Mental Health Nursing evolve

Laboratory work is prescribed for a client who has been experiencing delusions. When the laboratory technician approaches the client to obtain a specimen of the client's blood, the client begins to shout, "You're all vampires. Let me out of here!" The nurse present at the time should respond by stating which?

"Are you fearful and think that others may want to hurt you?"

The nurse is assigned to care for a client who is agitated. On entering the room, the client screams, "Why don't you just leave me alone?" The nurse should make which therapeutic response to the client?

"I can see that you are upset. I'll be back in a few minutes to see how you are doing."

The nurse is providing care to a client admitted to the hospital with a diagnosis of anxiety disorder. The nurse is talking with the client, and the client says, "I have a secret that I want to tell you. You won't tell anyone about it, will you?" Which is the appropriate nursing response?

"I can see that you are upset. I'll be back in a few minutes to see how you are doing."

A long-term care resident with a history of paranoid schizophrenia refuses to eat and tells the nurse that she believes that someone is poisoning the food. The nurse should make which appropriate response to the client?

"It must be frightening to you. Has something made you feel that your food is poisoned?"

Which client is most likely at risk to become a victim of elder abuse?

A 90-year-old woman with advanced Parkinson's disease

A confused and disoriented client is admitted to the psychiatric unit diagnosed with posttraumatic stress disorder (PTSD). The nurse initially plans to take which action with this client?

Accept the client as a person and make the client feel safe.

The nurse is preparing a client for the termination phase of the nurse-client relationship. Which task should the nurse appropriately plan for this phase?

Assist in making appropriate referrals

Which data indicates to the nurse that a client may be experiencing ineffective coping following the loss of her spouse?

Constantly neglects personal grooming

The nurse enters a client's room, and the client immediately demands to be released from the hospital. On review of the client's record, the nurse notes that the client was admitted 2 days ago for treatment of an anxiety disorder and that the admission was a voluntary admission. The nurse reports the findings to the registered nurse (RN) and expects that the RN will take which action?

Contact the health care provider (HCP).

The nurse is caring for a client with schizophrenia who states, "I decided not to take my medication because I realize that it really can't help me. Only I can help me." Which nursing response should be therapeutic?

Do you recall needing to be hospitalized because you stopped your medication?"

The licensed practical nurse is assisting the registered nurse in admitting a client with an exacerbation of schizophrenia and knows that which signs/symptoms displayed by the client are considered positive symptoms? Select all that apply.

Hallucinations Delusions Neologisms

A client with Alzheimer's disease became very agitated when a group of children came to sing and dance at a long-term care facility. The nurse should use which piece of information when approaching the client about this behavior?

Individuals with Alzheimer's disease have difficulty tolerating excess stimulation and changes in routine.

The nurse is assigned to care for a client admitted to the hospital after sustaining an injury from a house fire. The client attempted to save a neighbor involved in the fire, but despite the client's efforts, the neighbor died. Which action should the nurse take to enable the client to work through the meaning of the crisis?

Inquiring about the client's feelings that may affect coping

The nurse receives a telephone call from a male client who states that he wants to kill himself and has a bottle of sleeping pills in front of him. Which would be the best response by the nurse?

Keep the client talking and signal to another staff member to send help to the client.

The nurse working in a mental health unit hears that a client has been experiencing "flashbacks." The nurse interprets that this client is exhibiting a sign of which condition?

Posttraumatic stress disorder (PTSD)

The nurse notices a "paranoid stare" during a conversation with the client diagnosed with posttraumatic stress disorder (PTSD). The client then begins to fidget and gets up to pace around the room. Which action by the nurse would be most beneficial?

Share the observation with the client and help the client recognize his or her feelings.

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. The appropriate nursing intervention is which?

Sit beside the client in silence and verbalize occasional open-ended questions.

SELECT ALL THAT APPLY The nurse is working with an older client who has a diagnosis of depression. To work most effectively with this client, the nurse recalls that which information is accurate regarding depression and the older client? Select all that apply.

Suicide is a frequent cause of death among the older population. Some indications of dementia may actually originate as depression. Depression in an older person is likely to have physical manifestations.

A client is admitted to the psychiatric nursing unit. When collecting data from the client, the nurse notes that the client was admitted on an involuntary status. Based on this type of admission, the nurse expects which?

The client presents a harm to self.

The nurse in a psychiatric unit is assigned to care for a client admitted to the unit 2 days ago. On review of the client's record, the nurse notes that the admission was a voluntary admission. Based on this type of admission, the nurse should expect which?

The client will participate in the treatment plan

A client comes to the clinic after losing all of his personal belongings in a hurricane. The nurse notes that the client is coping ineffectively. Which is the least realistic goal for this client?

The client will stop blaming himself for the lack of insurance

The nurse is assisting with the data collection on a client admitted to the psychiatric unit. After review of the data obtained, the nurse should identify which as a priority concern?

The client's report of self-destructive thoughts

The nurse is reviewing the health care record of a client admitted to the psychiatric unit. The nurse notes that the admission nurse has documented that the client is experiencing anxiety as a result of a situational crisis. The nurse should determine that this type of crisis could be caused by which?

The death of a loved one

A client with delirium becomes agitated and confused at night. The best initial intervention by the nurse is which?

Use a night light and turn off the television.

A client says to the nurse, "I'm going to die, and I wish my family would stop hoping for a 'cure'! I get so angry when they carry on like this! After all, I'm the one who's dying." Which therapeutic response should the nurse make to the client?

You're feeling angry that your family continues to hope for you to be 'cured'?"

A client is admitted to a psychiatric unit for treatment of a psychotic disorder. The client is at the locked exit door and is shouting, "Let me out! There's nothing wrong with me! I don't belong here!" The nurse identifies this behavior as which?

denial

The nurse is assigned to care for a client experiencing disturbed thought processes. The nurse is told that the client believes that the food is being poisoned. Which communication technique should the nurse plan to use to encourage the client to eat?

open-ended questions and silence