Prep U: Foundations

When asked about her stresses before admission, an anxious client stares blankly at the nurse and mutters unintelligibly. Which description of the client's behaviors should the nurse document in the client's medical record?

"Client responded to questions with a blank look and incomprehensible mumble."

The nurse has been teaching a client about depression. Which statement indicates insight into the client's diagnosis?

"I believe that my sadness affects my work and feelings."

As a client is being released from restraints, he says, "I'll never get that angry and lose it again. Those restraints were the worst things that ever happened to me." Which response by the nurse is most appropriate?

"I'd like to talk with you about your experience."

A client in an acute care center lacerates her wrists. She has a history of conflicts and acting out and asks the nurse, "I did a good job, didn't I?" Which response by the nurse is best?

"What were you feeling before you hurt yourself?"

A client with acute stress disorder is telling the nurse about the tornado that leveled his house and killed his wife and baby while he was out of town on business. He states, "If only I had been at home, I could have saved them." Which response would be most appropriate?

"You could not have prevented the tornado; it just happened."

In group therapy, a client angrily speaks up and responds to a peer, "You're always whining, and I'm getting tired of listening to you! Here is the world's smallest violin playing for you." Which role is the client playing?

Aggressor

At an emergency shelter, an earthquake victim tells the nurse that he is going to spend the night in his own bed at home. Which defense mechanism is the client exhibiting?

Denial

The nurse is teaching a group of unlicensed assistive personnel (UAP) about providing care to clients with depression. Which approach by one of the UAPs indicates an understanding of the most effective approach to a depressed client?

Empathetic

When upset, the client curls into a fetal position in bed. The nurse judges the client to be exhibiting which condition?

Regression

A client seeking help at a community mental health center complains of fatigue, sensitivity to criticism, decreased libido, and feeling self-conscious. He also has aches and pains. A nursing diagnosis for this client might include:

Situational low self-esteem

What should be charted by the nurse when the client has an involuntary commitment or formal admission status?

The client's receipt of information about status and rights should be charted.

Erikson described the psychosocial tasks of the developing person in his theoretical model. He proposed that the primary developmental task of the young adult (ages 18 to 25) is:

intimacy versus isolation.

As an angry client becomes more agitated while talking about his problems, the nurse decides to ask for staff assistance in taking control of the situation when the client demonstrates which behavior?

picking up a pool cue stick and telling the nurse to get out of his way

A married female client has been referred to the mental health center because she is depressed. The nurse notices bruises on her upper arms and asks about them. After denying any problems, the client starts to cry and says, "He did not really mean to hurt me, but I hate for the kids to see this. I am so worried about them." What is the most crucial information for the nurse to determine?

the potential of immediate danger to the client and her children