Mental Health Midterm

Which of the following structural safety precautions is most important when attempting to prevent a common type of inpatient suicide? a. Break-away closet bars to prevent hanging b. Bedroom and dining areas with locked windows to prevent jumping c. Double-locked doors to prevent escaping from the unit d. Platform beds to prevent crush injuries

a. Hangings are the most common method of inpatient suicide. The other options are important safety measures but don't directly address the suicide method of hanging.

Based on the current understanding of brain physiology, which neurotransmitter would be the expected target of medication prescribed to manage depression? (Select all that apply.) a. Dopamine b. γ-aminobutyric acid (GABA) c. Serotonin d. Norepinephrine e. Acetylcholine

a. c. and d. Antidepressant medication targets serotonin and norepinephrine. While dopamine is implicated in schizophrenia (increase) and Parkinson's disease (decrease), it is also believed to be a factor in depression. GABA is implicated in anxiety disorders. Acetylcholine is implicated in Alzheimer's disease as well as Huntington's disease and Parkinson's disease.

Which hospitalized patient should the nurse identify as being a candidate for the appropriate use of a release from hospitalization known as against medical advice (AMA)? a. A 37-year-old patient scheduled for discharge in 24 hours wishes to be discharged immediately b. A 75-year-old patient with dementia who demands to be allowed to go back to his own home c. A 21-year-old actively suicidal patient who wants to be discharged to home and do outpatient counseling d. A 32-year-old female patient who wishes to stay in the hospital but whose husband demands that she be discharged into his care

a. AMS discharges are sometimes used when the patient does not agree with the provider, as long as the patient is not a danger to himself or herself or to others. The patient with dementia and the patient who is actively suicidal would pose a safety risk and would be not allowed to be discharged AMA. A patient who wishes to stay in the hospital can make that decision; a family member's opinion doesn't impact an AMA discharge.

Which nursing intervention demonstrates the theory behind operant conditioning? a. Rewarding the client with a token for avoiding an argument with another client b. Showing the client how to be assertive without being aggressive c. Demonstrating deep breathing techniques to a group of clients d. Explaining to the client the consequences of not following unit rules

a. Operant conditioning is the basis for behavior modification and uses positive reinforcement to increase desired behaviors. For example, when desired goals are achieved or behaviors are performed, clients might be rewarded with tokens. These tokens can be exchanged for food, small luxuries, or privileges. This reward system is known as a token economy. None of the remaining options demonstrate reward for positive behaviors, climate, and structure, for healing.

Which statements are true regarding the differences between a social relationship and a therapeutic relationship? (Select all that apply.) a. In a social relationship, both parties' needs are met; in a therapeutic relationship, only the patient's needs are to be considered. b. A social relationship is instituted for the main purpose of exploring one member's feelings and issues; a therapeutic relationship is instituted for the purpose of friendship. c. Giving advice is done in social relationships; in therapeutic relationships giving advice is not usually therapeutic. d. In a social relationship, both parties come up with solutions to problems and solutions may be implemented by both (a friend may lend the other money, etc.); in a therapeutic relationship, solutions are discussed but are only implemented by the patient. e. In a social relationship, communication is usually deep and evaluated; in a therapeutic relationship, communication remains on a more superficial level, allowing patients to feel comfortable.

a. c. and d. The other options describe the opposite meanings of social and therapeutic relationships.

A client diagnosed with bipolar disorder has a nursing care plan that includes several nursing diagnoses listed. List the nursing diagnosis to the level of priority (1 to 4). a. Risk for injury b. Self-care deficit, bathing, and hygiene c. Knowledge, deficient d. Nonadherence

1. a. Risk for injury 2. b. Self-care deficit, bathing, and hygiene 3. c. Knowledge, deficient 4. d. Nonadherence Risk for injury is the primary outcome for persons in the acute phase of mania. Injury could include suicide, not sleeping, or not eating, which could all lead to injury, as well as physical injury from hyperactivity and poor judgment, for example. Self-care deficit would be the next intervention because the client may not be able to care for himself during acute mania. Although client teaching to address knowledge deficit would be attempted, it may not be possible in the acute mania phase. Although client teaching to address nonadherence would be attempted, it may not be possible in the acute mania phase.

A 16 year old being treated on an adolescent psychiatric unit has become angry and is in the hallway yelling, "It's not fair! You all hate me! I hate this place!" When the client begins pounding on the wall the nurse should attempt to de-escalate the situation by providing which response? a. "I will help you calm down. Do you want to go to your room and talk or go to the quiet room?" b. "You may yell and bang your fists but you must do it in your own room so you don't upset the other patients." c. "Stop that right now! I will not allow you to behave like that!" d. "You will have to go into seclusion and restraints right now in order to be safe."

a. Approaching the patient in a calm manner and giving choices may de-escalate the situation and gives the patient some control. The patient would not be allowed to yell or possibly hurt himself/herself if left alone in his/her room. Commands such as "stop that right now!" could further escalate the situation. Seclusion and restraint may be premature because the situation may be able to be resolved using least restrictive means.

Which nursing statement illustrates the concept of client advocacy? a. "Dr. Raye, during the admission interview, the client stated they will refuse fluoxetine because of adverse effects they experienced previously." b. "Dr. Raye, during the admissions interview the client stated that there is a family history of three other suicide attempts in the past." c. "I'd like you tell me more about your depression and your suicide attempt?" d. "I will take you on a tour of the unit and orient you to the rules so you can get adjusted here."

a. By letting the provider know that the client does not want the treatment the provider is prescribing, you have advocated for the client and her right to make decisions regarding her treatment. The other selections do not describe client advocacy since they do not represent actions by the nurse that the client is incapable of on their own.

When preparing to hold an admission interview with a client, the nurse pulls up a chair and sits facing the client with their knees almost touching. When the nurse leans in close to speak, the client becomes visibly flustered and gets up and leaves the room. What is the most likely explanation for client's behavior? a. The nurse violated the client's personal space by physically being too close. b. The client has issues with sharing personal information. c. The nurse failed to explain the purpose of the admission interview. d. The client is responding to the voices by ending the conversation.

a. By sitting and leaning in so closely, the nurse has entered into intimate space (0 to 18 inches), rather than social distance. This has likely made the client may feel uncomfortable with being so close to someone unknown to them. All the other options lack evidence and jump to conclusions regarding the client's behavior.

While intoxicated a client unsuccessfully attempted suicide by using a gun. This method of using a gun to attempt suicide should be described in what terms? a. It is high risk, or a hard method. b. It is low risk, or a soft method. c. It was not an actual suicide attempt because the client was intoxicated. d. Considering the results, it is a nonlethal means.

a. Higher risk methods, also referred to as hard methods, include using a gun, jumping from a high place, hanging, and carbon monoxide poisoning. The other responses are incorrect.

A 38-year-old client diagnosed with major depression states, "my provider said something about the medicine I've been prescribed will affect my neurotransmitters. What exactly are neurotransmitters?" What is the nurse's best response to the client's question? a. "Neurotransmitters are chemical messengers in the brain that help regulate specific functions such as depression." b. "Neurotransmitters are too complicated to explain easily. Just know that the medication will help your mood and make you less depressed." c. "Neurotransmitters are chemicals in the brain that are the reason you are depressed." d. "I will ask your provider to give you a more in-depth explanation about why this medication will help your depression."

a. Neurotransmitters are chemicals released from neurons that function as a neuromessenger and influence brain functions. Telling the client that the answer is too complicated belittles the client by implying she cannot understand, while stating that neurotransmitters are the reason, she is depressed is too simplistic. Asking the provider to give the education abdicates your responsibility to provide client education.

Nurses working in emergency departments and walk-in clinics should be aware that some victims of violence may present with which assessment characteristic? a. Vague physical complaints such as insomnia or pain b. Extreme anger and unpredictable behavior c. Family members described as supportive d. Psychosis and/or mania as a result of long-term abuse

a. Patients may present with symptoms that may be vague and can include chronic pain, insomnia, hyperventilation, or gynecological problems. Attention to the interview process and setting is important to facilitate accurate assessment of physical and behavioral indicators of family violence. Presenting with extreme anger is possible but not as common as presenting with vague physical complaints. Having many family members there is unlikely as many victims keep their history of being battered a secret. It is not known that psychosis or mania is a result of physical violence, and this would not be a usual presenting complaint.

Two 16-year-old students were both involved in serious car accident. Both students have spoken with a counselor about the incident. One student has been able to move forward with little dysfunction as a result of the accident while the other has been experiencing anxiety and an inability to concentrate in school even after numerous counseling sessions. The difference in the way the accident affected both boys may be explained primarily by what factor? a. Personal perception of the event. b. Individual personality. c. Existence of previous, unresolved emotion trauma. d. One student received ineffective counseling.

a. People vary in the way they absorb, process, and use information from the environment. Some people may respond to a minor event as if it were life threatening. Conversely, others may experience a major event and look at it in a calmer fashion. The other options may be true but are not the primary reason for two people responding differently to the same event.

When considering mental illness, recovery is best described to a client by which statement? a. Working, living, and participating in the community b. Never having to visit a mental health provider again c. Being able to understand the nature of the diagnosed illness d. A period of time when signs and symptoms are being managed

a. Recovery is described as the ability of the individual to work, live, and participate in the community. Never having to visit a mental health provider is unrealistic. While important to recovery understanding of the disorder is not a demonstration of recovery. Remission is a period of time when signs and symptoms are being managed.

A patient admitted with anxiety asks, "What exactly are stressors?" What is the nurse's best response to the patient's question? a. "Stressors are events that happen that threaten your current functioning and require you to adapt." b. "Stressors are complicated neuro stimuli that cause mental illness." c. "It's best if you ask questions like that of your provider for a complete answer." d. "Instead of focusing on what stressors are, let's explore your coping skills."

a. Stressors are psychological or physical stimuli that are incompatible with current functioning and require adaptation. Stressors are not complicated neuro stimuli; telling the patient to address these questions to her provider fails to educate the patient, which is the nurse's responsibility. Exploring coping skills would be a good intervention at a later time but does not address the patient's question and changes the subject.

When considering the duty to warn and protect third parties, which client statement should the nurse report to the treatment team members? a. "That judge is going to really regret putting me in here." b. "All politicians need to be shot." c. "When I'm elected president, I'll make them all pay for doubting me." d. "The man out there who is laughing at me is going to die."

a. The duty to protect is an ethical and legal obligation of health care workers to protect patients from physically harming themselves or others. This duty arises when the patient presents a serious danger to another. While all that statements infer the client's intention to harm, only the correct option is credible since it actually identifies the possible victim.

What is the expected outcome for an individual who has successful resolved all the maturational crises they have been presented with? (Select all that apply.) a. The development of basic human qualities b. The elimination of future maturational crises c. The development of new, effective coping mechanisms d. The elimination to specific barriers to psychosocial growth e. The ability to pass through subsequent developmental stages

a. c. and e. Successful resolution of these maturational tasks leads to development of basic human qualities. Erikson believed that the way these crises are resolved at one stage affects the person's ability to pass through subsequent stages. Each crisis provides the starting point for movement toward the next stage with the opportunity to learn new coping mechanisms and experience personal psychosocial growth. Each new stage of development results in a maturational crisis.

Which of the following statements represent a nontherapeutic communication technique? (Select all that apply.) a. "Why didn't you attend group this morning?" b. "From what you have said, you have great difficulty sleeping at night." c. "What did your boyfriend do that made you leave? Are you angry at him? Did he abuse you in some way?" d. "If I were you, I would quit the stressful job and find something else." e. "I'm really proud of you for the way you stood up to your brother when he visited today." f. "You mentioned that you have never had friends. Tell me more about that." g. "It sounds like you have been having a very hard time at home lately."

a. c. d. and e. All these options reflect the nontherapeutic techniques of (in order) asking "why" questions; using excessive questioning; giving advice; and giving approval. The other options describe therapeutic techniques of restating, exploring, and reflecting.

Which of the following describe the symptoms of the manic phase of bipolar disorder? (Select all that apply.) a. Excessive energy b. Fatigue and increased sleep c. Low self-esteem d. Pressured speech e. Purposeless movement f. Racing thoughts g. Withdrawal from environment h. Distractibility

a. d. e. f. and h. All these options describe mania. The other options more aptly describe the opposite of what happens in mania.

When considering client rights, which client can be legally medicated against his or her wishes? a. The client has accepted the medication in the past. b. The client may cause imminent harm to self or others. c. The client's primary provider orders the medication. d. The client's mental illness may relate to cognitive impairment.

b. A patient may be medicated against their will without a court hearing in an emergency if the patient poses a danger to himself or herself or to others. The other options are not legally valid reasons to give medication against a patient's will.

Which statement is true regarding culture and protective factors against suicide? a. Asian Americans have the highest rates of suicide. b. Religion and the importance of family are protective factors for Hispanic Americans. c. Older women have the highest risk for suicide among African Americans. d. American Indians and Pacific Islanders have the lowest rates of suicide.

b. Among Hispanic Americans, Roman Catholic religion (in which suicide is a sin) and the importance given to the extended family decrease the risk for suicide. The other options are all incorrect and are in fact the opposite of what is known to be true.

Consider both Sullivan's term security operations and Freud's term defense mechanisms. Which statement suggests that the client's specialized treatment goal has been successfully met? a. "I really think I can succeed in school now." b. "I'm experiencing much less anxiety about school now." c. "Going back to school is hard and I'll need support." d. "I know that I'm not the only person who has a difficult time in school."

b. Both Sullivan and Freud coined terms to mean actions that individuals do that are an attempt to reduce anxiety. The terms to do not refer to activities that increase self-esteem. Security operations and defense mechanisms are not conscious and therefore do not increase self-awareness. These terms do not refer to reducing cognitive distortions.

Which statement by a patient who has been taught cognitive reframing indicates that the teaching was successful? a. "I do not have the ability to handle that job." b. "I can be successful if I do all the things required to learn the job." c. "I may be fired from the job but eventually I will find something else to do with my life." d. "I can never learn all there is to know for the job."

b. Cognitive reframing changes the individual's perceptions of stress by reassessing a situation and replacing irrational beliefs with more positive self-statements. The other options are all negative cognitive distortions that would prevent the individual from success.

A 52-year-old Chinese American client comes to the emergency room reporting anxiety and states, "I am a failure." During the assessment interview, the client shares that they have recently been reprimanded at work for an error they were responsible for. The nurse should explore which possible trigger for the client's anxiety and feelings of failure? a. The inability to achieve her personal goals in the workplace b. Shaming the family by being responsible for the error c. Feeling personally inadequate regarding dependability d. Traditional belief that failure may result in a changed fate

b. Eastern tradition, such as in China, sees the family as the basis for one's identity, and family interdependence as the norm. The views expressed in options A and C demonstrate Western tradition where self-reliance, individuality, and autonomy are highly valued. In the Eastern view one is born into an unchangeable fate.

Which client behavior illustrates eustress? A college student fails an exam. A bride is planning for her wedding. A man is laid off from his job. An adolescent gets into a fight at school.

b. Eustress is the result of a positive perception toward a stressor, such as having a baby, planning a wedding, or getting a new job. The other options all describe distress, or a negative energy.

A 36 year old comes to the crisis clinic with reports of not sleeping, anxiety, and excessive crying. After a tornado devastated his hometown, the client was suddenly unemployed and homeless. Which of the following statements regarding crisis accurately describes the client's situation? a. He is experiencing low self-esteem from the job loss, as well as anger because of the loss of his home. b. He is experiencing a situational crisis that is associated with both a natural disaster and a personal event. c. He is experiencing ineffective coping and should be hospitalized for intensive therapy. d. He is experiencing a situational crisis with the added stress of financial burden.

b. It is possible to experience more than one type of crisis situation simultaneously, and as expected, the presence of more than one crisis further taxes individual coping skills. The client lost his job (personal event) and also experienced the devastating effects of a tornado (natural disaster). The first option may be true but doesn't accurately describe the crisis criteria. There is nothing in the scenario suggesting he needs acute hospitalization at this time. He is experiencing not only a personal situational crisis but a natural disaster as well, which makes coping more difficult.

The nurse is caring for an admitted client with a history of becoming aggressive when angry and has caused physical injury to another client and two staff members. When this client begins to demonstrate signs of anger while in the day room what intervention should the nurse implement to address the safety of the milieu? a. Alert security to come to the unit for a show of strength b. Request that the client accompany the nurse to the client's room c. Inform the client that restraints will be used if the behavior continues d. Prepare to administer a prn chemical restraint to the client

b. Least restrictive alternative doctrine requires using the least drastic means of achieving a specific goal. By first attempting to remove the client to a safer location, the nurse is respecting the client's right to treatment that is less restrictive than the other options.

A client states, "I will always be alone because nobody could ever love me." The nurse recognizes that the client is expressing what cognitive-behavioral concept? a. Emotional consequence b. Schema c. Actualization d. Aversion

b. Schemas are unique assumptions about ourselves, according to Beck's theory. This statement is an example of a negative schema. Emotional consequence is the end result of negative thinking process, as described by Ellis. Actualization is a level of Maslow's Hierarchy of Needs. Aversion is a therapy characterized by punishment.

Which of the following is true of the relationship between bipolar disorder and suicide? a. Clients need to be monitored only in the depressed phase because this is when suicides occur. b. Suicide is a serious risk those diagnosed with bipolar disorder commit suicide. c. Clients with bipolar disorder are not considered high risk for suicide. d. As long as clients with bipolar disorder adhere to their medication regimen, there is little risk for suicide.

b. Mortality rates for bipolar disorder are severe because substantial numbers of individuals with bipolar disorder will make a suicide attempt at least once in their lifetime. Suicides occur in both the depressed and the manic phase. Bipolar clients are always considered high risk for suicide because of impulsivity while in the manic phase and hopelessness when in the depressed phase. Although staying on medications may decrease risk, there is no evidence to suggest that only clients who stop medications commit suicide.

A nurse, active in local consumer mental health groups and in local and state mental health associations, keeps aware of state and national legislation affecting mental illness treatment. How can this nurse positively affect the climate for effective, mental health treatment? a. By becoming active in politics leading to a potential political career. b. By educating the public on the effects that stigmatizing has on mental health clients. c. Advocating for laws that would make the involuntary long-term commitment process easier and faster for caregivers of mentally ill persons. d. Advocating for reduced mental health insurance benefits to discourage abuse of the system by inappropriate psychiatric admissions.

b. Nurses who are aware of legislative concerns and who are active in organizations that promote mental health awareness and appropriate and equal treatment for mental illness help achieve the goal of parity, or equality of treatment for mentally ill individuals. Becoming active in politics may be a personal goal but does not directly or necessarily reduce stigma or encourage treatment equality. The other options are undesirable outcomes.

When the nurse asks whether a client is having any thoughts of suicide, the client becomes angry and defensive, shouting, "I'm sick of you people! All you ever do is ask me the same question over and over. Get out of here!" What fact concerning hostility should the nurse's response be based upon? a. The client is getting better and is able to be assertive. b. The client may be at high risk for self-harm. c. The client is probably experiencing transference. d. The client may be angry at someone else and projecting that anger to staff.

b. Overt hostility is highly correlated with suicide; therefore the client may be considered high risk, and appropriate precautions should be taken. The other responses are incorrect with no evidence to support them.

Which of the following clients would be appropriate to refer to a partial hospitalization program (PHP)? a. A depressed client with a suicidal plan b. A client being discharged from an inpatient alcohol rehabilitation unit c. A client who has stopped taking his or her antipsychotic medication and is neglecting his or her basic needs d. Jeff, who has mild depression symptoms and is starting outpatient therapy

b. PHP is for clients who may need a "step-down" environment from inpatient status or for those who are being diverted from hospitalization with intensive, short-term care from which they return home each day. This client would be a good candidate after completing alcohol rehab; PHP could possibly help prevent relapse in the early stages after rehab. This client can be managed with regular outpatient therapy and does not need intensive short-term therapy such as PHP. Someone who is suicidal would require inpatient hospitalization for safety as would someone who is decompensated and not caring for herself. A client exhibiting mild depression would be managed with outpatient therapy and would not need intensive short-term therapy such as PHP.

Which assessment should the nurse perform to evaluate the pharmacokinetic effect of a monoamine oxidase inhibitors (MAOIs) antidepressant medication? a. The status of the client's appetite b. The results of the liver function test c. The level of depression exhibited by the client d. The client's current sleeping patterns

b. Pharmacokinetics refers to the movement of a drug through the body. Four basic processes of pharmacokinetics which determine the concentration of a drug at its sites of action are easily remembered with the acronym ADME: absorption, distribution, metabolism, and excretion. MAOIs can affect liver function and require monitoring. The other options are related to the medication's pharmacodynamic effects.

Which client statement demonstrates the mental health concept of resilience? a. "My mother made decisions about my husband's funeral when I just couldn't do that." b. "Losing my job was hard but my skills will help me get another one." c. "In spite of all the treatment, I know I'll never be really healthy." d. "My kids, happiness is worth any sacrifice I have to make."

b. Resilience is a characteristic that helps individuals cope with loss and trauma that may occur in life. Dependence is described as relying on others for decision making and care. Pessimism is a life philosophy that things are more likely to go wrong than right. Altruism is described as putting others before yourself.

A 49-year-old client diagnosed with schizophrenia at 22 years old is prescribed risperidone. Which nursing assessment is the priority for this client? a. Monitoring blood levels to avoid toxicity b. Monitoring for abnormal involuntary movements c. Observing for secondary mania d. Observing for memory changes

b. Risperidone has the highest rate of extrapyramidal side effects (EPSs) of the second-generation antipsychotic medications, thus making it imperative to monitor for EPSs. Risperidone is not monitored with blood levels and does not cause mania or memory changes.

When approaching a client who is acting out aggressively, what interventions should the nurse implement to assure personal safety? a. Stand close to the client for reassurance and to convey caring. b. Have other staff as backup, and stay out of the client's personal space. c. Take the client to his/her room so that his/her privacy will be protected. d. Call security and wait until they arrive before approaching the client.

b. Safety considerations for staff include enlisting other staff to be present, keeping a safe distance from the patient, and approaching the patient in a nonthreatening or nonconfrontational manner. None of the other options focus appropriately on staff safety; security personnel may escalate the patient's behavior and should be kept in the background until needed to assist. Furthermore, being alone in the client's room is not a safe environment when aggressive behavior is being demonstrated.

The mother of a 4-year-old daughter states that the child has recently begun, "Touching her vagina and rubs herself down there all the time." The child drew a picture showing two people with one on top of the other and said they were "doing sex." Based on the assessment description, what conclusion should the nurse explore further? a. Educate the mother to normal developmental behavior in a 4-year-old child. b. There is a possibility that the child has been sexually abused. c. The mother should be enrolled in parenting classes to improve her parenting skills. d. The child's exposure to graphic sexual images on television should be monitored closely.

b. Sexualized behavior is one of the most common symptoms of sexual abuse in children. Younger children may draw sexually explicit images, demonstrate sexual aggression, or act out sexual interactions in play, for example, with dolls. Masturbation may be excessive in sexually abused children. It is not normal developmental behavior for a 4-year-old child. The other options may be true, but sexual abuse is more likely and must be investigated.

A 55-year-old client recently came to the United States from England on a work visa. The client was admitted for severe depression following the death of a life partner weeks ago. While discussing the death and its effects the client shows little emotion. Which of the following explanations is most plausible for this lack of emotion? a. The client in denial. b. The response may reflect cultural norms. c. The response may reflect personal guilt. d. The client may have an antisocial personality.

b. Showing little emotion while in distress may be a cultural phenomenon. Some cultures, such as the British and German cultures, tend to value highly the concept of self-control and may show little facial emotion in the presence of emotional turmoil. There is no evidence to suggest the client's lack of emotion is a result of any of the other options.

A recent Hispanic immigrate comes to the mental health clinic after being referred to by her primary care provider. Josefina came to live in the United States from Brazil 5 years ago. During the initial intake assessment, the client reports headaches and backaches "almost every day" and "can't sleep at night." The client looks away when asked about anxiety or depression and states, "I don't know why I was referred to the mental health clinic." Which assessment information should the nurse further explore to assess for possible somatization? a. Impaired sleep patterns b. Denial of anxiety or depression c. Unexplained physical pain d. Recent immigration to the United States

b. Somatization is described as experiencing and expressing emotional or psychological distress as physical symptoms. The client's behavior associated with the denial of any mental illness or understanding of the possible connection between the symptom/signs and a mental illness presents a need to explore the possibility of somatization. None of the other options support this possibility as directly.

What is the major reason for the hospitalization of a depressed client? a. Inability to go to work b. Suicidal ideation c. Loss of appetite d. Psychomotor agitation

b. Suicidal thoughts are a major reason for hospitalization for clients with major depression. It is imperative to intervene with such clients to keep them safe from self-harm. The other options describe symptoms of major depression but aren't by themselves the major reason for hospitalization.

The nurse is conducting an admission interview with a client who was raped 2 weeks ago. When asked about the rape, the client becomes very anxious and upset and begins to sob. What should be the nurse's response to the client's reaction? a. Push gently for more information about the rape because the information needs to be documented. b. Acknowledge that the topic of the rape is upsetting and reassure the client that it can be discussed at another time when she feels more comfortable. c. Use silence as a therapeutic tool and wait until the client is done sobbing to continue discussing the rape. d. Reassure the client that anything she says to you will remain confidential.

b. The best atmosphere for conducting an assessment is one with minimal anxiety on the client's part. If a topic causes distress, it is best to abandon the topic at that time. It is important not to pry or push for information that is difficult for the client to discuss. The use of silence continues to expect the client to discuss the topic now. Reassurance of confidentiality continues to expect the client to discuss the topic now.

A 43-year-old client being seen in the mental health clinic states, "I have always been a practicing Jew, but in the past few months I am questioning everything. I just don't know if I believe in it anymore." Which of the following nursing diagnoses best describes the client's comment? a. Ineffective coping b. Spiritual distress c. Risk for self-harm d. Hopelessness

b. The client is expressing distress regarding his religion and spiritual well-being. The client could be experiencing ineffective coping, but this does not directly relate to his comment. There is nothing in the client's comment that would lead to the conclusion that the client is having thoughts of harming himself or experiencing hopelessness.

Which assessment data describes a client in phase IV of Caplan's phases of crisis? a. The client reports experiencing increased anxiety and feelings of extreme discomfort the day after the tornado. b. The client comes to the crisis clinic reporting depression and expresses that he does not want to go on living. c. The client reports experiencing a panic attack. d. The client reports experiencing anxiety symptoms the day after being fired.

b. This describes that phase IV, which, if coping is ineffective, may lead to depression, confusion, violence, or suicidality. The other options describe phase II, phase III, and phase I in Caplan's phases of crisis.

A nurse on the psychiatric unit has a past history of alcoholism and has regular meetings with a mentor. Which statement made to the nurse's mentor would indicate the presence of countertransference? a. "My patient is being discharged tomorrow. I provided discharge teaching and stressed the importance of calling the help line number should she become suicidal again." b. "My patient has been abusing alcohol. I told her that the only way to recover was to go 'cold turkey' and to get away from her dysfunctional family and to do it now!" c. "My patient started drinking after 14 years of sobriety. We are focusing on his treatment plan of attending AA (Alcoholics Anonymous) meetings five times a week after discharge." d. "My patient, is an elderly woman with depression. She calls me by her daughter's name because she says I remind her of her daughter."

b. This statement indicates countertransference; the nurse may be overidentifying with the patient because of a past history of alcoholism. Providing adamant advice to the patient that, besides being nontherapeutic, may be more relevant to personal past experiences than to the patient's. The discharge teaching for a patient being discharged and focusing on the treatment plan for the alcoholic patient are appropriate and show no signs of countertransference. The patient calling the nurse by her daughter's name is transference rather than countertransference.

What older concept of care is being used currently to help in violence reduction in disruptive clients? a. Aired grievances b. Trauma-informed care c. Shared governance d. Learned helplessness

b. Trauma-informed care is an older concept of providing care that has been reintroduced. It is based on the notion that disruptive patients often have histories that include violence and victimization. These traumatic histories can impede patients' ability to self-soothe, result in negative coping responses, and create a vulnerability to coercive interventions (e.g., restraint) by staff. Trauma-informed care focuses on the patients' past experiences of violence or trauma and the role it currently plays in their lives. None of the other options refer to a care concept that helps reduce violence.

What is the focus of the SAFE-T assessment tool? (Select all that apply.) a. Facilitate hospitalization. b. Identify level of suicidal risk. c. Development of client focused treatment. d. Introduce antidepressant medication therapy e. Stress collaboration with the client

b. c. and e. The Suicide Assessment Five-step Evaluation and Triage (SAFE-T) is an assessment tool that allows the clinician to benchmark relative risk (high, moderate, low) and to develop a treatment plan, in consultation with the patient, to reduce current risk. The tool does not provide for specific interventions.

A 17-year-old client confides to the nurse that they have been thinking of ways to kill a peer. What response should the nurse give when the client states, "you have to keep it a secret because its confidential information"? a. "I will keep it a secret, but you and I need to discuss ways to deal with this situation appropriately without committing a crime." b. "Yes, I will keep it confidential. We have laws to protect clients' confidentiality." c. "Issues of this kind have to be shared with the treatment team and your parents." d. "I will have to share this with the treatment team, but we will not share it with your parents."

c. Although adolescent clients request confidentiality, issues of sexual abuse, threats of suicide or homicide, or issues that put the client at risk for harm must be shared with the treatment team and the parents. A threat of this nature must be discussed with the treatment team and the parents. Confidentiality laws do not protect information that would lead to harm to the client or others.

A student nurse on the psychiatric unit expresses being uncomfortable discussing possible suicidal ideations with clients because "It might put ideas in their head about suicide." What is the nurse's best response to this student's concern? a. "I'm glad you are thinking that way. They may not have thought of suicide before, and we don't want to introduce that." b. "You are right; however, because of professional liability, we have to ask that question." c. "Actually, it's a myth that asking about suicide puts ideas into someone's head." d. "If I were you, I'd ask the health provider to talk to the patient about that subject."

c. Asking about suicidal thoughts does not "give person ideas" and is, in fact, a professional responsibility similar to asking about chest pain in cardiac conditions. Talking openly leads to a decrease in isolation and can increase problem-solving alternatives for living. Patients have usually been already thinking about suicide; it is a myth that bringing up the topic will somehow cause someone to become suicidal. Liability is not the reason we ask patients about suicidal thoughts or plan; it is for patient safety. Asking the physician to speak to the patient on that subject does not educate the student regarding the need for asking about suicidal ideation and abdicates professional and ethical responsibility for keeping the patient safe.

A nurse is providing care to a 28-year-old client diagnosed with bipolar disorder who was admitted in a manic state. According to Maslow's Hierarchy of Needs theory, the nurse should identify which client symptom as having priority? a. Rapid, pressured speech b. Grandiose thoughts c. Lack of sleep d. Hyperactive behavior

c. Based on Maslow's theory, physiological needs such as food, water, air, sleep, etc., are the priority and must be taken care of first. The other options are symptoms of mania but not as critical as lack of sleep.

A registered nurse has accepted a position as staff nurse on a psychiatric unit. Which statement made by the nurse requires additional instructions regarding the therapies provided on the unit? a. "You will participate in unit activities and groups daily." b. "You will be given a schedule daily of the groups we would like you to attend." c. "You will attend a psychotherapy group that I lead that will help you care for yourself." d. "You will see your provider daily in a one-to-one session."

c. Basic level RNs cannot perform psychotherapy. The other options are all appropriate expectations of a client's schedule on a psychiatric unit.

A client is sitting with arms crossed over their chest, with their left leg is rapidly moving up and down, and there is an angry facial expression. When approached by the nurse, the client states harshly, "I'm fine! Everything's great." Which statement related to communication should the nurse focus on when working with this client? a. Verbal communication is always more accurate than nonverbal communication. b. Verbal communication is more straightforward, whereas nonverbal communication does not portray what a person is thinking. c. Nonverbal and verbal communication may be different; nurses must pay attention to the nonverbal communication being presented to get an accurate message. d. Nonverbal communication is about 10% of all communication, and verbal communication is about 90%.

c. Communication is roughly 10% verbal and 90% nonverbal, so nurses must pay close attention to nonverbal cues to accurately assess what the client is really feeling. The other options are all untrue of verbal and nonverbal communication and are actually the opposite of what is believed of communication.

Which nursing behavior best demonstrates the concept of cultural competence? a. Acquiring knowledge about different cultures b. Educating clients about the cultural norms of the United States c. Adjusting personal practice to meet the clients' cultural preferences, beliefs, and practices d. Engaging in continuing education classes on culture in the process of becoming culturally competent

c. Cultural competence means that nurses adjust and conform to their clients' cultural needs, beliefs, practices, and preferences rather than their own. This option does not describe cultural competence. Although nurses are continually learning regarding culture, it is a career-long process. The goal is not to educate clients about our own culture but rather to adjust to their cultural preferences. Although nurses may take continuing education regarding culture, this does not describe the term cultural competence. The other options do not describe cultural competence.

Which statement, made by a female adult concerning her boyfriend, should cause the nurse to suspect that the client is at risk for being emotionally abused? a. "He has a good job and keeps control of all the finances but our electricity still got turned off last week." b. "I didn't tell him I was coming because he is under so much stress at work I didn't want to add to it." c. "He yells a lot and calls me names, but that's because I am so stupid and make so many mistakes." d. "He has always had a fiery temper."

c. Emotional abuse may be less obvious and more difficult to assess than physical violence, but it can be identified through indicators such as low self-esteem, reported feelings of inadequacy, and anxiety. Controlling the finances and having the electricity turned off describes the possibility of economic abuse. Not wanting to add to the boyfriend's stress does not describe an abusive situation. Describing the boyfriend as having a temper would more likely hint at physical abuse rather than emotional.

Which statement made by the nurse would acknowledge that they understand the difference between the ethnicity and culture? a. "So, ethnicity refers to having the same life goals whereas culture refers to race." b. "So, ethnicity refers to norms within a culture, and culture refers to shared likes and dislikes." c. "So, ethnicity refers to shared history and heritage, whereas culture refers to sharing the same beliefs and values." d. "So, ethnicity refers to race, and culture refers to having the same worldview."

c. Ethnicity is sharing a common history and heritage. Culture comprises the shared beliefs, values, and practices that guide a group's members in patterned ways of thinking and acting. The other options are all incorrect definitions of either ethnicity and/or culture.

A 31-year-old client admitted with acute mania tells the staff and the other clients that he is on a secret mission for the President of the United States. He states, "I am the only one he trusts, because I am the best!" What term will the nurse use when documenting this behavior? a. Unpredictability b. Rapid cycling c. Grandiosity d. Flight of ideas

c. Grandiosity is inflated self-regard. People with mania may exaggerate their achievements or importance, state that they know famous people, or believe they have great powers. Although clients with mania are unpredictable, the scenario does not describe unpredictability: rapid cycling is switching between mania and depression in a given time period. The scenario does not describe flight of ideas, which means a continuous flow of speech with abrupt topic changes.

A 38-year-old client is admitted with major depression. Which statement made by the client alerts the nurse to a common accompaniment to depression? a. "I still pray and read my Bible every day." b. "My mother wants to move in with me, but I want to independent." c. "I still feel bad about my sister dying of cancer. I should have done more for her!" d. "I've heard others say that depression is a sign of weakness."

c. Guilt is a common accompaniment to depression. A person may ruminate over present or past failings. Praying and reading the Bible describes a coping mechanism; the other responses do not describe a common accompaniment to depression.

Which of the following clients meets the criteria for an involuntary admission to a psychiatric mental health unit? a. A 23-year-old college student who has developed symptoms of anxiety and is missing classes and work b. A 30-year-old accountant who has developed symptoms of depression c. A 26-year-old kindergarten teacher who is not in touch with reality and was found wandering in and out of traffic on a busy road d. A 76-year-old retired librarian who is experiencing memory loss and some confusion at times

c. Inpatient involuntary admission is reserved for clients who are at risk for self-harm or who cannot adequately protect themselves from harm because of their illness (e.g., a psychotic client). The other options can all be managed at this point in the community setting and don't meet criteria (risk of harm to self and/or others) for admission.

A prescription for which medication would require the nurse to monitor the client for potential development of the side effect of hypothyroidism? a. Fluoxetine b. Bupropion c. Lithium d. Imipramine

c. Long-term use of lithium may cause hypothyroidism. The other options refer to drugs whose long-term use does not cause hypothyroidism.

Jacob, a college student whose friend recently committed suicide, rates his stress as low. Melissa was also friend with the person who committed suicide, but she rates her stress as high. The difference in how Jacob and Melissa rate their stress may be explained by which coping mechanism? a. Projection b. Denial c. Perception d. Repression

c. Perception, which is influenced by gender, culture, age, and life experience, plays a part in how someone will respond to a stress. The perception of a stressor determines the person's emotional and psychological reactions to it. The other options are all defense mechanisms that do not explain the difference in reactions to a stressor.

A 21-year-old client asks the nurse, "What's wrong with my brain that's causing me to be so angry and aggressive?" The nurse's response should be grounded on what research-supported basis? a. The diminishment of stress hormones causes anger and aggression. b. No abnormalities of the brain have been identified that correlate with anger and aggression. c. The limbic system, the prefrontal cortex, and neurotransmitters have been implicated in playing a part in aggression. d. Personality type plays a much greater part in anger and aggression than physical factors.

c. Research has supported the theory that the brain's limbic system and prefrontal cortex as well as some neurotransmitters play a part in anger and aggression. None of the other options are supported by current research.

Which scenarios describe a Health Insurance Portability and Accountability Act (HIPAA) violation associated with a nurse's behavior? a. An ED (Emergency Department) nurse gives the intensive care unit nurse a client report from a telephone at the nurse's station. b. A nurse on the medical-surgical floor calls a patient's primary care provider to obtain a list of current medications. c. A nurse on the cardiac unit gives report to the nurse on the step-down unit while transporting a client in the staff elevator. d. A nurse on the psychiatric unit gives discharge information to the counseling office regarding a client's outpatient treatment.

c. The duty to protect is an ethical and legal obligation of health care workers to protect patients from physically harming themselves or others. This duty arises when the patient presents a serious danger to another. While all that statements infer the client's intention to harm, only the correct option is credible since it actually identifies the possible victim.

A 26-year-old client is brought to the emergency room by a friend. The client is unable to give any coherent history. Which response should the nurse provide when the client's friend offers to provide information regarding the client? a. "I'm sorry, but I cannot take any information from you as it would violate confidentiality laws." b. "There is no need for that as I will call his primary care provider to obtain the information we need." c. "Yes, I will be happy to get any information and history that you can provide." d. "Yes, however, we will have to get a release signed from the client for you to be able to talk with me."

c. The friend is a secondary source of information that will be helpful since the client is not able to give any history or information at this time. Confidentiality laws do not prohibit obtaining information from a secondary source. The friend can provide information and/or history immediately and may be able to relate events that happened just before coming to the hospital. A release would not be necessary to take information about the client from a secondary source, and a psychotic client would not be competent to sign a release.

A client prescribed fluoxetine demonstrates an understanding of the medication teaching when making which statement? a. "I will make sure to get plenty of sunshine and not use sunscreen to avoid a skin reaction." b. "I will not take any over-the-counter medication while on the fluoxetine." c. "I will report any symptoms of high fever, fast heartbeat, or abdominal pain to my provider right away." d. "I will report increased thirst and urination to my provider."

c. This describes symptoms of serotonin syndrome, a life-threatening complication of SRRI medication. The other options are incorrect because the client should be wearing sunscreen to avoid sunburn, may take over-the-counter medications if sanctioned by the provider, and would not have been educated to report increased thirst and urination as a side effect of fluoxetine.

A patient who recently loss a parent begins crying during a one-to-one session with the nurse. Which response by the nurse illustrates empathy? a. "I'm so sorry. My father died 2 years ago, so I know how you are feeling." b. "You need to focus on yourself right now. You deserve to take time just for you." c. "That must have been such a hard situation for you to deal with." d. "I know that you will get over this. It just takes time."

c. This response reflects understanding of the patient's feelings, which is empathy. Feeling sorry for the client represents sympathy, whereas not addressing the patient's concern belittles the patient's feelings of grief she is expressing by changing the subject. Telling the patient, she will get over it does not reflect empathy and is closed-ended.

The primary goal and benefit of assertive community treatment (ACT) is demonstrated by which situation? a. A client and family members attend counseling sessions together at a neighborhood clinic b. Implementation of a more flexible work schedule for staff c. Improved reimbursement for services provided in the community d. A client diagnosed with schizophrenia has avoided being rehospitalization for 16 months.

d. A primary goal of ACT is working intensely with the client in the community to prevent rehospitalization. The other options are not goals of ACT.

A client admitted with major depression and suicidal ideation with a plan to overdose is preparing for discharge and asks you, "Why did I get a prescription for only 7 days of amitriptyline?" The nurse's response is based on what fact? a. Amitriptyline is very expensive, so the client may have to buy fewer at a time. b. The goal is to see how the client responds to the first week of medication to evaluate its effectiveness. c. The health care provider wants to see whether any side effects occur within the first week of administration. d. Amitriptyline is lethal in overdose.

d. Amitriptyline is a tricyclic antidepressant (TCA); these drugs are known to be lethal in smaller doses than other antidepressants. Because the client had a plan of overdose, the best course of action is to give a small prescription requiring her to visit her provider's office more often for monitoring of suicidal ideation and plan. Tricyclics are not known to be expensive. Antidepressant therapy usually takes several weeks to produce full results, so the client would not be evaluated after only 1 week. Side effects are always a consideration but not the most important consideration with TCAs.

The nurse in an emergency department notices a patient's spouse, pacing in the hallway, muttering silently, and looking angrily around the emergency department. Which statement should the nurse make to the spouse to help prevent escalation and/or violence? a. "You need to stay calm for your spouse's sake." b. "Hey, what's up? You look out of control." c. "I am calling security to deal with your behavior." d. "You appear upset. Can I help you with anything?"

d. Approaching a patient or a visitor with a calm, sincere, and caring manner can de-escalate a situation because the person may feel you are interested in helping. The other responses will not prevent escalation and may in fact anger the person further.

A client hospitalized for a psychotic relapse is being discharged home to family. Which topic is important to address when teaching both the client and the family to recognize possible signs of impending mania? a. Increased appetite b. Decreased social interaction c. Increased attention to bodily functions d. Decreased sleep

d. Changes in sleep patterns are especially important because they usually precede mania. Even a single night of unexplainable sleep loss can be taken as an early warning of impending mania. The other options do not indicate impending mania.

A nurse expresses an exclusive belief in the biological model for mental illness when stating "it's the only one I really believe." What conclusion should be drawn from this statement? a. The biological model is the oldest and most reliable model for explaining mental illness. b. The biological model has been proven to be successful in finding the cause of most symptoms of mental illness. c. The biological model is the most popular theory among leading psychiatrists and therefore the one that should be fully embraced. d. In believing only in the biological model, other influences on mental health including cultural, environmental, social, and spiritual influences are not taken into account.

d. In believing only in the biological model to the exclusion of other theories and perspectives, influences such as educational, social, spiritual, cultural, environmental, and economic are not considered, and these have also been proven to play a part in mental health and mental illness. The other options are untrue.

Which of the following persons has the highest risk factors for physical abuse? a. Emma, a 7-month-old baby who has colic and doesn't sleep through the night b. Roland, a 53-year-old man with cardiovascular disease living with his son c. Penny, a 28-year-old wife whose husband has a diagnosis of an anxiety disorder d. Rose, a 77-year-old woman living with her daughter and son-in-law

d. Older women dependent on family members for care are at higher risk for abuse. The other options do not describe specific characteristics that put them at higher risk for abuse.

A client, whose friend recently committed suicide, asks the nurse about some ways to help cope with the stress regarding the event. Which option should the nurse discuss with the client? a. Isolation for a short time so that the pain isn't reinforced by explaining her feelings over and over b. Antianxiety medication to help her relax c. Starting a hobby to keep her mind off the troubling event d. Talking with friends and attending a loss support group

d. Social supports and support groups are two effective ways to cope with stress and stressful events. Isolation is never a healthy option; talking about feelings usually decreases stress, not increases. There is no evidence to suggest Melissa is anxious. Trying to "keep her mind off" the stressor does not develop coping mechanisms to deal with stress but rather encourages not dealing with the problem.

Which response should the nurse provide a client who asks, "Why you need to conduct an assessment interview"? a. "I need to find out more about you and the way you think in order to best help you." b. "The assessment interview lets you have an opportunity to express your feelings." c. "You are able to tell me in detail about your past so that we can determine why you are experiencing mental health alterations." d. "We will be able to form a relationship together where we can discuss the current problems and come up with goals and a plan for treatment."

d. Some of the purposes of the assessment interview are to establish rapport, learn more about the presenting issues, and form mutual goals and a plan for treatment. The other options do not appropriately explain the assessment purpose.

What is the priority outcome for a toddler who has been sexually abused? a. The mother will learn coping techniques to support the child. b. The child will be able to verbalize exactly what happened to her. c. The child will no longer demonstrate inappropriate sexual behavior. d. The sexual abuse will cease immediately.

d. The highest priority in this case is that the abuse stops so that the patient can be safe and undergo recovery. The question is asked about the priority outcome for the victim, not the mother. Verbalizing exactly what happened is not a priority. The victim will most likely stop the sexualized behavior when the abuse has stopped and recovery is supported by age-appropriate interventions.

Consider the nurse-patient relationship on an inpatient psychiatric unit. Which statement made by the nurse reflects an accurate understanding of when the issue of termination should first be discussed? a. "You are being discharged today, so I'd like to bring up the subject of termination—discussing your time here and summarizing what coping skills you have attained." b. "I haven't met my new patient yet, but I am working through my feelings of anxiety in dealing with a patient who wanted to kill herself." c. "Now that we are working on your problem-solving skills and behaviors, you'd like to change; I'd like to bring up the issue of termination." d. "Now that we've discussed your reasons for being here and how often we will meet; I'd like to talk about what we will do at the time of your discharge."

d. The issue of termination is brought up first in the orientation phase. All the other options describe other phases of the nurse-patient relationship—the termination phase, the preorientation phase, and the working phase

What is the highest nursing priority for a client experiencing a situational crisis? a. Reduction of expressed anxiety. b. Development of new coping skills. c. Prevention of boundary blurring. d. Promoting client safety.

d. The nurse's initial task is to promote safety by assessing the patient's potential for suicide or homicide. The other options are all important components of the care plan, but safety of the patient takes the highest priority.

Which statement, made by a patient admitted with a diagnosis of depression, indicates the need for further assessment? a. "I know a lot of people care about me and want me to get better." b. "I have suicidal thoughts at times, but I don't have any plan and don't think I would ever actually hurt myself." c. "I don't have a good support system, but I am planning on joining a recovery group." d. "I think things will be better soon."

d. This response may be a covert, or indirect, clue that the patient is thinking of suicide. The other options are all statements that, while they may be discussed further, are not clues to suicidality but rather clear communication.

A client is presenting with behaviors that indicate anger. When approached, the client states harshly, "I'm fine! Everything's great." Which response should the nurse provide to the client? a. "Okay, but we are all here to help you, so come get one of the staff if you need to talk." b. "I'm glad everything is good. I am going to give you your schedule for the day and we can discuss how the groups are going." c. "I don't believe you. You are not being truthful with me." d. "It looks as though you are saying one thing but feeling another. Can you tell me what may be upsetting you?"

d. This response uses the therapeutic technique of clarifying; it addresses the difference between the client's verbal and nonverbal communication and encourages sharing of feelings. The other options do not address the client's obvious distress or are confrontational and judgmental. None of the other options provides this support.

A client has been admitted to an inpatient psychiatric unit with suicidal ideation. In a one-to-one session with the nurse, he shares the terrible guilt he feels over sexually abusing his stepdaughter and wanting to die because of it. Which response reflects a helpful trait in a therapeutic relationship? a. "It's good that you feel guilty. That means you still have a chance of being helped." b. "Of course you feel guilty. You did a horrendous thing. You shouldn't even forget what you did." c. "The biggest question is, will you do it again? You will end up having even worse guilt feelings because you hurt someone again." d. "You are suffering with guilt over what you did. Let's talk about some goals we could work on that may make you want to keep living."

d. This response demonstrates suspending value judgment, a helpful trait in establishing and maintaining a therapeutic relationship. Although it is difficult, nurses are more effective when they don't use their own value systems to judge patients' thoughts, feelings, or behaviors. The other options are all judgmental responses. Judgment on the part of the nurse will most likely interfere with further explorations of feelings and hinder the therapeutic relationship.

The nurse being aware that certain mental illness have a prevalence among a specific gender, will suspect which statement was made by a female client (Select all that apply.) a. "I freeze in panic when I see a spider." b. "There is no way I could make a presentation to a group of people." c. "I'm so anxious, about everything." d. "I've been arrested 6 times in the last 15 years." e. "I've been depressed most of my adult life."

d. and e. Antisocial personality disorder, characterized by repeated illegal behavior, is more commonly diagnosed in men while major depressive disorder, characterized by chronic feelings of sadness negatively impacts life, is more common among women.

A nurse states, "I am so frustrated trying to communicate with clients when they insist on speaking in their language instead of English. I think if people want to live here, they ought to have to speak our language and act like we do!" Which response by a peer best promotes culturally competent care? (Select all that apply.) a. "You are right, but all clients do have a right to an interpreter, so you need to comply." b. "I agree that it is frustrating. We should work with their family members to help convince them to speak English." c. "They will have to learn to speak English eventually to live and work successfully in this country. Just try to be client and encourage them to try speaking English." d. "What you are saying is actually considered cultural imposition, which is imposing our own culture onto someone from a different culture." e. "When their ability to speak and understand English is very limited, we need to have an interpreter present to make sure they can make their needs and feelings known."

d. and e. Cultural imposition is imposing our own cultural norms onto those from another cultural group. By obtaining an interpreter for Mr. Tran, the nurse is promoting culturally competent care, ensuring the client can communicate his feelings and needs thoroughly to the staff. Clients do have a right to an interpreter but stating that Mike is right is not promoting culturally competent care and is instead confirming his opinion. Asking family members to convince the client to speak English is not promoting culturally competent care and also undermines the trust between nurse and client. Instead of encouraging the client to speak English, an interpreter should be obtained for the client.