Nursing 212
A nurse is working in the emergency room when a police officer walks in with rape victim to be examined. If goal is to reduce clients anxiety, which interventions would be appropriate? SATA A. Admit the client to the treatment area right away B. Encourage client to undergo exam immediately in order to get it behind her? C. Assure the client of safety in the exam room D. Touch client early on demonstrating the nurse is supportive. E. Allow third party to be present if client request it? F. Ask factual questions to determine the type of assault?
* Admit the client to treatment area right away. * Assure the client of safety in the exam room * Allow third party to be present if client request it. * Ask factual questions to determine the type of assault.
Which situation reflects the defense mechanism of denial? 1. When his twin brother excels in golf, the client begins lessons with a golf pro. 2. After a mother spanks her child for misbehaving, the child pulls the cat's tail. 3. After years of excessive drinking, the client fails to acknowledge a problem. 4. The client expresses to his family that 50% of people with his diagnosis survive.
3. 1. This is an example of the defense mechanism of identification, which enables a person to manage anxiety by imitating the behavior of someone respected or feared. 2. This is an example of the defense mechanism of displacement, which enables a person to discharge emotional reactions from one object or person to another object or person. 3. This is an example of the defense mecha- nism of denial, which enables a person to ignore unacceptable realities by refusing to acknowledge them. 4. This is an example of the defense mechanism of intellectualization, which enables a person to use logic and reasoning to control or mini- mize painful situations or feelings.
Which type of child abuse can be most difficult to treat effectively? a. Emotional b. Neglect c. Physical d. Sexual
a. Emotional
Which of the following assessment findings might indicate elder self-neglect? a. Hesitancy to talk openly with nurse b. Inability to manage personal finances c. Missing valuables that are not misplaced d. Unusual explanations for injuries
b. Inability to manage personal finances
A depressed client on an inpatient unit says to a nurse, "My family would be better off without me." The nurse's best response is: 1. "Have you talked to your family about this?" 2. "Everyone feels this way when they are depressed." 3. "You will feel better once your medication begins to work." 4. "You sound very upset. Are you thinking of hurting yourself?"
. 4 Rationale: Clients who are depressed may be at risk for sui- cide. It is critical for the nurse to assess suicidal ideation and plan. The nurse should ask the client directly whether a plan for self-harm exists. Options 1, 2, and 3 do not deal directly with the client's feelings. Test-Taking Strategy: Using therapeutic communication techniques will assist in directing you to the correct option. Option 4 is the only option that deals directly with the cli- ent's feelings. Additionally, clients at risk for suicide need to be assessed directly regarding the potential for self-harm. Review care of the client at risk for suicide if you had diffi- culty with this question.
Which best exemplifies an individual's use of the defense mechanism of compensation? 1. A woman feels unattractive, but decides to pursue fashion design as a career. 2. A shy woman who abuses alcohol tells others that alcohol helps her overcome her shyness. 3. A poorly paid employee consistently yells at his assistant for minimal mistakes. 4. A teenager injures an ankle playing basketball and curls into a fetal position to deal with the pain
1 1. A woman who feels unattractive and pursues a career in fashion design is an example of the defense mechanism of com- pensation. Compensation is a method of covering up a real or perceived deficit by emphasizing a strength. The woman feels unattractive, a perceived deficit, but pursues a career in fashion to compensate for this.2. A woman who abuses alcohol and excuses it by claiming a need to use alcohol for socialization is an example of the defense mechanism of rationalization. Rationalization is a method of attempting to make excuses or formulating logical reasons to justify unac- ceptable feelings or behaviors. 3. A poorly paid employee who consistently yells at his assistant for minimal mistakes is an example of the defense mechanism of dis- placement. Displacement is a method of transferring feelings from one threatening target to another target that is considered less threatening or neutral. 4. Curling into a fetal position after injuring an ankle is an example of the defense mechanism of regression. Regression is a method of responding to stress by retreating to an earlier level of development. This allows the individual to embrace the comfort measures associated with this earlier level of functioning. TEST-TAKING HINT: To answer this question cor- rectly, the test taker needs to understand that compensation covers up a perceived weakness by emphasizing a more desirable trait. An example would be an inept mother working to becoming teacher of the year.
A nurse employed in a mental health clinic is greeted by a neighbor in a local grocery store. The neighbor says to the nurse, "How is Carol doing? She is my best friend and is seen at your clinic every week." The appropriate nursing response is which of the following? 1. "I cannot discuss any client situation with you." 2. "If you want to know about Carol, you need to ask her yourself." 3. "I'm not supposed to discuss this, but because you are my neighbor, I can tell you that she is doing great!"
1 Rationale: A nurse is required to maintain confidentiality regarding the client and the client's care. Confidentiality is basic to the therapeutic relationship and is a client's right. The most appropriate response to the neighbor is option 1. Option 2 is a blunt statement and does not acknowledge the issue that the nurse cannot reveal if the named person is or was a client. Options 3 and 4 identify statements that do not maintain client confidentiality. Option 1 is the most direct and correct. Test-Taking Strategy: Focus on the subject of the question, maintaining confidentiality. This should assist you easily in eliminating options 3 and 4. From the remaining options, select option 1 over option 2 because it is the most direct and correct. Option 2 is a blunt and rude statement.
A client who has just been sexually assaulted is calm and quiet. A nurse analyzes this behavior as indicating which defense mechanism? 1. Denial 2. Projection 3. Rationalization 4. Intellectualization
1 Rationale: Denial is refusal to admit to a painful reality and may be a response by a victim of sexual abuse. Projection is transferring one's internal feelings, thoughts, and unacceptable ideas and traits to someone else. Rationalization is justifying the unacceptable attributes about oneself. Intellectualization is the excessive use of abstract thinking or generalizations to decrease painful thinking. Test-Taking Strategy: Use the process of elimination and note the strategic words calm and quiet. These behaviors indi- cate denial in a sexually abused victim.
A client is admitted to a mental health unit for treatment of psychotic behavior. 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." A nurse analyzes this behavior as: 1. Denial 2. Projection 3. Regression 4. Rationalization
1 Rationale: Denial is refusal to admit to a painful reality, which is treated as if it does not exist. In projection, a person uncon- sciously rejects emotionally unacceptable features and attributes them to other persons, objects, or situations. In regression, the client returns to an earlier, more comforting, although less mature, way of behaving. Rationalization is justifying illogical or unreasonable ideas, actions, or feelings by developing acceptable explanations that satisfy the teller and the listener. Test-Taking Strategy: Use the process of elimination. The strategic words in the question that should direct you to the correct option are "There's nothing wrong with me." Select the option that recognizes the client's attempt to avoid looking at the reality of the situation.
A nurse has been observing a client closely who has been displaying aggressive behaviors. The nurse observes that the behavior displayed by the client is escalating. Which nursing intervention is least helpful to this client at this time? 1. Initiate confinement measures. 2. Acknowledge the client's behavior. 3. Assist the client to an area that is quiet. 4. Maintain a safe distance with the client.
1 Rationale: During the escalation period, the client's behav- ior is moving toward loss of control. Nursing actions include taking control, maintaining a safe distance, acknowled- ging behavior, moving the client to a quiet area, and medi- cating the client if appropriate. To initiate confinement measures during this period is inappropriate. Initiation of confinement measures is most appropriate during the crisis period. Test-Taking Strategy: Note the strategic words behavior, esca- lating, and least helpful. Recalling that the least restrictive mea- sures should be used will direct you to option 1. Review care of the client with aggressive behavior if you had difficulty with this question.
A nurse enters a client's room, and the client is demanding release from the hospital. The nurse reviews the client's record and notes that the client was admitted 2 days ago for treatment of an anxiety disorder and that the admission was a voluntary admission. Which of the following actions would the nurse take? 1. Contact the physician. 2. Call the client's family. 3. Persuade the client to stay a few more days. 4. Tell the client that discharge is not possible at this time.
1 Rationale: Generally, the client seeks voluntary admission. Voluntary clients have the right to demand and obtain release. If the client is a minor, the release may be contingent on the consent of a parent or guardian. The nurse needs to be familiar with the state and facility policies and procedures. Many states require that the client submit a written release notice to the facility staff members, who re-evaluate the cli- ent's condition for possible conversion to involuntary status if necessary, according to criteria established by laws. The best nursing action is to contact the physician. Test-Taking Strategy: Use the process of elimination. Noting the type of hospital admission will assist in eliminating option 4. To "persuade" a client to stay in the hospital is inap- propriate. Option 2 should be eliminated simply based on the subjects of client rights and confidentiality.
A client has been admitted to the mental health unit. On admission assessment, a nurse notes that the client was admitted by involuntary status. Based on this type of admission, the nurse would most likely expect that the client: 1. Presents a harm to self 2. Requested the admission 3. Consented to the admission 4. Provided written application to the facility for admission
1 Rationale: Involuntary admission is made without the client's consent. Involuntary admission is necessary when a person is a danger to self or others or is in need of psychiatric treatment. Options 2, 3, and 4 describe the process of voluntary admission. Test-Taking Strategy: Use the process of elimination and note the strategic words involuntary status. This should direct you easily to option 1. Also, note that options 2, 3, and 4 are comparable or alike.
A nurse is planning care for a client being admit- ted to the nursing unit who attempted suicide. Which of the following priority nursing interventions would the nurse include in the plan of care? 1. One-to-one suicide precautions 2. Suicide precautions with 30-minute checks 3. Checking the whereabouts of the client every 15 minutes 4. Asking the client to report suicidal thoughts immediately
1 Rationale: One-to-one suicide precautions are required for a cli- ent who has attempted suicide. Options 2 and 3 may be appro- priate, but not at the present time, considering the situation. Option 4 also may be an appropriate nursing intervention, but the priority is identified in option 1. The best intervention is constant supervision so that the nurse may intervene as needed if the client attempts to harm himself or herself. Test-Taking Strategy: Use the process of elimination, noting the strategic words attempted suicide. Option 1 is the only option that provides a safe environment.
A client admitted to the mental health unit is experiencing disturbed thought processes and believes that the food is being poisoned. Which communication technique would a nurse plan to use to encourage the client to eat? 1. Using open-ended questions and silence 2. Focusing on self-disclosure regarding food preferences 3. List possible reasons in the care plan that the client may not want to eat 4. Offering opinions about the necessity of adequate nutrition
1 Rationale: Open-ended questions and silence are strategies used to encourage clients to discuss their problems. Options 3 and 4 are not helpful to the client because they do not encourage the client to express feelings. The nurse should not offer opinions and should encourage the client to identify the reasons for the behavior. Option 2 is not a client-centered intervention. Test-Taking Strategy: Use the process of elimination. Eliminate options 3 and 4 first because they do not support client expres- sion of feelings. Eliminate option 2 next because it is not a cli- ent-centered response. Focusing on the client's feelings will direct you to option 1.
An emergency department nurse is caring for an adult client who is a victim of family violence. Which priority instruction would be included in the discharge instructions? 1. Information regarding shelters 2. Instructions regarding calling the police 3. Instructions regarding self-defense classes 4. Explaining the importance of leaving the violent situation
1 Rationale: Tertiary prevention of family violence includes assisting the victim after the abuse has already occurred. The nurse should provide the client with information regarding where to obtain help, including a specific plan for removing the self from the abuser and information regarding escape, hotlines, and the location of shelters. An abused person is usually reluctant to call the police. Teaching the victim to fight back is not the appropriate action for the victim when dealing with a violent person. Test-Taking Strategy: Note the strategic word priority. Focus on the subject of the question, which relates to providing the client with a safe environment. Use Maslow's Hierarchy of Needs theory to assist in directing you to option 1.
A student statements indicates that learning has occurred? Select all that apply. 1. "Defense mechanisms are used when anxiety increases, and the strength of the ego nursing instructor is teaching about defense mechanisms. Which of the following is tested." 2. "All individuals who use defense mechanisms as a means of stress adaptation exhibit healthy egos." 3. "When defense mechanisms are overused or maladaptive, unhealthy ego develop- ment may result." 4. "Defense mechanisms are used only by mentally ill individuals to assist with coping." 5. "At times of mild to moderate anxiety, defense mechanisms are used adaptively to deal with stress."
1,3,5 1. Ego defense mechanisms are used when anxiety increases, and the individual's ego is being tested. 2. Defense mechanisms can be used adaptively to deal with stress and protect the ego. Unhealthy ego development may result from the overuse or maladaptive use of defense mechanism. Not all individuals who use defense mechanisms as a means of stress adaptation exhibit healthy egos. The word "all" in this statement makes it incorrect. 3. When defense mechanisms are used excessively and interfere with an individ- ual's ability to cope, they are considered maladaptive and may result in unhealthy ego development. 4. Defense mechanisms are used by all individu- als, not just individuals diagnosed with mental illness. Whether defense mechanisms are used adaptively or maladaptively con- tributes to the individual's healthy ego development. 5. Defense mechanisms are used adaptively during times of mild to moderate anxiety to decrease stress and assist with coping TEST-TAKING HINT: To answer this question cor- rectly, the test taker needs to note important words in the answers, such "all" in "2." The use of the words "never," "only," and "always" should alert the test taker to reconsider the answer choice.
A client in the emergency department was violently attacked and raped. When discussing the incident with the nurse, the client shows no emotion related to the event. Which defense mechanism is the client using? 1. Isolation. 2. Displacement. 3. Compensation. 4. Regression.
1. 1. Isolation is the separation of thought or memory from the feeling, tone, or emo- tion associated with the memory or event. The client in the question showing no emotion related to the rape is using the defense mechanism of isolation. 2. Displacement is the transferring of feelings from one target to another target that is considered less threatening or neutral. An example would be when a client is angry with the physician, but directs this anger toward the nurse. 3. Compensation occurs when a person covers up a real or perceived weakness by emphasiz- ing a trait considered more desirable. An example would be when a physically handi- capped boy who is unable to participate in football compensates by becoming a great scholar. 4. Regression occurs when a person responding to stress retreats to an earlier level of devel- opment and the comfort measures associated with that level of functioning. An example would be when a hospitalized 2-year-old drinks only from a bottle, although his mother states he has been drinking from a cup for the last 4 months. TEST-TAKING HINT: The test taker needs to understand that the defense mechanism of isola- tion does not refer to physical seclusion, but rather to an emotional isolation of feelings
After failing an examination, a young physician in his psychiatric residency begins smoking a pipe and growing a beard that makes him look like Sigmund Freud. The nurse manager, realizing the physician's insecurities, recognizes the use of which defense mechanism? 1. Identification. 2. Repression. 3. Regression. 4. Reaction formation.
1. 1. Identification is an attempt to increase self-esteem by acquiring certain attributes of an admired individual. This psychiatric resident is identifying with Sigmund Freud. 2. Repression is the unconscious blocking of material that is threatening or painful. Example: "I know I took the MCAT, but I can't remember anything about the test." 3. Regression is used to respond to stress by retreating to an earlier, more comfortable level of development. Example: "It's not fair, the instructor's inept, and I'm quitting if things don't change." 4. Reaction formation prevents unacceptable thoughts or feelings from being expressed by exaggerating the opposite thoughts or feelings. Example: "I'm writing a letter of academic appreciation to the medical school faculty." TEST-TAKING HINT: To answer this question correctly, the test taker must pair the situation presented in the question with the appropriate defense mechanism. Although repression and regression may sound and be spelled similarly, there is a major difference in their meaning. Repression is an involuntary thought blocking defense, whereas regression is an abnormal return to an earlier level of development.
Which best exemplifies a client's use of the defense mechanism of reaction formation? 1. A client feels rage at being raped at a young age, which later is expressed by joining law enforcement. 2. A client is unhappy about being a father, although others know him to dote on his son. 3. A client is drinking 6 to 8 beers a day while still going to AA as a group leader. 4. A client is angry that the call bell is not answered and decides to call the nurse when it is unnecessary.
2 1.Feelings of rage at being raped at a young age, which later are expressed by joining law enforcement, is an example of the defense mechanism of sublimation, not reaction for- mation. Sublimation is a method of rechan- neling drives or impulses that are personally or socially unacceptable into activities that are constructive. 2. Doting on his son publicly, while privately being unhappy with fatherhood, would be an example of the defense mechanism of reaction formation. Reaction formation assists in preventing unacceptable or undesirable thoughts or behaviors from being expressed by exaggerating opposite thoughts or types of behavior. 3. Drinking 6 to 8 beers a day while still going to AA as a group leader is an example of the defense mechanism of denial, not reaction formation. Denial assists the client in ignor- ing the existence of a real situation or the feelings associated with it. 4. When a client is angry that the call bell is not answered and then decides to use the call bell when it is unnecessary, this is an example of passive-aggressive behavior, not reaction for- mation. Passive-aggressive behavior occurs when an individual's behavior is expressed in sly, devious, and undermining actions that convey the opposite of what the client is really feeling. TEST-TAKING HINT: To answer this question cor- rectly, the test taker needs to understand that reaction formation prevents thoughts or behav- iors from being expressed by expressing opposite thoughts or feelings. In the correct answer choice, publicly treasuring the client's son cam- ouflages the client's parental misgiving.
Which behavior observed by a nurse indicates a suspicion that a depressed adolescent client may be suicidal? 1. The client runs out of the therapy group, swearing at the group leader, and runs to her room. 2. The client gives away a prized CD and a cherished autographed picture of the performer. 3. The client becomes angry while speaking on the telephone and slams down the receiver. 4. The client gets angry with her roommate when the roommate borrows the client's clothes without asking.
2 Rationale: A depressed suicidal client often gives away that which is of value as a way of saying goodbye and wanting to be remembered. Options 1, 3, and 4 deal with anger and acting-out behaviors that are often typical of any adolescent. Test-Taking Strategy: Use the process of elimination. Elimi- nate options 1, 3, and 4 because they are comparable or alike. Option 2 is different and is an action that could indicate that the client may be "saying goodbye."
A nurse is reviewing the assessment data of a client admitted to the mental health unit. The nurse notes that the admission nurse documented that the client is experiencing anxiety as a result of a situational crisis. The nurse determines that this type of crisis could be caused by: 1. Witnessing a murder 2. The death of a loved one 3. A fire that destroyed the client's home 4. A recent rape episode experienced by the client
2 Rationale: A situational crisis arises from external rather than internal sources. External situations that could precipitate a crisis include loss of or change of a job, the death of a loved one, abortion, change in financial status, divorce, addition of new family members, pregnancy, and severe illness. Options 1, 3, and 4 identify adventitious crises. An adventitious crisis refers to a crisis of disaster; it is unplanned or accidental. Test-Taking Strategy: Use the process of elimination. Eliminate options 1, 3, and 4 because they are comparable or alike types of occurrences. If you had difficulty with this question, review the types of crisis.
A nurse in the emergency department is caring for a young female victim of sexual assault. The client's physical assessment is complete, and physical evidence has been collected. The nurse notes that the client is withdrawn, confused, and at times physically immobile. These behaviors are interpreted by the nurse as: 1. Signs of depression 2. Normal reactions to a devastating event 3. Evidence that the client is a high suicide risk 4. Indicative of the need for hospital admission
2 Rationale: During the acute phase of the rape crisis, the client can display a wide range of emotional and somatic responses. The symptoms noted indicate a normal reaction. Options 1, 3, and 4 are incorrect interpretations. Test-Taking Strategy: Use the process of elimination and knowledge regarding client responses to devastating events to answer the question. Focus on the symptoms noted in the question to direct you to option 2. If you had difficulty with this question, review normal and abnormal client responses to dealing with devastating crisis events.
A nurse is preparing a client for the termination phase of the nurse-client relationship. The nurse prepares to implement which nursing task appropriate for this phase? 1. Planning short-term goals 2. Making appropriate referrals 3. Developing realistic solutions 4. Identifying expected outcomes
2 Rationale: Tasks of the termination phase include evaluating client performance, evaluating achievement of expected out- comes, evaluating future needs, making appropriate referrals, and dealing with the common behaviors associated with ter- mination. Options 1, 3, and 4 identify the tasks of the work- ing phase of the relationship. Test-Taking Strategy: Use the process of elimination. Noting the strategic words termination phase should direct you easily to option 2.
The police arrive at the emergency department with a client who has seriously lacerated both wrists. The initial nursing action is to: 1. Administer an antianxiety agent. 2. Examine and treat the wound sites. 3. Secure and record a detailed history. 4. Encourage and assist the client to ventilate feelings.
2 Rationale: The initial nursing action is to assess and treat the self-inflicted injuries. Injuries from lacerated wrists can lead to a life-threatening situation. Other interventions, such as options 1, 3, and 4, may follow after the client has been trea- ted medically. Test-Taking Strategy: Note the strategic word initial. Use Maslow's Hierarchy of Needs theory to prioritize. Physiologi- cal needs come first. Option 2 addresses the physiological need.
A nurse is providing care to a client admitted to the hospital with a diagnosis of acute anxiety disorder. The client says to the nurse, "I have a secret that I want to tell you. You won't tell anyone about it, will you?" The appropriate nursing response would be which of the following? 1. "No, I won't tell anyone." 2. "I cannot promise to keep a secret." 3. "If you tell me the secret, I will tell it to your doctor." 4. "If you tell me the secret, I will need to document it in your record."
2 Rationale: The nurse should never promise to keep a secret. Secrets are appropriate in a social relationship, but not in a therapeutic one. The nurse needs to be honest with the client and tell the client that a promise cannot be made to keep the secret. Options 1, 3, and 4 are inappropriate responses. Test- Taking Strategy: Use the process of elimination. Option 1 can be eliminated easily because it is inappropriate. Options 3 and 4 are not only inappropriate, but are also threatening and may block further communication.
Which situation reflects the defense mechanism of projection? 1. A husband has an affair, then buys his wife a diamond anniversary bracelet. 2. A promiscuous wife accuses her husband of having an affair. 3. A wife, failing to become pregnant, works hard at becoming teacher of the year. 4. A man who was sexually assaulted as a child remembers nothing of the event.
2. 1. This is an example of the defense mechanism of undoing, which is an act of atonement for one's unacceptable acts or thoughts. 2. This is an example of the defense mecha- nism of projection, in which a person attributes unacceptable impulses and feel- ings to another. 3. This is an example of the defense mechanism of compensation, in which a person counter- balances a deficiency in one area by excelling in another. 4. This is an example of the defense mechanism of repression, which is the involuntary block- ing from consciousness of unacceptable ideas or impulses from one's awareness. TEST-TAKING HINT: To answer this question correctly, the test taker needs to understand that projection is a defense mechanism in which the individual "passes the blame," or attributes undesirable feelings or impulses to another, pro- viding relief from associated anxiety.
A client has been fired from work because of downsizing. Although clearly upset, when explaining the situation to a friend, the client states, "Imagine what I can do with this extra time." Which defense mechanism is this client using? 1. Denial. 2. Intellectualization. 3. Rationalization. 4. Suppression.
2. Some ego defenses are more adaptive than others, but all are used either consciously or unconscious- ly as a protective device for the ego in an effort to relieve mild to moderate anxiety. Until an individ- ual is able to deal with stressful situations, ego defense mechanisms are commonly used. 1. Denial occurs when an individual refuses to acknowledge the existence of a real situation or the feeling associated with it. The client in the question is not exhibiting denial. 2. Intellectualization occurs when an individ- ual attempts to avoid expressing actual emotions associated with a stressful situa- tion by using the intellectual processes of logic, reasoning, and analysis. The individ- ual in the stem is using reasoning to avoid dealing with feelings about being fired. 3. Rationalization occurs when an individual attempts to make excuses or formulate logical reasons to justify unacceptable feelings or behaviors. The client in the question is not exhibiting rationalization.4. Suppression occurs when an individual volun- tarily blocks unpleasant feelings and experi- ences from awareness. The client in the question is not exhibiting suppression. TEST-TAKING HINT: To answer this question cor- rectly, the test taker needs to differentiate defense mechanisms and recognize behaviors that reflect the use of these defenses.
A nurse is conducting an initial assessment on a client in crisis. When assessing the client's perception of the precipitating event that led to the crisis, the appropriate question to ask is: 1. "With whom do you live?" 2. "Who is available to help you?" 3. "What leads you to seek help now?" 4. "What do you usually do to feel better?"
3 Rationale: A nurse's initial task when assessing a client in crisis is to assess the individual or family and the problem. The more clearly the problem can be defined, the better the chance a solution can be found. Option 3 would assist in determining data related to the precipitating event that led to the crisis. Options 1 and 2 assess situational supports. Option 4 assesses personal coping skills. Test-Taking Strategy: Use the process of elimination and note the strategic words precipitating event. Focus on these strategic words when selecting the correct option. Eliminate options 1 and 2 because these data would determine support systems. Eliminate option 4 because this question would be asked when determining coping skills.
A moderately depressed client who was hospitalized 2 days ago suddenly begins smiling and reporting that the crisis is over. The client says to a nurse, "I'm finally cured." The nurse interprets this behavior as a cue to modify the treatment plan by: 1. Suggesting a reduction of medication 2. Allowing increased "in-room" activities 3. Increasing the level of suicide precautions 4. Allowing the client off-unit privileges as needed
3 Rationale: A client who is moderately depressed and has only been in the hospital 2 days is unlikely to have such a dramatic cure. When a depression suddenly lifts, it is likely that the cli- ent may have made the decision to harm himself or herself. Suicide precautions are necessary to keep the client safe. Test-Taking Strategy: Use the process of elimination. Options 1 and 4 support the client's notion that a cure has occurred. Option 2 allows the client to increase isolation and would present a threat to the client's safety. Safety is of the utmost importance; option 3 is the correct option.
A client is admitted to the mental health unit after an attempt of suicide by hanging. A nurse's most important aspect of care is to maintain client safety. This is accomplished best by: 1. Requesting that a peer remain with the client at all times 2. Removing the client's clothing and placing the client in a hospital gown 3. Assigning a staff member to the client who will remain with the client at all times 4. Admitting the client to a seclusion room where all potentially dangerous articles are removed
3 Rationale: Hanging is a serious suicide attempt. The plan of care must reflect action that ensures the client's safety. Con- stant observation status (one-to-one) with a staff member who is never less than an arm's length away is the best choice. Seclusion should not be the initial intervention, and the least restrictive measure should be used. Placing the client in a hos- pital gown and requesting that a peer remain with the client would not ensure a safe environment. Test-Taking Strategy: Use the process of elimination. Elimi- nate option 4 because seclusion should not be the initial intervention. Eliminate option 1 next because the responsibil- ity to safeguard a client is not the peer's responsibility. Elimi- nate option 2 because removing one's clothing would not maximize all possible safety strategies.
A female victim of a sexual assault is being seen in the crisis center. The client states that she still feels "as though the rape just happened yesterday," even though it has been a few months since the incident. The appropriate nursing response is which of the following? 1. "You need to try to be realistic. The rape did not just occur." 2. "It will take some time to get over these feelings about your rape." 3. "Tell me more about the incident that causes you to feel like the rape just occurred." 4. "What do you think that you can do to alleviate some of your fears about being raped again"?
3 Rationale: Option 3 allows the client to express her ideas and feelings more fully and portrays a nonhurried, nonjudgmen- tal, supportive attitude on the part of the nurse. Clients need to be reassured that their feelings are normal and that they may express their concerns freely in a safe, caring environ- ment. Option 4 places the problem solving totally on the client. Option 2 places the client's feelings on hold. Option 1 immediately blocks communication. Test-Taking Strategy: Use the process of elimination. Option 3 is the only option that addresses the client's feelings. Always address the client's feelings first.
A client says to a 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." The therapeutic response by the nurse is: 1. "Have you shared your feelings with your family?" 2. "I think we should talk more about your anger with your family." 3. "You're feeling angry that your family continues to hope for you to be cured?" 4. "Well, it sounds like you're being pretty pessimistic. After all, years ago, people died of pneumonia."
3 Rationale: Restating is a therapeutic communication tech- nique in which the nurse repeats what the client says to show understanding and to review what was said. Option 3 uses the therapeutic technique of restating. In option 1, the nurse is attempting to assess the client's ability to discuss feelings openly with family members. In option 2, the nurse attempts to use focusing, but the attempt to discuss central issues is premature. In option 4, the nurse makes a judgment and is nontherapeutic in the one-to-one relationship. Test-Taking Strategy: Use therapeutic communication tech- niques to answer the question. Option 3 is the only option that identifies the use of a therapeutic technique and focuses on the client's feelings.
A nurse observes that a client with a potential for violence is agitated, pacing up and down the hallway, and is making aggressive and belligerent gestures at other clients. Which statement would be appropriate to make to this client? 1. "You need to stop that behavior now." 2. "You will need to be placed in seclusion." 3. "You seem restless; tell me what is happening." 4. "You will need to be restrained if you do not change your behavior."
3 Rationale: The best statement is to ask the client what is caus- ing the agitation. This will assist the client to become aware of the behavior and may assist the nurse in planning appropriate interventions for the client. Option 1 is demanding behav- ior that could cause increased agitation in the client. Options 2 and 4 are threats to the client and are inappropriate. Test-Taking Strategy: Use the process of elimination. Elimi- nate option 1 because of the demand that it places on the client. Eliminate options 2 and 4 because they indicate threats to the client. Review appropriate nursing actions for the agitated client if you had difficulty with this question.
A nurse is preparing to care for a dying client, and several family members are at the client's bedside. Select the therapeutic techniques that the nurse would use when communicating with the family. Select all that apply. 1. Discourage reminiscing. 2. Make the decisions for the family. 3. Encourage expression of feelings, concerns, and fears. 4. Explain everything that is happening to all family members. 5. Touch and hold the client's or family mem- ber's hand if appropriate. 6. Be honest and let the client and family know that they will not be abandoned by the nurse.
3, 5, 6 Rationale: The nurse must determine whether there is a spokesperson for the family and how much the client and family want to know. The nurse needs to allow the family and client the opportunity for informed choices and assist with the decision-making process if asked. The nurse should encourage expression of feelings, concerns, and fears and reminiscing. The nurse needs to be honest and let the client and family know that they will not be abandoned. The nurse should touch and hold the client's or family member's hand, if appropriate. Test-Taking Strategy: Recalling therapeutic communication techniques and client and family rights will assist you in answering this question.
During visiting hours, a client who is angry at her ex-husband's charges of child neglect expresses this anger by lashing out at her sister-in-law. The nurse understands that the client is demonstrating the use of which defense mechanism? 1. Denial. 2. Projection. 3. Displacement. 4. Rationalization.
3. 1. The client would use denial to negate her unacceptable guilt related to child neglect. Example: "I don't know where my husband gets the idea that I have neglected our children." 2. Projection involves behaviors that are person- ally unacceptable. These behaviors are then attributed to others. Example: "My husband's a workaholic, and he is the one who has neg- lected the children." 3. Displacement transfers feelings that are unacceptable to express to one person (her husband) to a less threatening person (her sister-in-law). 4. Rationalization is the attempt to make excus- es or formulate logical reasons to justify unac- ceptable feelings or behaviors. Example: "My job is so demanding, I have little time to devote to the children." TEST-TAKING HINT: To answer this question cor- rectly, the test taker needs to understand that projection is often confused with displacement. Projection occurs when a person's unacceptable feelings or impulses are attributed to others. Displacement occurs when feelings are trans- ferred from one target to a less threatening or neutral target.
Which best exemplifies the use of the defense mechanism of sublimation? 1. A child who has been told by parents that stealing is wrong reminds a friend not to steal. 2. A man who loves sports but is unable to play decides to become an athletic trainer. 3. Having chronic asthma with frequent hospitalizations, a young girl admires her nurses. She later chooses nursing as a career. 4. A boy who feels angry and hostile decides to become a therapist to help others.
4 1. A child telling a friend not to steal after being told it is wrong is an example of the defense mechanism of introjection, not sublimation. Introjection is a method of integrating the beliefs and values of another individual into one's own ego structure. 2.A man becoming an athletic trainer because of his inability to play sports is an example of the defense mechanism of compensation, not sublimation. Compensation is the method of covering up a real or perceived weakness by emphasizing a trait one considers more desirable. 3. By choosing a nursing career as the result of admiring nurses who have cared for her, this young girl is implementing the defense mechanism of identification, not sublimation. Identification is a method of attempting to increase self-worth by acquiring certain attributes and characteristics of an admired individual. 4. Directing hostile feelings into productive activities, such as becoming a therapist to help others, is an example of the defense mechanism of sublimation. Sublimation is the method of rechanneling drives or impulses that are personally or socially unacceptable into activities that are constructive. TEST-TAKING HINT: To answer this question cor- rectly, the test taker must review and understand the differences between similar defense mecha- nisms, such as sublimation and compensation.
A client is admitted to the emergency department after a car accident, but does not remember anything about it. The client is using which defense mechanism? 1. Undoing. 2. Rationalization. 3. Suppression. 4. Repression.
4 1. Undoing is an act of atonement for one's unacceptable acts or thoughts. An example of this would be a client accusing his wife of infidelity and then buying her a diamond bracelet. The situation in the question is not reflective of undoing. 2. Rationalization is an attempt to make excuses or formulate logical reasons to justify unac- ceptable feelings or behaviors. An example would be a client stating, "I drink because it's the only way I can deal with my bad marriage and my job." The situation in the question is not reflective of rationalization. 3. Suppression is the voluntary blocking of unpleasant feelings and experiences from one's awareness. An example would be a client stating, "I don't want to think about it now; I will think about that tomorrow." The situation in the question is not reflective of suppression. 4. The client in the question is using the defense mechanism of repression. Repression is the unconscious, involuntary blocking of unpleasant feelings and experiences from one's own awareness. TEST-TAKING HINT: To answer this question cor- rectly, the test taker must pair the situation pre- sented in the question with the appropriate defense mechanism.
A client was admitted involuntarily to the mental health unit because of episodes of extremely violent behavior. The client is demanding to be discharged from the hospital, and a nurse does not allow the client to leave. Which of the following represents the legal ramifications associated with the nurse's behavior? 1. The nurse will be charged with assault. 2. The nurse will be charged with slander. 3. The nurse will be charged with imprisonment. 4. No charge will be made against the nurse because the nurse's actions are reasonable.
4 Rationale: False imprisonment is an act with the intent to con- fine a person to a specific area. A nurse can be charged with false imprisonment if the nurse prohibits a client from leaving the hospital if the client has been admitted voluntarily and if no agency or legal policies exist for detaining the client. If the client has been admitted involuntarily or had agreed to an evaluation before discharge, the nurse's actions are reasonable. Test-Taking Strategy: Noting the strategic words admitted involuntarily will assist you in eliminating option 3 and direct you to option 4. Options 1 and 2 are unrelated to the subject of the question and can be eliminated easily.
A nurse employed in a mental health 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 anticipates which of the following? 1. The client will resist treatment measures. 2. The client will be angry and will refuse care. 3. The client's family will resist treatment measures. 4. The client will participate in the planning of the care and treatment plan.
4 Rationale: Generally, the client seeks voluntary admission. A voluntary admission permits a client to make a writtenapplication for admission. If the client seeks voluntary admis- sion, the most likely expectation is that the client will partici- pate in the treatment program. Options 1, 2, and 3 are not characteristics of this type of admission. Test-Taking Strategy: Use the process of elimination. Note the strategic words voluntary admission. This should direct you to option 4. Additionally, options 1, 2, and 3 are compa- rable or alike.
Unresolved feelings related to loss most likely may be recognized during which phase of the therapeutic nurse-client relationship? 1. Working 2. Trusting 3. Orientation 4. Termination
4 Rationale: In the termination phase, the relationship comes to a close. Ending treatment sometimes may be traumatic for clients who have come to value the relationship and the help. Because loss is an issue, any unresolved feelings related to loss may resur- face during this phase. Options 1, 2, and 3 are incorrect. Test-Taking Strategy: Note the strategic words unresolved, loss, and recognized in the question. Considering the phases of the therapeutic nurse-client relationship will direct you to option 4.
A nurse is working with a client who has sought counseling after trying to rescue a neighbor involved in a house fire. Despite the client's efforts, the neighbor died. Which action does the nurse engage in with the client during the working phase of the nurse-client relationship? 1. Exploring the client's ability to function 2. Exploring the client's potential for self-harm 3. Inquiring about the client's perception or appraisal of the neighbor's death 4. Inquiring about and examining the client's feelings that may block adaptive coping
4 Rationale: The client must first deal with feelings and negative responses before the client can work through the meaning of the crisis. Option 4 pertains directly to the client's feelings. Options 1 and 2 do not directly address the client's feelings. Option 3 does not directly focus on the clients's feelings.. Test- Taking Strategy: Focus on the subject of the question, the working phase of the nurse-client relationship. Think about the interventions that occur in this phase. Using the process of elimination, focus on this subject and on the option that focuses on the feelings of the client. This will direct you to option 4.
Women in battering relationships often remain in those relationships as a result of faulty or incorrect beliefs. Which of the following beliefs is valid? a. If she tried to leave, she would be at increased risk for violence. b. If she would do a better job of meeting his needs, the violence would stop. c. No one else would put up with her dependent cling- ing behavior. d. She often does things that provoke the violent episodes.
a. If she tried to leave, she would be at increased risk for violence.
A female client comes to an urgent care clinic and says, "I've just been raped." What should the nurse do? SATA a. Allow the client to express whatever she wants. b. Ask the client if staff can call a friend or family mem- ber for her. c. Offer the client coffee, tea, or whatever she likes to drink. d. Get the examination completed quickly to decrease trauma to the client. e. Provide the client privacy--let her go to a room to make phone calls. f. Stay with the client until someone else arrives to be with her.
a. Allow the client to express whatever she wants. b. Ask the client if staff can call a friend or family member for her. f. Stay with the client until someone else arrives to be with her.
Which of the following is the best action for the nurse to take when assessing a child who might be abused? a. Confront the parents with the facts and ask them what happened. b. Consult with a professional member of the health team about making a report. c. Ask the child which of his parents caused this injury. d. Say or do nothing; the nurse has only suspicions, not evidence.
b. Consult with a professional member of the health team about making a report.