Psychiatric and Mental Health Nursing - Foundations of Psychiatric Nursing

A nurse may use self-disclosure with a client if: the nurse has experienced the same situation as the client. the client asks directly about the nurse's experience. it helps the client to talk more easily. it achieves a specific therapeutic goal.

it achieves a specific therapeutic goal.

A nurse is caring for a client with schizoaffective disorder. The client is scheduled for the first round of electroconvulsive therapy (ECT). What is the priority nursing action post-ECT? withholding food and fluids for 12 hours maintaining bed rest for 8 hours performing a respiratory assessment assessing the client's skin for burns

performing a respiratory assessment

A nurse is developing a care plan for a client who has undergone electroconvulsive therapy (ECT). The nurse should include which intervention? monitoring the client's vital signs every hour for 4 hours placing the client in Trendelenburg's position encouraging early ambulation reorienting the client to time and place

reorienting the client to time and place

What is a generally accepted criterion of mental health? absence of anxiety self-acceptance ability to control others happiness

self-acceptance

According to Freud's psychosexual theory, the ego has several functions. The primary function of the ego is to: serve as the source of instinctual drives. stimulate psychic energy. operate as a conscience that controls unacceptable drives. test reality and direct behavior.

test reality and direct behavior.

Based on a client's history of violence toward others and inability to cope with anger, what should the nurse use as the most important indicator of goal achievement before discharge? acknowledgment of the client's angry feelings ability to describe situations that provoke angry feelings development of a list of how anger has been handled in the past verbalization of feelings in an appropriate manner

verbalization of feelings in an appropriate manner

The client has tearfully described her negative feelings about herself to the nurse during their last three interactions. Which goal would be most appropriate for the nurse to include in the plan of care at this time? The client will: increase her self-esteem write her negative feelings in a daily journal verbalize her work-related accomplishments verbalize three things she likes about herself

verbalize three things she likes about herself

A nurse is conducting a group session for parents of toddlers recently diagnosed with autism. Which parent statement indicates a need for additional teaching? "Children with autism may develop normally until 18 to 24 months old." "Children with autism may have poor coordination of the large muscles." "Children with autism may be extremely sensitive to sounds and smells." "Children with autism may be overwhelmed by rules and structure."

"Children with autism may be overwhelmed by rules and structure."

Which statement indicates to the nurse that the client is progressing toward recovery from a somatoform disorder? "I understand my pain will feel worse when I am worried about my divorce." "My stomach pain will go away once I get properly diagnosed." "My headache feels better when I time my medication dose." "I need to find a health care provider who understands what my pain is like."

"I understand my pain will feel worse when I am worried about my divorce."

A client is admitted to the hospital because of threatening, aggressive behavior toward his family. In the first group meeting after the client is admitted, another client sits near the nurse and says loudly, "I'm sitting here because I'm afraid of Ted. He's so big, and I heard him talk about hitting people." The nurse should say to the client: "Everyone is here for different problems. You know you don't have to worry." "Ted is new to the group. Let's go around and introduce ourselves to him." "You don't know Ted yet. Once you get to know him, I'm sure you won't be afraid." "It's frightening to have new people on the unit. We're here to talk about things like being afraid."

"It's frightening to have new people on the unit. We're here to talk about things like being afraid."

A nurse is assessing the family of a 10-year-old child brought into the emergency department with severe injuries. Which statement made by the parents could indicate child abuse? "You should ask my child about his injuries. They will know best what happened." "My child fell off his bike and into the street." "I don't know what I will do if something happens to my child." "The injury happened a few days ago but I didn't think it was bad."

"The injury happened a few days ago but I didn't think it was bad."

The nurse meets with a client in the outpatient clinic who is suicidal and refuses participate in creating a suicide safety plan. What should the nurse do next? Arrange for the client to be sent back to the group home. Refer the client to a partial program until the client is no longer suicidal. Arrange for immediate hospitalization on a locked unit. Arrange for admission to a subacute unit for 2 weeks.

Arrange for immediate hospitalization on a locked unit.

A nurse overhears a second nurse making plans to meet a hospitalized client for a drink after the client has been discharged. Which is the best action for the first nurse to take? Tell the client not to meet the nurse socially. Report the conversation to the nurse manager. Encourage the interaction with the client after discharge. Discuss the conversation directly with the other nurse.

Discuss the conversation directly with the other nurse.

When assessing an aggressive client, which behavior warrants the nurse's prompt reporting and use of safety precautions? crying when talking about his divorce starting a petition to delay bedtime declining attendance at a daily group therapy session naming another client as his adversary

Naming another client as his adversary

A client doesn't make eye contact with the nurse during an interview. The nurse suspects that the client's behavior has a cultural basis. What should the nurse do first? Read several articles about the client's culture. Ask staff members of a similar culture about the client's behavior. Observe how the client and the client's family and friends interact with one another and with other staff members. Accept the client's behavior because it's probably culturally based.

Observe how the client and the client's family and friends interact with one another and with other staff members.

The client is suspicious of staff members and other clients. To help establish a therapeutic relationship with the client, which plan would be best? Initiate conversations with the client whenever he becomes agitated. Spend brief intervals with the client each day. Allow the client to initiate conversations when he feels ready for them. Do not approach the client for interactions until he has been stabilized on medications.

Spend brief intervals with the client each day.

A nurse is evaluating a family in which chronic child abuse has occurred and the parents have experienced chronic alcohol and drug abuse. Significant social supports have been established by social services and the parents have both received drug and alcohol treatment and parenting classes. Which indicates that the parents have progressed in their treatment? The parents report continued use of spanking as discipline. The parents report high expectations for the young children to manage the household tasks. The parents report an understanding of normal growth and development. The parents say they hope to attend parenting classes.

The parents report an understanding of normal growth and development.

When preparing to present a community program about women who are victims of physical abuse, the nurse should stress what information about the incidence of battering? Death from battering is rare. Battering is a major cause of injury to women. Lower socioeconomic groups are primarily affected. Physical abuse typically begins early in a relationship, well before a women gets pregnant.

Battering is a major cause of injury to women.

As the nurse arrives to visit a family 2 days after release from the hospital, she hears shouting and swearing between the mother and father and several loud crashes, just as she is going to knock on the door. What action by the nurse is the most appropriate? Knock on the door and wait to see if someone comes to the door. Knock on the door and shout, "It is the nurse. Can I help you?" Return to the car and call the family on a cell phone. Return to the car and call the police.

Return to the car and call the police.

A nurse working at an outpatient mental health center primarily with chronically mentally ill clients receives a telephone call from the mother of a client who lives at home. The mother reports that the client has not been taking her medication and now is refusing to go to the work center where she has worked for the past year. What should the nurse do first? Call the director of the work center for information about the client. Reserve an inpatient bed in preparation for the client's admission. Ask to speak to the client directly on the phone. Make an appointment for the client to see the health care provider (HCP).

Ask to speak to the client directly on the phone.

When a client is about to lose control, the extra staff who come to help commonly stay at a distance from the client unless asked to move closer by the nurse who is talking to the client. What statement best explains the primary rationale for staying at a distance initially? The client is more likely to act out if there is an audience, even additional staff. The nurse talking to the client makes the decisions about other staff actions. The client is likely to perceive others as being closer than they are and feel threatened. When the extra staff is visible, the client is less likely to regain self-control.

The client is likely to perceive others as being closer than they are and feel threatened.

When developing the plan of care for a client with acute stress disorder who lost her sister in a boating accident, which intervention should the nurse initiate? helping the client to evaluate her sister's behavior telling the client to avoid details of the accident facilitating progressive review of the accident and its consequences postponing discussion of the accident until the client brings it up

facilitating progressive review of the accident and its consequences

The nurse manager of a psychiatric unit notices that one of the nurses commonly avoids a 75-year-old client's company. Which factor should the nurse manager identify as being the most likely cause of this nurse's discomfort with older adult clients? fears and conflicts about aging dislike of physical contact with older people a desire to be surrounded by beauty and youth recent experiences with her mother's older adult friends

fears and conflicts about aging

A mute client begins to express herself verbally on occasion. Which nursing action should be credited with helping a mute client express herself verbally? asking direct questions that draw the client out using hand signals to entice the client to communicate making open-ended statements followed with silence expressing perceptions about what the client is experiencing

making open-ended statements followed with silence

A nurse hears a client state, "I've had it with this marriage. It would be so much easier to just hire someone to kill my husband!" What action should the nurse take? Since the client is still admitted to the hospital, the nurse must hold the statement in confidence. The nurse must start the process to warn the client's husband. An assessment of the client's response to treatment must be performed. The comment must be held in confidence because the client did not report the statement directly to the nurse.

The nurse must start the process to warn the client's husband.

The nurse observes a client in a group who is reminiscing about his past. Which effect should the nurse expect reminiscing to have on the client's functioning in the hospital? Increase the client's confusion and disorientation. Cause the client to become sad. Decrease the client's feelings of isolation and loneliness. Keep the client from participating in therapeutic activities.

Decrease the client's feelings of isolation and loneliness.

A client is admitted to an inpatient psychiatric unit. After the assessment and admission procedures have been completed, the nurse states, "I'll try to be available to talk with you when needed and will spend time with you each morning from 10:00 until 10:30 in the corner of the dayroom." What is the rationale for communicating these planned nursing interventions? To attempt to establish a trusting relationship To provide a structured environment for the client To instill hope in the client To provide time for completing nursing responsibilities

To attempt to establish a trusting relationship