Unit 4: Foundations of Psychiatric Nursing

A client diagnosed with antisocial personality disorder asks the nurse for an additional smoke break because of anxiety. Which response by the nurse is best?

"Clients are permitted to smoke at designated times. You have to follow the rules." Consistency is essential when dealing with antisocial clients. They disregard social norms and don't believe the rules apply to them. Agreeing to give the client a smoke break would be detrimental to the client because it reinforces the client's acting-out behaviors. Saying the nurse is too busy avoids the client's attempt to manipulate. Telling the client that an extra smoke break is not allowed because smoking is harmful is inappropriate because the nurse is lecturing the client.

On admission to the inpatient psychiatric unit, a client's facial expression indicates severe panic. The client repeatedly states, "I know the police are going to shoot me. They found out that I'm the child of the devil." What should the nurse say to initiate a therapeutic relationship with this client?

"Hello, my name is ___. I'm a nurse, and I'll care for you when I'm on duty. Should I call you ___, or do you prefer something else? The first task during the introductory, or orientation, phase of the nurse-client relationship is to formulate a contract, which begins with the exchange of names and an explanation of the roles and limits of the relationship. These tasks should precede the exploration of relevant stressors and new coping mechanisms. Offering false reassurance is never therapeutic.

The nurse is performing an admission interview when the client attempts to shift the session focus to the nurse by asking personal questions. Which statement by the nurse is most appropriate?

"I have a family. Tell me about you and your family. The nurse's self-disclosure should be brief, vague, and to the point so that the interaction can be refocused on the client's experience. Because the client is the focus of the nurse-client relationship, discussion should not dwell on the nurse's experience. Telling the client that the nurse should control the conversation or not give personal personal information could be considered argumentative.

A nurse is teaching self-esteem to a client. Which statements by the client would indicate understanding of the concept? Select all that apply.

"I need to have consistent limits." "Living in a critical environment is not good for me." "I need to have healthy boundaries." Self-esteem is how we value or feel worthwhile about ourselves. A variety of factors can aide a person in developing a healthier self-esteem. Here are a few: A structured lifestyle demonstrates acceptance and caring and provides a sense of security. A critical environment erodes a person's esteem. Inconsistent boundaries lead to feelings of insecurity and lack of concern. Physical discipline can decrease self-esteem. When the client starts to make decisions, this can help increase their self-esteem.

A client who has had AIDS for years is being treated for a serious episode of pneumonia. A psychiatric nurse consult was arranged after the client stated, "I'm tired of being in and out of the hospital. I'm not coming in here anymore. I have other options." The nurse would evaluate the psychiatric nurse consult as helpful if the client makes which statements?

"I realize that I really do have more time to enjoy my friends and family." Focusing on enjoying time with family and friends conveys a renewal of hope for the future and a decreased risk of suicide. Simply saying that no one wants the client to commit suicide does not say the client does not want to do it. Avoiding a transfer to a psychiatric unit does not mean the client is no longer suicidal. Fear of not being successful with suicide usually is not a deterrent.

Which statement indicates to the nurse that the client is progressing toward recovery from a somatoform disorder?

"I understand my pain will feel worse when I am worried about my divorce." The client who states, "I understand my pain will feel worse when I am worried about my divorce" recognizes the connection between his pain and the divorce and indicates developing insight into his problem. The nurse should then be able to assist the client with developing adaptive coping strategies. The other statements indicate a lack of insight into his disorder and lack of progress toward recovery. The client is still searching for the "right" diagnosis, medication, and health care provider (HCP).

A distraught father is waiting for his son to come out of surgery. He accidentally backed the car into his son, causing multiple fractures and a serious head injury. Which statement by the father would most alert the nurse to the need for a psychiatric consultation?

"If he dies, there will be nothing for me to do but join him." The statement about joining the son if he dies indicates potential for self-harm and subsequent suicide, always a risk during crisis. Although the father may be charged with reckless driving, this is not an indication for a psychiatric consultation. Verbalizing that the accident may lead to divorce may or may not be a real risk; however, this situation is not urgent. The statement about not seeing the son run behind the car illustrates the father's attempts at trying to process the situation

The nurse is teaching an unlicensed assistive personnel (UAP) about the care of clients with self-mutilation. Which statement by the UAP would indicate teaching about self-mutilation has been effective?

"It's a way to express anger and rage." Self-mutilation is a way to express anger and rage, commonly seen in clients with borderline personality disorder. It typically is a cry for help, an expression of intense anger, helplessness, or guilt. When a client is experiencing numbness or feelings of unreality, self-mutilation induces physical pain that validates the person's being alive because of the ability to feel the physical pain. Self-mutilation is not a means of getting what the person wants. It is not used as a form of manipulation, although it is often misinterpreted as such. Self-mutilation is a serious behavior that is harmful to the self and cannot be ignored.

A new client has just been admitted to an adolescent psychiatric inpatient unit. The charge nurse and an unlicensed assistive personnel (UAP) are discussing the client's needs. The UAP says, "She is just showing off to try and get our sympathy. There is no need for her to cut herself. Why would adolescents want to do such a thing to themselves?" What response by the charge nurse would most help the UAP understand the client and her illness?

"It's hard to see a young person harm herself as she does, but she has serious family issues and doesn't know better ways to handle them, so we have to help her with that. The UAP is concerned about the behavior of the client and confused about why it is occurring, so the nurse needs to explain a bit about the issues involved as well as demonstrate empathy for the aide. It is appropriate to explain that the client is not cutting for attention, but the nurse's response does not address the reason for the teen's behavior and is therefore inadequate. It could also appear that the nurse is denigrating the UAP, which will not encourage the aide to listen to what she has to say. The comments that the UAP cannot work with the client or that she should transfer are punitive and do nothing to help the UAP understand self-mutilation.

An obese client has returned to the unit after receiving electroconvulsive therapy (ECT). A nurse requests assistance in moving the client from the stretcher to the bed. Which direction should the nurse give to a nurse who volunteers to help?

"Obtain the sliding board or two other people to assist us." To successfully move an obese client from the stretcher to the bed without incurring injury, at least four staff members must perform the transfer. If only two people are available, the nurse should use the sliding board. The hydraulic lift isn't the appropriate equipment to use with a sedated patient. The nurse shouldn't place the client in a semi-Fowler's position unless there is a head injury or other complicated medical condition. To perform a safe transfer using a drawsheet, the nurse must place the sheet directly under the client's body.

A client with depression has not responded to drug therapy. At a team conference, staff members recommend electroconvulsive therapy (ECT). Which statement should the nurse add when explaining the procedure to the client?

"This treatment has been proven to be effective, and we expect a positive outcome." To emphasize the therapeutic value of ECT, the nurse should refer to it as a "treatment." Although ECT is the medically correct terminology, this term should not be used unless the client is familiar with it and comfortable with it. Referring to the procedure as ECT may cause the client to focus on the disturbing elements of this treatment. The client should be as involved as possible in the decision-making process and not just refer to the client's family as having made all the decisions.

As the nurse stands near the window in the client's room, the client shouts, "Come away from the window! They will see you!" Which response by the nurse would be best?

"Who are 'they'?" Asking the client who "they" are when he is fearful helps the nurse understand his behavior and is least demanding of the client. The client is unlikely to accept statements that indicate that no one will see the nurse. The client is unlikely to accept statements that there is no reason to be afraid. Asking the client what will happen if someone sees the nurse is also unlikely to be acceptable and validates the client's delusion.

A client in a group therapy setting is very demanding. The client repeatedly interrupts others and monopolizes most of the group time. The nurse's best response would be:

"Will you briefly summarize your point? Others also need time." Asking the client to summarize directs the client to focus the comments and allows the client to make a point. Saying the client's behavior is obnoxious is judgmental. Telling the client that the behavior is frustrating doesn't facilitate communication. Ignoring the client's behavior focuses more on the nurse's need than on the client's.

A client states the following to the nurse: "I am a failure, and I wish I had died." Which statement by the nurse demonstrates a therapeutic response?

"You feel like a failure; would you like to talk more about the way you feel? Acknowledging the client's feelings by repeating what the client states is therapeutic. It is also therapeutic for the nurse to offer to discuss the client's feelings further. The other options are incorrect because they dismiss the client's feelings.

An agitated client demands to see the chart to read what has been written about the client. Which statement is the nurse's best response to the client?

"You have the right to see your chart. Please discuss your wish with your physician." The Bill of Rights for Psychiatric Clients includes the right for clients to access their medical records unless doing so would be detrimental to their health. The client should discuss the request with the physician so the physician can determine if information might be detrimental to the client. The client doesn't need an attorney's intervention to view the chart or wait until after discharge to view it.

A nurse working in an alcohol rehabilitation program is teaching staff how to give clients constructive feedback. Which statement given as an example illustrates that the staff member understands the nurse's teaching regarding the use of constructive feedback?

"You interrupted twice in 4 minutes." The statement, "You interrupted twice in 4 minutes," indicates an understanding of the use of constructive feedback by describing specifically what was seen and heard in an objective manner. The other statements are judgmental and blame the client without specifying what the objectionable behavior is.

A young client is diagnosed with enuresis. Tests revealed there is no medical cause attributed to the client's bed wetting. The client's mother is upset and is blaming the client's father, from whom she has recently separated, for the problem. "It is all his father's fault!" the client's mother declares to the nurse. What would be the nurse's best response?

"You seem really upset by this situation." Hearing her child's diagnosis has led the client's mother to express her emotions and to project blame. Acknowledging her feelings would build further trust and encourage her to discuss her thoughts and feelings. Asking her to pinpoint blame or denying her feelings will not build the helping relationship during this time of perceived distress.

A client with psychosis is prescribed quetiapine 400 mg by mouth daily in two divided doses. The pharmacy dispenses 200-mg tablets. How many tablets should the nurse administer with each dose? Record your answer using a whole number.

1 The prescribed dosage is 400 mg by mouth daily in two divided doses. 400 mg divided by 2 doses equals 200 mg per dose. The nurse should give one tablet with each dose.

A psychiatric nurse in the emergency department is assigned to care for a group of clients. Which client should the nurse see first?

A client who states she was sexually assaulted an hour ago. A rape or assault of any kind is a crisis situation and the primary nursing focus should be safety for the client. In addition to the psychological crisis, the client could have physiologic injuries that need immediate medical attention. The client with a panic disorder does have acute symptoms of anxiety, but is not in crisis. The client off their medication and worsening depressive symptoms is a concern but is not in immediate danger.

A young client has been arrested for assault and battery. The client has been admitted to the forensic psychiatric facility for a pretrial evaluation. Which client goal is most appropriate for the client?

Accept responsibility for personal behavior. Accepting responsibility indicates an insight into the reasons for the client's hospitalization. This client is not hospitalized to receive treatment but for an evaluation, so group therapies would not be a goal. Verbalizing ways to express anger, such as playing age-appropriate video games is not indicated, as video games could be a further stimulus for violent behavior. The client should be assessed before a treatment plan is begun. Avoiding contact with others on the psychiatric forensic unit is not indicated, and interaction would be useful for assessment. Further, the client has the right to interact with other clients on the unit.

Which principle of the psychoanalytic model is particularly useful to psychiatric nurses?

All behavior has meaning. The principle that all behavior has meaning is of particular importance to the psychiatric nurse. It serves as the basis for the nurse's assessment and analysis of the client's behavior, which reflects the client's needs. Psychoanalytic theory also proposes that the first 6 years of a person's life determine personality; these early influences are difficult, if not impossible, to counteract. However, this assumption is less useful to the nurse in planning interventions that meet the client's current needs. Reinforcement as a means of perpetuating behavior is associated with behavioral theory — not the psychoanalytic model. Incongruence between verbal and nonverbal communications is an element of communications theory.

Which intervention(s) should the nurse include in the plan of care for a school-age child with an autism spectrum disorder who has been admitted to the hospital? Select all that apply.

Allow a family member in the room 24 hours per day. Limit the number of health care providers and nurses interacting with the child. Dim lights and keep noise levels low. Show medical equipment to the child before procedures. Have family member bring possessions from home. Children with an autism spectrum prefer routine and familiarity. Having a family member in the room 24 hours a day may decrease the child's anxiety. Limiting the number of different health care providers and nurses that interact with the child may also help reduce anxiety. Dimming lights and keeping noise levels low will reduce sensory stimulation. Introducing a child with an autism spectrum disorder to equipment prior to a procedure may help reduce anxiety. Bringing in possessions from home will help with routine and familiarity. People with an autism spectrum disorder often have a limited ability to communicate. Health care providers need to approach a child with an autism spectrum disorder carefully with minimal

A client with depression has been admitted to the mental health unit and is attending group therapy sessions as part of treatment. The client asks the nurse leading the group if he is married or has a girlfriend. The nurse responds, "I am curious what made you ask this question; however, what is important is how you are feeling today." The nurse's response is which of the following?

Appropriate, because the focus of the therapeutic relationship is the client, not the nurse. The nurse's response is appropriate, because the focus of the therapeutic relationship is the client. The other options do not place the focus of care on the client's needs or reflect a full understanding of the therapeutic relationship.

A client lives in a group home and visits the community mental health center regularly. During one visit with the nurse, the client states, "The voices are telling me to hurt myself again." Which question by the nurse is most important to ask?

Are you going to hurt yourself?" The nurse needs to ask the client whether he is going to hurt himself to determine the client's ability to cope with the voices and to assess the client's impulse control. The nurse's assessment will then determine the course of action to take regarding the client's safety. Asking when the client hears the voices and how long the client has heard them is important but not as important as determining whether the client will act on what the voices are saying. Asking, "Why are the voices starting again?" would be inappropriate because the client may not know why and may not be able to answer the nurse.

The client is laughing and telling jokes to a group of clients. Suddenly, the client is crying and talking about a death in the family. A moment later, the client is laughing and joking again. What should the nurse do?

Ask the client to come to a quiet area to talk to the nurse individually. Decreasing external stimuli is the intervention most likely to decrease the emotional lability and minimize its effect on other clients. While the client is displaying emotional lability, this behavior has not reached the level where involuntary isolation (seclusion) or physical restraint is needed. The client is not totally out of control or threatening others. However, ignoring the behavior will not result in a decrease in the lability. Lorazepam can be used, but benzodiazepines can lead to dependence and should not be used before other measures have been tried

Two nurses disagree on what is the most important information for the client with a stress related illness to have during a discharge teaching session. How should the nurse assigned to provide the discharge teaching proceed?

Ask the client what is most important for them as they prepare for discharge. The discharge teaching session will be most effective if the nurse uses a client-centered approach to better assess what the client needs and, therefore, what information to share. Sharing all the information does not respect the knowledge that the client already has. Reviewing the policies is one area to help identify important areas for teaching, but in order to ensure that client needs are met further assessment is required. Awareness of personal biases should not be used to determine what is important for the client.

While listening to a taped-report at shift change, one of the other team members remarks that "My mother lives near this client, and his yard is always full of junk." What should the nurse assigned to provide care to this client do in this situation?

Ask the team member what the purpose was in sharing the information. The assigned nurse should determine if the comment has any relevance to the care of this client. Ignoring the comment or asking the team member to be quiet does not help determine if the comment was appropriate. Only information that has therapeutic value should be shared with other team members.

A nurse working at an outpatient mental health center primarily with chronically mentally ill clients receives a telephone call from the mother of a client who lives at home. The mother reports that the client has not been taking her medication and now is refusing to go to the work center where she has worked for the past year. What should the nurse do first?

Ask to speak to the client directly on the phone. The first thing that the nurse should do is to speak with the client on the phone and question her about perceptions or reasons that are interfering with her going to the sheltered workshop. This conveys that the nurse is interested and willing to help the client. The nurse should call the director of the work center for information only if the nurse receives the client's permission. Making preparations for the client's admission is inappropriate and would not be done until the client's needs have been assessed and it is determined that the client requires hospitalization. Making an appointment with the HCP is inappropriate until the nurse has assessed the client's needs.

A client with a personality disorder is upset and calls the nurse a "stupid cow." Which is the most effective initial response by the nurse to this client's behavior?

Calmly discuss the inappropriateness of displacing anger to others. It is important to maintain open and clear lines of communication. The nurse would calmly set limits for the client's inappropriate expressions of anger. The client may view touch as a threat, so touching the client would not be appropriate. Reporting the behavior to the physician would not be an initial response to the client's anger. Walking away and leaving the client does not help the client learn to recognize anger without losing control.

A nurse is explaining electroconvulsive therapy (ECT) to members of a depression support group. Which statement would indicate understanding?

ECT treatments are given for severe depression when other meds have failed." ECT is primarily indicated for severe depression in the elderly. Usually, the person has failed a long list of antidepressants prior to ECT. More than one treatment is frequently necessary. Remission is usually achieved in 6 to 12 sessions, and then maintenance ECT treatments may be required. Electrodes for ECT are applied to the scalp and forehead, and hair removal is not necessary. There are many complications of ECT including respiratory distress, persistent memory loss, arrhythmias, and seizures.

Parents tell a nurse that they have not met their goal of home management of their child with schizoaffective disorder. They report that the client poses a threat to their safety. Based on this information, what recommendation should the nurse make?

Evaluate the client for voluntary admission to a mental health facility. A voluntary admission is the preferred approach because it involves having the client recognize existing problems and facilitates the client's involvement in treatment. Chemical restraints would violate the client's rights to freedom from the use of restraints and seclusion. The duty of care is a legal concept that applies only to the nurse-client relationship, not to family relationships. Respite care isn't an appropriate recommendation at this time. The nurse must address the safety issue and institute effective treatment and care. At a later time, it would be prudent for the nurse to talk with the client's family about caregiver burden and the option of using respite care.

The campus health nurse is caring for a client after she was sexually assaulted. Which of the following intervention would be most beneficial for this client?

Explore the client's strengths and resources with her. The goal of crisis intervention is to support clients to resume pre-crisis levels of functioning. Variables in a client's recovery include support and access to resources. Suggesting courses in martial arts could be a strategy, but more important for the client's adjustment would be helping the client identify strengths and resources that could give her support. Assessing for coping should include all client activity, not only negative coping behaviors. Agreeing with the client that she should move on would be giving advice, a nontherapeutic technique.

After talking with the nurse, a client admits to being physically abused by her husband. She says that she has never called the police because her husband has threatened to kill her if she does. She says, "I don't want to get him into trouble, because he's the father of my children. I don't know what to do!" Which nursing intervention would be most therapeutic at this time?

Express concern for the client's safety. The nurse's expression of concern for the client's safety may help the client validate her fears and choose to take action. Talking to the client about changing her behavior is a form of victim blaming and reinforces the message that the client is responsible for the abuse. She is likely getting the same message from the abuser and others. Talking to the client about reducing family stress is also a form of victim blaming. Telling the client to leave her husband is inappropriate advice. The idea of leaving the marriage may be so overwhelming that it may push the client away from the nurse as a support person.

After months of counseling, a client abused by her husband tells the nurse that she has decided to stop treatment. There has been no abuse during this time, and she feels better able to cope with the needs of her husband and children. How should the nurse begin the discussion of the decision with the client?

Find out more about the client's rationale for her decision to stop treatment. The nurse needs more information about the client's decision before deciding what intervention is most appropriate. Judgmental responses could make it difficult for the client to return for treatment should she want to do so. Telling the client that this is a bad decision that she will regret is inappropriate because the nurse is making an assumption. Warning the client that abuse commonly stops when one partner is involved in treatment may be true for some clients. However, until the nurse determines the basis for the client's decision, this type of response is an assumption and therefore inappropriate. Reminding the client about her duty to protect the children would be appropriate if the client had talked about episodes of current abuse by her partner and the fear that her children might be hurt by him, but the scenario offers no evidence that the husband has threatened the children.

A client suddenly behaves in an impulsive, hyperactive, unpredictable manner. Which approach would be best for the nurse to use first if the client becomes violent?

Get help to handle the situation safely. The recommended first course of action is to prevent accidents and injuries when a client becomes violent. In this situation, it would be best to call for help to handle the situation safely.Providing a physical outlet for the client's energies is an appropriate course of action but only after the situation is safely under control.Letting the client know that her behavior is not acceptable is an important useful intervention but is not likely to be useful in an unstable, escalating situation.Using sedation to control behavior is not the nurse's first course of action. The first course of action is to summon help.

A nurse is counseling a married woman who has two children under 4 years of age and is a victim of spousal abuse. Before the client leaves the clinic, what is the most important thing the nurse should do?

Help the client develop a safety plan. It is most important for the nurse to help the client develop a safety plan because the abuse will occur again, and the client will need a plan to seek a safe environment for herself and her children.Teaching about the cycle of violence is not as important as the client's safety and the safety of her children.Discussing the abuser's behaviors is not as important as the client's safety and the safety of her children.Giving the client the name of a domestic violence shelter can be part of the safety plan, but the nurse needs to assure other safety measures are in place until the woman is ready to leave the abusive partner.

The nurse is meeting a client on the mental health unit. When beginning a therapeutic relationship, which nursing actions are appropriate? Select all that apply.

Help the client explore different problem-solving techniques. Encourage the practice of new coping skills. The goal of a therapeutic relationship is to enhance the personal growth of the client. This is achieved by helping clients explore problem-solving techniques and develop coping skills. Giving advice, exchanging social media information, and striving to meet the personal needs and special desires of the client are characteristic of social relationships. Discussing the client's feelings with family members is a breach of confidentiality, unless previously approved by the client.

A healthcare provider has ordered a new antipsychotic medication for a client with schizophrenia whose previous medication no longer provides the expected symptom relief. The client tells the nurse, "I can't afford the additional cost of this new medication." What is the first action the nurse should take to be a client advocate?

Help the client explore other financial options for obtaining medication reimbursement with a social worker. Helping the client find other financial options for obtaining this medication is an important client advocacy strategy. Simply stating the client should contact friends or family is not assisting the client with this problem. The healthcare provider ordered this drug as a result of symptom exacerbation; reassessing the client's need for this medication is appropriate only after exhausting other options. Teaching the client to accept that financial reimbursement is not available does not facilitate client advocacy.

Which finding indicates that a client who has been raped will have future adjustment problems and need additional counseling?

Her parents show shame and suspicion about her part in the rape. The potential for problems in adjusting after a rape will be increased when those around the victim treat her as though she is to blame for the rape, especially when she already may feel some guilt and shame about it.A rape victim is likely showing adjustment to her experience when she is upset about her experience, when she seeks out formerly ignored relatives and friends for support, or when she attempts to help other rape victims. A rape victim is likely showing adjustment to her experience when she is upset about her experience, when she seeks out formerly ignored relatives and friends for support, or when she attempts to help other rape victims. A rape victim is likely showing adjustment to her experience when she is upset about her experience, when she seeks out formerly ignored relatives and friends for support, or when she attempts to help other rape victims.

A nurse is assessing military personnel who have experienced combat and are diagnosed with posttraumatic stress disorder. Which client statement requires immediate intervention?

I cannot stop the nightmares, even the extra oxycodone pills I take do not work. It is not worth it." Client safety is the priority. Increased use of opioids and stating "it is not worth it" can be considered suicidal. A client who increased lorazepam intake requires follow up, but this client is not the priority. Increasing benzodiazepine will cause fatigue, so afternoon naps are expected. Increasing the frequency of visits to a therapist are encouraged; there are no immediate concerns with seeing a therapist more often. Avoiding alcohol with posttraumatic stress disorder is encouraged; however, there's nothing immediately concerning with an adult having one glass of wine with supper.

A client is admitted to a mental health unit with a diagnosis of depression and is participating in group sessions. The client asks a nurse if they are married or in a romantic relationship. What is the best response by the nurse to maintain a therapeutic relationship?

I'm curious about your question but I want to know how you are feeling today." Nurses must practice in a manner that is consistent with providing safe, competent, and ethical care. If the nurse shared personal information with the client, the nurse would have crossed the boundary of a therapeutic relationship and changed the focus of the discussion from a client focus to a social focus. It is very important in all areas of care, but especially in the mental health setting, that the relationship between the nurse and the client has very clear boundaries and is client focused. The other options are incorrect because they do not follow the principles of a therapeutic nurse-client relationship.

A client has chronic low self-esteem related to self-doubt as evidenced by self-deprecatory statements. What goal should the nurse establish for the client?

Identify positive aspects of self. The expected outcome is that the client identify positive aspects of self-related to self-doubt as evidenced by self-deprecatory comments. An expression of positive self-comments indicates a realistic view of the client's self-concept. Demonstrating reality-based thinking relates to altered thought processes. Using relaxation exercises relates more to decreasing anxiety. Setting attainable goals relates to hopelessness.

After 2 days on a psychiatric unit, a client is still isolating himself in his room, except for meals. The client says he is uncomfortable around crowds of people. Which nursing intervention is the mostappropriate initially?

Invite the client to go for a walk with the nurse and one other client. Going for a walk with the nurse and another client is a more gradual introduction to being with others. The goal is to gradually encourage interaction with others; playing games in the client's room promotes continued isolation. Going to a group session and participating in crafts is exposing the client to large groups too rapidly.

A client doesn't make eye contact with the nurse during an interview. The nurse suspects that the client's behavior has a cultural basis. What should the nurse do first?

Observe how the client and the client's family and friends interact with one another and with other staff members. Assessing the client's interactions with others helps the nurse determine whether the behavior is part of a usual pattern. It also may help the nurse understand the meaning of the behavior for this particular client. Reading about a different culture, consulting other staff members, and talking with the client are helpful after the nurse has observed the client's interaction with others. The nurse must be able to accept the client as an individual but need not accept unhealthy or inappropriate behaviors. The nurse should work with the client to better understand the cultural differences

A 6-year-old client is diagnosed with attention deficit hyperactivity disorder (ADHD). When asking this client to complete a task, what techniques should the nurse use to communicate mosteffectively with him?

Obtain eye contact before speaking, use simple language, and have him repeat what was said. Praise him if he completes the task. Because the client with ADHD is easily distractible, it is important to obtain eye contact before explaining the task. Simple language and having him repeat what he is told are necessary because of his age. Praise encourages the client to repeat the task in the future as well as building the client's self-esteem. A full explanation with verbal praise and a food reward is inappropriate because a food reward increases the chance that he will expect a physical reward for completing tasks. In addition, a full explanation might be too confusing for someone his age. Explaining consequences focuses on punishment, rather than praise. Although demonstration and imitation is an effective teaching method, rewarding with food fosters dependence on food reward for task completion.

A tour bus has overturned on an exit ramp. Many passengers are injured, but there are no fatalities. The injured passengers will be transported to an emergency center. The nurse at the emergency center who will receive the passengers should plan to respond to which situation in addition to treating injuries?

Passengers may be experiencing feelings of victimization. Major accidents can induce feelings similar to those of victims of other kinds of disasters and crime. Therefore, the nurse should also be prepared to assist the passengers with their feelings of victimization. Passengers may mourn the loss of a vacation, but with no fatalities, major grief reactions are not expected. Other personnel can take calls from relatives while the nurse helps the passengers. Psychiatric hospitalization is a premature assumption.

When planning care for a client with schizophrenia, who lacks motivation to shower and dress, which outcome should the nurse expect the client to achieve by the end of 4 days?

Perform showering and dressing for herself. By the end of 4 days, the client should be able to perform showering and dressing for herself. The client with schizophrenia commonly appears to be apathetic and lack initiative. Therefore, demonstrating the ability to complete the tasks indicates improvement. Although the client may be able to recognize, verbalize, or explain the need to shower and dress herself, she may be unable to do so because of the ambivalence associated with schizophrenia that impedes the client's ability to initiate and complete self-care. Therefore, evidence of improvement would be lacking.

When providing a therapeutic milieu for clients, which intervention would be most appropriate?

Promote optimal functioning of an individual or group. The milieu should provide an atmosphere that fosters growth, change, and self-responsibility. Staff interventions should also be flexible and open and encourage clients to achieve optimal functioning.Using psychotropic drugs is only one component of a therapeutic milieu. Other components include nurse-client interaction, therapeutic groups, recreation, and client-staff treatment meetings.Independent, not dependent, behavior is fostered and supported to promote the client to assume responsibility for self.Meeting one's own needs while helping clients meet their needs is inappropriate for the nurse or the staff in a therapeutic milieu. The nurse focuses on the client's needs without expecting personal needs to be met.

The client goes to her room and slams the door immediately after the first family therapy session. Later she tells the nurse, "I'm so mad. The therapist didn't let me tell my side of the story. He just agreed with everything my parents said." Which nursing action would be most therapeutic in this situation?

Redirect the client to the therapist to tell him how she feels. Because self-responsibility is part of the focus of family therapy, direct communication between the people involved in the situation is encouraged. Learning to express oneself clearly and to give direct feedback is part of healthy communication. Neither terminating therapy because it upsets the client nor suggesting to the therapist that the client be allowed to speak is appropriate. These interventions do not allow the client to deal directly with the person she is angry with and discourage the client from taking responsibility for her own feelings. It is satisfactory to allow a client to ventilate to a nurse; however, in this situation it would be best for the client to have open communication with her therapist.

A nurse learns that another staff nurse in an outpatient mental health clinic has recently sought money from a group of mental health center clients to invest in a new business. How should the nurse respond to learning this information?

Report concerns to the nursing supervisor. The correct lines of communication must be followed in addressing professional practice concerns. The first line of communication is to communicate your concerns directly to the person. If this has been attempted or is not possible, then the manager or direct supervisor should be called for problem solving and decision making. In this case, because client safety is of paramount concern, the professional association must be notified to review the nurse's professional practice in a larger investigation.

As the nurse arrives to visit a family 2 days after release from the hospital, she hears shouting and swearing between the mother and father and several loud crashes, just as she is going to knock on the door. What action by the nurse is the most appropriate?

Return to the car and call the police. The nurse needs to consider his/her own personal safety in this situation and how he/she will be the most help to this family. The nurse needs to get some back-up support before entering the house due to the potential for violence. The nurse should not go into the home if his/her safety is in danger.

The nurse documents the initial care of a suspected abuse victim. Which information would be mosthelpful for others to know when caring for the client?

Seems fearful to discuss how bruises on her body had been caused." Stating that a client seems fearful to discuss what caused the bruises on her body is most helpful. A victim of partner abuse tends to conceal her victimization because disclosure could be met with denial; minimization by her partner, friends, and relatives; and increased abuse by her partner.Documenting that the client is not employed outside the home does not help others caring for the client in relation to the needs of an abuse victim.Documenting that the client asks that her husband not be called because he is very busy is important but not as important as the client's fear about disclosing the cause of the bruises.Documenting the client's refusal for follow-up with her statement about not having time is less important compared to the client's fear about disclosing the cause of the bruises.

The nurse notes that a client is too busy investigating the unit and overseeing the activities of other clients to eat dinner. To help the client obtain sufficient nourishment, which plan would be best?

Serve foods that the client can carry with her. Because the client is very active, it would be best to give her food she can carry with her and eat as she moves.Neither allowing the client to send out for her favorite foods nor serving food in small, attractively arranged portions will address her need to be active. Allowing the client in the unit kitchen is impractical, and she most likely would be too busy to eat anyway.

A client is complaining to other clients about not being allowed by staff to keep food in the client's room. What should the nurse do?

Set limits on the behavior. The nurse needs to set limits on the client's manipulative behavior to help the client control dysfunctional behavior. The manipulative client bends rules to have needs met without regard for rules or the needs or rights of others. A consistent approach by the staff is necessary to decrease manipulation. Ignoring the client's behavior reinforces or promotes the continuation of the client's manipulative behavior. Reprimanding the client may be perceived as a threat, resulting in aggressive behavior. Allowing the client to keep a snack in the client's room reinforces the dysfunctional behavior.

Assessment of a client who has just been admitted to the inpatient psychiatric unit reveals an unshaven face, noticeable body odor, visible spots on the shirt and pants, slow movements, gazing at the floor, and a flat affect. Which of the following should the nurse interpret as indicating psychomotor retardation?

Slow movements. Psychomotor retardation refers to a general slowdown of motor activity commonly seen in a client with depression. Movements appear lethargic, energy is absent or lacking, and performance of activity is slow and difficult. A flat affect reflects a lack of emotion. An unkempt appearance reflects lack of self-care. Avoiding eye contact reflects low self-esteem or suspiciousness.

A client is playing music loudly in the music room, and other clients are complaining about the volume. What should the nurse do?

State to the client what volume is and is not permissible. Setting limits here is essential. The nurse should set limits by stating to the client what volume is and is not permissible. Limit setting is the art of clearly identifying acceptable and unacceptable behaviors that are objective, fair, and reflective of the situation at hand. Limits should be identified clearly and early, especially with clients who may "test the system."Redirecting the client does nothing to establish limits and does not help the client recognize unacceptable behaviors.Turning down the volume and saying nothing does not identify the limits for the client and may lead to repetition of the same behavior.

While the nurse is providing preoperative teaching for a client with peripheral vascular disease who is to have a below-the-knee amputation, the client says, "I hate the idea of being an invalid after they cut off my leg." What would be the nurse's most therapeutic response?

Tell me more about how you are feeling." Encouraging the client who is undergoing amputation to verbalize feelings is the most therapeutic nursing intervention. By eliciting concerns, the nurse may be able to provide information to help the client cope. The nurse should avoid value-laden responses, such as "You will still have one good leg," that may make the client feel guilty or hostile and block further communication. The nurse should not ignore the client's expressed concerns, nor should the nurse reinforce the client's concern about invalidism and dependency or assume that his wife is willing to care for him.

Which of the following client behaviors indicates the nurse-client relationship is in the working phase?

The client makes an effort to describe his or her problems in detail. The client's effort to describe his or her problems to the nurse indicates that nurse-client relationship is most probably in the working phase. The client's action illustrates that the client has gone beyond testing and acquainting himself or herself with a new relationship and is now working on his problems.The relationship is in an orientation phase when the client attempts to familiarize himself or herself with the nurse or when the client challenges the boundaries of the relationship.The relationship is in a termination phase when the client summarizes and evaluates his or her progress.

What client behaviors would be most important for the nurse to consider in deciding to institute suicide precautions because of high-risk behavior?

The client recently attempted suicide with a lethal method. A recent suicide attempt using a lethal method always indicates the need for suicide precautions. The client is at high risk for suicide, and his life must be protected and safety maintained.Having feelings of being in control of suicidal thoughts, worrying about a child's reaction, or expressing guilt and shame about a suicide attempt indicates a lower risk for suicide.

A client is irritable and hostile. He becomes agitated and verbally lashes out when his personal needs are not immediately met by the staff. When the client's request for a pass is refused by the healthcare provider, he utters a stream of profanities. Which statement best describes the client's behavior?

The client's anger is not intended personally. Staff members sometimes are the recipients of a client's angry behavior because they are safe targets and are available for attack. The display of anger is rarely intended to be personal.Such behavior is not necessarily a sign of serious pathology but must be weighed in conjunction with other behaviors.An angry outburst is not an attack on a healthcare provider's skills.While not necessarily pathologic, the client's behavior is not a sign that his condition is improving.

What should be charted by the nurse when the client has an involuntary commitment or formal admission status?

The client's receipt of information about status and rights should be charted. Nurses are required to document that clients have been given information about their status and rights. Seclusion is not related to people becoming involuntary or certified clients. Including details contained within the certificates, such as an HCP signing the certificates, is not required.

A client with severe and persistent depression is debating undergoing electroconvulsive therapy (ECT). The client's family asks a nurse to convince the client that this treatment would be beneficial. In educating the family about the client's situation, what statement about client rights should the nurse make?

The client, treatment team, and family will need to meet to discuss this treatment option." When a client is undecided about treatment, the best approach is to assemble the client, family, and appropriate healthcare providers to discuss what option serves the client's best interests while acknowledging the client's right to refuse treatment. Because the client has the right to refuse treatment, there's no need for the family to obtain legal counsel or for the client to sign any refusal-of-treatment forms. Neither family members nor healthcare providers should coerce the client to reconsider the decision under the guise of addressing the ethical aspects of treatment.

A nurse hears a client state, "I've had it with this marriage. It would be so much easier to just hire someone to kill my husband!" What action should the nurse take?

The nurse must start the process to warn the client's husband. Confidentiality must be broken if there are credible threats made against another person's safety. Confidentiality does not override the safety of other persons.

A client with substance abuse and bipolar disorder has recently stabilized after experiencing a crisis resulting from a psychotic episode. The client tells the nurse, "I want to live in the community again." What is most important for the nurse to communicate with the healthcare provider if advocating for the client's discharge into the community?

There's extensive documentation to support the client's improved functioning level." Safety is the expected outcome of a client who was in a crisis; documentation of improved functioning is required when considering a discharge to the community. Communicating family opinions on the success of the client is not a priority. Often, a transitional place of care will be sought, and the client must form a treatment alliance or make an agreement to pursue further treatment before being referred to care in residential rehabilitation. The nurse cannot be certain the client will abstain from substances after discharge. Although the client may experience a decrease in or relief from symptoms, the client may still manifest symptoms of substance abuse and bipolar disorder. Stating the acute symptoms have resolved may be true, but does not necessarily indicate that the client's new baseline is one of safe functioning. The nurse cannot be certain the symptoms will not reappear.

Two unlicensed assistive personnel (UAP) are discussing which person is responsible for taking the dirty linen bags into the utility room. One UAP approaches the charge nurse and complains about the other. Which action should the nurse employ?

Urge the UAP to discuss the problem with his coworker. The nurse should urge the UAP to discuss the problem with his coworker to solve their interpersonal conflict. Many times, the nurse is inappropriately expected to solve interpersonal conflicts when subordinates should be urged to handle their own conflicts. The nurse manager facilitates the resolution of conflicts between others.Advising the UAP to be more tolerant or telling him to take care of the linen bags himself is a method of accommodating. However, the actual problem is not addressed, so it is a win-lose situation.Taking care of the linen bags is a method of avoiding conflict, but the conflict will reemerge at a later time. Even though it may be easier for the nurse to take care of the linen bags, this does not help staff deal with their interpersonal conflict. Therefore, personal growth does not occur.

A client is admitted for a surgical biopsy of a suspicious lump in the right breast. At the time the nurse arrives to take the client to surgery, the client is finishing a letter to the client's children. The client tearfully tells the nurse, "I just want to leave this for my children in case anything goes wrong in the surgery." Which nursing response will be most therapeutic?

What are you concerned about right now?" The most therapeutic response is one in which the nurse reflects back to the client what the client has said and asks the client to reflect further. Making light of the client's worries about the biopsy does not help the client process their feelings or concerns. The client did not express questions about the biopsy; therefore calling the doctor is not appropriate at this time. Confronting the client about what the nurse feels is misplaced anxiety of the biopsy versus cancer would not be beneficial to the client and not therapeutic in these circumstances.

A nurse is instructing a client with bipolar disorder on proper use of lithium carbonate, the drug's adverse effects, and symptoms of lithium toxicity. Which client statement indicates that additional teaching is required?

When my moods fluctuate, I'll increase my dose of lithium." A client who states that mood fluctuation warrants increasing the dose of lithium requires additional teaching. Increasing the dose of lithium without evaluating the client's laboratory values can cause serious health problems, such as lithium toxicity, overdose, and renal failure. Clients taking lithium don't need to limit their sodium intake. A low-sodium diet causes lithium retention. A therapeutic lithium blood level indicates that the drug concentration has stabilized. The client demonstrates effective teaching by stating his lithium levels will be affected by foods that have a diuretic effect, such as watermelon, cantaloupe, grapefruit juice, and cranberry juice.

A nurse is assessing a client at a mental health clinic who threatens suicide and describes having a plan. Which should the nurse recognize as the priority goal for the client?

Working with the client to resolve the immediate crisis The goal of crisis intervention is the resolution of an immediate problem. The client must learn to solve their own problems. Although some clients do enter long-term therapy or are admitted to an acute care facility, these are not the goals of crisis intervention.

An experienced nurse is precepting a new nurse in a psychiatric emergency room and is discussing criteria for involuntary commitment. Which client would signal to the experienced nurse that the new nurse understands the criteria?

a person who threatens to kill their spouse of 38 years One of the criteria for involuntary commitment is an emergency in which the client is a threat to themself or others. A parent might have a child removed from the home because of neglect but that doesn't meet the criteria for involuntary commitment. Many individuals with schizophrenia can learn to live with hallucinations and delusions and don't require hospitalization. To meet criteria for involuntary commitment, a depressed individual must have a suicide plan and be a direct threat to themself.

When preparing to use seclusion as an alternative to restraint for a client who has not yet lost control, the nurse expects to use a room with limited furniture and no access to dangerous articles. What should the nurse also consider as critical for the safety of the client?

a security window in the door or a room camera When using seclusion, the safety of the client is paramount. Therefore, staff must be able to see the client in seclusion at all times, such as through a security window in the door or with a room camera. Although outside access for dimming the lights to decrease stimuli may be appropriate, it is not critical for the client's safety. Having one staff member stay in a room alone with a potentially violent client is unsafe. A prescription for seclusion can be obtained before or after it is initiated.

The nurse at a substance abuse center answers the phone. A probation officer asks if a client is in treatment. The nurse responds, "No, the client you're looking for isn't here." Which statement bestdescribes the nurse's response?

a violation of confidentiality because the nurse informed the officer that the client wasn't there The nurse violated confidentiality by informing the officer that the client wasn't in treatment. Even with law enforcement agents, the nurse must be a client advocate and protect the client's confidentiality. Information may be legally withheld when a court order isn't in effect.

During the mental status examination, a client may be asked to explain such proverbs as "Don't cry over spilled milk." The purpose of this is to evaluate the client's ability to think:

abstractly. Abstract thinking is the ability to conceptualize and interpret meaning. It's a higher level of intellectual functioning than concrete thinking, in which the client explains the proverb by its literal meaning. Rational thinking involves the ability to think logically, make judgments, and be goal-directed. Tangential thinking is scattered, non-goal-directed, and hard to follow. Clients with such conditions as organic brain disease and schizophrenia typically can't conceptualize and comprehend abstract meaning. They interpret such statements as "Don't cry over spilled milk" in a literal sense, such as "Even if you spill your milk, you shouldn't cry about it."

The nurse understands that with the right help at the right time, a client can successfully resolve a crisis and function better than before the crisis, based primarily on which factor?

acquisition of new coping skills Learning new coping skills is the major factor necessary for higher functioning. Better coping is likely to lead to regaining support systems, giving up dysfunctional coping, and awareness of how to prevent future crises.

A client is taking clozapine and complains of a sore throat. This symptom may be an indication of which adverse reaction?

agranulocytosis The complaint of a sore throat may indicate an infection caused by agranulocytosis, a depletion of white blood cells. Although extrapyramidal reaction and tardive dyskinesia may occur, a sore throat isn't an indication of these conditions. Reye's syndrome is caused by a virus unrelated to clozapine.

The most common reason given by mentally ill clients for noncompliance with medications is their uncomfortable adverse effects. When teaching the families, what need should the nurse identify as the greatest?

alternative ways to manage the adverse effects Providing ways to decrease or manage adverse effects without additional medications is crucial. Although home visits, family monitoring, and outpatient monitoring may help, if the adverse effects are not controlled, the client is less likely to take the drug, which would interfere with its effectiveness.

A client who is taking olanzapine states he is being poisoned and refuses to take his scheduled medication. The nurse states, "If you don't take your medication, you'll be put into seclusion." The nurse's statement is an example of which legal concept?

assault The nurse's statement exemplifies assault, which is the threat of being touched in an offensive way without consent. Battery is touching another person without consent. Malpractice is care below the standard of care that results in injury. Invasion of privacy is a violation of a person's right to be left alone.

A nurse is counseling a client at a crisis center after the client's house burned down and the client's daughter was killed. Which action by the nurse is a priority?

assisting in psychological resolution of the immediate crisis The goal of crisis intervention is to resolve the immediate problem. The client must learn to resolve the issues. Although some clients do enter long-term therapy or are admitted to an acute care facility, long-term therapy is not the goal of crisis intervention.

A client tells the nurse that she has been raped but has not reported it to the police. After determining whether the client was injured, whether it is still possible to collect evidence, and whether the client wants to file a report, the nurse's next priority is to offer which intervention to the client?

crisis intervention The experience of rape is a crisis. Crisis intervention services, especially with a rape crisis nurse, are essential to help the client begin dealing with the aftermath of a rape. Legal assistance may be recommended if the client decides to report the rape and only after crisis intervention services have been provided. A rape support group can be helpful later in the recovery process. Medications for sleep disturbance, especially benzodiazepines, should be avoided if possible. Benzodiazepines are potentially addictive and can be used in suicide attempts, especially when consumed with alcohol.

An older adult experiences short-term memory problems and occasional disorientation a few weeks after her husband's death. She also is not sleeping, has urinary frequency and burning, and sees rats in the kitchen. The home care nurse calls the woman's health care provider to discuss the client's situation and background, assess, and give recommendations. The nurse concludes that the client most likely has which problem?

delirium and a urinary tract infection (UTI) Delirium is commonly due to a medical condition such as a UTI in the older adult. Delirium often involves memory problems, disorientation, and hallucinations. It develops rather quickly. There are not enough data to suggest Alzheimer's disease especially given the quick onset of symptoms. Delayed grieving and adjusting to being alone are unlikely to cause hallucinations.

A nurse must assess a client's judgment to determine the client's mental status. To best accomplish this, the nurse should have the client:

discuss hypothetical ethical situations. The best way to assess a client's judgment is to discuss hypothetical ethical situations, such as "What would you do if you found a wallet that contained several credit cards and identification?" Interpreting proverbs tests thinking. Spelling words backward and counting by serial sevens test concentration.

A client becomes angry and belligerent toward the nurse after speaking on the phone with the client's mother. The nurse recognizes this as what defense mechanism?

displacement Displacement is a defense mechanism in which the client transfers feelings for one person to another person who is less threatening. Rationalization is a defense mechanism in which the client makes excuses to justify unacceptable feelings or behaviors. Repression is characterized by an involuntary blocking of unpleasant experiences from one's consciousness. Suppression is the conscious blocking of unpleasant experiences from one's awareness.

A major role in crisis intervention is getting a client's family and friends involved in helping with the immediate crisis as soon as possible. The nurse should determine that the support persons are prepared to help when they verbalize what information?

emergency resources and when to use them During a crisis, support persons demonstrate preparedness to help the client by verbalizing the emergency resources available and knowing when to use them. Follow-up medical care may be helpful as the crisis subsides. The coping strategies used by the support persons may or may not be relevant to the client's needs and situation. Long-term solutions and advice may or may not be appropriate. The focus needs to be on the client's immediate needs and situation.

The nurse teaches a group of unlicensed assistive personnel (UAP) about providing care to clients with depression. Which approach by one of the UAPs indicates an understanding of the mosteffective approach to a depressed client?

empathetic To care effectively for clients with depression, the nurse should teach the importance of demonstrating empathetic concern. Caregivers must accept clients as they are even though many will be angry and negative, acknowledge their emotional pain, and offer to help them work through their pain. For the client who is depressed, using a cheerful demeanor or a humorous, light-hearted approach may be overwhelming because the client will be unable to meet the caregiver's expectations, subsequently leading to decreased self-worth. A serious, business-like affect may threaten the client and inhibit the development of trust.

The nurse is working with a client with depression in a mental health clinic. During the interaction, the nurse uses the technique of self-disclosure. In order for this technique to be therapeutic, which step must be a priority for the nurse?

ensuring relevance to, and quickly refocusing upon, the client's experience The nurse's self-disclosure should be brief and to the point so that the interaction can be refocused on the client's experience. Because the client is the focus of the nurse-client relationship, the discussion should not dwell on the nurse's own experience.

When developing the plan of care for a client with acute stress disorder who lost her sister in a boating accident, which intervention should the nurse initiate?

facilitating progressive review of the accident and its consequences The nurse should facilitate progressive review of the accident and its consequences to help the client integrate feelings and memories and to begin the grieving process. Helping the client to evaluate her sister's behavior, telling the client to avoid details of the accident, or postponing the discussion of the accident until the client brings it up is not therapeutic and does not facilitate the development of trust in the nurse. Such actions do not facilitate review of the accident, which is necessary to help the client integrate feelings and memories and begin the grieving process.

A client changes topics quickly while relating past psychiatric history. This client's pattern of thinking is called:

flight of ideas. Flight of ideas describes a thought pattern in which a client moves rapidly from one topic to the next with some connection. Looseness of association describes a pattern in which ideas lack an apparent logical connection to one another. Tangential thoughts seem to be related but miss the point. A client who talks around a subject and includes a lot of unnecessary information is exhibiting circumstantial thinking.

A client is to be discharged from an alcohol rehabilitation program. What should the nurse emphasize in the discharge plan as a priority?

follow-up care Follow-up care is essential to prevent relapse. Recovery has just begun when the treatment program ends. The first few months after program completion can be difficult and dangerous for the chemically dependent client. The nurse is responsible for discharge plans that include arrangements for counseling, self-help group meetings, and other forms of aftercare. Supportive friends, a list of goals, and returning to work may be important and helpful to the client, but follow-up care is essential.

An adolescent girl is brought to the hospital emergency department in a state of unconsciousness after having swallowed "a bottle of pain pills" 45 minutes earlier. The pills are identified as oxycodone. A suicide note is found that asks for forgiveness. Which measure should the nurse be prepared to carry out when this client is admitted?

giving naloxone IV Naloxone is an opioid antagonist used as an antidote for opioids.Forcing fluids is inappropriate because the client is unconscious.Giving a diuretic will not help eliminate the oxycodone.In an unconscious client, inducing vomiting is inappropriate.

The most effective way for a nurse to set limits for a newly admitted client who puts out cigarettes on the floor of the designated smoking room is to:

hand the client an ashtray and state that the client must use it or the client will not be allowed to smoke Setting limits is necessary to help clients behave in socially acceptable ways. By handing the client an ashtray and stating objectively that the client won't be allowed to smoke if the client doesn't use the ashtray, the nurse is setting limits on the client's libehavior. Because this client is newly admitted, the nurse may need to restate these limits in a manner that shows disapproval of the behavior but doesn't reject the client as a person. A matter-of-fact, nonpunitive tone of voice is important. The nurse must stress that noncompliance will have consequences — in this case, a prohibition against smoking. The nurse can't bend the rules to accommodate the client. Encouraging other clients to deal with a new client isn't advisable. Asking if the client puts out cigarettes on the floor at home has no bearing on whether this behavior is acceptable in the hospital.

A client is being discharged after 3 days of hospitalization for a suicide attempt that followed the receipt of a divorce notice. Which client finding indicates to the nurse that the client is ready for discharge?

has a list of support persons and community resources The risk of suicide can persist for 2 to 3 months even after a crisis has abated. Therefore, it is important for the client to be able to verbalize information about appropriate support persons and community resources and to have this information readily available. Although the client may state feeling ready to be discharged, this is not the most reliable indicator. A divorce lawyer may not be appropriate at this point. At 3 days after a suicide attempt, emotional stability is not likely.

Several former clients from a mental health facility have recently collected their stories to corroborate that a nurse working there has attempted to befriend them. The clients state that during their therapy, the nurse encouraged them to invest in a new business. The nursing supervisor, upon hearing of the clients' reports, begins an investigation. How can the nursing supervisor best describe the nurse's behavior with these former clients?

having poor boundaries Although the staff nurse had dismissed the actual needs of these clients when they were in the nurse's care, the client's behavior is an example of poor boundaries or the failure to differentiate between the needs of oneself and others in the nurse's professional role. Poor boundaries are often a symptom of passive-aggressive and antisocial traits, but these behaviors are indicative of the nurse's failure to distinguish between themself and the former clients in order to stand by the nurse's professional obligations and the needs of their clients.

The client approaches various staff with numerous requests and needs to the point of disrupting the staff's work with other clients. The nurse meets with the staff to decide on a consistent, therapeutic approach for this client. Which approach will be most effective?

having the client discuss needs with the staff person assigned For the client with attention-seeking behaviors, the nurse would institute a behavioral contract with the client to help decrease dysfunctional behaviors and promote self-sufficiency. Having the client approach only the assigned staff person sets limits on the attention-seeking behavior. Telling the client to stay in the client's room until staff approach, limiting the client to a certain area, or giving the client a list of permissible requests is punitive and does nothing to help the client gain control over the dysfunctional behavior.

When planning the care for a client who is being abused, which measure is most important to include?

helping the client develop a safety plan The client's safety, including the need to stay alive, is crucial. Therefore, helping the client develop a safety plan is most important to include in the plan of care. Being empathetic, teaching about abuse, and explaining the person's rights are also important after safety is ensured.

A client who is suspicious of others, including staff, is brought to the hospital wearing a wrinkled dress with stains on the front. Assessment also reveals a flat affect, confusion, and slow movements. Which goal should the nurse identify as the initial priority when planning this client's care?

helping the client feel safe and accepted The initial priority for this client is to help her overcome suspiciousness of others, including staff, and thereby feel safe and accepted. Introducing the client to others, giving the client information about the program, and providing clean clothes are important, but these are of lower priority than helping the client feel safe and accepted.

A nurse may use self-disclosure with a client if:

it achieves a specific therapeutic goal. Self-disclosure (making personal statements about oneself) can be a useful nursing tool. However, a nurse should use self-disclosure judiciously and with a specific therapeutic purpose in mind. The nurse should listen closely to the client and remember that the experiences of different people are sometimes similar but never identical. Using too many self-disclosures is unethical and can shift the focus from the client to the nurse. Self-disclosure that distracts the client from treatment issues doesn't benefit the client and may alienate the client from the nurse.

A nurse is reviewing home medications for a client recently admitted to a long-term psychiatric unit. The charge nurse asks why this client has frequent blood draws over the next few weeks. The nurse would be correct to state which home medication dosages vary according to the blood levels of the drug?

lithium carbonate Dosages for lithium, an antimania drug, are individualized to achieve a maintenance blood level of 0.8 to 1.2 mEq/L for acute mania and 0.8 to 1.0 mEq/L for long-term control of bipolar disorder. Although clozapine use requires monitoring of white blood cell counts and clonazepam use requires monitoring of complete blood count and liver function tests, these tests aren't used to individualize dosages of the drugs. Alprazolam dosages aren't based on blood levels of the drug.

A nurse is assessing a client with bipolar disorder. Findings include coarse hand tremors, muscle twitching, and mental confusion. These findings suggest:

lithium toxicity. Symptoms of lithium toxicity include muscle twitching, mental confusion, incoordination, and coarse hand tremors. Symptoms of severe lithium toxicity include ataxia, giddiness, blurred vision, and severe hypotension. These findings don't indicate hypomania or manic behaviors.

Which facility would the nurse rank as the lowest priority to expand when developing a community-based service program for clients with chronic mental illnesses?

long-term hospitals For a community-based program, the need for long-term hospitalization is least needed if the other services, such as partial hospitalization programs, psychiatric home care, and residential services, are available and accessible.

Which nursing intervention is the highest priority when a client is placed in restraints?

monitoring the client every 15 minutes Safety of the client and staff is the utmost priority. Therefore, the client must be monitored closely and frequently, such as every 15 minutes, to ensure that the client is safe and free from injury. Assisting with nutrition and elimination, performing range-of-motion exercises on each limb, and changing the client's position every 2 hours are important after the safety of the client and staff is ensured by close, frequent monitoring.

A nurse is teaching the families of clients with chronic mental illnesses about causes of relapse and rehospitalization. What should the nurse include as the primary cause?

noncompliance with medications Noncompliance with medications is documented as the primary cause of relapse. Although loss of family support, sudden changes in medications, and nonattendance at treatment programs may contribute to relapse, these factors are not as significant as medication noncompliance as causes of relapse.

A client in group therapy is restless. The client's face is flushed and the client makes sarcastic remarks to group members. The nurse responds by saying, "You look angry." The nurse is using which technique?

observation The nurse is using observation to give the client feedback about behavior and attitude. A broad statement doesn't give feedback to the client. The nurse didn't ask the client to explain the actions (the clarifying technique) and didn't reassure the client.

The charge nurse in an acute care setting assigns a client who is on one-on-one suicide precautions to a psychiatric aide. This assignment is considered:

reasonable nursing practice because one-on-one requires the total attention of a staff member A psychiatric aide may sit with a client to ensure safety. The nurse is still responsible for assessing the client and ensuring that one-on-one supervision occurs. Aides are capable of providing one-to-one observation. It isn't illegal to delegate observation to an aide.

The nurse who uses self-disclosure should:

refocus on the client's experience as quickly as possible. The nurse's self-disclosure should be brief and to the point so that the interaction can be refocused on the client's experience. Because the client is the focus of the nurse-client relationship, discussion shouldn't dwell on the nurse's experience.

A client refuses the evening dose of haloperidol and then becomes extremely agitated in the day room while other clients are watching television. The client begins cursing and throwing furniture. The nurse's first action is to:

remove all other clients from the day room. The nurse's first priority is to consider the safety of the clients in the therapeutic setting. Checking for an as-needed drug order and calling the physician are appropriate responses after ensuring the safety of other individuals. Because the client poses a danger to self and others, restraints may be used; however, less restrictive interventions should be attempted first.

The basis for building a strong, therapeutic nurse-client relationship begins with a nurse's:

self-awareness and understanding. The nurse must be self-aware and understand personal feelings before understanding and helping others. Although wanting to help others, accepting others, and being knowledgeable of psychiatric nursing are desirable traits, self-awareness and understanding are the basis of a therapeutic nurse-client relationship.

During an assessment interview, a depressed 15-year-old client reports "I can't sleep at night." The nurse begins to explore factors that might contribute to this situation by asking if the client is sexually active. The client changes the subject. What should the nurse suspect based on the client's response to the assessment question?

sexual abuse Victims of sexual abuse commonly refuse to talk about the abuse or change the subject because they have been threatened by their abuser. Although there may be other explanations for the adolescent's inability to sleep at night, such as noise, anxiety, spiritual distress, pain, or other disturbances, adolescents are typically willing to discuss these factors as contributors to their inability to sleep. An adolescent with narcolepsy would experience brief periods of deep sleep followed by periods of feeling refreshed and wouldn't complain of being unable to sleep at night.

Nursing implications for a client taking central nervous system (CNS) stimulants include monitoring the client for which conditions?

tachycardia, weight loss, and mood swings Stimulants produce mood swings, anorexia and weight loss, and tachycardia. Hyperpyrexia, slow pulse, weight gain, hypotension, listlessness, increased appetite, slowing of sensorium, and arrhythmias indicate CNS depression.

A client has been involuntarily committed to a hospital because he has been assessed as being dangerous to self or others. The client has lost which right?

the right to leave the hospital against medical advice An involuntarily admitted client loses the right to leave the hospital until the condition is stable enough that the client no longer poses a danger to self or others. While hospitalized, the client retains all civil rights such as receiving mail, making phone calls, refusing treatment, and also receiving the least restrictive treatment. Should the involuntarily admitted client refuse treatment once admitted, he will be evaluated for the need to receive treatment against wishes in order to decrease the risk for self-harm or harm to others.

Which factor is a priority for the nurse to evaluate when completing discharge planning for a client who has had a lobectomy for treatment of lung cancer?

the support available to assist the client at home Because clients are discharged as soon as possible from the hospital, it is essential to evaluate the support they have to assist them with self-care at home. The distance the client lives from the hospital is not a critical factor in discharge planning. There are no data indicating that home blood pressure monitoring is needed. Knowledge of the causes of lung cancer, although important, is not the most essential area to evaluate given the client's postoperative status.

The nurse is performing an assessment on a client with a history of a dysfunctional family. Which findings should the nurse anticipate? Select all that apply.

unhealthy personal boundaries abuse and neglect Healthy boundaries setting limits are established in childhood when parents provide consistent, supportive limits, and attention. In a dysfunctional family, the parents are unable to give the support, attention, care, discipline, and direction that children need in order to develop into mature adults. Often they are abused, emotionally or otherwise, or neglected. This leads to a poor self-concept and role confusion, the basis for unhealthy personal boundaries

When assessing a client for suicidal risk, which method of suicide should the nurse identify as mostlethal?

use of a gun to the stomach A crucial factor in determining the lethality of a method is the amount of time that occurs between initiating the method and the delivery of the lethal impact of the method. Lethal methods of suicide include using a gun, jumping from a high place, hanging, drowning, carbon monoxide poisoning, and overdose with certain drugs, such as central nervous system depressants, alcohol, and barbiturates. The more detailed the suicide plan, the more lethal and accessible the method, and the more effort exerted to block rescue, the greater the chance is for the suicide to be completed. Impulsive attempts at suicide even with rescuers in sight may be lethal depending on the method. Less lethal methods may include overdosing on aspirin and wrist cutting. Jumping of an 8-foot bridge may cause injury, but it is not likely to be lethal.

Based on a client's history of violence toward others and inability to cope with anger, what should the nurse use as the most important indicator of goal achievement before discharge?

verbalization of feelings in an appropriate manner Verbalizing feelings, especially feelings of anger, in an appropriate manner is an adaptive method of coping that reduces the chance that the client will act out these feelings toward others. The client's ability to verbalize feelings indicates a change in behavior, a crucial indicator of goal achievement. Although acknowledging feelings of anger and describing situations that precipitate angry feelings are important in helping the client reach her goal, they are not appropriate indicators that behavior has changed. Asking the client to list how anger has been handled in the past is helpful if the nurse discusses coping methods with the client. However, based on this client's history, this would not be helpful because the nurse and client are already aware of the client's aggression toward others.