Psychosocial integrity
A 2-year-old child is brought to the emergency department with a broken arm. Which finding should lead the nurse to suspect child abuse? The child's clothes are dirty, torn, and obviously "hand-me-downs." The child has bruises on the forearms. The child's mother does not come to the hospital with the child. The child's father alters the story of the injury each time he tells it.
The child's father alters the story of the injury each time he tells it. The nurse should suspect child abuse when the child's caregiver changes the story of the injury each time it is told. A child who is still learning to walk and run commonly will have bruises on the forearms and shins; bruises on the upper arms and thighs are suspicious. Children commonly become dirty and tear clothes when they play. A parent may not be able to come to the hospital with the child for many reasons, such as care of other children, illness, or lack of transportation.
A client who suffered a brain injury after falling off a ladder has recently developed syndrome of inappropriate antidiuretic hormone (SIADH). Which findings indicate that the treatment being received for SIADH is effective? Select all that apply. rise in blood pressure and drop in heart rate increase in urine output decrease in urine osmolarity decrease in body weight absence of wheezing
decrease in body weight increase in urine output decrease in urine osmolarity SIADH is an abnormality involving an excessive release of ADH. The predominant feature is water retention with oliguria, edema, and weight gain. Successful treatment would result in a reduction in weight, increased urine output, and a decrease in urine osmolarity (concentration). Wheezes are not typically associated with SIADH. The client's blood pressure would remain the same or decrease after treatment.
Tourette syndrome is characterized by the presence of multiple motor and vocal tics. A vocal tic that involves repeating one's own sounds or words is known as: echolalia. apraxia. aphonia. palilalia.
palilalia. Palilalia is defined as the repetition of sounds and words. Echolalia is the act of repeating the words of others. Apraxia is the inability to carry out motor activities, and aphonia is the inability to speak.
After a client reveals a history of childhood sexual abuse, what question should the nurse ask first? "Does your abuser still have contact with young children?" "What other forms of abuse have you experienced?" "How long has the abuse went on for?" "Was there a time when you did not remember the abuse?"
"Does your abuser still have contact with young children?" The safety of other children is a primary concern. It is critical to know whether other children are at risk for being sexually abused by the same perpetrator. Asking about other forms of abuse, how long the abuse went on, and if the victim did not remember the abuse are important questions after the safety of other children is determined.
A client with paranoid personality disorder is admitted to a psychiatric facility. Which remark by the nurse would best establish rapport and encourage the client to confide in the nurse? "Sometimes it's normal not to trust anyone" "I get upset once in a while, too." "I worry when people talk about me, too" "I know how you feel"
"I get upset once in a while, too." Sharing a benign, nonthreatening, personal fact or feeling helps the nurse establish rapport with the client and encourages the client to confide in the nurse. The nurse can't know how the client feels. Telling the client otherwise would justify the suspicions of a paranoid client; furthermore, the client relies on the nurse to interpret reality. The nurse stating that she worries when people talk about her is incorrect because the statement focuses on the nurse's feelings, not the client's. Saying it's normal not to trust anyone wouldn't help establish rapport or encourage the client to confide in the nurse.
The client has been instructed in anger management. Which statement would indicate understanding of introjection? "I will blame someone else for my anger." "I will go for a long walk or exercise." "I will react to anger like I have seen my parents react." "I will take my anger out onto another person or object."
"I will react to anger like I have seen my parents react." Introjection is (assuming as one's own) one's parents' belief that anger shouldn't be outwardly expressed. Displacement is the discharge of negative feelings onto another person or an object. Projection is the attribution of one's own thoughts or impulses to another person. Sublimation is the channeling of unbearable or socially unacceptable behaviors into more socially acceptable outlets.
The nurse is planning care for a client with GAD (generalized anxiety disorder). Which statements by the nurse are made in the working phase of the nurse-client relationship? Select all that apply. "I know this will be difficult for you but you can do this by yourself." "I plan to meet with you every day after breakfast for 15 minutes." "Let's talk about how you would like to deal with your anxiety." "Tell me how you have dealt with anxiety in the past." "I can see you are learning some of these new relaxation techniques."
"Let's talk about how you would like to deal with your anxiety." "Tell me how you have dealt with anxiety in the past." "I can see you are learning some of these new relaxation techniques." The therapeutic nurse-client relationship consists of three phases: orientation, working, and termination. During the working phase, the nurse and client evaluate and refine the goals established during the orientation phase. In addition, major therapeutic work takes place and insight is integrated into a plan of action. This is seen where the nurse is asking the client about how they have dealt with anxiety in the past, how they plan to in the future, and the improvement that has been recognized through education. The orientation phase involves assessing the client, formulating a contract, exploring feelings, and establishing expectations about the relationship. Here this is seen when the nurse plans appointments with the client. During the termination phase, the nurse prepares the client for separation and explores their feelings about the end of the relationship. This is seen above where the nurse assures the client that "this can be done by them."
A client with major depression states to the nurse, "My heart is turning to stone." Which reply by the nurse is most therapeutic? "You are alive and breathing" "Depression is causing you to make those statements" "You sound like you feel frightened" "What makes you say that?"
"You sound like you feel frightened." The nurse's best response will be to focus on the underlying meanings of the client's remark without focusing on or challenging the content. Telling the client that she is alive and breathing challenges the client and minimizes the underlying feelings. Stating that the depression is causing the client to make those statements will force the client to defend and reinforce those beliefs. Asking the client what makes her say that forces her to defend her statement.
A client admitted to the psychiatric unit for treatment of substance abuse tells a nurse, "It felt so wonderful to get high." What is an appropriate response? "If you continue to talk like that, I'm going to stop speaking to you." "Don't you know it's illegal to use drugs?" "Tell me more about how it felt to get high." "You told me you got fired from your last job for missing too many days after taking drugs all night."
"You told me you got fired from your last job for missing too many days after taking drugs all night." Confronting the client with the consequences of substance abuse helps break through the client's denial. Making threats, such as not speaking to the client, isn't an effective way to promote self-disclosure or establish a rapport with the client. Although the nurse should encourage the client to discuss feelings, the discussion should focus on how the client felt before, not during, an episode of substance abuse. Encouraging the client to elaborate about the experience of getting high may reinforce the abusive behavior. The client is undoubtedly aware that drug use is illegal; a reminder to this effect is unlikely to alter behavior.
A client is a gravida 1, para 0. During the first 24 hours after birth, she doesn't show consistent interest in her neonate. What should the nurse do next? Question the client about how she feels about being a mother. Request a social service consultation. Document these expected behaviors of the taking-in period. Call the physician for an order for an antidepressant.
Document these expected behaviors of the taking-in period. According to Rubin, dependence and passivity are typical during the taking-in period, which may last up to 3 days after childbirth. It isn't appropriate for the nurse to administer an antidepressant; the client shows no signs of ongoing depression. Because the client's feelings are typical, the nurse doesn't need to ask about her feelings on being a mother, nor does she need to request a social service consultation.
When assessing a client's level of stress caused by significant life events, the nurse should use: Selye's general adaptation syndrome theory. Lazarus's theory. the general systems theory. Holmes and Rahe's theory.
Holmes and Rahe's theory. Holmes and Rahe's theory suggests that all life events, whether positive or negative, cause stress. Holmes and Rahe have created a readjustment scale that ranks life events according to how much stress they cause. Selye's general adaptation syndrome theory explains a person's organized response to stress in three stages. The general systems theory takes a holistic view of the stress response, recognizing internal and external stimuli affecting the person's health. Lazarus's theory suggests that the stress response occurs in three stages, with each stage being a conscious evaluation of the stimulus, not an automatic reaction.
A client with symptoms of amphetamine psychosis that are improving is anxious and still experiencing some delusions. When developing the client's plan of care, which measure should the nurse include? Advise the client to watch television. Wait for the client to approach the nurse. Invite the client to play a game of ping-pong with the nurse. Assign the client to a group about the physiologic effects of drugs.
Invite the client to play a game of ping-pong with the nurse. The nurse should invite the client who is anxious to participate in an activity that involves gross motor movements. Doing so helps to direct energy toward a therapeutic activity. Appropriate activities include walking, riding a stationary bicycle, or playing volleyball. Assigning the client to an educational group is not helpful because the anxious client would be unable to sit in a group setting and concentrate on what was occurring in the group. Watching television may be too stimulating for the client, possibly increasing anxiety. Additionally, the client may be too anxious to sit and focus. Waiting for the client to approach the nurse is not helpful or appropriate. The nurse is responsible for initiating contact with the client.
The nurse is assessing an older adult for signs of dementia. The nurse gives the client three words to remember: "cat," "crackers," and "toys." After having the client perform a short task, the nurse asks the client to repeat the words. The client says "toys," "boys," and "joys." What should the nurse do next? Ask the client to repeat the original words one more time. Repeat the test when a family member is present. Note on the medical record that the client has echolalia. Refer the client to a health care provider for further follow-up.
Refer the client to a health care provider for further follow-up. That the client is not able to recall the three words is a likely indicator of dementia; the nurse should make a referral for further testing. It is recommended not to repeat the test a second time if the client is not able to recall the words. Although the client repeated rhyming words, echolalia refers to repletion of the same word. It is not necessary to have a family member present when conducting the test, but the nurse should communicate the findings to the family and encourage them to seek follow-up assessment.
A nurse observes several interactions between a client and her neonate. Which behaviors by the mother would the nurse identify as evidence of mother-infant attachment? Select all that apply. She talks and coos to her neonate. She cuddles her neonate close to her. She does not make eye contact with her neonate. She requests that the nurse take the neonate to the nursery for feedings. She counts the fingers and toes of her neonate. She takes a nap when the neonate is also sleeping.
She talks and coos to her neonate. She cuddles her neonate close to her. She counts the fingers and toes of her neonate. Talking to, cooing at, and cuddling with her neonate are positive signs that the client is adapting to her new role as a mother. Eye contact, inspecting the neonate by touching, and speaking help establish attachment with a neonate. Avoiding eye contact is a nonbonding behavior. Feeding a neonate is an important role of a new mother and facilitates attachment. Resting while the neonate is sleeping will conserve needed energy and allow the mother to be alert and awake when her infant is awake; however, it is not evidence of bonding.
A client experiencing paranoid thought distortions states, "The voices are telling me the others are aliens trying to steal my brain." How should the nurse therapeutically approach this client?
State other voices are not heard, but do not argue. Paranoid clients develop a delusional system to defend against anxiety. It is best to insert doubt but not to argue with the client, because refuting and arguing with the delusion would just add to the client's anxiety. Encouraging venting would not address the thought distortion, and a logical, persistent approach would not be a match for distorted thinking. Confronting the client could cause the client to become agitated.
A client admitted to the psychiatric hospital with somatic symptom disorder is to be discharged tomorrow. The client starts screaming, "Nobody believes that I have real physical illnesses. I'll prove to you that I can't be discharged until my physical problems are treated." Which of the following actions should the nurse take? Select all that apply. Restate that the discharge will take place the next day. Tell the client to calm down or the nurse will not talk. Talk about fears and feelings with the client. Place the client on suicide and self-mutilation precautions as a nursing measure. Document the client's behaviors and verbalizations in the chart. Call the psychiatrist to report the client's behavior and statements.
Talk about fears and feelings with the client. Place the client on suicide and self-mutilation precautions as a nursing measure. Document the client's behaviors and verbalizations in the chart. Call the psychiatrist to report the client's behavior and statements. Talking about fears and feelings is a typical intervention for clients with somatic symptom disorder. Although the client's threat is vague, self-mutilation, suicide, or both are possibilities, so monitoring for them is important. Documenting in the chart and calling the psychiatrist are essential for client care and safety. Saying that the nurse will not talk to the client and discharge will happen anyway is likely to increase the client's anger and anxiety and is punitive.
The nurse is planning care for a client after being admitted in the emergency room for domestic violence. What would be the best action for the nurse?
Teach client problem-solving techniques and structured activities. Individuals in crisis need immediate assistance. They are unable to solve problems and need structure and assistance in accessing resources. Clients in crisis do not need lengthy explanations or have time to develop insight on their own. Although clients in crisis might need medication, in most cases, support and direction can be most helpful. Free association like Freud's approach or Beck's thought and feelings approach are too complicated for the client to understand in her state of anxiety.
A client has impairments in immediate recall and short-term memory. A nurse is planning for the client's daily activities. Which action by the nurse would be most effective? Take the client to each activity if he does not attend on time. Write out the client's schedule in large print, and show the client where the schedule is placed. Tell the client about each activity 10 minutes before it begins. Describe each activity and the time of the events at the beginning of the day.
Tell the client about each activity 10 minutes before it begins. Telling the client about one activity at a time with 10 minutes' notice gives the client time to prepare for that activity. Writing out the schedule does not ensure that the client will remember to look at it. It is overwhelming to explain an entire day's schedule all at once to a client diagnosed with dementia. Leading a client to an activity after the fact does not allow the client to prepare.
A nurse at a community mental health clinic is caring for a client diagnosed with a specific phobia of being in enclosed spaces. The client wants assistance to stop these troubling symptoms. The nurse determines which goal is the most appropriate? The client will become aware of times when the phobia occurs The client will recognize signs of escalating anxiety and be able to make decisions about life situations. The client will avoid ritualistic behaviors The client will be able to meet social and occupational functioning in the presence of the phobic situation.
The client will be able to meet social and occupational functioning in the presence of the phobic situation. The client with a phobia typically avoids the anxiety-producing stimulus. Learning to function in the presence of the stimulus will bring the client to a better level of functioning. The client is already aware of times when the phobic response occurs. Recognizing signs of escalating anxiety is not appropriate for specific phobia, because the client already knows when the symptoms will occur. Ritualistic behaviors are symptomatic of obsessive-compulsive disorders, not phobic disorders.
The nurse discusses the possibility of a client's attending day treatment for clients with early Alzheimer's disease. What is the best rationale for encouraging day treatment? More daily structure Excellent staff Benefit from increased social interaction Allow caregivers more time for themselves
The client would benefit from increased social interaction. The best rationale for day treatment for the client with Alzheimer's disease is the enhancement of social interactions. More daily structure, excellent staff, and allowing caregivers more time for themselves are all positive aspects, but they are less focused on the client's needs.
The nurse notices that a client recovering from a barbiturate overdose spends most of his time with other young adults who have substance-related problems. This group of clients is a dominant force on the unit, keeping the non-drug users entertained with stories of their "highs." Which method is best to use when dealing with this problem? discussing the behavior at the daily community meeting providing additional recreation speaking with the clients individually about their behavior breaking up drug-oriented discussions
discussing the behavior at the daily community meeting The best method to deal with the problem is to discuss observations with clients at the daily community meeting because the problem involves all of the clients and this provides them with the opportunity to offer their views. Peer pressure is valuable in confronting self-defeating and destructive behaviors. Providing additional recreation avoids or ignores the problem and is damaging to all clients because it decreases trust in the nurse. Breaking up drug-oriented discussions would not be sufficient to stop the behavior. Speaking with the clients individually about their behavior is not as effective as dealing with the problem openly and directly with everyone.
A nurse is developing a plan of care for a postpartum client of Arab American descent. The nurse integrates knowledge of which cultural belief as important for this client? reluctance to bathe due to belief that air gets into the mother and causes illness importance of ensuring that the client's mother is present for emotional support use of a bellyband on the abdomen to promote uterine contraction emphasis on healing ceremonies to restore health
reluctance to bathe due to belief that air gets into the mother and causes illness A postpartum Arab American client may be reluctant to bathe after childbirth because of beliefs that air gets into the mother and causes illness. Emotional support from the client's mother is important for an African American woman during labor. Bellybands placed on top of the infant's umbilicus are common in the Asian American culture. Healing ceremonies to restore health are associated with the Native American culture.
The nurse should integrate which principle when a client's mental status interferes with the ability to participate in milieu activities? Norms Structure Balance Schedule modification
schedule modification When a client's mental status interferes with the ability to participate in milieu activities, the nurse uses schedule modification to allow a flexible approach to treatment. Flexibility on the part of the nurse and the entire milieu is a necessary aspect of a therapeutic milieu. Norms, structure, and balance are necessary for an effective, therapeutic milieu. Norms are expectations of behavior that are communicated to clients in direct and indirect ways. Structure is the framework for the therapeutic environment. Balance refers to the negotiating of dependence versus independence found in psychiatric care.