my chapter 10

A newly hired psychiatric-mental health nurse has learned about the suicide risk assessment. Which statement made by the nurse would indicate A NEED for further teaching? "Asking clients if they are having suicidal thoughts may put that idea into their head." "It's okay that I feel uncomfortable asking clients about suicidal thoughts." "It is our responsibility to keep all clients safe on the unit; therefore, we have to assess for suicidal risk." "A suicide risk assessment is part of our comprehensive assessment."

"Asking clients if they are having suicidal thoughts may put that idea into their head."

A client has learned about conflict resolution. Which statement made by the client to the nurse would indicate a need for further teaching? "Both parties should seek to understand each other's point of view in a successful resolution." "Conflict is always a negative situation where individuals both have to compromise." "It's important for both parties to be motivated to seek a solution." "An important component of conflict resolution is collaboration."

"Conflict is always a negative situation where individuals both have to compromise." B/C Conflict resolution is a process of helping an individual or family identify a problem underlying a disagreement or dispute and developing alternative possibilities for solving the conflict. Conflict can be positive if individuals see the problem as solvable and as providing an opportunity for growth and interpersonal understanding.

The nurse is performing an initial assessment for a client newly admitted to the behavioral health unit. When initiating the assessment, which question will the nurse ask to obtain the most relevant data? "Have you thought about which goals that you would like to achieve while you are here?" "Do you live at home alone or with family?" "Discuss with me what brought you in to the behavioral health unit today?" "Are you feeling well today?"

"Discuss with me what brought you in to the behavioral health unit today?" The nurse should use open-ended questions when gathering assessment data from the client. Doing so allows the client to begin as they feel comfortable and also gives the nurse an idea about the client's perception of their situation. When asking the client to discuss what brought them to the unit, an opportunity exists to discover more information. T

Which question is best to ask when assessing the client's judgment? "On a scale of 1 to 10, how stressed would you rate yourself?" "If you found yourself downtown without money or a car, how would you get home?" "Can you describe your usual daily activities for me?" "What problem would you like to work on while you're hospitalized?"

"If you found yourself downtown without money or a car, how would you get home?" Judgment refers to the ability to interpret one's environment and situation (such as being stranded downtown) correctly and to adapt one's own behavior and decisions accordingly.

A client's nursing diagnosis of "risk for self-directed violence" has been identified because of her recent history of cutting and self-mutilation. Which of the following expected outcomes is most appropriate for this client's plan of care during inpatient treatment? "The client will demonstrate better coping skills." "The client will demonstrate resolution of her psychiatric diagnosis." "Staff will observe the client for signs of self-mutilation." "The client will refrain from cutting or self-mutilation."

"The client will refrain from cutting or self-mutilation." An expected outcome is a measurable, client-oriented goal, such as the goal of abstaining from self-harm.

The nurse is interviewing a new client at the clinic and attempts to identify the client's perception of their situation. Which question will best elicit this information? "Which medications do you take on a regular basis?" "Did a family member come to the clinic with you today? "What brings you to the clinic today?" "How have you been sleeping lately?"

"What brings you to the clinic today?"

The nurse is assessing the client's cognition and intellectual performance. Which statement assesses abstract reasoning? "Can you count backward from 20 subtacting by 3 until you get to zero?" "What is the meaning of 'A penny saved is a penny earned'?" "What would you do if you found a bag of money on a busy street?" "I'm going to say three things, then in a few minutes I will ask you what they were. Can you do this?"

"What is the meaning of 'A penny saved is a penny earned'?" Abstract thinking is considered a type of higher-order thinking, usually about ideas and principles that are often symbolic or hypothetical. Abstract reasoning is reflective in the statement when the nurse gives the patient a proverb to interpret, such as "A penny saved is a penny earned.

The psychiatric nurse is interviewing a new client. The psychiatric nurse teaches the client to reflect on one's own personal-identity. Which client statement reflects that the client is determining personal-identity? "What words would I use to describe who I am?" "How does my body image affect my self-esteem? "When do I feel confident and good about myself?" "How important is my physical appearance and will I measure up?"

"What words would I use to describe who I am?" The correct response is when the client is best determining personal-identity with reflection by using words such as adjectives describing who they are.

The nurse is performing an assessment for a client and attempting to determine the client's ability to concentrate. Which question will the nurse ask the client to elicit this information? "What does 'A stitch in time saves nine' mean?" "What is the name of the current president?" "Will you spell the word 'world' backward?" "Are you thinking about killing yourself?"

"Will you spell the word 'world' backward?"

The nurse is assessing which of the following when he asks the client to interpret a common proverb? Memory Concentration Concrete thinking Abstract thinking

"Will you spell the word 'world' backward?" To evaluate abstract thinking, the nurse can ask the client to interpret a common proverb such as "a stitch in time saves nine." Abstract thinking is considered a type of higher-order thinking, usually about ideas and principles that are often symbolic or hypothetical.

The nurse is interviewing a client who has a diagnosis of panic disorder. Which statement by the nurse indicates the use of summarizing? "You have had several stressful events occur." "I can see that your hands are shaking." "Your stress level seems really high right now." "You may need to find ways to relax."

"You have had several stressful events occur." The nurse is summarizing by stating that several stressful events have occurred.

The nurse asks a client to explain the meaning of the saying, "A penny saved is a penny earned." Which statement by the client indicates abstract reasoning? "I just feel that I'm broke all the time, let's go have a snack." "The three words you gave me were kite, grass, and lollipop." "You have to work hard if you want anything out of life." "Subtracting 3 in increments from 100 is 97, 94, 91, and 87."

"You have to work hard if you want anything out of life." When assessing abstract reasoning and comprehension, the client is given a proverb such as "a penny saved is a penny earned" and asked to interpret it. The client may say that you have to work hard if you want to have anything in life, which is reflective of abstract reasoning.

If the client provides a literal explanation of a proverb and cannot interpret its meaning, which thought process is lacking? Concrete thinking Concentration Memory Abstract thinking

Abstract thinking

A client describes the recent breakup of a dating relationship when being interviewed by the nurse. Which finding will the nurse determine is the client's affect? An emotionless tone and flat facial expression Prolonged emotional state of mood of client Client perception of events that has occurred Placing quotes in nurse's notes of client statement

An emotionless tone and flat facial expression

A client is yelling, pacing, and becoming violent toward staff members. What technique should be tried first to control the situation initially? Seclusion Chemical restraints Deescalation Client observation

Deescalation

A client states, "I don't want to eat anything because I am afraid that my food is poisoned." Which intervention is best for the nurse to perform to encourage the client to eat? Encourage the client to help with meal preparation. Ask the client about favorite foods to add for meals. Tell the client to take vitamins on a daily basis. Discuss the importance of proper nutrition with the client.

Encourage the client to help with meal preparation. Explanation: The client who demonstrates paranoia about food being poisoned should be encouraged to help with food preparation so that there is certainty about food being not poisoned.

A 22-year-old client who has been diagnosed with paranoid personality disorder has been receiving treatment. The final stage of the nursing process in the care of this client should focus on what? Engaging the client's friends and family Selecting specific interventions Evaluating the effectiveness of the treatment Encouraging the client to develop coping skills and life skills

Evaluating the effectiveness of the treatment = last stage

A client is showing no facial expression when engaging in a game with peers during an outing at a park. How will the nurse document the client's affect? Flat affect Broad affect Restricted affect Absent affect

Flat affect flat affect= showing no facial expression;

When a client talks about the recent loss of a family member while laughing or smiling, this type of affect would be labeled as what? Inappropriate Flat Blunted Restricted

Inappropriate An inappropriate affect is displaying a facial expression that is incongruent with the mood or situation.

When the nurse asks the client, "Are you thinking about killing yourself?" The nurse is questioning which component of a suicide assessment? Plan Method Ideation Access

Ideation This question is an example of evaluating suicidal ideation of the client. The nurse must determine whether the depressed or helpless client has suicidal ideation or a lethal plan.

How should the nurse describe the mood and effect of a client who has a mask-like facial expression but states, "I'm really happy?" Broad Incongruent Congruent Restricted

Incongruent The client has a flat affect yet tells the nurse that his or her mood is "really happy." In this situation, the nurse would accurately describe the mood and affect as incongruent. does not match to what the client is saying

A nurse awaits the arrival of a client who is being transferred from a nursing home. The client has a history of schizophrenia and has been behaving bizarrely. The nurse begins preparing the plan of care by outlining expected outcomes. The nurse's actions are which of the following? Consistent with the nursing process, because the goals generally will be applicable to all clients with schizophrenia Consistent with the nursing process, because goals should be identified before interventions Inconsistent with the nursing process, because the nurse should establish goals with the client Inconsistent with the nursing process, because assessment always comes first

Inconsistent with the nursing process, because assessment always comes FIRSTTTT.

A client reported to the nurse that on the client's way to the clinic, a police officer in a patrol car turned on the car's lights and pulled the client over. When asked what the client did next, the client stated, "I pulled over, of course." Which was the nurse trying to assess? Self-concept Judgment Insight Concentration

Judgment

When the nurse asks the client, "If you found a stamped addressed envelope on the ground, what would you do?" The nurse is assessing which component of the assessment? Self-concept Orientation Judgment Insight

Judgment

In the space of five minutes, the client has been laughing and euphoric, then angry, and then crying for no reason that is apparent to the nurse. This behavior would be best described as ... Tangential thinking Flight of ideas Lack of insight Labile mood

Labile mood Labile = liable to change; easily altered.

During the assessment, the nurse asks the client to describe the client's problems. The purpose of this question is to obtain information about what? Perception of the problem Personal needs Communication skills Admitting diagnosis

Perception of the problem determining what they perceive

After assessing a client, a nurse noted: "The client was tearful, tried to commit suicide, had no immediate plan for another suicide attempt, was unable to concentrate, and reported having trouble sleeping and having little or no appetite." The nurse also noted that the client's appearance was unkempt, and the client spoke with a low monotone voice and was unable to establish and maintain eye contact. Based on this information, which nursing diagnosis would be the most appropriate? Risk for Self-Mutilation Ineffective Role Performance Risk for Suicide Risk for Infection

Risk for Suicide The client's history of a recent suicide attempt in conjunction with signs of depression, such as difficulty sleeping, lack of appetite, and inability to concentrate, put the client at risk for suicide.

Mrs. Yamada has been admitted to the psychiatric unit because of her worsening diagnosis of major depression that has not responded appreciably to treatment. In light of Mrs. Yamada's statement that "everything would be better if I was just dead and gone," the nurse would be justified in identifying what type of nursing diagnosis related to suicide? Wellness nursing diagnosis Risk nursing diagnosis Syndrome nursing diagnosis Actual nursing diagnosis

Risk nursing diagnosis This client's psychiatric diagnosis coupled with her statement that refers to suicide would justify a risk nursing diagnosis of "risk for suicide related to depression."

During an assessment, which would be the most important question topic? Motor behavior Suicidal ideation Roles and relationships History

Suicidal ideation

A nurse is viewing laboratory values for a client on psychotropic drugs who has elevated BUN (blood urea nitrogen) and serum creatinine levels. Why should the nurse be concerned regarding these laboratory values?

The client may be at risk for toxicity from the medication. Explanation: Elevated BUN and creatinine levels can be an indication of a problem with the kidneys that would affect excretion of the medication. If the client is unable to excrete the medication, there is a risk for drug toxicity.

A nurse assesses a client with depression, experiencing lethargy during the day, and not actively participating in unit activities. The notes from the night shift document that the client did not sleep well. How will the nurse interpret this data? The client's medications are ineffective and need to be reevaluated. The client's depressed mood may be impairing restful sleep patterns. The client is being kept awake at night due to noise on the unit. The client is resisting treatment recommendations to participate in unit activities.

The client's depressed mood may be impairing restful sleep patterns.

In planning the care of a client who has been admitted to the hospital after a suicide attempt, an expected outcome should relate directly to what? The client's mood and affect The client's coping skills The client's compliance with therapy The client's refraining from suicide attempts

The client's refraining from suicide attempts b/c The outcome statement should be directly related to the nursing diagnosis. In the case of client who has attempted suicide, an expected outcome should be the absence of further attempts. b/c An expected outcome is a measurable, client-oriented goal, such as the goal of abstaining from self-harm.

A client's frequent night awakenings, early morning rising, and daytime drowsiness have prompted the nurse to add a diagnosis of "disturbed sleep pattern" to the client's plan of care. What information should immediately follow this diagnosis? The DSM-IV-TR diagnosis that corresponds to the nursing diagnosis Previous attempts at alleviating the diagnosis The client's preferred intervention for the diagnosis The evidence supporting the diagnosis

The evidence supporting the diagnosis A nursing diagnosis should be followed by the cues and judgments that underlie the diagnosis. This is normally accomplished by following the diagnosis with statements such as "evidenced by," "related to," and "demonstrated by."

The nurse states to a client who calls out for help, "I am happy to help you. Please let me know what I can do." Which process is the nurse using with this statement? conflict resolution containment psychoeducation validation

The nurse is practicing validation which demonstrates respect for clients and their human rights.

Which aspect of the mental status exam refers to information about how the client's thoughts connect to one another? Orientation Thought process Behavior Mood

Thought process

A client states to the nurse "I am so excited about my family coming to visit" and is smiling and laughing. How will the nurse document the client's mood? dysphoric labile euphoric euthymic

euphoric The nurse would document that the client is exhibiting a euphoric mood, which means being elated, when expressing excitement and appearing happy by smiling and laughing.

When observing a client diagnosed with mania, the nurse observes his mood to be elated. What is another term for this type of mood? euthymic euphoric dysphoric labile

euphoric b/c euphoric = (elated),

A nurse is caring for a client who has automatic thought patterns that interfere with the client's ability to function optimally. What type of intervention would the nurse anticipate be initiated with the client? cognitive conflict resolution behavior relaxation

cognitive Cognitive interventions aim to change or reframe an individual's automatic thought patterns that have developed over time and that interfere with the individual's ability to function optimally.

A psychiatric-mental health nurse is gathering psychosocial assessment data from a client experiencing anxiety. Upon assessment, the client is restless and cannot concentrate on answering the questions from the nurse. What is the priority intervention from the nurse before proceeding in the interview? decreasing the client's anxiety level assessing the client's support system rescheduling the interview assessing the client's coping ability

decreasing the client's anxiety level The client's health status may affect the client's psychosocial assessment. If the client is anxious, the nurse may have difficulty eliciting the client's full participation in the assessment. The nurse needs to recognize these feelings and deal with them before continuing the full assessment. Therefore, the first intervention by the nurse would be to decrease the client's anxiety level.

A client is crying while talking about a distressing situation. The nurse states to the client, "That must be very upsetting for you." Which assessment interview behavior is the nurse demonstrating? reflecting exhibiting empathy restating demonstrating acceptance

exhibiting empathy . The nurse's behavior of exhibiting empathy is showing empathy to the client and saying statements such as, "That must have been upsetting for you" or "I can understand your hurt feelings."

A client being counseled states to the nurse, "I am so stressed all the time. I live paycheck to paycheck." Which aspect of the client's well-being needs to be assessed further by the nurse? financial occupational environmental spiritual

financial

A client is showing no facial expression when engaging in a game with peers during an outing at a park. How will the nurse document the client's affect? Flat affect Broad affect Absent affect Restricted affect

flat affect = showing no facial expression

What is a nursing intervention used in the social domain? milieu therapy counseling nutrition promotion self-care education

milieu therapy Examples of nursing interventions used in the social domain include behavior therapy, milieu therapy, and various home and community interventions.

Upon assessment, the nurse notes that they client is using made-up words that have meaning only to the client. How would the nurse document these findings? psychomotor retardation neologisms automatisms waxy flexibility

neologisms (newly coined term (new) (logos/word))

A hospitalized client diagnosed with panic attacks is being assessed by the nurse on shift. Upon assessment, the client states their name correctly and that they are in the hospital. The client believes the year is 5 years ago and that they are hospitalized because their pet died. How would the nurse document the client's orientation status? oriented X 2 oriented X 1 oriented X 3 oriented X 4

oriented X 2 The client in the scenario knows who they are (person) and that they are in the hospital (place).

A home health nurse is documenting and meeting with their supervisor about the client's home visit. Which phase of the home visit does the nurse identify that includes documentation and reporting? postvisit closure greetings previsit

postvisit

A client with a history of schizophrenia states "I am the ruler of a magical land." When the nurse replies by stating who and where the client is, which interview behavior is the nurse using? focusing restating giving recognition presenting reality

presenting reality By replying with facts when the client makes a statement that is not true and is likely a delusion, the nurse is using the technique of presenting reality.

The nurse encourages an older adult client to write a letter to an old friend. What therapy is the nurse utilizing as an intervention? cultural brokering bibiliotherapy reminiscence behavior therapy

reminiscence Reminiscing 'bout them days