(N129/2) Treatment of Mental Health Disorders
A client comes to the mental health clinic for treatment of a phobia of large dogs. What should the nurse anticipate that this client will demonstrate? 1. Fear of discussing the phobia 2. Resentment toward the feared object 3. Inadequate impulse control when threatened 4. Distortion of reality when discussing the phobia
1 Rationale: A discussion of the feared object will trigger an emotional response to the object. Extreme fear is more of a problem than resentment. Clients with phobias generally have rigid impulse control. Distortion of reality is not a problem for a client with a phobia.
What response from the nurse demonstrates an understanding of hallucinating behavior by a client? 1. Asking, "What are the voices telling you to do?" 2. Calmly noting that the "rat on the floor" is really a stuffed toy 3. Allowing the family to bring prepackaged foods from the store 4. Explaining to the family that the behavior will worsen during the night
1 Rationale: A hallucination involves false perceptions of sensory stimuli that may be visual, auditory, tactile, or olfactory. Hearing voices is a common hallucination, and it is appropriate for the nurse to clarify exactly what the client is hearing. When a misperception of a sensory stimuli can be rationally explained (e.g., mistaking a stuffed toy for a real animal), it is considered an illusion. Paranoia is an extreme, unfounded distrust expressed by an individual. Paranoid beliefs regarding poisoned foods are fairly common. When a client is at risk for insufficient nutritional intake, prepackaged foods may offer an acceptable alternative. Sundowning is the demonstration of psychotic behaviors similar to delirium that occur or worsen in the evening and nighttime hours.
A client comes to the hospital because of intense feelings of unrest, inability to sleep, and frequent episodes of panic. The client tells the nurse, "I admitted myself because I think I'm going crazy." What does the nurse identify the client's remark to be? 1. A plea for support 2. A reflection of insight 3. A symptom of depression 4. A test of the nurse's trustworthiness
1 Rationale: Anxiety is a threat to the identity of the individual; the client is seeking assurance that the fear and panic being experienced will not mean loss of control. This is not evidence of insightfulness but instead is a plea for help in reducing the anxiety. The client is exhibiting not depression but instead severe anxiety and panic. The client is not seeking the nurse's trust; the client is asking for help
An 84-year-old widow with dementia who had been living with her daughter before hospitalization is being discharged with a referral to the visiting nurse. When the nurse visits, the client is in bed sleeping at 10:00 am. Her daughter states that she gives her mother sleeping pills to stop her wandering at night. How should the nurse respond? 1. Explore hiring a home health aide to stay with the client at night. 2. Discuss the possibility of having the client placed in a nursing home. 3. Suggest moving the client among family members on a monthly basis. 4. Empathize with the daughter but suggest that wrist restraints would be preferable.
1 Rationale: Exploring hiring a home health aide to stay with the client at night will reduce the need for sleeping pills, which may exacerbate the older client's confusion. The family is not asking that the client be moved from the home; the nurse's focus should be helping reduce the confusion the client experiences at night, keeping the client safe, and easing the burden on the family. Continually changing a cognitively impaired client's environment and routine will increase confusion and anxiety. This client needs a consistent environment with a set daily routine of activities, which provides structure and comfort. Restraints add to the client's confusion and tend to worsen inappropriate behavior.
The parent of a child with a tentative diagnosis of attention deficit-hyperactivity disorder (ADHD) arrives at the pediatric clinic insisting on getting a prescription for medication that will control the child's behavior. What is best response by the nurse? 1. "It must be frustrating to deal with your child's behavior." 2. "Have you considered any alternatives to using medication?" 3. "Perhaps you're looking for an easy solution to the problem." 4. "Let me teach you about the side effects of medications used for ADHD."
1 Rationale: Stating that it must be frustrating acknowledges the parent's distress and encourages verbalization of feelings. Asking whether any alternatives have been considered is insensitive to the parent's feelings; it may be more appropriate later, when the parent's stress has diminished. Although the parent may be looking for an easy answer to the problem, this response is confrontational and may close off communication. Asking to teach the parent about the side effects of ADHD medications is insensitive to the parent's feelings; it may be more appropriate later if medication is prescribed and health teaching is started.
A young adult client is admitted to the hospital with a diagnosis of schizophrenia, paranoid type. The client has been saying, "The voices in heaven are telling me to come home to God." What should initial nursing care be focused on? 1. Disturbed self-esteem 2. Potential for self-harm 3. Dysfunctional verbal communication 4. Impaired perception of environmental stimuli
2 Rationale: Client safety always is the priority over any other client need, and command hallucinations increase the risk of injury. Although promoting self-esteem is important, this is not a priority at this time. There are no data to support the need to focus on the client's ability to verbally communicate. Verbal hallucinations occur within the individual; they are not precipitated by an environmental stimulus.
A client who was in an automobile accident is admitted to the hospital with multiple injuries. Approximately 14 hours after admission, the client begins to experience signs and symptoms of withdrawal from alcohol. Which signs and symptoms should the nurse connect to alcohol withdrawal? Select all that apply. 1. Fatigue 2. Anxiety 3. Runny nose 4. Diaphoresis 5. Psychomotor agitation
2, 4, 5 Rationale: Anxiety is commonly associated with withdrawal from alcohol. When a person is withdrawing from alcohol, associated autonomic hyperactivity causes an increased heart rate and diaphoresis. The withdrawal of alcohol affects the central nervous system, resulting in excited motor activity. Fatigue is associated with withdrawal from caffeine or stimulants. A runny nose and tearing of the eyes are associated with withdrawal from opioids.
Suicide precautions are prescribed for a newly admitted client. What is the most therapeutic way to provide these precautions? 1. Keeping the client in the lounge during the daytime 2. Encouraging the client to express feelings frequently 3. Assigning a staff member to be with the client at all times 4. Having a nursing aide observe the client every half hour at night
3 Rationale: Emotional support and close surveillance can demonstrate the staff's caring and their attempt to prevent the client from acting on suicidal ideation. Although surveillance may meet the client's safety needs, it does not meet the client's emotional needs. Also, the client would still have the opportunity to attempt suicide at night. Encouraging the client to express feelings frequently is not a suicide precaution. Having a nursing aide check the client every half hour at night is unsafe; the client could still find a way to carry out a suicide attempt in the room.
A nurse, along with an adolescent client and the client's parents, set bolstering the adolescent's self-esteem as a high-priority goal. The client expresses an interest in earning money. What nursing action will contribute to the achievement of this goal? 1. Telling the adolescent how much the client is loved by the parents 2. Urging the adolescent to join a neighborhood volunteer group 3. Supporting the adolescent's interest in enrolling in a babysitting course 4. Encouraging the adolescent to talk about feelings of pride in successful siblings
3 Rationale: Enrolling in a babysitting course is an achievable action that involves a personal goal; it should also bolster the adolescent's self-esteem. Telling the adolescent how much the client is loved by the parents, urging the client to join a neighborhood volunteer group, and encouraging the adolescent to talk about pride in siblings may not improve the adolescent's self-esteem.
A client who has a phobia about dogs is about to begin systematic desensitization. The client asks what the treatment will involve. What is the best response by the nurse? 1. "You'll be exposed to dogs until you no longer feel anxious." 2. "Rewards will be given when you don't become anxious around dogs." 3. "Your contact with dogs will be increased, and we'll teach you relaxation techniques." 4. "We'll be engaging in detailed discussions to help you identify what caused your phobia."
3 Rationale: Increased contact with the object of the phobia or the situation that causes phobia, accompanied by the use of relaxation techniques, is an accurate description of the behavioral therapy method of systematic desensitization. Exposure to the object or situation that inspires fear until the anxiety is gone is a different behavioral approach called flooding. Giving rewards when the client is no longer made anxious by a fear-inspiring object or situation is a different behavioral approach called operant conditioning. Detailed discussions of the reason for the phobia constitute a type of psychoanalytical therapy rather than a behavioral approach.
A hospitalized client with borderline personality disorder consistently breaks the unit's rules. How will confronting the client about this behavior help the client? 1. By controlling anger 2. By reducing anxiety 3. By setting realistic outcomes 4. By fostering self-awareness
4 Rationale: Clients must become aware of their behavior before they can change it. Confrontation may increase anxiety, anger, and agitation. Setting of realistic outcomes occurs after the client is aware of the behavior and has a desire to change it.
A client is admitted to the hospital with the diagnosis of schizophrenia, undifferentiated type. The client sits rocking in a corner for long periods and responds to voices with words that the staff cannot understand. What should the nurse include when developing the plan of care for this client? 1. Including the client in a discussion group on the unit 2. Encouraging the client to talk to other clients during the day 3. Allowing the client to be alone while observing from a distance 4. Arranging the client's day to allow for short periods to be spent with the nurse
4 Rationale: Clients with undifferentiated schizophrenia manifest psychotic signs and symptoms that preclude interaction with others for more than just short periods. Clients with undifferentiated schizophrenia cannot function in a discussion group. Psychotic manifestations such as fragmented delusions, vague hallucinations, disorientation, and incoherence prevent these clients from interacting with others. Clients with undifferentiated schizophrenia have problems with interpersonal relations because their behavior is often bizarre and disorganized. Allowing the client to be alone will not relieve anxiety; instead, it will foster further withdrawal.
