MENTAL HEALTH CHAPTERS 1,2,9, & 27 (Halter)
When preparing to hold an admission interview with a client, the nurse pulls up a chair and sits facing the client with his or her knees almost touching. When the nurse leans in close to speak, the client becomes visibly flustered and gets up and leaves the room. What is the most likely explanation for client's behavior? The nurse violated the client's personal space by physically being too close. The client has issues with sharing personal information. The nurse failed to explain the purpose of the admission interview. The client is responding to the voices by ending the conversation.
The nurse violated the client's personal space by physically being too close. By sitting and leaning in so closely, the nurse has entered into intimate space (0 to 18 inches), rather than social distance. This has likely made the patient may feel uncomfortable with being so close to someone unknown to them. All the other options lack evidence and jump to conclusions regarding the patient's behavior. DIF: Cognitive Level: Analyze (Analysis) REF: page 34 TOP: Nursing Process: Assessment *NCLEX: Psychosocial Integrity*
The nurse is planning care for a 14-year-old. The nurse demonstrates an understanding of the developmental task appropriate for this client by providing which experience? Spending one-on-one time with staff to establish trust Providing them with the opportunity to select which unit activities they will participate in to gain autonomy Encouraging them to talk about their school plans to help achieve identity Assign them to help clean up the day-room to develop a sense of industry
Encouraging them to talk about their school plans to help achieve identity According to Erikson, the task of adolescence is to achieve identity rather than to be left in role confusion. A sense of identity is essential to making the transition into adulthood. While appropriate activities none of the options are specifically identified with the developmental task for a 14-year-old. REF: 23; Table 2-2
The nurse is working with a client experiencing depression stemming from low self-esteem. The client is distrustful of unit staff and "just wants to go home." Initially what is the nurse's priority? Making the client feel physically and emotionally safe Teaching the client effective coping skills Identifying the client's positive traits Focusing on preparing the client for a speedy discharge
Making the client feel physically and emotionally safe Maslow describes safety as a basic need, meaning that it is so basic to existence that it must be resolved to reduce the tension associated with it. These needs have the greatest strength and must be satisfied before a person turns his attention to higher level needs. REF: 27
A patient is sitting with arms crossed over his or her chest, his or her left leg is rapidly moving up and down, and there is an angry expression on his or her face. When approached by the nurse, the patient states harshly, "I'm fine! Everything's great." Which statement related to communication should the nurse focus on when working with this patient? Verbal communication is always more accurate than nonverbal communication. Verbal communication is more straightforward, whereas nonverbal communication does not portray what a person is thinking. Nonverbal and verbal communication may be different; nurses must pay attention to the nonverbal communication being presented to get an accurate message. Nonverbal communication is about 10% of all communication, and verbal communication is about 90%.
Nonverbal and verbal communication may be different; nurses must pay attention to the nonverbal communication being presented to get an accurate message. Communication is roughly 10% verbal and 90% nonverbal, so nurses must pay close attention to nonverbal cues to accurately assess what the patient is really feeling. The other options are all untrue of verbal and nonverbal communication and are actually the opposite of what is believed of communication. DIF: Cognitive Level: Analyze (Analysis) REF: pages 7-9 TOP: Nursing Process: Planning *NCLEX: Psychosocial Integrity*
A patient is presenting with behaviors that indicate anger. When approached, the patient states harshly, "I'm fine! Everything's great." Which response should the nurse provide to the patient? "Okay, but we are all here to help you, so come get one of the staff if you need to talk." "I'm glad everything is good. I am going to give you your schedule for the day and we can discuss how the groups are going." "I don't believe you. You are not being truthful with me." "It looks as though you are saying one thing but feeling another. Can you tell me what may be upsetting you?"
"It looks as though you are saying one thing but feeling another. Can you tell me what may be upsetting you?" This response uses the therapeutic technique of clarifying; it addresses the difference between the patient's verbal and nonverbal communication and encourages sharing of feelings. The other options do not address the patient's obvious distress or are confrontational and judgmental. None of the other options provides this support. DIF: Cognitive Level: Analyze (Analysis) REF: pages 7-9 TOP: Nursing Process: Implementation *NCLEX: Psychosocial Integrity*
Which of the following statements represent a nontherapeutic communication technique? "Why didn't you attend group this morning?" "From what you have said, you have great difficulty sleeping at night." "What did your boyfriend do that made you leave? Are you angry at him? Did he abuse you in some way?" "If I were you, I would quit the stressful job and find something else." "I'm really proud of you for the way you stood up to your brother when he visited today." "You mentioned that you have never had friends. Tell me more about that." "It sounds like you have been having a very hard time at home lately."
"Why didn't you attend group this morning?" "What did your boyfriend do that made you leave? Are you angry at him? Did he abuse you in some way?" "If I were you, I would quit the stressful job and find something else." "I'm really proud of you for the way you stood up to your brother when he visited today." All these options reflect the nontherapeutic techniques of (in order) asking "why" questions; using excessive questioning; giving advice; and giving approval. The other options describe therapeutic techniques of restating, exploring, and reflecting. DIF: Cognitive Level: Apply (Application) REF: pages 18, 19 TOP: Nursing Process: Implementation *NCLEX: Psychosocial Integrity*
The nurse in an emergency department notices a patient's husband, pacing in the hallway, muttering to himself, and looking angrily around the emergency department. Which statement should the nurse make to the spouse to help prevent escalation and/or violence? "You need to stay with your wife. She needs you." "Hey, what's up? You look out of control." "I am calling security to deal with your behavior." "You appear upset. Can I help you with anything?"
"You appear upset. Can I help you with anything?" Approaching a patient or a visitor with a calm, sincere, and caring manner can de-escalate a situation because the person may feel you are interested in helping. The other responses will not prevent escalation and may in fact anger the person further. DIF: Cognitive Level: Analyze (Analysis) REF: page 14 TOP: Nursing Process: Implementation *NCLEX: Safe and Effective Care Environment*
Using Maslow's model of needs, the nurse providing care for an anxious client identifies which intervention as being a priority? Assessing the client's ability to fulfill appropriate developmental level tasks Assessing the client for strengths upon which a nurse-client relationship can be based Planning one-on-one time to assist in identifying the fears trigger the client's anxiety Evaluating the client's ability to learn and retain essential information regarding their current condition
Assessing the client for strengths upon which a nurse-client relationship can be based The value of Maslow's model in nursing practice is twofold. First, the emphasis on human potential and the client's strengths is key to successful nurse-client relationships. The second value lies in establishing what is most important in sequencing of nursing actions in the nurse-client relationship. REF: 27-28
A nurse is providing care to a 28-year-old patient diagnosed with bipolar disorder who was admitted in a manic state. According to Maslow's Hierarchy of Needs theory, the nurse should identify which patient symptom as having priority? Rapid, pressured speech Grandiose thoughts Lack of sleep Hyperactive behavior
Lack of sleep Based on Maslow's theory, physiological needs such as food, water, air, sleep, etc., are the priority and must be taken care of first. The other options are symptoms of mania but not as critical as lack of sleep. DIF: Cognitive Level: Analyzing REF: page 23 TOP: Nursing Process: Outcome Identification *NCLEX: Physiological Integrity*
A 55-year-old patient recently came to the United States from England on a work visa. The patient was admitted for severe depression following the death of a life partner weeks ago. While discussing the death and its effects the patient shows little emotion. Which of the following explanations is most plausible for this lack of emotion? The patient in denial. The response may reflect cultural norms. The response may reflect personal guilt. The patient may have an antisocial personality.
The response may reflect cultural norms. Showing little emotion while in distress may be a cultural phenomenon. Some cultures, such as the British and German cultures, tend to value highly the concept of self-control and may show little facial emotion in the presence of emotional turmoil. There is no evidence to suggest the patient's lack of emotion is a result of any of the other options. DIF: Cognitive Level: Analyze (Analysis) REF: page 9 TOP: Nursing Process: Assessment *NCLEX: Psychosocial Integrity*