CP- Foundations in Psychiatric Nursing

A client reveals a history of childhood sexual abuse. What question should the nurse ask first? "How long did the abuse go on?" "What other forms of abuse did you experience?" "Was there a time when you did not remember the abuse?" "Does your abuser still have contact with young children?"

"Does your abuser still have contact with young children?"

When preparing to present a community program about women who are victims of physical abuse, the nurse should stress what information about the incidence of battering? Death from battering is rare. Lower socioeconomic groups are primarily affected. Battering is a major cause of injury to women. Physical abuse typically begins early in a relationship, well before a women gets pregnant.

Battering is a major cause of injury to women.

A nurse assesses a client with psychotic symptoms and determines that the client likely poses a safety threat and needs vest restraints. The client is adamantly opposed to this. What would be the best nursing action? Ask a family member to come in to supervise the client. Restrain the client with vest restraints. Apply wrist restraints instead of vest restraints. Contact the physician and obtain necessary orders.

Contact the physician and obtain necessary orders.

During a mental health assessment interview, a client does not make eye contact with the nurse. The nurse suspects this behavior is culturally based. What should the nurse do first in relation to this assumption? Read several articles about this cultural group and their behaviors Observe how the client and the client's family interact with each other and with other staff members Accept this behavior because it is culturally based Ask staff members of a similar cultural group about their habits and behaviors

Observe how the client and the client's family interact with each other and with other staff members

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 them. Serve the client food in small, attractively arranged portions. Allow the client to send out for their favorite foods. Allow the client to enter the unit kitchen for extra food as necessary.

Serve foods that the client can carry with them.

The health care provider (HCP) refers a client diagnosed with somatization disorder to the outpatient clinic because of problems with nausea. The client's past symptoms involved back pain, chest pain, and problems with urination. The client tells the nurse that the nausea began when their spouse asked for a divorce. Which intervention is most appropriate? asking the client to describe their problem with nausea directing the client to describe their feelings about the impending divorce informing the client about a different medication for their nausea allowing the client to talk about the HCPs they have seen and the medications they have taken

directing the client to describe their feelings about the impending divorce

The nurse manager of a psychiatric unit notices that one of the nurses commonly avoids a 75-year-old client's company. Which factor should the nurse manager identify as being the most likely cause of this nurse's discomfort with older clients? recent experiences with their parents' older adult friends desire to be around youth and beauty fears and conflicts about aging dislike of physical contact with older people

fears and conflicts about aging Explanation:The most common reason for the nurse's discomfort with elderly clients is that she has not examined her own fears and conflicts about aging

A client who has been physically abused by their spouse agrees to meet with the nurse. What is most important for the nurse to do before the nurse ends the meeting? Ask the client what they could do to de-escalate the situation at home. Give the client the telephone numbers of a shelter or a safe house and the crisis line. Tell the client not to do anything that could upset their spouse. Advise the client to leave their spouse.

Give the client the telephone numbers of a shelter or a safe house and the crisis line.

A client is admitted to an inpatient psychiatric unit. After the assessment and admission procedures have been completed, the nurse states, "I'll try to be available to talk with you when needed and will spend time with you each morning from 10:00 until 10:30 in the corner of the dayroom." What is the rationale for communicating these planned nursing interventions? To instill hope in the client To provide time for completing nursing responsibilities To provide a structured environment for the client To attempt to establish a trusting relationship

To attempt to establish a trusting relationship

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? establishing a basis for long-term therapy assisting in psychological resolution of the immediate crisis providing a basis for admission to an acute care facility solving the client's problems

assisting in psychological resolution of the immediate crisis

A client with a chronic mental illness who does not always take their medications is separated from their spouse and receives public assistance funds. The client lives with their parent and older sibling and manages their own medication. The client's parent is in poor health and also receives public assistance benefits. The client's sibling works outside the home, and the client's other parent is dead. Which issue should the nurse address first? medication compliance marital communication family support financial concerns

medication compliance

Which term refers to the primary unconscious defense mechanism that blocks intense, anxiety-producing situations from a person's conscious awareness? denial repression introjection regression

repression

The nurse is admitting a client with Borderline Personality Disorder. When planning care for this client, the nurse should give priority to which item? empathy manipulation safety splitting

safety

What is a generally accepted criterion of mental health? self-acceptance absence of anxiety happiness ability to control others

self-acceptance

The nurse is explaining the concept of poor personal boundaries to a client. Which statement by the client requires priority action by the nurse? "I know that I should not try to control others." "I know that it is okay to expect others to fulfill my needs." "I understand that poor boundaries are unhealthy for me." "I understand that I should not share too much information with others."

"I know that it is okay to expect others to fulfill my needs."

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? "Place the client on the side then use a drawsheet to bring the client to the bed." "Obtain the sliding board or two other people to assist us." "Place the client in a semi-Fowler's position to make the move easier." "Get the hydraulic lift; the client is still groggy."

"Obtain the sliding board or two other people to assist us."

As the nurse helps a client prepare for discharge, the client says, "You know, I've been in lots of hospitals, and I know when I'm sick enough to be there. I'm not that sick now. You don't need to worry about me." What would be the most therapeutic response by the nurse?

"We're concerned about you. How can we help you before you leave?"

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." "Eating too much watermelon will affect my lithium level." "I can still eat my favorite salty foods." "A good blood level of the drug means the drug concentration has stabilized."

"When my moods fluctuate, I'll increase my dose of lithium."

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: "I'm so frustrated by your behavior." "Will you briefly summarize your point? Others also need time." to ignore the behavior and allow the client to vent. "Your behavior is obnoxious and drains the group."

"Will you briefly summarize your point? Others also need time."

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." "These things are generally no one's fault." "Why are you blaming your child's father?" "Why do you say that, exactly?"

"You seem really upset by this situation."