Mental Health Disorders
The nurse is preparing for the hospital discharge of a client with a history of command hallucinations to harm self or others. The nurse instructs the client about interventions for hallucinations and anxiety and determines that the client understands the interventions when the client makes which statement?
"I can call my therapist when I'm hallucinating so I can talk about my feelings and plans and not hurt anyone."
A client is admitted to the in-patient unit and is being considered for ECT. The client appears calm, but the family is hypervigilant and anxious. The client's mother begins to cry and states, "My child's brain will be destroyed. How can the doctor do this?" The nurse should make which therapeutic response?
"It sounds as though you have some concerns about the ECT procedure. Why don't we sit down together and discuss and concerns you may have?"
The nurse is collecting data on a client who is actively hallucinating. Which nursing statement would be therapeutic at this time?
"Sometimes people hear things or voices others can't hear."
A client who is diagnosed with pedophilia and recently has been paroled as a sex offender says, "I'm in treatment and I have served my time. Now this group has posters all over the neighborhood with my photo and details of my crime." Which is an appropriate response by the nurse?
"You understand that people fear for their children, but you're feeling unfairly treated?"
The nurse observes that a client is psychotic, pacing and agitated and is making aggressive gestures. The client's speech pattern is rapid, and the client's effect is belligerent. Based on these observations, which is the nurse's immediate priority of care?
Provide safety for the client and other clients on the unit
The nurse is caring for a client with a diagnosis of depression. The nurse monitors for signs of constipation and urinary retention, knowing that these problems are likely caused by which situation?
Psychomotor retardation and side effects of medication
The nurse is caring for a client diagnosed with catatonic stupor. The client is lying on the bed, with the body pulled into a fetal position. Which is the appropriate nursing intervention?
Sit beside the client in silence and verbalize occasional open-ended questions
The nurse notes documentation in a client's record that the client is experiencing delusions of persecution. The nurse recognizes that these types of delusions are characteristic of which thoughts?
The false belief that one is being singled out for harm by others
A mother of a teenage client with an anxiety disorder is concerned about her daughter's progress during discharge. She states that her daughter "stashes food, eats all the wrong things that make her hyperactive," and "hangs out with the wrong crowd." While helping the mother prepare for her daughter's discharge, the nurse should make which suggestion?
The mother should restrict the amount of chocolate and caffeine products in the home
A client with delirium becomes agitated and confused at night. The best initial intervention by the nurse is which action?
Use a night light and turn off the tv
Which nursing interventions are appropriate for a hospitalized client with mania who is exhibiting manipulative behavior? Select all that apply.
Communicate expected behaviors to the client Follow through about the consequences of behavior in a non-punitive manner Assist the client with developing a means of setting limits on personal behavior Be clear with the client regarding the consequences of exceeding limits set regarding behavior
A client is unwilling to get out of the house for fear of "doing something crazy in public." Because of this fear, the client remains homebound except when accompanied outside by the spouse. The spouse asks the nurse, "what is the name of my wife's disorder?" Which answer should the nurse give to the spouse?
Agoraphobia
