Quiz 2 9/11

How should a nurse intervene when a regressed, emotionally disturbed client voids on the floor in the sitting room of the mental health unit?

Toilet the client more frequently with supervision.

A client with schizophrenia has a history of hearing voices that say, "You are a bad person." While having a conversation with the nurse with whom the client has been working, the client states, "I am starting to hear the same voices again." What is the nurse's best response?

Try to ignore the voices.

While watching TV in the day room a client who has demonstrated withdrawn, regressed behavior suddenly screams, bursts into tears, and runs out of the room to the far end of the hallway. What is the most therapeutic action by the nurse?

Walk to the end of the hallway where the client is standing.

A client diagnosed with schizophrenia is experiencing auditory hallucinations. A nurse makes the following statements when interacting with this client. Place these statements in the order in which they should occur.

1. Hearing voices must be frightening 2. The voices you hear are part of your illness. 3. I do not hear any voices. 4. Come with me for a walk. 5. Let's play cards with another client in the recreation room.

What are the four "As" for which nurses should assess clients suspected of having Alzheimer disease?

Amnesia, apraxia, agnosia, aphasia

What is the most appropriate way for the nurse to help a withdrawn, emotionally disturbed adolescent client accept the realities of daily living?

Assist the client to care for personal hygiene needs.

A nurse assigned to care for a regressed college student who has been talking to unseen people and refusing to get out of bed, go to class, or get involved in daily grooming activities. What is the nurse's initial effort toward helping this client?

Attempting to establish a meaningful relationship with the client

What is a nurse's most appropriate action when a client is seen openly masturbating in the recreation room?

Escorting the client out of the room.

What clinical manifestation is the most serious indication of impending assaultive behavior by a client on a mental health unit?

Experiences command hallucinations

A client with a hx of schizophrenia attends the mental health clinic for a regularly scheduled group therapy session. The client arrives agitated and exhibits behaviors that indicates the hearing of voices. When a nurse begins to walk toward the client, the client pulls out a large knife. Which is the nurse's best approach?

Firm

What is the best nursing intervention to encourage a withdrawn, noncommunicative client to talk?

Focus on nonthreatening subjects

What should the nurse do to achieve a primary objective of providing a therapeutic daycare environment for a client who is withdrawn and reclusive?

Foster a trusting relationship.

A nurse observes a regressed, emotionally disturbed client using the hands to eat soft foods. What is the best nursing intervention?

Give the client a spoon and suggest it be used.

An older adult on the mental health unit begins acting out while in the day room. What is a nurse's initial intervention?

Give the client directions in a firm, low-pitched voice.

What should a nurse do when caring for a client whose behavior is characterized by pathologic suspicion?

Help the client feel accepted by the staff on the unit.

A client with schizophrenia is admitted to an acute care psychiatric unit. Which clinical findings indicate positive signs and symptoms associated with schizophrenia?

Hyperactivity, auditory hallucinations, loose associations

A nurse enters a client's room and identifies that the client appears preoccupied. Turning to the nurse, the client states, "They are saying terrible things about me. Can't you hear them?" What is the nurse's most therapeutic response?

I don't hear anyone else talking, but I can see you are upset.

An older adult is brought to the clinic by a family member because of increasing confusion over the past week. What can the nurse ask clients to assess their orientation to place?

Identify the name of the town.

Why is observation an especially important aspect of nursing care for a withdrawn client?

It helps in understanding the client's behavior.

A client is delusional, talking about people who are plotting to do harm. A nurse identifies that the client is pacing more than usual and is concerned that the client is beginning to lose control. What is the best nursing intervention?

Move the client to a quiet place on the unit.!

A client is experiencing hallucinations tells a nurse, "The voices are telling me I'm no good." the client asks whether the nurse hears the voices. Which is the nurse's most appropriate response?

No, I do not hear the voices, but I believe you can hear them.

What is the most appropriate nursing intervention for clients who exhibit mild cognitive impairment?

Reality orientation

While a nurse is talking with a client, another client comes up and yells, "I hate you! You're talking about me again," and throws a glass of juice at the nurse. What is the nurse's best response to this outburst?

Remove the client from the room because limits must be placed on the behavior.

A nurse is assessing an older adult with the diagnosis of dementia. Which manifestations are expected in this client?

Resistance to change. Inability to recognize familiar objects Inability to concentrate on a new activities or interests Tendency to dwell on the past and ignore the present

During the admission procedure, a client appears to be responding to voices. The client cries out at intervals, "No, no, I didn't kill him. You know the truth; tell that police officer. Please help me!" What is the nurse's most appropriate response?

Respond by saying, "I want to help you. I realize you must be frightened."

A client tells the nurse, "I am a terrible, evil person, the voices are telling me that God needs to punish me." What is the nurse's most therapeutic initial response.

Tell me what you are thinking about yourself.

A client in the early dementia stage of Alzheimer's disease is admitted to a long-term care facility. Which activities must the nurse initiate?

Weigh the client once a week. Have specialized rehabilitation equipment available. Establish a schedule with periods of rest after activities.

One evening a nurse finds a client who has been experiencing persecutory delusions trying to get out the door. The client states, "Please let me go, I trust you. The Mafia is going to kill me tonight." Which response is most therapeutic?

You are frightened. Come with me to your room, and we can talk about it.

A regressed, emotionally disturbed client who has been watching a nurse for a few days suddenly walks up and shouts, "You think you're so damned perfect and good. I think you stink!" What is the nurse's most appropriate response?`

You seem angry with me.

A client who experiences auditor hallucinations agrees to discuss alternative coping strategies with a nurse. For the next three days when the nurse attempts to focus on alternative strategies, the client gets up and leaves the interaction. What is the nurse's most therapeutic response?

You seem uncomfortable every time I bring up a new way to cope.

When answering questions from the family of a client with Alzheimer disease, the nurse explains, "This disease is:

a slow and relentless deterioration of the mind."

Nurses working with clients who have a dx of dementia should adopt a common approach of care because these clients need to:

have sameness and consistency in their environment.

As a nurse enters a room and approaches a client who has schizophrenia, the client states, "Get out of here before I hit you! Go away!" The nurse concludes that this aggressive behavior is probably related to the fact that the client felt:

trapped when the nurse walked into the room.

A nurse's best approach when caring for a confused, older client is to provide an environment with:

trusting relationships

What is an important aspect of nursing care for a client exhibiting psychotic patterns of thinking and behavior?

Help keep the client orientated to reality

A client with schizophrenia plans an activity schedule with the help of the treatment team. A written copy is posted in the client's room. What should the nurse say when it is time for the client to go for a walk?

It's time for you to go for a walk.

What is the priority nursing objective of the therapeutic psychiatric environment for a confused client?

Maintain the highest level of safe, independent functioning.

An acutely ill client with the dx of schizophrenia has just been admitted to the mental health unit. What is the most therapeutic initial nursing intervention?

Spend time with the client to build trust and demonstrate acceptance.

A delusional client refuses to eat because of a belief that the food is poisoned. What is the most appropriate initial nursing intervention?

State that the food is not poisoned.

A nurse is assessing a client with dementia. Which clinical manifestations are expected?

Agitation Short attention span Disordered reasoning Impaired motor activities