreted as indifference, or it represents an emotional reaction that the client is unable to express.Anger is healthy when appropriately expressed but is a less healthy reaction than grief.Humor may be a defense against feelings of loss.

When planning the care of a client experiencing aggression, the nurse incorporates the principle of "least restrictive alternative," meaning that less restrictive interventions must be tried before more restrictive measures are employed. Which measure should the nurse consider to be the most restrictive? haloperidol given intramuscularly haloperidol given orally tension reduction strategies voluntary seclusion or time-out

haloperidol given intramuscularly When given intramuscularly, haloperidol is considered most restrictive because it is intrusive and a client usually does not receive the drug voluntarily. Oral haloperidol is considered less restrictive because the client usually accepts the pill voluntarily. Tension reduction strategies and voluntary seclusion are considered less restrictive because they are not intrusive and the client usually consents to their use.

The nurse who uses self-disclosure should: discuss the nurse's experience in detail. refocus on the client's experience as quickly as possible. allow the client to ask questions about the nurse's experience. have the client examine what the nurse has revealed.

refocus on the client's experience as quickly as possible. 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, discussion shouldn't dwell on the nurse's experience.

A teenage client is a high school wrestler who fasts before every wrestling tournament and then binges immediately after the tournament. On the way to each tournament, the client walks rapidly up and down the bus aisle and spits repeatedly into a cup. Which is the best initial intervention for this client? Ask the physician for medication to treat the eating disorder. Teach the client's parent about nutritional requirements of teenagers. Call the high school principal to report the wrestling coach for not stopping this behavior. Discuss secondary gains that are unconsciously driving the client's behavior.

Discuss secondary gains that are unconsciously driving the client's behavior. Discuss secondary gains that are unconsciously driving the client's behavior as a first step in assessment and intervention. The client and their family need assistance to examine motives for this behavior and the extent of the behavior. The client first needs to discuss the altered behaviors and deal with the issue openly. Teaching the parent about nutrition appears to blame the parent and puts the responsibility for the problem solely on the parent. Psychopharmacology may be helpful but there is no specific medication for the treatment of eating disorders, and this is not indicated at this stage of the client's assessment and treatment. Calling the high school principal to report the wrestling coach would be inappropriate at this stage, although the parents may want to talk with the wrestling coach about their concerns.

Which of the following client behaviors indicates the nurse-client relationship is in the working phase? The client starts to challenge the boundaries or outer limits of the relationship. The client makes an effort to describe his or her problems in detail. The client tries to summarize his or her progress in the relationship. The client attempts to familiarize himself or herself with the nurse.

The client makes an effort to describe his or her problems in detail. The client's effort to describe his or her problems to the nurse indicates that nurse-client relationship is most probably in the working phase. The client's action illustrates that the client has gone beyond testing and acquainting himself or herself with a new relationship and is now working on his problems.The relationship is in an orientation phase when the client attempts to familiarize himself or herself with the nurse or when the client challenges the boundaries of the relationship.The relationship is in a termination phase when the client summarizes and evaluates his or her progress.

An experienced nurse is precepting a new nurse in a psychiatric emergency room and is discussing criteria for involuntary commitment. Which client would signal to the experienced nurse that the new nurse understands the criteria? a person with depression who says they are tired of living and does not have a suicidal plan the parent who leaves their minor children unattended and stays out all night snorting cocaine a client with schizophrenia who can manage activities of daily living but has grandiose delusions a person who threatens to kill their spouse of 38 years

a person who threatens to kill their spouse of 38 years One of the criteria for involuntary commitment is an emergency in which the client is a threat to themself or others. A parent might have a child removed from the home because of neglect but that doesn't meet the criteria for involuntary commitment. Many individuals with schizophrenia can learn to live with hallucinations and delusions and don't require hospitalization. To meet criteria for involuntary commitment, a depressed individual must have a suicide plan and be a direct threat to themself.

An older adult experiences short-term memory problems and occasional disorientation a few weeks after her husband's death. She also is not sleeping, has urinary frequency and burning, and sees rats in the kitchen. The home care nurse calls the woman's health care provider to discuss the client's situation and background, assess, and give recommendations. The nurse concludes that the client most likely has which problem? delayed grieving related to her Alzheimer's disease delirium and a urinary tract infection (UTI) trouble adjusting to living alone without her husband the onset of Alzheimer's disease

delirium and a urinary tract infection (UTI) Delirium is commonly due to a medical condition such as a UTI in the older adult. Delirium often involves memory problems, disorientation, and hallucinations. It develops rather quickly. There are not enough data to suggest Alzheimer's disease especially given the quick onset of symptoms. Delayed grieving and adjusting to being alone are unlikely to cause hallucinations.

A major role in crisis intervention is getting a client's family and friends involved in helping with the immediate crisis as soon as possible. The nurse should determine that the support persons are prepared to help when they verbalize what information? the coping strategies they are using the name and phone number of the client's health care provider emergency resources and when to use them long-term solutions they plan to tell the client to use

emergency resources and when to use them During a crisis, support persons demonstrate preparedness to help the client by verbalizing the emergency resources available and knowing when to use them. Follow-up medical care may be helpful as the crisis subsides. The coping strategies used by the support persons may or may not be relevant to the client's needs and situation. Long-term solutions and advice may or may not be appropriate. The focus needs to be on the client's immediate needs and situation.

The stigma related to having a mental illness, especially a chronic illness, persists despite improvements in the management of illnesses and an increase in public education. Which view most perpetuates the stigma? Clients can recover from mental illness if they have willpower. Mental illness is hereditary. Clients cannot prevent mental illness if they want to do so. Mental illnesses have biochemical bases.

Clients can recover from mental illness if they have willpower. Many still believe that recovery from mental illness is a matter of willpower—for example, "pull yourself up by your bootstraps" or "just get over it." This belief persists despite awareness that mental illness is can be hereditary and has a biochemical basis. Mental illness can be prevented only if there is early intervention. Clients cannot prevent it just by the desire to do so.

Which finding indicates that a client who has been raped will have future adjustment problems and need additional counseling? She becomes upset when talking about the rape to anyone. Her parents show shame and suspicion about her part in the rape. Her life becomes focused on helping other rape victims like herself. She seeks support from formerly ignored relatives and friends.

Her parents show shame and suspicion about her part in the rape. The potential for problems in adjusting after a rape will be increased when those around the victim treat her as though she is to blame for the rape, especially when she already may feel some guilt and shame about it.A rape victim is likely showing adjustment to her experience when she is upset about her experience, when she seeks out formerly ignored relatives and friends for support, or when she attempts to help other rape victims.

Detention center staff asked for a mental health evaluation of a 21-year-old woman after the client stabbed themself with a fork and woke from nightmares in fits of rage. The evaluation revealed that the client was kidnapped and held from ages 8 to 16 by a convicted child pornographer. The client said they never contacted their family after being released from captivity. In what order of priority from first to last should the nurse implement the steps? All options must be used.

Initiate suicide precautions. Offer empathy and support, and be nonjudgmental and honest with the client. Encourage safe verbalizations of the client's emotions, especially anger. Ask the client if they wish to contact the their family while hospitalized. Safety is a priority after the client stabbed herself. A survivor of trauma/torture needs empathy, support, honestly, and a nonjudgmental stance from the nurse. Then the client is more willing to learn safe ways to express feeling, especially anger. It will be the client's decision if the client wants to contact their family and, if so, under what conditions. The client would need extensive preparation before any contact with family.

A nurse in a psychiatric care unit finds that a client with psychosis has become violent and has struck another client in the unit. What action should the nurse take in this case? Do not restrain the client, as it is equivalent to false imprisonment. Restrain the client, as they are harmful to the other clients. Inform the physician and complete a comprehensive assessment. Do not restrain the client, as it is equivalent to battery.

Restrain the client, as they are harmful to the other clients. The nurse should restrain the client because they are potentially harmful to other clients in the psychiatric care unit. Restraints should be used as a last resort and their use should be justified. Unnecessary restraining can lead to allegations of false imprisonment and battery; both are not applicable in this case, however. The nurse should inform the physician about the client but sometimes it may not be logical to wait for orders to restrain a violent client.

The nurse notes that a client is too busy investigating the unit and overseeing the activities of other clients to eat dinner. To help the client obtain sufficient nourishment, which plan would be best? Serve the client food in small, attractively arranged portions. Allow the client to send out for favorite foods. Serve foods that the client can carry with her. Allow the client to enter the unit kitchen for extra food as necessary.

Serve foods that the client can carry with her. Because the client is very active, it would be best to give her food she can carry with her and eat as she moves.Neither allowing the client to send out for her favorite foods nor serving food in small, attractively arranged portions will address her need to be active. Allowing the client in the unit kitchen is impractical, and she most likely would be too busy to eat anyway.

The treatment team recommends that a client take an assertiveness training class offered in the hospital. Which behavior indicates that the client is becoming more assertive? The client asks the nurse to call the client's employer about obtaining insurance. The client arrives late for unit activities, and when asked about the lateness, the client says, "Because I feel like it!" The client follows the nurse's advice of asking the health care provider (HCP) about being passive aggressive. The client asks a roommate to put away dirty clothes because the untidiness bothers the client.

The client asks a roommate to put away dirty clothes because the untidiness bothers the client. By requesting that the roommate respect the client's rights (asking the roommate to put the dirty clothes on the floor away after telling him that this bothers him), the client is asserting himself. Arriving late is commonly passive resistance and thus not an indicator that the client is becoming assertive. Asking the nurse to call is dependent behavior. Although asking the HCP is more assertive, the client is relying on the nurse's direction to do so.

Two days after a client's wife and child were found dead in a flood, the client returns to the crisis center and says he thinks it would be better to "end it all right now and join my wife and kid, wherever they are." The nurse has already determined that the client has no history of psychiatric problems. What should the nurse consider this client's risk for suicide to be? The risk is high; the client's suicide threat can be considered a call for help and should be taken seriously. The risk is very low; as long as the client speaks of suicide, he is unlikely to carry out the act. The risk is low; a person who has not had psychiatric problems in the past rarely carries out a first suicide threat. The risk is moderate; the client appears to be making an effort to gain attention and extra support.

The risk is high; the client's suicide threat can be considered a call for help and should be taken seriously. The client who threatens suicide should be considered at high risk. His threat should be taken seriously, as a call for help.It is untrue that people who talk about suicide will not do it.It is also untrue that a person without a history of psychiatric problems will be unlikely to carry out a first threat.It is a common misconception that a suicide threat is only a bid for attention. All comments about suicide should be taken seriously.

A nurse is teaching self-esteem to a client. Which statements by the client would indicate understanding of the concept? Select all that apply. "Living in a critical environment is not good for me." "I need to have healthy boundaries." "Physical discipline does not affect my self-esteem." "I need to have consistent limits." "I do not like to make decisions."

"Living in a critical environment is not good for me." "I need to have healthy boundaries." "I need to have consistent limits." Self-esteem is how we value or feel worthwhile about ourselves. A variety of factors can aide a person in developing a healthier self-esteem. Here are a few: A structured lifestyle demonstrates acceptance and caring and provides a sense of security. A critical environment erodes a person's esteem. Inconsistent boundaries lead to feelings of insecurity and lack of concern. Physical discipline can decrease self-esteem. When the client starts to make decisions, this can help increase their self-esteem.

A young client is diagnosed with enuresis. Tests revealed there is no medical cause attributed to the client's bed wetting. The client's mother is upset and is blaming the client's father, from whom she has recently separated, for the problem. "It is all his father's fault!" the client's mother declares to the nurse. What would be the nurse's best response? "Why do you say that, exactly?" "You seem really upset by this situation." "These things are generally no one's fault." "Why are you blaming your child's father?"

"You seem really upset by this situation." Hearing her child's diagnosis has led the client's mother to express her emotions and to project blame. Acknowledging her feelings would build further trust and encourage her to discuss her thoughts and feelings. Asking her to pinpoint blame or denying her feelings will not build the helping relationship during this time of perceived distress.

Parents tell a nurse that they have not met their goal of home management of their child with schizoaffective disorder. They report that the client poses a threat to their safety. Based on this information, what recommendation should the nurse make? Discuss what the family can do to chemically restrain the client at home. Arrange for respite care; family members could be aggravating the client's condition. Evaluate the client for voluntary admission to a mental health facility. Tell the parents that the client's behavior releases them from the duty of care.

Evaluate the client for voluntary admission to a mental health facility. A voluntary admission is the preferred approach because it involves having the client recognize existing problems and facilitates the client's involvement in treatment. Chemical restraints would violate the client's rights to freedom from the use of restraints and seclusion. The duty of care is a legal concept that applies only to the nurse-client relationship, not to family relationships. Respite care isn't an appropriate recommendation at this time. The nurse must address the safety issue and institute effective treatment and care. At a later time, it would be prudent for the nurse to talk with the client's family about caregiver burden and the option of using respite care.

A 26-year-old is being treated for delirium due to acute alcohol intoxication. The client is restless, does not want to stay seated, and has a staggering gait. What should the nurse do first? Place the client in a chair with a waist restraint. Provide one-to-one supervision of the client until detoxification treatment can begin. Decrease stimuli by putting the client in bed with the room door closed. Ask the client to sit in a chair next to the nurses' station.

Provide one-to-one supervision of the client until detoxification treatment can begin. One-to-one supervision provides safety until appropriate detoxification can be given. Restraints are the last intervention after less restrictive alternatives have been tried. It is unlikely that the client can cooperate with staying in a chair. Putting the client in bed in his room puts him at risk for falling and a closed door prevents close observation.

A client is playing music loudly in the music room, and other clients are complaining about the volume. What should the nurse do? Turn down the volume and say nothing. Redirect the client to another activity. State to the client what volume is and is not permissible. Tell the other clients that the time to use the room is almost over.

State to the client what volume is and is not permissible. Setting limits here is essential. The nurse should set limits by stating to the client what volume is and is not permissible. Limit setting is the art of clearly identifying acceptable and unacceptable behaviors that are objective, fair, and reflective of the situation at hand. Limits should be identified clearly and early, especially with clients who may "test the system."Redirecting the client does nothing to establish limits and does not help the client recognize unacceptable behaviors.Turning down the volume and saying nothing does not identify the limits for the client and may lead to repetition of the same behavior.Telling the other clients that the time to use the music room is almost over may cause them to feel that the nurse is unfair and not respectful of their needs.

A nurse is reviewing home medications for a client recently admitted to a long-term psychiatric unit. The charge nurse asks why this client has frequent blood draws over the next few weeks. The nurse would be correct to state which home medication dosages vary according to the blood levels of the drug? lithium carbonate clonazepam clozapine alprazolam

lithium carbonate Dosages for lithium, an antimanic drug, are individualized to achieve a maintenance blood level of 0.8 to 1.2 mEq/L for acute mania and 0.8 to 1.0 mEq/L for long-term control of bipolar disorder. Although clozapine use requires monitoring of white blood cell counts and clonazepam use requires monitoring of complete blood count and liver function tests, these tests aren't used to individualize dosages of the drugs. Alprazolam dosages aren't based on blood levels of the drug.

A client with a chronic mental illness who does not always take her medications is separated from her husband and receives public assistance funds. She lives with her mother and older sister and manages her own medication. The client's mother is in poor health and also receives public assistance benefits. The client's sister works outside the home, and the client's father is dead. Which issue should the nurse address first? family support financial concerns medication compliance marital communication

medication compliance Medication noncompliance is a primary cause of exacerbation in chronic mental illnesses. Of the issues listed, medications should be addressed first. Other issues, such as family, marriage, and finances, can be addressed as client stabilization is maintained.

A client with schizophrenia started risperidone 2 weeks ago. Today, the client reports feeling flu-like symptoms. The nurse's assessment reveals the following: temperature 104.4° F (40.2° C), respirations 24 breaths/minute, blood pressure 130/102 mm Hg, pulse rate 120 beats/minute. The nurse also notes muscle stiffness and pain, excessive sweating and salivation, and changes in mental status. The nurse suspects the client is experiencing: septicemia. neuroleptic malignant syndrome. malignant hyperthermia. the flu.

neuroleptic malignant syndrome. Neuroleptic malignant syndrome is a rare but potentially life-threatening reaction to an antipsychotic or neuroleptic. The cardinal symptom is a high temperature. Other commonly observed symptoms include altered mental status and autonomic dysfunction. Although fever may be present with the flu, it doesn't normally cause altered mental status or autonomic dysfunction. Malignant hyperthermia is a complication associated with general anesthesia. These findings don't suggest the client has septicemia. Findings in septicemia include severe hypotension, fever, tachycardia, and a history of a recent infection.

A client with depression has been admitted to the mental health unit and is attending group therapy sessions as part of treatment. The client asks the nurse leading the group if he is married or has a girlfriend. The nurse responds, "I am curious what made you ask this question; however, what is important is how you are feeling today." The nurse's response is which of the following? Appropriate, because the nurse is neither married nor has a girlfriend. Appropriate, because the focus of the therapeutic relationship is the client, not the nurse. Inappropriate, because the client was just making small talk about the nurse's personal situation to get to know the nurse better. Inappropriate, because the nurse should have answered to establish a therapeutic relationship.

Appropriate, because the focus of the therapeutic relationship is the client, not the nurse. The nurse's response is appropriate, because the focus of the therapeutic relationship is the client. The other options do not place the focus of care on the client's needs or reflect a full understanding of the therapeutic relationship.

During therapy, a client on the mental health unit is restless and is starting to make sarcastic remarks to others in the therapy session. The nurse responds by saying, "you look angry." Which communication techniques is the nurse using? clarification making observations mirroring reaffirming

making observations The nurse has provided direct feedback as an observation to the client and the group. The nurse is not mirroring the behavior or seeking clarification or an explanation of the behavior. This is not an open-ended question. Making direct observations and providing feedback in this manner is useful in demonstrating attention and concern for group members as well as providing an external vantage point on behaviors exhibited in a group setting. While such a statement makes a space for later clarification, this statement itself if not a statement of clarification, it is simply an observation.

The client exhibits a flat affect, psychomotor deficits, and depressed mood. The nurse attempts to engage the client in an interaction but the client does not respond to the nurse. Which response by the nurse is most appropriate? "I'll come back a little bit later to talk." "I'll get you something to read." "I'll sit here with you for 15 minutes." "I'll find someone else for you to talk with."

"I'll sit here with you for 15 minutes." The most appropriate action is for the nurse to remain with the client even if the client does not engage in conversation with the nurse. A client with severe depression may be unable to engage in an interaction with the nurse because the client feels worthless and lacks the necessary energy to do so. However, the nurse's presence conveys acceptance and caring, thus helping to increase the client's self-worth. Telling the client that the nurse will come back later, stating that the nurse will find someone else for the client to talk with, or telling the client that the nurse will get her something to read conveys to the client that she is not important, reinforcing the client's negative view of herself. Additionally, such statements interfere with the client's development of a sense of security and trust in the nurse.

The client approaches various staff with numerous requests and needs to the point of disrupting the staff's work with other clients. The nurse meets with the staff to decide on a consistent, therapeutic approach for this client. Which approach will be most effective? limiting the client to the dayroom and dining area giving the client a list of permissible requests having the client discuss needs with the staff person assigned telling the client to stay in the client's room until staff approach

having the client discuss needs with the staff person assigned For the client with attention-seeking behaviors, the nurse would institute a behavioral contract with the client to help decrease dysfunctional behaviors and promote self-sufficiency. Having the client approach only the assigned staff person sets limits on the attention-seeking behavior. Telling the client to stay in the client's room until staff approach, limiting the client to a certain area, or giving the client a list of permissible requests is punitive and does nothing to help the client gain control over the dysfunctional behavior.

An obese client has returned to the unit after receiving electroconvulsive therapy (ECT). A nurse requests assistance in moving the client from the stretcher to the bed. Which direction should the nurse give to a nurse who volunteers to help? "Get the hydraulic lift; the client is still groggy." "Obtain the sliding board or two other people to assist us." "Place the client on the side then use a drawsheet to bring the client to the bed." "Place the client in a semi-Fowler's position to make the move easier."

"Obtain the sliding board or two other people to assist us." To successfully move an obese client from the stretcher to the bed without incurring injury, at least four staff members must perform the transfer. If only two people are available, the nurse should use the sliding board. The hydraulic lift isn't the appropriate equipment to use with a sedated patient. The nurse shouldn't place the client in a semi-Fowler's position unless there is a head injury or other complicated medical condition. To perform a safe transfer using a drawsheet, the nurse must place the sheet directly under the client's body.

A client asks the nurse to help make out a will. What should the nurse tell the client? "I don't believe in getting involved in legal matters, but maybe I can find another nurse who will help you." "You have a long way to go before you'll need to do that. Let's wait on it a while, shall we?" "You need to consult an attorney because I'm not trained in such matters. Is there a family lawyer you can call?" "I'm not a lawyer, but I'll do what I can for you."

"You need to consult an attorney because I'm not trained in such matters. Is there a family lawyer you can call?" A will is an important legal document. It is best to have one prepared with the help of an attorney. It would be unwise to help the client or to seek another nurse's help because a nurse is not a lawyer. Asking the client to delay preparing the will just avoids the problem.

A client in an inpatient psychiatric unit tells the nurse, "I'm going to divorce my no-good husband. I hope he rots in hell. But I miss him so bad. I love him. When is he going to come get me out of here?" The nurse interprets the client's statements as indicative of which condition? auditory hallucinations autistic thinking associative looseness ambivalence

ambivalence Ambivalence refers to strong conflicting attitudes or feelings toward an object, person, goal, or situation, evidenced in this instance by the client stating she is going to divorce her husband and then stating that she misses and loves him.Autistic thinking is preoccupation with self with little concern for external reality. For example, a client's attention cannot be diverted from examining his hands.Associative looseness is characterized by simultaneous expression of unrelated, or only slightly related, ideas or thoughts. For example, a client states, "We went to a basketball game. Where is my father?"Auditory hallucinations involve hearing sounds, words, or voices not heard by others.

On admission to the inpatient psychiatric unit, a client's facial expression indicates severe panic. The client repeatedly states, "I know the police are going to shoot me. They found out that I'm the child of the devil." What should the nurse say to initiate a therapeutic relationship with this client? "Hello, ___. I'm going to be caring for you while I'm on duty. You look very frightened, but I'm sure you'll feel better by tomorrow." "You're having very frightening thoughts. I'll help you find ways to cope with this scary thinking." "Hello, my name is ___. I'm a nurse, and I'll care for you when I'm on duty. Should I call you ___, or do you prefer something else?" "You certainly look stressed. Can you tell me about the upsetting events that have occurred in your life recently?"

"Hello, my name is ___. I'm a nurse, and I'll care for you when I'm on duty. Should I call you ___, or do you prefer something else?" The first task during the introductory, or orientation, phase of the nurse-client relationship is to formulate a contract, which begins with the exchange of names and an explanation of the roles and limits of the relationship. These tasks should precede the exploration of relevant stressors and new coping mechanisms. Offering false reassurance is never therapeutic.

A nurse is assessing the family of a 10-year-old child brought into the emergency department with severe injuries. Which statement made by the parents could indicate child abuse? "I don't know what I will do if something happens to my child." "The injury happened a few days ago but I didn't think it was bad." "You should ask my child about his injuries. They will know best what happened." "My child fell off his bike and into the street."

"The injury happened a few days ago but I didn't think it was bad." A delay in seeking treatment for a child's serious injuries is a sign of abuse. Anxiety is expected and is a normal response. The parent's specific description of the origin of the injury is not congruent with child abuse. In abuse cases, vague descriptions of the injuries are more common than detailed ones, and abusers often prevent a child from explaining the nature of their injuries rather than encouraging it.

A client with a diagnosis of bipolar disorder is energetic, impulsive, and verbalizing loudly in the community room. To prevent injury while complying with the principle of the least-restrictive environment, which action should the nurse take to prevent escalation of the client's mood? Place the client in seclusion with the door open. Monitor the client for escalation of manipulative behavior. Obtain a court order for a higher level of treatment. Try to channel the client's energy into appropriate activities.

Try to channel the client's energy into appropriate activities. Constructive activities, such as painting, are a positive way to prevent inappropriate or destructive use of the client's excessive energy. Placing the client in seclusion with the door open allows the client to leave the seclusion room; this action doesn't comply with the principle of providing the least-restrictive environment. It isn't appropriate for the nurse to obtain a court order for a higher level of treatment. Monitoring the client's behavior isn't as effective as intervening before a crisis occurs.

When preparing to use seclusion as an alternative to restraint for a client who has not yet lost control, the nurse expects to use a room with limited furniture and no access to dangerous articles. What should the nurse also consider as critical for the safety of the client? lights that can be dimmed from outside the room a security window in the door or a room camera a staff member to stay in the room with the client a prescription for the seclusion before it is initiated

a security window in the door or a room camera When using seclusion, the safety of the client is paramount. Therefore, staff must be able to see the client in seclusion at all times, such as through a security window in the door or with a room camera. Although outside access for dimming the lights to decrease stimuli may be appropriate, it is not critical for the client's safety. Having one staff member stay in a room alone with a potentially violent client is unsafe. A prescription for seclusion can be obtained before or after it is initiated.

During the mental status examination, a client may be asked to explain such proverbs as "Don't cry over spilled milk." The purpose of this is to evaluate the client's ability to think: concretely. rationally. abstractly. tangentially.

abstractly. Abstract thinking is the ability to conceptualize and interpret meaning. It's a higher level of intellectual functioning than concrete thinking, in which the client explains the proverb by its literal meaning. Rational thinking involves the ability to think logically, make judgments, and be goal-directed. Tangential thinking is scattered, non-goal-directed, and hard to follow. Clients with such conditions as organic brain disease and schizophrenia typically can't conceptualize and comprehend abstract meaning. They interpret such statements as "Don't cry over spilled milk" in a literal sense, such as "Even if you spill your milk, you shouldn't cry about it."

As an angry client becomes more agitated while talking about problems, the nurse decides to ask for staff assistance in taking control of the situation when the client demonstrates which behavior? coming out of the room instead of staying in time-out picking up a pool cue stick and telling the nurse to get out of the way swearing about a spouse's behaviors when discussing marital problems making a fist and pounding loudly on the table

picking up a pool cue stick and telling the nurse to get out of the way Asking the staff for assistance is appropriate when the client demonstrates behaviors that involve the direct threat of violence. Holding a stick and telling the nurse to move is the most direct threat of violence. Swearing and pounding on a table may be disturbing, but these actions are less of a threat. Coming out of his room may indicate noncompliance with directions. However, further assessment is needed to determine whether this behavior was a direct threat of violence.

A client is brought to the emergency department dead on arrival (DOA) from a gunshot wound. The client's family arrives and is escorted to a private area. A multidisciplinary team composed of a physician, nurse, and social worker interacts with the family. All members work together to complete the following tasks. Which are the priority nursing responsibilities? Select all that apply. escorting the client's family for viewing of the body explaining the cause of the client's death caring for body organs which are appropriate for transplantation arranging disposition of the client's personal belongings providing therapeutic touch and support as needed

providing therapeutic touch and support as needed caring for body organs which are appropriate for transplantation escorting the client's family for viewing of the body The death of a loved one in a violent nature is extremely painful and unanticipated for families. Nursing responsibilities include care of the family and maintenance of organs which may be used for transplantation. The physician would explain the client's status and cause of death to the family. Since the social worker is involved, coordination with the funeral director and disposition of personal belongings are efficiently completed. All members offer support as needed.

A client brought to the clinic after being arrested for harassing and stalking his ex-wife denies any other symptoms or problems except anger about being arrested. The ex-wife reports to the police, "He's fine except for this irrational belief that we'll remarry." When collaborating with the health care provider about a plan of care, which intervention would be most effective for the client at this time? a joint session with the client and his ex-wife referral to an outpatient therapist a prescription for olanzapine 10 mg daily a prescription for fluoxetine 20 mg every morning

referral to an outpatient therapist Follow-up counseling is appropriate because of the client's anger and inappropriate behaviors. The goal is to help the client deal with the end of his marriage. A joint session might have been useful before the divorce and arrest, but not after. The client is exhibiting no signs or symptoms of schizophrenia or psychosis, so olanzapine is not indicated. The client is not exhibiting signs of depression, so fluoxetine is not indicated.

A nurse has been working with a battered woman who is being discharged and returning home with her husband. The nurse says, "All this work with her has been useless. She's just going back to him as usual." Which statement by a nursing colleague would be most helpful to this nurse? "These women almost never leave for good because of their emotional and financial dependency." "You did your best. You'll see her again and have another chance." "Her reasons for staying are complex. She can leave only when she's ready and can be safe." "I know it's frustrating to work with clients who don't follow our advice."

"Her reasons for staying are complex. She can leave only when she's ready and can be safe." The colleague needs to provide the nurse with information about spouse abuse. Giving information about reasons for staying is useful for decreasing the nurse's frustration. Although expressing empathy is appropriate, it does not help the nurse understand the client's needs and behaviors. Telling the nurse that there will be another chance is not helpful and fails to educate the other nurse about the dynamics of abuse. Although dependence is a problem, women who are abused can overcome this and leave if they have support, not criticism. Saying that abused women almost never leave does not help the nurse understand the client's needs and behavior.

A client is admitted to the psychiatric unit following a suicide attempt. The client has suffered identity theft through the Internet and states, "My savings, checking, and retirement accounts are empty. I have nothing left to pay my bills or buy food and medicines. The only thing left is to die." After 1 week, the nurse would conclude that the client has been helped upon hearing which statements? Select all that apply. "The staff has given me a lot of options, but I'm not sure they are even possible." "With all the help I got here, I think I may be able to survive after all." "I know all the actions I can take, but they take so much time and energy. I'm so tired." "I realize that I still can get monthly public assistance benefits." "I filed identity theft claims with the bank, my retirement account, and the government authorities."

"I realize that I still can get monthly public assistance benefits." "I filed identity theft claims with the bank, my retirement account, and the government authorities." "With all the help I got here, I think I may be able to survive after all." Realizing financial resources and benefits will continue gives hope and decreases the risk of future suicide.Filing the claim forms may help regain some of the losses and shows the client is looking to the future.Lacking energy and motivation will inhibit taking positive actions and demonstrates the client has not been sufficiently helped as yet.Positive statements about survival also suggest the client has a new perspective. Not believing in the solutions will inhibit taking positive actions and demonstrates the client has not been sufficiently helped as yet.

A client being released from restraints says, "I'll never get that angry and lose it again. Those restraints were the worst things that ever happened to me." Which response by the nurse is most appropriate? "Someday this experience won't bother you like it does now." "I'd like to talk with you about your experience." "That was the worst thing that ever happened to you?" "Do you really mean what you just said?"

"I'd like to talk with you about your experience." After a client is released from restraints, the client and the nurse need to process the experience by discussing why restraints were used and any other information the client wishes to discuss. Asking if the client meant what was said challenges or questions the validity of the statement. Simple reflection of the client's words may not open up discussion about the experience. Stating that the experience won't bother the client in the future is judgmental and trivializes the client's remark.

A client is admitted to a mental health unit with a diagnosis of depression and is participating in group sessions. The client asks a nurse if they are married or in a romantic relationship. What is the best response by the nurse to maintain a therapeutic relationship? "Tell me how you knew that I was not married or in a romantic relationship." "I'm curious about your question but I want to know how you are feeling today." "It sounds as though you are interested in developing a relationship with me." "Group therapy is not the appropriate time to discuss my relationships."

"I'm curious about your question but I want to know how you are feeling today." Nurses must practice in a manner that is consistent with providing safe, competent, and ethical care. If the nurse shared personal information with the client, the nurse would have crossed the boundary of a therapeutic relationship and changed the focus of the discussion from a client focus to a social focus. It is very important in all areas of care, but especially in the mental health setting, that the relationship between the nurse and the client has very clear boundaries and is client focused. The other options are incorrect because they do not follow the principles of a therapeutic nurse-client relationship.

The nurse is caring for a client who has been physically abused. Which statement by the nurse expresses empathy for this client? "It must be difficult what you have been going through." "Our staff will do the best they can to make you feel comfortable." "Do you have questions about what is happening?" "I am so sad to see you going through so much pain."

"It must be difficult what you have been going through." Empathy is a person's ability to understand what another person is going through and be objective at the same time. The nurse does not carry those feelings or that situation with them as in sympathy but is still able to relate to the person well. "It must be difficult what you have been going through" is such an example. It gives the client an opening to express any feelings regarding the abuse. "Our staff will do the best they can to make you feel comfortable" is a stereotypical response that does not empathize with the client. "Do you have questions about what is happening?" is a closed question and also a stereotypical question that nurses often ask when no other statement is known to them. "I am so sad to see you going through so much pain" is an example of a sympathetic response because the nurse is showing feelings of sadness over the client's situation.

A 6-year-old child is brought to the walk-in clinic in their neighborhood for onset of symptoms of a urinary tract infection (UTI). The child is reluctant to give a urine specimen or to remove their clothing. Which one of these reports by the parent requires further investigation? "My child doesn't like going to the doctor." "I think my child drinks an adequate fluid intake throughout the day." "My child slept over at my friend's last night while I worked the night shift." "My child has never had a UTI before."

"My child slept over at my friend's last night while I worked the night shift." The child's symptoms of a UTI and their reluctance to undress and give a urine sample could be normal for the child's age, but the nurse needs to follow up with suspicion of sexual abuse due to the parent's statement about staying with her friend the night before. The child staying at her friend's house could make the child vulnerable to abuse, and the nurse must follow up with assessment of the child. The other responses would not signal to the nurse that there are potential issues associated with the symptoms of a UTI.

A client is admitted to the psychiatric unit and appears agitated. While putting personal items away, the client talks rapidly and folds and unfolds garments several times. The client cannot seem to relax. What statement by the nurse is best? "You have been folding the same clothing several times. How do you feel right now?" "You need to calm down. Take some deep breaths into this paper bag." "Let's see if the healthcare provider ordered any medications to help you relax." "Please come with me to the common room; it's time for group therapy."

"You have been folding the same clothing several times. How do you feel right now?" This client's behavior exhibits objective signs of anxiety, which include restlessness, irritability, rapid speech, inability to complete tasks, and verbal expressions of tension. Nursing staff should encourage clients to express feelings and concerns. Making an accurate statement and asking an open-ended question are the best ways to elicit information about the client's anxiety. Asking the client to accompany the nurse to group therapy or inquiring about medication is not allowing the client to express feelings of anxiety. There is no indication the client is hyperventilating; even if the client was at risk for respiratory alkalosis, breathing into a paper bag is not considered best practice.

The client was admitted to the psychiatric unit yesterday evening. In the morning, the client approaches the nurse and states, "The psychiatrist and all of you nurses are conspiring against me. I've been warned and I know it's true. You know what I mean." Which response by the nurse would be most therapeutic? "You must feel very frightened. You're safe here." "That simply isn't true. Just stay calm." "I'll see if I can find your psychiatrist for you." "I don't know what you mean, but you're secure here."

"You must feel very frightened. You're safe here." The nurse should verbalize the feelings conveyed by the client or the impact the delusion has on the client and assure the client he is safe and that no harm will come to him. Reasoning, arguing, challenging, or trying to disprove the client's delusion may force the client to adhere to and defend it. Offering to find the client's psychiatrist ignores the client and conveys nonacceptance. Telling the client, "I don't know what you mean," ignores his needs and conveys nonacceptance as an individual.

A nurse is leading a group on medication management. One of the group members is beginning to monopolize the session, talking about experiences with medications. Which statement by the nurse would be best? "I can't let you continue because too much time has passed." "You're doing well in contributing to the group, but I'd like to hear what others are thinking." "You're very talkative today and seem to have a lot to say." "I'm happy to hear about your experiences with medications."

"You're doing well in contributing to the group, but I'd like to hear what others are thinking." The nurse should forestall monopolization by a single client while avoiding putting the client down and should give others the opportunity to express themselves. Saying that hearing about this client's experiences makes the nurse happy allows the client to continue monopolizing the group session. The same is true for commenting on how the client is very talkative. Telling the client that she cannot continue because too much time has passed puts the client down and decreases self-esteem.

A nurse makes a home visit to a client who was discharged from a psychiatric hospital. The client is irritable and walks about her room slowly and gloomily. After 10 minutes, the nurse prepares to leave, but the client plucks at the nurse's sleeve and quickly asks for help rearranging her belongings. She also anxiously makes inconsequential remarks to keep the nurse with her. In view of the fact that the client has previously made a suicidal gesture, which intervention by the nurse should be a priority at this time? To draw out the client, mention others the nurse has known who have acted like the client and attempted suicide. Outline some alternative measures to suicide for the client to use during periods of sadness. Ask the client frankly if she has suicidal thoughts or plans. Avoid bringing up the subject of suicide to prevent giving the client ideas of self-harm.

Ask the client frankly if she has suicidal thoughts or plans. Investigating the presence of suicidal thoughts and plans by overtly asking the client if she is thinking of or planning to commit suicide is a priority nursing action in this situation.Direct questioning about thoughts or plans related to self-harm does not give a person the idea to harm herself. Self-harm is an individual decision. Avoiding the subject when a client appears suicidal is unwise; the safest procedure is to investigate.It would be premature in this situation to outline alternative measures to suicide.Describing other clients who have attempted suicide is too indirect to be helpful and minimizes the client's feelings.

A client suddenly behaves in an impulsive, hyperactive, unpredictable manner. Which approach would be best for the nurse to use first if the client becomes violent? Use sedation to keep the client calm. Get help to handle the situation safely. Let the client know that her behavior is not acceptable. Provide a physical outlet for the client's energies.

Get help to handle the situation safely. The recommended first course of action is to prevent accidents and injuries when a client becomes violent. In this situation, it would be best to call for help to handle the situation safely.Providing a physical outlet for the client's energies is an appropriate course of action but only after the situation is safely under control.Letting the client know that her behavior is not acceptable is an important useful intervention but is not likely to be useful in an unstable, escalating situation.Using sedation to control behavior is not the nurse's first course of action. The first course of action is to summon help.

A 6-year-old client is diagnosed with attention deficit hyperactivity disorder (ADHD). When asking this client to complete a task, what techniques should the nurse use to communicate most effectively with him? Explain to the client what he is to do, the consequences if he does not comply, and follow through with praise or consequences as appropriate. Obtain eye contact before speaking, use simple language, and have him repeat what was said. Praise him if he completes the task. Demonstrate to the client what he is to do, have him imitate the nurse's actions, and give a food reward if he completes the task. Fully explain to the client the actions required of him, and offer verbal praise and a food reward for task completion.

Obtain eye contact before speaking, use simple language, and have him repeat what was said. Praise him if he completes the task. Because the client with ADHD is easily distractible, it is important to obtain eye contact before explaining the task. Simple language and having him repeat what he is told are necessary because of his age. Praise encourages the client to repeat the task in the future as well as building the client's self-esteem. A full explanation with verbal praise and a food reward is inappropriate because a food reward increases the chance that he will expect a physical reward for completing tasks. In addition, a full explanation might be too confusing for someone his age. Explaining consequences focuses on punishment, rather than praise. Although demonstration and imitation is an effective teaching method, rewarding with food fosters dependence on food reward for task completion.

When planning care for a client with schizophrenia, who lacks motivation to shower and dress, which outcome should the nurse expect the client to achieve by the end of 4 days? Recognize the need to shower and dress herself. Verbalize the need to shower and dress herself. Perform showering and dressing for herself. Explain reasons for showering and dressing herself.

Perform showering and dressing for herself. By the end of 4 days, the client should be able to perform showering and dressing for herself. The client with schizophrenia commonly appears to be apathetic and lack initiative. Therefore, demonstrating the ability to complete the tasks indicates improvement. Although the client may be able to recognize, verbalize, or explain the need to shower and dress herself, she may be unable to do so because of the ambivalence associated with schizophrenia that impedes the client's ability to initiate and complete self-care. Therefore, evidence of improvement would be lacking.

When providing a therapeutic milieu for clients, which intervention would be most appropriate? Promote optimal functioning of an individual or group. Use psychotropic drugs primarily. Meet one's own needs while helping clients meet their needs. Foster dependent client behavior.

Promote optimal functioning of an individual or group. The milieu should provide an atmosphere that fosters growth, change, and self-responsibility. Staff interventions should also be flexible and open and encourage clients to achieve optimal functioning.Using psychotropic drugs is only one component of a therapeutic milieu. Other components include nurse-client interaction, therapeutic groups, recreation, and client-staff treatment meetings.Independent, not dependent, behavior is fostered and supported to promote the client to assume responsibility for self.Meeting one's own needs while helping clients meet their needs is inappropriate for the nurse or the staff in a therapeutic milieu. The nurse focuses on the client's needs without expecting personal needs to be met.

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? Spend time sitting in silence with the client. Introduce another client to her and ask him to join you. Ask another staff member to include the client in an informal group discussion. 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.

A client who has experienced the loss of her husband through divorce, the loss of her job and apartment, and the development of drug dependency is suffering situational low self-esteem. Which outcome is most appropriate initially? The client will prioritize problems. The client will discuss her feelings related to her losses. The client will explore her strengths. The client will identify two positive qualities.

The client will discuss her feelings related to her losses. The most appropriate initial outcome for the client is to discuss thoughts and feelings related to her losses. The nurse should help the client identify and verbalize her feelings so that she can externalize her thoughts and emotions and begin to deal with them. This prevents the client from internalizing feelings, which leads to depression and self-harm. The ability to identify two positive qualities, explore strengths, and prioritize problems would be appropriate after the client has explored her thoughts and feelings, gained awareness of the issues, and then can participate in the treatment plan.

A client is irritable and hostile. He becomes agitated and verbally lashes out when his personal needs are not immediately met by the staff. When the client's request for a pass is refused by the healthcare provider, he utters a stream of profanities. Which statement best describes the client's behavior? The client's anger is a sign that his condition is improving. The client's anger is not intended personally. The client's anger is an intended attack on the health care provider's skills. The client's anger is a reliable sign of serious pathology.

The client's anger is not intended personally. Staff members sometimes are the recipients of a client's angry behavior because they are safe targets and are available for attack. The display of anger is rarely intended to be personal.Such behavior is not necessarily a sign of serious pathology but must be weighed in conjunction with other behaviors.An angry outburst is not an attack on a healthcare provider's skills.While not necessarily pathologic, the client's behavior is not a sign that his condition is improving.

A client stalks a person the client met briefly 3 years earlier. The client believes the person loves and eventually will marry the client, who has been sending the person cards and gifts. When the client violates a restraining order the person has obtained, a judge orders the client to undergo a 10-day psychiatric evaluation. What is the most probable psychiatric diagnosis for this client? induced psychotic disorder delusional disorder — erotomanic type delusional disorder — jealous type schizophreniform disorder

delusional disorder — erotomanic type In delusional disorder of the erotomanic type, the client has an erotic delusion of being loved by another person and tries to contact the object of the delusion through such behaviors as sending gifts, calling, and stalking. The object of the undesired attention may be a complete stranger or someone the client knows, and usually is of higher status. In a delusional disorder of the jealous type, the client has a delusion that the sexual partner is unfaithful. In a psychotic disorder, a delusion of suspicion occurs within the context of a close relationship. The client may believe that someone has an inappropriate or sexual interest in the client. Schizophreniform disorder involves bizarre delusions and hallucinations of less than 6 months' duration.

When assessing an aggressive client, which behavior warrants the nurse's prompt reporting and use of safety precautions? starting a petition to delay bedtime naming another client as his adversary crying when talking about his divorce declining attendance at a daily group therapy session

naming another client as his adversary The client exhibits aggression against his perceived adversary when he names another client as his adversary. The staff will need to watch him carefully for signs of impending violent behavior that may injure others. Crying about a divorce would be appropriate, not pathologic, behavior demonstrating grief over a loss. A petition to delay bedtime would be a positive, direct action aimed at a bothersome situation. Although declining to attend group therapy needs follow-up, there may be any number of unknown reasons for this action.

In closed or locked units, the nurse judges the milieu as therapeutic when priorities are given to which factors? communication, social, and leisure skills safety, structure, and support recreation and vocation counseling socialization and self-understanding

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.

When assessing a client for suicidal risk, which method of suicide should the nurse identify as most lethal? slashing both wrists jumping off an 8-foot bridge overdosing on aspirin use of a gun to the stomach

use of a gun to the stomach A crucial factor in determining the lethality of a method is the amount of time that occurs between initiating the method and the delivery of the lethal impact of the method. Lethal methods of suicide include using a gun, jumping from a high place, hanging, drowning, carbon monoxide poisoning, and overdose with certain drugs, such as central nervous system depressants, alcohol, and barbiturates. The more detailed the suicide plan, the more lethal and accessible the method, and the more effort exerted to block rescue, the greater the chance is for the suicide to be completed. Impulsive attempts at suicide even with rescuers in sight may be lethal depending on the method. Less lethal methods may include overdosing on aspirin and wrist cutting. Jumping of an 8-foot bridge may cause injury, but it is not likely to be lethal.