N450 Exam #3 Mental Health

The nurse is assisting with the data collection on a client admitted to the psychiatric unit. After review of the data obtained, the nurse should identify which as a priority concern? 1. The client's report of not eating or sleeping 2. The presence of bruises on the client's body 3. The client's report of self-destructive thoughts 4. The family member is disapproving of the treatment

3. The client's report of self-destructive thoughts The client's thoughts are extremely important when verbalized. Self-destructive thoughts are the highest priority. Options 1, 2, and 4 will all affect the treatment of the client but are not of greatest importance at this time.

A housekeeping staff member in a mental health unit reports to the nurse that food was found hidden in a client's room. Knowing that the client was admitted with a fluid and electrolyte imbalance because of anorexia nervosa, the nurse should ask housekeeping personnel to: 1. Point this out to the client and remove the food 2. Keep the nursing staff informed if this happens again 3. Disregard this because it is common behavior of clients with anorexia 4. Keep a record of when this happens and report to the nursing staff weekly

2. Keep the nursing staff informed if this happens again Keeping the nursing staff informed indicates that housekeeping members are part of the health team and their input is valued; this will help keep lines of communication open.

The psychiatric nurse is greeted by a neighbor in a local grocery store. The neighbor says to the nurse, "How is Carol doing? She is my best friend and is seen at your clinic every week." Which is the appropriate nursing response? 1. "I cannot discuss any client situation with you." 2. "I'm not supposed to discuss this, but since you are my neighbor, I can tell you that she is doing great!" 3. "You may want to know about Carol, so you need to ask her yourself so you can get the story firsthand." 4. "I'm not supposed to discuss this, but since you are my neighbor, I can tell you that she really has some problems!"

1. "I cannot discuss any client situation with you." The nurse is required to maintain confidentiality regarding clients and their care. Confidentiality is basic to the therapeutic relationship and is a client's right. Option 3 is correct in a sense, but it is a rather blunt statement. Both options 2 and 4 identify statements that do not maintain client confidentiality.

A client is admitted to a psychiatric unit for treatment of a psychotic disorder. The client is at the locked exit door and is shouting, "Let me out! There's nothing wrong with me! I don't belong here!" The nurse identifies this behavior as which? 1. Denial 2. Projection 3. Regression 4. Rationalization

1. Denial Denial is refusal to admit to a painful reality and is treated as if it does not exist. In projection, a person unconsciously rejects emotionally unacceptable features and attributes them to other people, objects, or situations. In regression, the client returns to an earlier, more comforting, although less mature, way of behaving. Rationalization is justifying the unacceptable attributes about oneself.

The nurse is assigned to care for a client experiencing disturbed thought processes. The nurse is told that the client believes that the food is being poisoned. Which communication technique should the nurse plan to use to encourage the client to eat? 1. Open-ended questions and silence 2. Focusing on self-disclosure regarding food preferences 3. Stating the reasons that the client may not want to eat 4. Offering opinions about the necessity of adequate nutrition

1. Open-ended questions and silence Open-ended questions and silence are strategies used to encourage clients to discuss their problem. Options 3 and 4 do not encourage the client to express feelings. The nurse should not offer opinions and should not state the reasons but should encourage the client to identify the reasons for the behavior. Option 2 is not a client-centered intervention.

The nurse in the mental health unit reviews the therapeutic and nontherapeutic communication techniques with a nursing student. Which are therapeutic communication techniques? Select all that apply. 1. Restating 2. Listening 3. Asking the client, "Why?" 4. Maintaining neutral responses 5. Giving advice or approval or disapproval 6. Providing acknowledgment and feedback 6. Providing acknowledgment and feedback

1. Restating 2. Listening 4. Maintaining neutral responses 6. Providing acknowledgment and feedback Some of the therapeutic communication techniques include listening, maintaining silence, maintaining neutral responses, using broad openings and open-ended questions, focusing and refocusing, restating, clarifying and validating, sharing perceptions, reflecting, providing acknowledgment and feedback, giving information and presenting reality, encouraging formulation of a plan of action, providing nonverbal encouragement, and summarizing. Asking why, giving advice, and approving or disapproving are nontherapeutic.

A client is admitted to the psychiatric nursing unit. When collecting data from the client, the nurse notes that the client was admitted on an involuntary status. Based on this type of admission, the nurse expects which? 1. The client presents a harm to self. 2. The client requested the admission. 3. The client consented to the admission. 4. The client provided written application to the facility for admission.

1. The client presents a harm to self. Involuntary admission is made without the client's consent. Involuntary admission is necessary when a person is a danger to self or others or is in need of psychiatric treatment or physical care. Options 2, 3, and 4 describe the process of voluntary admission.

The nurse enters a client's room, and the client immediately demands to be released from the hospital. On review of the client's record, the nurse notes that the client was admitted 2 days ago for treatment of an anxiety disorder and that the admission was a voluntary admission. The nurse reports the findings to the registered nurse (RN) and expects that the RN will take which action? 1. Call the client's family. 2. Contact the health care provider (HCP). 3. Persuade the client to stay a few more days. 4. Tell the client that discharge is not possible at this time.

2. Contact the health care provider (HCP). Rationale: Generally, voluntary admission is sought by the client or client's guardian. Voluntary clients have the right to demand and obtain release. The best nursing action is to contact the HCP. Option 1 violates client confidentiality. Option 3 is not therapeutic or appropriate. Option 4 does not apply to a voluntary admission status.

The nurse is providing care to a client admitted to the hospital with a diagnosis of anxiety disorder. The nurse is talking with the client, and the client says, "I have a secret that I want to tell you. You won't tell anyone about it, will you?" Which is the appropriate nursing response? 1. "No, I won't tell anyone." 2. "I cannot promise to keep a secret." 3. "If you tell me the secret, I will tell it to your doctor." 4. "If you tell me the secret, I will need to document it in your record."

2. "I cannot promise to keep a secret." The nurse should never promise to keep a secret. Secrets are appropriate in a social relationship but not in a therapeutic one. The nurse needs to be honest with the client and tell the client that a promise cannot be made to keep the secret.

The nurse in a psychiatric unit is assigned to care for a client admitted to the unit 2 days ago. On review of the client's record, the nurse notes that the admission was a voluntary admission. Based on this type of admission, the nurse should expect which? 1. The client will be angry and will refuse care. 2. The client will participate in the treatment plan. 3. The client will be very resistant to treatment measures. 4. The client's family will be very resistant to treatment measures.

2. The client will participate in the treatment plan. Rationale: Generally, voluntary admission is sought by the client or client's guardian. If the client seeks voluntary admission, the most likely expectation is that the client will participate in the treatment program. Options 1 and 3 are not likely for a client seeking voluntary admission. Option 4 is not centered on the individual client.

Laboratory work is prescribed for a client who has been experiencing delusions. When the laboratory technician approaches the client to obtain a specimen of the client's blood, the client begins to shout, "You're all vampires. Let me out of here!" The nurse present at the time should respond by stating which? 1. "The technician will leave and come back later for your blood." 2. "What makes you think that the technician wants to hurt you?" 3. "Are you fearful and think that others may want to hurt you?" 4. "The technician is not going to hurt you but is going to help."

3. "Are you fearful and think that others may want to hurt you?" Option 3 is the only option that recognizes the client's need. This response helps the client focus on the emotion underlying the delusion but does not argue with it. If the nurse attempts to change the client's mind, the delusion may, in fact, be even more strongly held. Options 1, 2, and 4 do not focus on the client's feelings.

A client says to the nurse, "I'm going to die, and I wish my family would stop hoping for a 'cure'! I get so angry when they carry on like this! After all, I'm the one who's dying." Which therapeutic response should the nurse make to the client? 1. "Have you shared your feelings with your family?" 2. "I think we should talk more about your anger with your family." 3. "You're feeling angry that your family continues to hope for you to be 'cured'?" 4. "Well, it sounds like you're being pretty pessimistic. After all, years ago people died of pneumonia."

3. "You're feeling angry that your family continues to hope for you to be 'cured'?" Reflection is the therapeutic communication technique that redirects the client's feelings back to validate what the client is saying. In option 2, the nurse attempts to use focusing, but the attempt to discuss central issues is premature. In option 4, the nurse makes a judgment and is nontherapeutic in the one-on-one relationship. In option 1, the nurse is attempting to assess the client's ability to openly discuss feelings with family members. Although this may be appropriate, the timing is somewhat premature and closes off facilitation of the client's feelings.

The nurse is preparing a client for the termination phase of the nurse-client relationship. Which task should the nurse appropriately plan for this phase? 1. Plan short-term goals. 2. Identify expected outcomes. 3. Assist in making appropriate referrals. 4. Assist in developing realistic solutions.

3. Assist in making appropriate referrals. Tasks of the termination phase include evaluating client performance, evaluating achievement of expected outcomes, evaluating future needs, making appropriate referrals, and dealing with the common behaviors associated with termination. Options 1, 2, and 4 identify the tasks of the working phase of the relationship.

The nurse is assigned to care for a client admitted to the hospital after sustaining an injury from a house fire. The client attempted to save a neighbor involved in the fire, but despite the client's efforts, the neighbor died. Which action should the nurse take to enable the client to work through the meaning of the crisis? 1. Identifying the client's ability to function 2. Identifying the client's potential for self-harm 3. Inquiring about the client's feelings that may affect coping 4. Inquiring about the client's perception of the cause of the neighbor's death

3. Inquiring about the client's feelings that may affect coping The client must first deal with feelings and negative responses before the client is able to work through the meaning of the crisis. Option 3 pertains directly to the client's feelings. Options 1, 2, and 4 do not directly address the client's feelings.

Which represents a primary characteristic of an autism spectrum disorder? 1. Normal social play 2. Consistent imitation of others' actions 3. Lack of social interaction and awareness 4. Normal verbal and nonverbal communication

3. Lack of social interaction and awareness A primary characteristic of an autism spectrum disorder is a lack of social interaction and awareness. Social behaviors include a lack of or an abnormal imitation of others' actions and a lack of or abnormal social play. Additional characteristics include a lack of or impaired verbal communication and markedly abnormal nonverbal communication.

An intoxicated client is brought to the emergency department by local police. The client is told that the health care provider (HCP) will be in to see the client in about 30 minutes. The client becomes very loud and offensive and wants to be seen by the HCP immediately. The nurse assisting to care for the client should plan for which appropriate nursing intervention? 1. Watch the behavior escalate before intervening. 2. Attempt to talk with the client to de-escalate the behavior. 3. Offer to take the client to an examination room until he or she can be treated. 4. Inform the client that he or she will be asked to leave if the behavior continues.

3. Offer to take the client to an examination room until he or she can be treated. Rationale: Safety of the client, other clients, and staff is of prime concern. Option 3 is in effect an isolation technique that allows for separation from others and provides a less stimulating environment where the client can maintain dignity. When dealing with an impaired individual, trying to talk may be out of the question. Waiting to intervene could cause the client to become even more agitated and a threat to others. Option 4 would only further aggravate an already agitated individual.

Following a group therapy session, a client approaches the nurse and verbalizes a need for seclusion because of uncontrollable feelings. The nurse reports the findings to the registered nurse (RN) and expects that the RN will take which action? 1. Call the client's family. 2. Place the client in seclusion immediately. 3. Inform the client that seclusion has not been prescribed. 4. Get a written prescription from the health care provider (HCP) and obtain an informed consent.

4. Get a written prescription from the health care provider (HCP) and obtain an informed consent. Rationale: A client may request to be secluded or restrained. Federal laws require the consent of the client unless an emergency situation exists in which an immediate risk to the client or others can be documented. The use of seclusion and restraint is permitted only on the written prescription of the health care provider (HCP), which must be reviewed and renewed every 24 hours, depending on state law requirements. It must also specify the type of restraint to be used.

Introjection

A type of identification in which the individual incorporates the traits or values of another into himself or herself

Rationalization

An attempt to make unacceptable feelings and behaviors acceptable by justifying the behavior

Repression

An unconscious process in which the client blocks undesirable and unacceptable thoughts from conscious expression

Reaction formation

Developing conscious attitudes and behaviors and acting out behaviors opposite to what one really feels

Denial

Disowning consciously intolerable thoughts and impulses

Undoing

Engaging in behavior that is considered to be opposite of a previous unacceptable behavior, thought, or feeling

Intellectualization

Excessive reasoning to avoid feelings; the thinking is disconnected from feelings, and situations are dealt with at a cognitive level

Displacement

Feelings about one person are directed to another who is less threatening, thereby satisfying an impulse with a substitute object

Fantasy

Fixation: Never advancing to the next level of emotional development and organization; the persistence in later life of interests and behavior patterns appropriate to an earlier age

Compensation

Putting forth extra effort to achieve in areas where one has a real or imagined deficiency.

Conversion

Putting forth extra effort to achieve in areas where one has real or imagined deficiency.

Sublimation

Replacement of an unacceptable need, attitude, or emotion with one more socially acceptable

Isolation

Response in which a person blocks feelings associated with an unpleasant experience

Regression

Returning to an earlier developmental stage to express an impulse to deal with anxiety

Splitting

Splitting is a very common ego defense mechanism. It can be defined as the division or polarization of beliefs, actions, objects, or persons into good and bad by focusing selectively on their positive or negative attributes

Disassociation

The blocking off of an anxiety-provoking event or period of time from the conscious mind

Symbolization

The conscious use of an idea or object to represent another actual event or object; many times the meaning is not clear because the symbol may be representative of something unconscious

Suppression

The conscious, deliberate forgetting of unacceptable or painful thoughts, ideas, and feelings

Substitution

The replacement of a valued unacceptable object with an object that is more acceptable to the ego

Identification

The unconscious attempt to change oneself to resemble an admired person

Projection

Transferring one's internal feelings, thoughts, and unacceptable ideas and traits to someone else

Insulation

Withdrawing into passivity and becoming inaccessible to avoid further threatening situations