MH: Foundations and Practice of MH Nursing

When talking with a client who has been receiving paroxetine (Paxil), the nurse determines that more clarification is needed when the client says:

"I've been on the medication for 8 days now, and I don't feel any better."

A parent who is visiting a hospitalized adolescent gets into an argument with the adolescent. Leaving the adolescent's room in tears, the parent meets the nurse and relates the argument, saying, "I can't believe I got so angry that I could have hit her." What is the most therapeutic response by the nurse?

"Sometimes we find it difficult to live up to our own expectations of ourselves." The response "Sometimes we find it difficult to live up to our own expectations of ourselves" is the best response because it reflects the feelings being expressed at this time. "Teenagers really can drive you to distraction" avoids the real issue. Telling the parent to bring a surprise for the adolescent on the next visit does not address the real concern; the parent's argument may have been justified, and the child's behavior should not be rewarded. The response "You can't compare yourself to an abusive parent—after all, you didn't beat your child" avoids the issue; the parent may fear that next time control will be lost and abuse will occur.

A nurse is interviewing an 8-year-old girl who has been admitted to the pediatric unit. Which statement by the child needs to be explored?

"Those boys are so cute. I hope their room's next to mine!" An 8-year-old child should be more concerned with same-gender relationships. A child who demonstrates a strong attraction to opposite-gender relations should be questioned further to explore the possibility of sexual abuse. A statement such as "Wow! This place has bright colors" is not unusual because 8-year-old children are usually attracted to colorful environments. A statement such as "Is my mother allowed to visit me tonight?" or "I'm scared about being here. Can you stay with me awhile?" is not unusual because 8-year-old children will want the support of a trusted person when experiencing stress.

After a therapy session with a health care provider in the mental health clinic, a client tells the nurse that the therapist is uncaring and impersonal. What is the best response by the nurse?

"You have strong feelings about your therapy session and your therapist." The use of reflection assists the client in expressing feelings, which is the major goal of therapy. Telling the client that the therapist is good is a defensive response by the nurse that may cut off communication and limit the expression of feelings. Telling the client to try to cooperate avoids discussion of the client's feelings about the therapist.

A depressed client has been taking Paroxetine (Paxil) 20 mg by mouth once a day for 4 weeks. The practitioner concludes that there is no clinical improvement in the client's condition and increases the daily dose to 30 mg. The medication is supplied in an oral suspension of 10 mg/5 mL. How many milliliters of Paxil solution should the nurse instruct the client to take? Record your answer as a whole number. ___ mL

15mL

The practitioner prescribes valproic acid (Depakene) 750 mg daily to be administered in two divided doses. The medication is supplied as a syrup of 250 mg/5 mL. How many milliliters of solution should the nurse administer per dose? Record the answer using one decimal place. ___ mL

7.5 mL

A client on the psychiatric unit asks a nurse about psychiatric advance directives (PADs). What information should form the basis of the nurse's response?

A client is allowed to consent to or refuse potential psychiatric treatments if a future incapacitating mental health crisis occurs.

As the nurse is discussing psychiatric care with an older adult client, the client says, "When I was growing up I was taught to accept my lot in life and not complain. I'm proud of the fact that despite my issues I can still function independently. I don't want to be just put away." The nurse understands that the factors that influence the client's mental health are examples of:

Attitudes and beliefs Some attitudes and beliefs include reluctance by older people to seek help because of pride in their independence, stoic acceptance of difficulty, unawareness of resources, and fear of being "put away." Although the client mentions "being put away", that is an attitude. He is not talking about all the resources that might be available to him. Anxiety is defined as an unpleasant and unwarranted feeling of apprehension. The client does not mention any cultural or ethnic issues, just his own feelings.

A client's methods of coping are maladaptive. How can the nurse best help the client develop healthier coping mechanisms?

By setting realistic limits on the client's maladaptive behavior Setting realistic limits on the client's maladaptive behavior provides structure and helps the client learn acceptable behavior. The client may not be ready for promotion of interpersonal relationships at this time. No environment is stress free. The client may not be ready to assume responsibilities at this time.

When planning care for an older client, the nurse remembers that aging has little effect on a client's:

Capacity to handle life's stresses An individual's ability to handle stress develops through experience with life; aging does not reduce this ability but often strengthens it. The senses of taste and smell are often diminished in the older individual. Muscle or motor strength is diminished in the older individual. Short-term memory is diminished in the older individual, whereas long-term memory remains strong.

A hospitalized 7-year-old boy wakes up crying because he has wet his bed. It is most appropriate for the nurse to:

Change the child's bed while he changes his pajamas. Changing the child's bed while the child changes his pajamas will not call attention to the accident and will minimize the child's embarrassment. The child would probably be unable to change the bed without assistance; failure to complete the task might add to his embarrassment. Taking the child to the bathroom to change his pajamas and reminding the child to call a nurse next time will only add to the child's embarrassment.

A nurse is aware that after the administration of alprazolam (Xanax) is started, it is important to assess the client for side effects. What is the nurse's initial action?

Check the client's blood pressure. Orthostatic hypotension is a common side effect of alprazolam (Xanax) that occurs early in therapy. Central nervous system depression is not an early side effect, but it may occur after prolonged use. An alteration in urine output is not a common side effect, but it may occur after prolonged use. Distention is not a common side effect, but distention from constipation may occur after prolonged use.

In the process of development the individual strives to maintain, protect, and enhance the integrity of the self. The nurse determines that this is usually accomplished through the use of:

Defense mechanisms When the individual experiences a threat to self-esteem, anxiety increases, and defense mechanisms are used to protect the self. Affective reactions are mood disorders. Withdrawal patterns are deviant ways of coping with stress; if carried to an extreme, behavior may become pathological. Ritualistic behaviors are not an aspect of the developmental process.

According to Erikson, an individual who fails to master the maturational crisis of adolescence will most often:

Experience role confusion. According to Erikson, adolescents are struggling with identity versus role confusion. Rebellion against parental orders reflects part of the struggle for independence; it does not indicate failure to resolve the conflicts of adolescence. Adolescents tend to be group oriented, not isolated; they struggle to belong, not to escape. Adolescents may experiment with drug and alcohol use, but most of them do not become abusers.

Which functions are registered nurses legally permitted to perform in a mental health hospital? Select all that apply.

Health promotion Case management Treating human responses Health promotion, case management, and treating human responses are all within the legal scope of nursing practice. Registered nurses may use counseling interventions but may not perform psychotherapy; the members of the nursing team permitted to perform psychotherapy are psychiatric/mental health clinical nurse specialists and psychiatric/mental health nurse practitioners. Only those who are legally licensed to prescribe medications, such as psychiatric nurse practitioners, may do so.

What conflict associated with Erikson's psychosocial stages of development should the nurse remember when caring for a client 30 years of age?

Intimacy versus isolation The major task of the young adult is to develop close, sharing relationships that may include a sexual partnership; the person develops a sense of belonging and avoids isolation. During the integrity-versus-despair stage the adjusted older adult can look back with satisfaction and acceptance of life and resolve the inevitability of death; failure at these tasks results in despair. The middle school-aged child gains a sense of competence and self-assurance as social interactions and academic pursuits are mastered; failure in these tasks leads to feelings of inferiority. During adolescence the individual develops a sense of self, self-esteem, and emotional stability; failure to establish self-identity results in a lack of self-confidence and difficulty with occupational choices.

A psychiatric unit uses a behavioral approach to determine a client's level of privileges. Which factor should a nurse use to determine whether an increase in privileges is warranted?

Performing hygiene activities independently Independent performance of hygiene activities is evidence of the client's ability to act responsibly. Although an improvement in short-term memory is good, it is not related to the critical element of behavioral therapy. Verbalizations without actions do not show the improvement in behavior sought in behavioral therapy.

When a diagnosis of child abuse is established, the priority of nursing care is:

Protecting the total well-being of the child Management of the abused child places protection of the child's total being above consideration of parents' rights or wishes. Protecting the child, not promotion of parental attachment, is the priority at this time. Supervision may be necessary, but it is only part of maintaining the child's well-being. Teaching methods of discipline is not appropriate at this time.

What should a nurse ensure when creating an environment that is conducive to psychological safety?

Realistic limits are set. Realistic limits and controls provide a degree of security that adds to emotional safety by limiting choices, reducing the need for self-regulation, and decreasing the need for decision-making. Passive acceptance is not conducive to psychological safety and often signifies a degree of resignation. It is impossible to meet all of a client's physical needs in any situation. An orderly physical environment bears little relationship to psychological safety.

An 8-year-old child with a terminal illness is demanding of the staff. The child asks for many privileges that other children on the unit do not have. The staff members know that the child does not have long to live. The nurse can best help the staff members cope with the child's demands by encouraging them to:

Set reasonable limits to help the child feel more secure and content. Reasonable limits are necessary because they provide security and help keep the child's behavior within acceptable bounds. Relationships, not special privileges, should provide the necessary security. Providing treats is an unrealistic approach that allows the child to manipulate the situation.

A young man who is socially inept and rarely dates takes a job assisting a photographer who specializes in photographs of female nude models. What defense mechanism is being used by the assistant photographer?

Sublimation Sublimation is the channeling of instinctual drives into acceptable activities. The photographer is finding a safe outlet for his sexual drive. Denial is defined as an unconscious refusal to admit an unacceptable idea or behavior. Suppression is the voluntary exclusion from awareness of anxiety-producing feelings, ideas, and situations. Displacement is the transfer of feelings related with a particular person, object, or experience to a nonthreatening person, object, or experience.

A client has been taking prescribed risperidone (Risperdal) 3 mg twice a day for the past 8 days. A friend brings the client to the outpatient clinic. The client reports tremors, shortness of breath, a fever, and sweating. What should the nurse do?

Take the client's vital signs and arrange for immediate transfer to a hospital. These clinical manifestations signal the presence of neuroleptic malignant syndrome; the cardinal sign of this condition is a high body temperature. Therefore the nurse first should document the hyperthermia and then arrange for immediate hospitalization. Unless the client is experiencing impaired ventilation, it is important to complete a focused assessment before transfer. The care needed can be provided in an emergency department or medical unit, not a psychiatric unit. Neuroleptic malignant syndrome may occur without an overdose; this syndrome can occur when a high-potency antipsychotic drug is prescribed, with typical onset within 3 to 9 days after initiation of the medication. Benztropine (Cogentin) will have little or no effect on neuroleptic malignant syndrome.

When communicating with a client with a psychiatric diagnosis, the nurse uses silence. When silence is used in therapeutic communication, clients should feel:

There is no hurry to answer. Silence is a tool employed during therapeutic communication that indicates that the nurse is listening and receptive; it allows the client time to collect thoughts, gain control of emotions, or speak without hurrying. Silence should be comfortable and should not create pressure to talk. The client should feel that she has an opportunity to think about the interaction. The client's perception that the nurse expects that further communication is unnecessary will close communication.

The parents of an adolescent who engages in self-injurious cutting behavior ask the nurse why their child self-mutilates. What should the nurse give as the reason for the cutting?

Way to manage overwhelming feelings

A client who has been sexually abused tearfully says, "I'm no good now; there's nothing to live for." What is the most therapeutic response by the nurse?

"Tell me more about your feelings." The response "Tell me more about your feelings" is on a feeling level and therefore encourages the exploration of feelings. The statement "I can understand why you feel worthless" supports the negative feelings of worthlessness. The response "Why do you feel that there's nothing to live for?" focuses on negative feelings; "why" questions are difficult and sometimes impossible to answer. The question "Do you feel this way because of what has happened?" will elicit a yes or no response and will not encourage the exploration of feelings.

The nurse manager is observing the performance of a nursing assistant. What behavior by the nursing assistant toward a client reflects a boundary violation?

Accepting a gift from the client A boundary violation occurs when a provider of care goes beyond the established therapeutic relationship standard and enters into a personal or social relationship with a client. Offering advice to the client is an example not of a boundary violation but rather of inadequate communication skills; advice should not be given because it undermines the client's ability to solve problems and may precipitate dependency and helplessness. False reassurance is an example not of a boundary violation but rather of inadequate communication skills; false reassurance should not be given because it is not based in reality and may close off communication. Engaging in excessive probing is an example not of a boundary violation but rather of inadequate communication skills; inappropriate probing is not therapeutic and may be done by the provider of care to avoid uncomfortable silences or obtain information because of curiosity.

A male client who is taking clozapine (Clozaril) is seen by the nurse in the outpatient mental health clinic. The nurse interviews the client, sends a venous blood specimen to the laboratory, obtains the vital signs, and finally reviews all the collected information. Which complication associated with clozapine does the nurse suspect that the client is experiencing?

Agranulocytosis Clozapine (Clozaril) can cause bone marrow suppression. The expected white blood cell (WBC) value for an adult is 4500 to 10,000 mm3. The client has a reduction in WBCs, making him vulnerable to infection. A fever with complaints of a sore throat and weakness supports the conclusion that the client may have an infection. The red blood cell (RBC) count does not indicate anemia. The expected range of RBCs for an adult male is 4.6 to 6.2 ´ 106/mL3. The small change in the blood pressure from standing to sitting does not support the conclusion of orthostatic hypotension. Labile hypertension is associated with neuroleptic malignant syndrome. There are insufficient data to support the conclusion that the client is experiencing neuroleptic malignant syndrome. Although tachycardia and tachypnea are associated with neuroleptic malignant syndrome, the client's fever would be more than 100.6° F (38.1° C). Additional characteristics of neuroleptic malignant syndrome include labile hypertension, diaphoresis, drooling, increased muscle tone, and decreased level of consciousness.

With the client's permission, the nurse should inform the family about what is happening. The main reason for this action is that informed families:

Are better equipped to assist the client Families who are informed about the client's status can help with treatment goals and discharge planning. Relief of anxiety, relaxation, and fewer nursing problems may all be secondary gains, but none is the primary purpose.

A client who is going to be discharged has been receiving risperidone (Risperdal) 3 mg three times a day. The nurse should teach the client that the medication:

May cause sedation if taken concurrently with alcohol Risperidone (Risperdal) potentiates the action of alcohol and can cause oversedation if the drug and alcohol are taken together. This medication should be taken consistently to prevent recurrence of symptoms and maintain a therapeutic blood drug level. Medications should be taken as prescribed; taking them all at one time may interrupt the maintenance of a constant therapeutic blood level.

One morning, during the working phase of a therapeutic relationship after several sessions in which difficult issues were discussed, the client suddenly becomes very hostile. What is the most appropriate interpretation of this behavior by the nurse?

Hostility is being used as a defense because previous self-disclosure has raised anxiety. Emotional closeness after self-disclosure increases anxiety, which cannot be tolerated; hostility is used to keep the nurse at a distance. Hostility is more extreme than assertiveness and is not an indication of improvement. Although flare-ups often occur even when there is a positive working relationship, the expression of hostility is not a flare-up in this situation. Regressive behavior is the resumption of behavior characteristic of an earlier stage of development; hostility does not fit this definition.

A nurse is assigned to lead a relaxation group. Which techniques should the nurse incorporate? Select all that apply.

Meditation Mental imagery Deep-breathing exercises Meditation lowers heart and blood pressure rates, decreases levels of adrenal corticosteroids, improves mental alertness, and increases a sense of calmness and peace. Imagery is the internal experience of memories, dreams, fantasies, and visions that serves as a bridge connecting the body, mind, and spirit; its distractive ability decreases adrenal corticosteroids, promotes muscle relaxation, and increases a sense of calmness and peace. Deep breathing increases oxygenation and releases tension in the muscles of the neck, shoulders, and torso. Token economy is a behavioral theory that acknowledges acceptable behavior with a reward (token) that can be redeemed for something that has a perceived value (e.g., a desirable activity). Operant conditioning, a behavioral therapy, is the learning of a particular type of behavior followed by a reward.

A nurse enters the room of an agitated, angry client to administer the prescribed antipsychotic medication. The client shouts, "Get out of here!" The nurse's best approach is to:

Say, "I'll be back in 15 minutes, and then we can talk." Saying, "I'll be back in 15 minutes, and then we can talk" allows the agitated, angry client time to regain self-control; telling the client that the nurse will return will decrease possible guilt feelings and implies to the client that the nurse cares enough to come back. Getting assistance and giving the medication by way of injection does not respect the client's feelings; it may decrease trust and increase feelings of anger, helplessness, and hopelessness. An agitated, angry client will not be able to accept a logical explanation. Continued insistence may provoke increased anger and further loss of control.

A high school adolescent undergoing lithium therapy has not been following the prescribed pharmacological regimen. What should the school nurse do to help promote adherence to the regimen?

Talk with the adolescent about the importance of a consistent lithium blood level in ensuring that the medication will be effective.

A female client in the psychiatric unit has been monopolizing a group discussion about prenatal care for more than 10 minutes, sharing her feelings about the way in which her husband has treated her. The nurse conducts a quick assessment of the group and finds that about half of the clients are inattentive. Which is the most appropriate nursing intervention?

Thanking the client for sharing her feelings and asking what the other group members have on their minds

According to Erikson, a child's increased vulnerability to anxiety in response to separation or pending separation from significant others results from failure to complete a developmental stage. What does the nurse call this stage?

Trust Without the development of trust, the child has little confidence that the significant other will return; separation is considered abandonment by the child. Without identity, the individual will have a problem forming a social role and a sense of self; this results in identity diffusion and confusion. Without initiative, the individual will experience the development of guilt and feelings of inadequacy. Without autonomy, the individual has little self-confidence, develops a deep sense of shame and doubt, and learns to expect defeat.