250 Psychiatric Nursing - Exam 1

b. "You're feeling pretty down on yourself right now."

Carol, an adolescent, just returned from group therapy and is crying. She says to the nurse, "All the other kids laughed at me! I try to fit in, but I always seem to say the wrong thing. I've never had a close friend. I guess I never will." Which is the most appropriate response by the nurse? a. "What makes you think you will never have any friends?" b. "You're feeling pretty down on yourself right now." c. "I'm sure they didn't mean to hurt your feelings." d. "Why do you feel this way about yourself?"

Tort Examples

most common examples of intentional torts involve instances of: Assault and / or Battery False imprisonment Trespassing Fraud Invasion of privacy

What are case managers responsible for?

nurses can be case managers responsible for negotiating with multiple health care providers to obtain a variety of services for the client

Assualt

occurs when an individual threatens to harm an innocent person using words, gestures, or both.

For which of the following reasons may an individual be considered "gravely disabled"? (Select all that apply) a. A person, because of mental illness, cannot fulfill basic needs. b. A mentally ill person is in danger of physical harm based on inability to care for self. c. A mentally ill person lacks the resources to provide the neccessities of life. d. A mentally ill person is unable to make use of available resources to meet daily living requirements.

a, b, d

9. On the milieu unit, duties of the staff psychiatric nurse include which of the following? (Select all that apply.) a. Medication administration b. Client teaching c. Medical diagnosis d. Reality orientation e. Relationship development f. Group therapy

a, b, d, e

3. In prioritizing care within the therapeutic environment, which of the following nursing interventions would receive the highest priority? a. Ensuring that the physical facilities are conducive to achievement of the goals of therapy. b. Scheduling a community meeting for 8:30 each morning. c. Attending to the nutritional and comfort needs of all clients. d. Establishing contacts with community resources.

c

7. Which of the following activities would be a responsibility of the clinical psychologist member of the IDT? a. Locates halfway house and arranges living conditions for client being discharged from the hospital. b. Manages the therapeutic milieu on a 24-hour basis. c. Administers and evaluates psychological tests that assist in diagnosis. d. Conducts psychotherapy and administers electroconvulsive therapy treatments.

c

Nursing diagnosis are prioritized according to which of the following? a. degree of potential for resolution b. legal implications associated with nursing intervention c. life-threatening potential d. client and family requirements

c.

The nurse is using nursing process to care for a suicidal client. which of the following nursing actions is a part of the implementation step of then nursing process? a. Prioritizes the necessity for maintaining a safe environment for the client b. Determines if nursing interventions have been appropriate to achieve desired results c. Obtains a short-term contract from the client to seek out staff if feeling suicidal d. Establishes goal of care: client will not harm self during hospitalization

c.

A competent, voluntary client has stated he wants to leave the hospital. The nurse hides his clothes in an effort to keep him from leaving. Which of the following legal actions might the nurse be charged because of this nursing action? a. Assault b. Battery c. False imprisonment d. Breach of confidentiality

c. False imprisonment

Attempting to calm an angry client by using "talk therapy" is an example of which of the following client's rights? a. the right to privacy b. The right to refuse medications c. The right to the least restrictive treatment alternative d. The right to confidentiality

c. The right to the least restrictive treatment alternative

involuntary outpatient commitment

court-ordered mechanism used to compel a person with mental illness to submit to treatment on an outpatient basis. The patient usually has hx of previous commitments.

Spirituality

the human quality that gives meaning and sense of purpose to an individuals life

Mental Health

the state of mental well-being in which one can cope with the demands of daily life Textbook: The successful adaptation to stressors from the internal and external environment, evidenced by thoughts, feelings, and behaviours that are age-appropriate and congruent with local and cultural norms.

Civil Law

the system of law concerned with private relations between members of a community rather than criminal, military, or religious affairs. Two types: Torts and Contracts

Proper Nursing Diagnosis Format

(1) the problem and its definition, (2) the etiology, and (3) the defining characteristics or risk factors. Example: (1) acute pain r/t (2) tissue ischemia aeb (3) pain rating 8/10, grimacing, guarding behavior

Mentally ill person in need of treatment

-A type of involuntary admission is for the observation and treatment of the mentally ill person in need of treatment. -Vary from state to state, but generally: --Unable to make informed decisions concerning treatment --Likely to cause harm to self or others --Unable to fulfill basic personal needs necessary for health and safety

What is the six steps of nursing process

1. assessment 2. diagnosis 3. outcome identification 4. planning 5. implementation 6. evaluation

Asian/Pacific Islander Americans

4.9% of US pop Older generation uphold traditional values and practices Newer gen embrace western culture more May be soft spoken individuals Touching may not be appropriate Family and loyalty to family above everything else Education is valued Past and present time oriented Psych illnesses may bring great shame to family Alcohol dependence is low

African American Culture

40% of household headed by women Large support groups of families HTN and sickle cell anemia genetic tendencies Alcoholism Lower class follow folk medicine

10. Sally was sexually abused as a child. She is a client on the milieu unit with a diagnosis of borderline personality disorder. She has refused to talk to anyone. Which of the following therapies might the IDT team choose for Sally? (Select all that apply.) a. Music therapy b. Art therapy c. Psychodrama d. Electroconvulsive therapy

a, b, c

2. Nancy, a depressed client who has been unkempt and untidy for weeks, today comes to group therapy wearing makeup and a clean dress and having washed and combed her hair. Which of the following responses by the nurse is most appropriate? a. "Nancy, I see you have put on a clean dress and combed your hair." b. "Nancy, you look wonderful today!" c. "Nancy, I'm sure everyone will appreciate that you have cleaned up for the group today." d. "Now that you see how important it is, I hope you will do this every day."

A

5. Mrs. S. asks the nurse, "Do you think I should tell my husband about my affair with my boss?" Which is the most appropriate response by the nurse? a. "What do you think would be best for you to do?" b. "Of course you should. Marriage has to be based on truth." c. "Of course not. That would only make things worse." d. "I can't tell you what to do. You have to decide for yourself."

A

8. The client says to the nurse, "I've been offered a promotion, but I don't know if I can handle it." The nurse replies, "You're afraid you may fail in the new position." This is an example of which therapeutic technique? a. Restating b. Making observations c. Focusing d. Verbalizing the implied

A

Involuntary Commitment

A civil proceeding in which people are hospitalized in psychiatric facilities against their will due to the person being a danger to themselves or others or if they are unable to take care of their basic needs

b. "I have a hard time believing that is true."

A client states: "I refuse to shower in this room. I must be very cautious. The FBI has placed a camera in here to monitor my every move." Which of the following is the therapeutic response? a. "That's not true." b. "I have a hard time believing that is true." c. "Surely you don't really believe that." d. "I will help you search this room so that you can see there is no camera."

Criminal Law

A law that defines crimes against the public order. Example: theft by a hospital employee of supplies or drugs

9. The environment in which the communication takes place influences the outcome of the interaction. Which of the following are aspects of the environment that influence communication? (Select all that apply.) a. Territoriality b. Density c. Dimension d. Distance e. Intensity

A, B, D

The nurse assists the physician with electroconvulsive therapy on his client who has refused to give consent. Which of the following legal actions might the nurse be charged with because of this nursing action? a. Assault b. Battery c. False imprisonment d. Breach of confidentiality

b. Battery

milieu therapy

An inpatient treatment approach involving professionals and staff members encouraging a person with a severe mental disorder to engage in prosocial and therapeutic activities.

Norepinephrine

Antidepressant, moderate mood, booster, energizer, motivator ↓ = depression. Apathy, no motivation ↑ = anxiety, hyperreactivity, mania, schizo.

Nurse Jones decides to go against family wishes and tell the client of his terminal status because that is what she would want if she were the client. Which of the following ethical theories is considered in this decision? a. Kantianism b. Christian ethics c. Natural law theories d. Ethical egoism

b. Christian ethics

GABA

Antianxiety, soother, calmer ↓ = anxiety, Huntington's, mania, schizophrenia ↑ = edgy, anxious, sedation, confusion

1. A client states: "I refuse to shower in this room. I must be very cautious. The FBI has placed a camera in here to monitor my every move." Which of the following is the therapeutic response? a. "That's not true." b. "I have a hard time believing that is true." c. "Surely you don't really believe that." d. "I will help you search this room so that you can see there is no camera."

B

10. The nurse says to a client, "You are being readmitted to the hospital. Why did you stop taking your medication?" What communication technique does this represent? a. Disapproving b. Requesting an explanation c. Disagreeing d. Probing

B

6. Carol, an adolescent, just returned from group therapy and is crying. She says to the nurse, "All the other kids laughed at me! I try to fit in, but I always seem to say the wrong thing. I've never had a close friend. I guess I never will." Which is the most appropriate response by the nurse? a. "What makes you think you will never have any friends?" b. "You're feeling pretty down on yourself right now." c. "I'm sure they didn't mean to hurt your feelings." d. "Why do you feel this way about yourself?"

B

4. Judy has been in the hospital for 3 weeks. She has used Valium "to settle my nerves" for the past 15 years. She was admitted by her psychiatrist for safe withdrawal from the drug. She has passed the physical symptoms of withdrawal at this time, but states to the nurse, "I don't know if I will be able to make it without Valium after I go home. I'm already starting to feel nervous. I have so many personal problems." Which is the most appropriate response by the nurse? a. "Why do you think you have to have drugs to deal with your problems?" b. "Everybody has problems, but not everybody uses drugs to deal with them. You'll just have to do the best that you can." c. "We will just have to think about some things that you can do to decrease your anxiety without resorting to drugs." d. "Just hang in there. I'm sure everything is going to be okay."

C

Neurotransmitters

Chemical messengers that transmit information from one neuron to another

Transference

Client unconsciously displaces to the nurse feelings formed toward a person from his or her past. Can also take the form of overwhelming affection for the nurse or excessive dependency on the nurse.

Acetylcholine

Cognitive function, learning, memory ↓ = Alzheimer's, parkinsons, huntingtons ↑ = depression

Kantianism

Ethical theory by which decisions are based on a sense of duty (goes directly against utilitarianism)

Termination phase

Evaluate goal attainment and ensure therapeutic closure

3. Dorothy was involved in an automobile accident while under the influence of alcohol. She swerved her car into a tree and narrowly missed hitting a child on a bicycle. She is in the hospital with multiple abrasions and contusions. She is talking about the accident with the nurse. Which of the following statements by the nurse is most appropriate? a. "Now that you know what can happen when you drink and drive, I'm sure you won't let it happen again." b. "You know that was a terrible thing you did. That child could have been killed." c. "I'm sure everything is going to be okay now that you understand the possible consequences of such behavior." d. "How are you feeling about what happened?"

D

7. Walter is angry with his psychiatrist and says to the nurse, "He doesn't know what he is doing. That medication isn't helping a thing!" The nurse responds, "He has been a doctor for many years and has helped many people." This is an example of what nontherapeutic technique? a. Rejecting b. Disapproving c. Probing d. Defending

D

Ethical Egoism

Decisions are based on what is best for the individual making the decision.

False imprisonment

Deliberate and unauthorized confinement of a person. May occur if a voluntary admittee is restrained or secluded against their wishes (outside an emergency situation).

Common law

Derived from decisions made in previous cases

Christian Ethics

Do unto others as you would have them do unto you

d. "How are you feeling about what happened?"

Dorothy was involved in an automobile accident while under the influence of alcohol. She swerved her car into a tree and narrowly missed hitting a child on a bicycle. She is in the hospital with multiple abrasions and contusions. She is talking about the accident with the nurse. Which of the following statements by the nurse is most appropriate? a. "Now that you know what can happen when you drink and drive, I'm sure you won't let it happen again." b. "You know that was a terrible thing you did. That child could have been killed." c. "I'm sure everything is going to be okay now that you understand the possible consequences of such behavior." d. "How are you feeling about what happened?"

Orientation (introductory) phase

Establish trust and formulate contract for intervention -Create an environment for trust and rapport. -Establish contract for intervention. -Gather assessment data. -Identify client's strengths and weaknesses. -Formulate nursing diagnoses. -Set mutually agreeable goals. -Develop a realistic plan of action. -Explore feelings of both client and nurse.

nurse-client relationship

Facilitates communication of distressing thoughts, feelings, and assisting patients with problem solving. Helps patients examine self defeating behaviors. Promotes self care and independence.

American Indian & Alaska Native Culture

Fewer than half live on reservations Touch is not highly regarded- a handshake may be seen as aggressive More silent and reserved Can be uncomfortable expressing emotions Children taught to respect tradition Present time oriented Health problems: Diabetes, TB, alcoholism, nutritional deficiencies, heart disease

Reportable events

If a client threatens violence towards themselves or another individual; if child/elderly abuse is suspected

c. "We will just have to think about some things that you can do to decrease your anxiety without resorting to drugs."

Judy has been in the hospital for 3 weeks. She has used Valium "to settle my nerves" for the past 15 years. She was admitted by her psychiatrist for safe withdrawal from the drug. She has passed the physical symptoms of withdrawal at this time, but states to the nurse, "I don't know if I will make it without Valium after I go home. I'm already starting to feel nervous. I have so many personal problems." Which is the most appropriate response by the nurse? a. "Why do you think you have to have drugs to deal with your problems?" b. "Everybody has problems, but not everybody uses drugs to deal with them. You'll just have to do the best that you can." c. "We will just have to think about some things that you can do to decrease your anxiety without resorting to drugs." d. "Just hang in there. I'm sure everything is going to be okay."

Statutory Law

Law passed by the U.S. Congress or state legislatures

Dopamine

Mood stabilizer, antidepressant, energizer, motivator ↓ = no motivation, parkinsons, social withdrawal, apathy ↑ = psychosis, mania, schizo

a. "What do you think would be best for you to do?"

Mrs. S. asks the nurse, "Do you think I should tell my husband about my affair with by boss?" Which is the most appropriate response by the nurse? a. "What do you think would be best for you to do?" b. "Of course you should. Marriage has to be based on truth." c. "Of course not. That would only make things worse." d. "I can't tell you what to do. You have to decide for yourself."

a. "You are very angry now. This is a normal response to your loss."

Nancy says to the nurse, "I worked as a secretary to put my husband through college, and as soon as he graduated, he left me. I hate him! I hate all men!" Which is an empathetic response by the nurse? a. "You are very angry now. This is a normal response to your loss." b. "I know what you mean. Men can be very insensitive." c. "I understand completely. My husband divorced me, too." d. "You are depressed now, but you will feel better in time."

a. "Nancy, I see you have put on a clean dress and combed your hair."

Nancy, a depressed client who has been unkempt and untidy for weeks, today comes to group therapy wearing makeup and a clean dress and having washed and combed her hair. Which of the following responses by the nurse is most appropriate? a. "Nancy, I see you have put on a clean dress and combed your hair." b. "Nancy, you look wonderful today!" c. "Nancy, I'm sure everyone will appreciate that you have cleaned up for the group today." d. "Now that you see how important it is, I hope you will do this every day."

c. "Thank you. I will share these with the rest of the staff."

Nurse Mary has been providing care for Tom during his hospital stay. On Tom's day of discharge, his wife brings a bouquet of flowers and box of chocolates to his room. He presents these gifts to Nurse Mary saying, "Thank you for taking care of me." What is a correct response by the nurse? a. "I don't accept gifts from patients." b. "Thank you so much! It is so nice to be appreciated." c. "Thank you. I will share these with the rest of the staff." d. "Hospital policy forbids me to accept gifts from patients."

Pre-Interaction Phase

Obtain information about the client from the chart, significant others or other health team members. Examine one's own feelings, fears, and anxieties about working with a particular client.

empathy

Perceives and understands another's situation, feelings, and motives

Restraints & Seclusion

Physician orders for R or S must be renewed and reevaluated every 4 hours Within an hour of R or S an in person evaluation must occur Must be continuously monitored by staff Restraints can be chemical I.E. drugs

Phases of a Therapeutic Nurse-Client Relationship

Pre-interaction phase Orientation (introductory) phase Working phase Termination phase

working phase

Promote client change -Maintain trust and rapport -Promote client's insight and perception of reality -Use a problem-solving model to work toward - achievement of established goals -Overcome resistance behaviors -Continuously evaluate progress toward goal attainment

Countertransference

Refers to the nurse's behavioral and emotional response to the client

limbic system

The "emotional brain" associated with fear, anxiety, rage, anger aggression, love, hope, joy, sexual and social behavior.

Battery

Unconsented touching of another person. Harm or injury do not have to occur.

Emergency Commitments

When a patient is danger to themselves or others. They are time limited and a court hearing for the individual is scheduled, usually within 72 hours.

a. The nurse repeatedly requests to be assigned to a specific client. b. The nurse shares the details of her divorce with the client. c. The nurse makes arrangements to meet the client outside of the therapeutic environment.

Which of the following behaviors suggest a possible breach of professional boundaries? Select all that apply. a. The nurse repeatedly requests to be assigned to a specific client. b. The nurse shares the details of her divorce with the client. c. The nurse makes arrangements to meet the client outside of the therapeutic environment. d. The nurse shares how she dealt with a similar difficult situation.

b. Creating an environment for the establishment of trust and rapport. e. Formulating nursing diagnoses and setting goals.

Which of the following tasks are associated with the orientation phase of relationship development? Select all that apply. a. Promoting the client's insight and perception of reality. b. Creating an environment for the establishment of trust and rapport. c. Using the problem-solving model toward goal fulfillment. d. Obtaining available information about the client from various sources. e. Formulating nursing diagnoses and setting goals.

5. One of the goals of therapeutic community is for clients to become more independent and accept self-responsibility. Which of the following approaches by staff best encourages fulfillment of this goal? a. Including client input and decisions into the treatment plan. b. Insisting that each client take a turn as "president" of the community meeting. c. Making decisions for the client regarding plans for treatment. d. Requiring that the client be bathed, dressed and attend breakfast on time each morning.

a

Gravely disabled client

a condition in which an individual, as a result of mental illness is in danger of serious physical harm resulting from inability to provide basic needs such as food, clothing, shelter, medical care, and personal safety.

Mental Illness

a disorder that affects a person's thoughts, emotions, and behaviors Textbook: Maladaptive responses to stressors from the internal or external environment, evidenced by thoughts, feelings, and behaviors that are incongruent with the local and cultural norms and interfere with the individual's social, occupational, or physical functioning

What is the APIE method?

a problem oriented system, PIE charting uses accompanying flow sheets that are individualized by each institution Assessment Problem Intervention Evaluation

Religion

a set of beliefs, values, rites, & rituals adopted by a group of people. A religious commitment is assoc with: lower suicide, drug & ETOH abuse, juvenile delinquency, less divorce, improved mental illness.

sympathetic nervous system

a set of nerves that prepares the body for action in challenging or threatening situations. Fight or flight response, increase in HR, RR, decrease in peristalsis, digestive secretions. Blood is shunted to vital organs and skeletal muscles.

Natural Law Theory

a theory asserting that the morally right action is the one that follows the dictates of nature. Do good and avoid evil.

Guidelines relating to "duty to warn" state that a therapist should consider taking action to warn a third party when his or her client: (Select all that apply) a. Threatens violence toward another individual b. Identifies a specific intended victim c. Is having command hallucinations d. Reveals paranoid delusions about another individual

a, b

1. Which of the following are basic assumptions of milieu therapy? (Select all that apply.) a. The client owns his or her own environment. b. Each client owns his or her behavior. c. Peer pressure is a useful and powerful tool. d. Inappropriate behaviors are punished immediately.

a, b, c

S.T. is a 15 year old girl who has just been admitted to the adolescent psychiatric unit with a diagnosis of Anorexia Nervosa. she is 5'5'' tall and weighs 82 lbs. She was elected to the cheerleading for the fall but states that she is not as good as the others on the squad. The treatment team has identified the following problems: refusal to eat, occasional purging, refusing to interact with staff and peers, and fear of failure. Which of the following nursing diagnoses would be appropriate diagnosis for S.T.? Select all that apply. a. social isolation b. disturbed body image c. low self-esteem d. imbalanced nutrition: less than body requirements

a,b,c,d

Which of the following describes advantages to electronic health records (EHRs)? Select all that apply. a. EHRs reduce redundancy of information b. EHRs reduce issues regarding privacy c. EHRs decrease charting time d. EHRs facilitate communication between disciplines

a,c,d

The nurse is using nursing process to care for a suicidal client. Which of the following nursing actions is a part of the planning step of the nursing process? a. Prioritizes the necessity for maintaining a safe environment for the client b. Determines if nursing interventions have been appropriate to achieve desired results c. Obtains a short-term contract from the client to seek out staff if feeling suicidal d. Establishes goal of care: client will not harm self during hospitalization

a.

The nurse is using nursing process to care for a suicidal client. Which of the following nursing actions is part of the diagnosis step of the nursing process? a. Identifies nursing diagnosis: Risk for suicide b. Notes that client's family reports recent suicide attempt c. Prioritizes the necessity for maintaining a safe environment for the client d. Obtains a short-term contract from the client to seek out staff if feeling suicidal

a.

Nurse Jones decides to tell the client of his terminal status because she believes it is her duty to do so. Which of the following ethical theories in considered in this decision? a. Natural law theories b. Ethical egoism c. Kantianism d. Utilitarianism

a. Natural law theories

Which of the following behaviors suggest a possible breach of professional boundaries? Select all that apply.a. The nurse repeatedly requests to be assigned to a specific client.b. The nurse shares the details of her divorce with the client.c. The nurse makes arrangements to meet the client outside of the therapeutic environment.d. The nurse shares how she dealt with a similar difficult situation.

a. The nurse repeatedly requests to be assigned to a specific client. b. The nurse shares the details of her divorce with the client. c. The nurse makes arrangements to meet the client outside of the therapeutic environment.

Nurse Jones decides to respect the family wishes and not tell the client of his terminal status because that would bring the most happiness to the most people. Which of the following ethical theories is considered in this decision? a. Utilitarianism b. Kantianism c. Christian ethics d. Ethical egoism

a. Utilitarianism

What is case management?

an innovative model of care delivery that serves to provide quality client care while controlling health-care costs. Critical pathways of care (CPCs) serve as the tools for provision of care in a case management system

2. John tells the nurse, "I think lights out at 10 o'clock on a weekend is stupid. We should be able to watch TV until midnight!" Which of the following is the most appropriate response from the nurse on the milieu unit? a. "John, you were told the rules when you were admitted." b. "You may bring it up before the others at the community meeting, John." c. "Some people want to go to bed early, John." d. "You are not the only person on this unit, John. You must think of others besides yourself."

b

4. In the community meeting, which of the following actions is most important for reinforcing the democratic posture of the therapy setting? a. Allowing each person a specific and equal amount of time to talk. b. Reviewing group rules and behavioral limits that apply to all clients. c. Reading the minutes from yesterday's meeting. d. Waiting until all clients are present before initiating the meeting.

b

8. Which of the following activities would be a responsibility of the psychiatric clinical nurse specialist on the IDT team? a. Manages the therapeutic milieu on a 24-hour basis. b. Conducts group therapies and provides consultation and education to staff nurses. c. Directs a group of clients in acting out a situation that is otherwise too painful for a client to discuss openly. d. Locates halfway house and arranges living conditions for client being discharged from the hospital.

b

Which of the following statements is (are) correct regarding the use of restraints? (Select all that apply) a. Restraints may never be initiated without a physician's order. b. Orders for restraints must be reissued by a physician every 2 hours for children and adolescents. c. Clients in restraints must be observed and assessed every hour for issues regarding circulation, nutrition, respiration, hydration, and elimination. d. An in-person evaluation must be conducted within one hour of initiating restraints.

b, d

The nurse is using nursing process to care for a suicidal client. Which of the following nursing actions is a part of the evaluation step of the nursing process? a. prioritizes the necessity for maintaining a safe environment for the client b. Determines if nursing interventions have been appropriate to achieve desired results c. Obtains a short term contract from the client to seek out staff if feeling suicidal d. Establishes goal of care: client will not harm self during hospitalization

b.

The nurse is using nursing process to care for a suicidal patient. Which of the following nursing actions is a part of the assessment step of the nursing process? a. Identifies nursing diagnosis: Risk for suicide b. Notes that client's family reports recent suicide attempt c. prioritizes the necessity for maintaining a safe environmental for the client d. obtains a short term contract from the client to seek out staff if feeling suicidal

b.

6. Client teaching is an important nursing function in milieu therapy. Which of the following statements by the client indicates the need for knowledge and a readiness to learn? a. "Get away from me with that medicine! I'm not sick!" b. "I don't need psychiatric treatment. It's my migraine headaches that I need help with." c. "I've taken Valium every day of my life for the last 20 years. I'll stop when I'm good and ready!" d. "The doctor says I have bipolar disorder. What does that really mean?"

d

S.T. is a 15 year old girl who has just been admitted to the adolescent psychiatric unit with a diagnosis of Anorexia Nervosa. she is 5'5'' tall and weighs 82 lbs. She was elected to the cheerleading for the fall but states that she is not as good as the others on the squad. The treatment team has identified the following problems: refusal to eat, occasional purging, refusing to interact with staff and peers, and fear of failure. Which of the following nursing diagnoses would be the priority diagnosis for S.T.? a. social isolation b. disturbed body image c. low self-esteem d. imbalanced nutrition: less than body requirements

d

The nurse is using nursing process to care for a suicidal client. which of the following nursing actions is a part of the outcome identification step of the nursing process? a. Prioritizes the necessity for maintaining a safe environment for the client b. Determines if nursing interventions have been appropriate to achieve desired results c. Obtains a short-term contract from the client to seek out staff if feeling suicidal d. Establishes goal of care: client will not harm self during hospitalization

d.

Joe is very restless and pacing a lot. The nurse says to Joe, "If you don't sit down in the chair and be still, I'm going to put you in restraints!" Which of the following legal actions might the nurse be charged because of this nursing action? a. Defamation of character b. Battery c. Breach of confidentiality d. Assault

d. Assault

Sympathy

feelings of pity and sorrow for someone else's misfortune

Utilitarianism

idea that the goal of society should be to bring about the greatest happiness for the greatest number of people

Rapport

implies special feelings on the part of both the client and the nurse based on acceptance, warmth, friendliness, common interest, a sense of trust, and a nonjudgmental attitude.