Saunders - Mental Health Questions w/ Rationale
During an admission assessment, the nurse notes that the client's diagnosis is documented as obsessive-compulsive disorder. The nurse plans care knowing that the client is most likely to experience which type of compulsive behavior? 1.An unreasonable fear of something 2.Repetitive actions to manage anxiety 3.Misinterpretation of common events 4.Recurring thoughts that are intrusive
Answer: 2. Repetitive actions to manage anxiety Rationale: A compulsion is a repetitive act. The client with a phobia is likely to experience unreasonable fears. Illusions are characterized by misinterpretation of events. An obsession is a repetitive thought.
A client diagnosed with delirium becomes disoriented and confused at night. Which intervention should the nurse implement initially? 1.Move the client next to the nurses' station. 2.Use an indirect light source and turn off the television. 3.Keep the television and a soft light on during the night. 4.Play soft music during the night, and maintain a well-lit room
Answer: 2. Use an indirect light source and turn off the television Rationale: Provision of a consistent daily routine and a low-stimulating environment is important when a client is disoriented. Noise, including radio and television, may add to the confusion and disorientation. Moving the client next to the nurses' station may become necessary but is not the initial action.
When discussing an individual's tendency to substance abuse, the nurse should identify which assessment data as a primary biological factor? 1.The client is a 25-year-old male. 2.The client is employed as a firefighter. 3.The client is of German ethnic background. 4.The client has 2 family members who have abused.
Answer: 4. The client has 2 family members who have been abused Rationale: Family history of substance abuse is considered the key biological factor in affecting individual abuse. The remaining options do not have the same degree of effect as does the correct option.
An older resident in a long-term care facility prepares to walk out into a rainstorm after saying, "My father is waiting to take me for a ride." Which is the appropriate response by the nurse? 1."I need you to sign a form before leaving." 2."You will get sick if you go out in the rain." 3."How old are you? Your father must no longer be living." 4."Let's have a cup of coffee, and you can tell me about your father."
Answer: "Let's have a cup of coffee, and you can tell me about your father." Rationale: The correct response acknowledges the client's comment and behavior. Allowing the client to leave after forms are signed fails to protect the client from possible harm. The remaining options do not preserve the client's dignity.
Which statement made by a severely depressed client requires the nurse's immediate attention? 1."Feeling better really isn't important to me anymore." 2."No one can really understand what I've had to deal with." 3."I really don't like the way that new depression pill makes me feel." 4."I've not been the least bit interested in socializing since my divorce."
Answer: 1. "Feeling better isn't important to me anymore" Rationale: The suicidal client may subtly express the intention to harm oneself in the form of a covert suicidal threat. The statement in option 1 should receive the nurse's priority attention because it is directly related to the client's safety. The remaining options are not related to safety as directly.
When planning the discharge of a client with chronic anxiety, the nurse directs the goals at promoting a safe environment at home. Which is the most appropriate maintenance goal? 1.Suppressing feelings of anxiety 2.Identifying anxiety-producing situations 3.Continuing contact with a crisis counselor 4.Eliminating all anxiety from daily situations
Answer: 2. Identifying anxiety-producing situations Rationale: Recognizing situations that produce anxiety allows the client to prepare to cope with anxiety or avoid a specific stimulus. Counselors will not be available for all anxiety-producing situations, and this option does not encourage the development of internal strengths. Suppressing feelings will not resolve anxiety. Elimination of all anxiety from life is impossible.
A client experiencing disturbed thought processes believes that his food is being poisoned. Which communication technique should the nurse use to encourage the client to eat? 1.Using open-ended questions and silence 2.Sharing personal preference regarding food choices 3.Documenting reasons why the client does not want to eat 4.Offering opinions about the necessity of adequate nutrition
Answer: 1. Using open-ended questions and silence Rationale: Open-ended questions and silence are strategies used to encourage clients to discuss their problems. Sharing personal food preferences is not a client-centered intervention. The remaining options are not helpful to the client because they do not encourage the client to express feelings. The nurse should not offer opinions and should encourage the client to identify the reasons for the behavior.
A client diagnosed with depression is scheduled to receive 3 sessions of electroconvulsive therapy. The nurse should tell the client that he or she will likely start to see improvement in approximately what time frame? 1.1 week after the 3rd treatment session 2.3 weeks after the treatment sessions begin 3.Midway between the 2nd and 3rd treatment session 4.8 weeks after the treatment sessions are completed
Answer: 1. 1 week after the 3rd treatment session Rationale: Psychiatrists generally prescribe electroconvulsive therapy (ECT) treatments 3 times a week, with an average series including 8 to 12 treatments. After 3 sessions of ECT, the client should start to demonstrate improvement in 1 week. The remaining options are incorrect.
The nurse should be prepared to manage which occurrence unique to the abuse of hallucinogenic drugs? 1.Flashbacks 2.Amotivational syndrome 3.Enhanced physical strength 4.Absence of pain perception
Answer: 1. Flashbacks Rationale: Flashbacks, the recurrence of perceptual distortions, are unique to the use of hallucinogenic drugs. Enhanced physical strength and the inability to feel pain are indicative of phencyclidine use, whereas marijuana abuse can result in amotivational syndrome
A client comes into the emergency department in a severe state of anxiety after a car crash. Which is the best nursing intervention at this time? 1.Remain with the client. 2.Put the client in a quiet room. 3.Teach the client deep breathing. 4.Encourage the client to talk about his or her feelings and concerns.
Answer: 1. Remain with the client Rationale: If left alone, the severely anxious client may feel abandoned and become overwhelmed. Placing the client in a quiet room is also important, but the nurse must stay with the client. Teaching the client deep breathing or relaxation is not possible until the anxiety decreases. Encouraging the client to discuss concerns and feelings would not take place until the anxiety has decreased.
The nurse visits a client at home. The client states, "I haven't slept at all the last couple of nights." Which response by the nurse demonstrates therapeutic communication? 1."I see." 2."Really?" 3."You're having difficulty sleeping?" 4."Sometimes I have trouble sleeping too."
Answer: 2. "You're having difficulty sleeping?" Rationale: The correct option uses the therapeutic communication technique of restatement. Although restatement is a technique that has a prompting component to it, it repeats the client's major theme, which assists the nurse to obtain a more specific perception of the problem from the client. The remaining options are not therapeutic responses since none encourages the client to expand on the problem. Offering personal experiences moves the focus away from the client and onto the nurse.
Which statement made by an assistive personnel (AP) indicates to the registered nurse that the AP understands the concepts related to suicide? 1."Discussing suicide with a client is not harmful." 2."Those clients who talk about suicide never do it." 3."Depressed clients are the only persons who commit suicide." 4."A suicide threat is a cry for attention from family and friends."
Answer: 1. "Discussing suicide with a client is not harmful." Rationale: An open discussion of suicide will not encourage a client to make a decision to commit suicide and in fact often will help to prevent it. Such a discussion offers the health care professional the opportunity to assess the reality of suicide for the client and take necessary precautions to keep the client safe. The remaining options are inaccurate statements regarding suicide.
A client with diabetes mellitus is told that amputation of the leg is necessary to sustain life. The client is very upset and tells the nurse, "This is all my primary health care provider's fault. I have done everything I've been asked to do!" Which nursing interpretation is best for this situation? 1.An expected coping mechanism 2.An ineffective defense mechanism 3.A need to notify the hospital lawyer 4.An expression of guilt on the part of the client
Answer: 1. An expected coping mechanism Rationale: The nurse needs to be aware of the effective and ineffective coping mechanisms that can occur in a client when loss is anticipated. The expression of anger is known to be a normal response to impending loss, and the anger may be directed toward the self, God or other spiritual being, or caregivers. Notifying the hospital lawyer is inappropriate. Guilt may or may not be a component of the client's feelings, and the data in the question do not indicate that guilt is present.
A hospitalized client with a history of alcohol abuse tells the nurse, "I am leaving now. I have to go. I don't want any more treatment. I have things that I have to do right away." The client has not been discharged and is scheduled for an important diagnostic test to be performed in 1 hour. After the nurse discusses the client's concerns with the client, the client dresses and begins to walk out of the hospital room. What action should the nurse take? 1.Call the nursing supervisor. 2.Call security to block all exit areas. 3.Restrain the client until the primary health care provider (PHCP) can be reached. 4.Tell the client that the client cannot return to this hospital again if the client leaves now.
Answer: 1. Call the nursing supervisor Rationale: Most health care facilities have documents that the client is asked to sign relating to the client's responsibilities when the client leaves against medical advice. The client should be asked to wait to speak to the PHCP before leaving and to sign the "against medical advice" document before leaving. If the client refuses to do so, the nurse cannot hold the client against the client's will. Therefore, in this situation, the nurse should call the nursing supervisor. The nurse can be charged with false imprisonment if a client is made to believe wrongfully that he or she cannot leave the hospital. Restraining the client and calling security to block exits constitutes false imprisonment. All clients have a right to health care and cannot be told otherwise.
The nurse is planning relapse prevention information for a client diagnosed with schizophrenia. The nurse understands that it is important to ensure which primary intervention? 1.Including the client's support system in the teaching 2.Facilitating weekly maintenance therapy for the client 3.Having the client restate discharge goals and strategies 4.Stressing the importance of client compliance with the medication plan
Answer: 1. Including the client's support system in the teaching Rationale: Of the options provided, including the client's support system in the teaching has the greatest effect on relapse prevention management because it will provide the client with valuable support. Although the remaining options are helpful, they all focus on the client's having the resources and abilities to be self-managing and self-reflective.
The nurse in the mental health unit plans to use which therapeutic communication techniques when communicating with a client? (Select all that apply) 1.Restating 2.Listening 3.Asking the client "Why?" 4.Maintaining neutral responses 5.Providing acknowledgment and feedback 6.Giving advice and approval or disapproval
Answer: 1. Restating 2. Listening 4. Maintaining neutral responses 5. Providing acknowledgment and feedback Rationale: 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, presenting reality, encouraging formulation of a plan of action, providing nonverbal encouragement, and summarizing. Asking why is often interpreted as being accusatory by the client and should also be avoided. Providing advice or giving approval or disapproval are barriers to communication.
The nurse determines that the wife of an alcoholic client is benefiting from attending an Al-Anon group if the nurse hears the wife make which statement? 1."I no longer feel that I deserve the beatings my husband inflicts on me." 2."My attendance at the meetings has helped me to see that I provoke my husband's violence." 3."I enjoy attending the meetings because they get me out of the house and away from my husband." 4."I can tolerate my husband's destructive behaviors now that I know they are common among alcoholics."
Answer: 1."I no longer feel that I deserve the beatings my husband inflicts on me." Rationale: Al-Anon support groups are a protected, supportive opportunity for spouses and significant others to learn what to expect and to obtain excellent pointers about successful behavioral changes. The correct option is the healthiest response because it exemplifies an understanding that the alcoholic partner is responsible for his behavior and cannot be allowed to blame family members for loss of control. Option 2 is incorrect because the nonalcoholic partner should not feel responsible when the spouse loses control. Option 3 indicates that the group is viewed as an escape, not as a place to work on issues. Option 4 indicates that the wife remains codependent.
The nurse is caring for a client with a diagnosis of agoraphobia. Which statement made by the client would support this diagnosis? 1."I'd be sure to have a panic attack if I left my house." 2."I couldn't touch a public doorknob unless I wore gloves." 3."Just the thought of getting into an elevator causes me to panic." 4."Speaking to more than 1 or 2 people would be impossible for me."
Answer: 1."I'd be sure to have a panic attack if I left my house." Rationale: Agoraphobia is a fear of leaving the house and experiencing panic attacks when doing so. The remaining options describe obsessive-compulsive behavior, claustrophobia, and a social phobia.
A client diagnosed with depression says to the nurse, "Things would be so much better for everyone if I just weren't around." Which response should the nurse make at this time to assess the client's state of mind? 1."You sound very unhappy. Are you thinking of harming yourself?" 2."Have you talked to anyone specifically about what is bothering you?" 3."Those feelings will go away when your medication really takes effect." 4."I know what you mean; everyone gets that way when they are depressed."
Answer: 1."You sound very unhappy. Are you thinking of harming yourself?" Rationale: Clients who are depressed may be at higher risk for suicide. When clients make statements such as the one in the question, it is critical for the nurse specifically to assess suicidal ideation and plan. The best method is to ask the client directly about whether a specific plan has been formed. The incorrect options either do not address the client's concern or place the client's feelings on hold.
The nurse is preparing a client with depression for electroconvulsive therapy, which is scheduled for the next morning. Which interventions would be included in the preprocedural plan? (Select all that apply) 1.Have the client void. 2.Obtain an informed consent. 3.Administer tap water enemas. 4.Avoid discussing the procedure. 5.Remove dentures and contact lenses. 6.Withhold food and fluids for 6 hours.
Answer: 1.Have the client void. 2.Obtain an informed consent. 5.Remove dentures and contact lenses. 6.Withhold food and fluids for 6 hours. Rationale: Enemas are not a component of the pretreatment care for a client scheduled for electroconvulsive therapy (ECT). The nurse should teach the client and family what to expect with ECT and allow the client to discuss his or her feelings regarding the procedure. The remaining options are a part of the pretreatment plan.
Which information provided by the nurse accurately describes electroconvulsive therapy? (Select all that apply) 1.The average series involves 8 to 12 treatments. 2.Some confusion may be noted after the procedure. 3.Memory loss may occur but will resolve with time. 4.This treatment is a permanent cure to the condition. 5.This treatment is tried before the use of medications.
Answer: 1.The average series involves 8 to 12 treatments. 2.Some confusion may be noted after the procedure. 3.Memory loss may occur but will resolve with time. Rationale: Electroconvulsive therapy (ECT) as a form of treatment is considered when medication therapy has failed, the client is at high risk for suicide, or depression is judged to be overwhelmingly severe. Treatments are administered 3 times a week, with an average series involving 8 to 12 treatments over a duration of 2 to 4 weeks. The most common side effect is amnesia for events occurring near the period of treatment. Memory deficits may occur and tend to resolve with time. This treatment is not a permanent cure to the client's condition.
What statement should the nurse make to a client diagnosed with post-traumatic stress disorder who appears to be experiencing anxiety? 1."Try not to worry so much." 2."I can see that you are becoming upset." 3."Everything is going to be all right; just relax." 4."Why are you having trouble controlling your anxiety?"
Answer: 2. "I can see that you are becoming upset." Rationale: The correct option is the only one that addresses the client's feelings and concerns. Avoid options that provide false reassurance and place the client's feelings on hold. Avoid options that ask "why"; this nontherapeutic communication technique will increase the client's anxiety.
A client whose wife recently died of cancer says to the home care nurse, "I can't believe that my wife died yesterday. I keep expecting to see her everywhere I go in this house." What is the therapeutic nursing response? 1."It will take time to adjust to your terrible loss." 2."It must be hard to accept that she has passed away." 3."Try to focus on the fact that you and your wife loved one another for years." 4."Focus on the fact that her suffering is over and that she had a good life with you."
Answer: 2. "it must be hard to accept that she has passed away" Rationale: The therapeutic nursing response is the one that recognizes the difficulties of grieving the loss of a loved one and that facilitates expression of feelings. The remaining options are not therapeutic because they do not encourage expression of feelings.
The nurse is caring for a client diagnosed with paranoid personality disorder who is experiencing disturbed thought processes. In formulating a nursing plan of care, which best intervention should the nurse include? 1.Increase socialization of the client with peers. 2.Avoid using a whisper voice in front of the client. 3.Begin to educate the client about social supports in the community. 4.Have the client sign a release of information to appropriate parties for assessment purposes.
Answer: 2. Avoid using a whisper voice in front of the client Rationale: Disturbed thought process related to paranoid personality disorder is the client's problem, and the plan of care must address this problem. The client is distrustful and suspicious of others. The members of the health care team need to establish a rapport and trust with the client. Laughing or whispering in front of the client would be counterproductive. The remaining options ask the client to trust on a multitude of levels. These options are actions that are too intrusive for a client with this disorder.
The nurse monitors a client diagnosed with anorexia nervosa understanding that the client manages anxiety by which action? 1.Engaging in self-mutilating acts 2.Observing rigid rules and regulations 3.Always reverting to the independent role 4.Constantly striving to avoid making decisions
Answer: 2. Observing rigid rules and regulations Rationale: Clients with anorexia nervosa have the desire to please others. Rules and rituals help them manage their anxiety. Their need to be correct or perfect interferes with rational decision-making processes. These clients generally don't engage in self-mutilation
The nurse is assigned to a client who is pacing, agitated, and using aggressive gestures and rapid speech. The nurse should determine that which action is the priority of care at this time? 1.Providing the other clients on the unit with a sense of comfort and safety 2.Providing a safe place for the client to pace that is away from the other clients 3.Offering the client a less stimulated area in which to calm down and gain control 4.Assisting in caring for the client in a controlled environment, such as a quiet room
Answer: 2. Providing a safe place for the client to pace that is away from the other clients Rationale: Safety for the client and other clients is the priority. The correct option is the only choice that addresses the client's and other clients' safety needs. This action also focuses on the client's need to pace and safely physically work off anxious feelings. None of the other options addresses the needs of all the clients.
A client who has a history of being sexually assaulted is found sucking her thumb while rocking in her bed and does not respond to verbal communication. The nurse should recognize that this behavior demonstrates which coping mechanism? 1.Fantasy 2.Regression 3.Displacement 4.Compensation
Answer: 2. Regression Rationale: Regression is a coping mechanism in which a client returns to an earlier, less threatening level of adaptation (development). Fantasy is the gratification of frustrated desires, achievement, and relationships by substituting them with daydreams and imagery. Displacement is the discharge of pent-up feelings onto something or someone else less threatening than the original source of the feelings. Compensation is excelling in 1 area to counterbalance deficiencies in another area.
During a mental status examination, the client states, "Glass breaks if you throw stones or shoot at it with a gun. My cousin shoots guns at the police all the time at target practice. People who live in glass houses shouldn't throw stones." How will the nurse appropriately document the client's speech? 1.Speech is incoherent and tangential. 2.Speech is illogical and loosely associated. 3.Speech is distractible and contains flight of ideas. 4.Speech is pressured and contains clang associations.
Answer: 2. Speech is illogical and loosely associated Rationale: Loose associations are speech patterns in which there is a lack of a logical relationship between thoughts and ideas; this causes speech and thought to seem inexact, vague, unfocused, and diffuse. Incoherence is characterized by speech that cannot be understood. Tangential speech refers to an inappropriate response to a statement in which the content of the statement is disregarded. Flight of ideas is over-productive speech, characterized by the client's quickly switching from 1 subject to another. Clanging is a form of rhyming that is not comprehensible; a client whose speech features clanging seems to be caught up in the sound of the words.
The nurse is monitoring a client diagnosed with schizophrenia who demonstrates a dysfunctional affect. Which situation is congruent with inappropriate affect? 1.When told that a beloved pet has died, the client responds, "OK." 2.The client giggled while describing being physically abused as a child. 3.The client's facial expressions are unchanged during the entire admission process. 4.When staff members attempt to engage the client in conversation, the client only mumbles.
Answer: 2. The client giggled when describing being physically abused as a child Rationale: An inappropriate affect refers to an emotional response to a situation that is incongruent with the tone of the situation. A flat affect is manifested as an immobile facial expression or blank look. A bizarre affect such as grimacing, laughing, and self-directed mumbling is marked when the client is unable to relate logically to the environment. A blunted affect is a minimal emotional response or outward affect that typically does not coincide with the client's inner emotions.
A client with a history of anxiety appears to be in the second phase of crisis response. The nurse prepares for which client behavior? 1.The client will show the initial signs that coping methods are failing. 2.The client will employ new coping methods that will resolve the problem. 3.The client will experience severe anxiety as a result of failed coping methods. 4.The client will begin to implement coping methods that have been successful in the past.
Answer: 2. The client will employ new coping methods that will resolve the problem Rationale: In the first phase of the crisis response, the client implements usual coping methods to bring about relief from the problem and shows signs of anxiety when these methods are failing. The second phase of crisis response involves a redefining of the threat or implementation of new coping methods that can result in resolution of the problem. If resolution does not occur in the second phase, the client progresses to severe or panic levels of anxiety reflective of the third phase of the response.
When assessing a client for a possible physical dependency on alcohol, the nurse should ask which priority question? 1."Are you drinking more than you did 5 years ago?" 2."How do you feel when you haven't had a drink all day?" 3."Does your drinking ever cause you problems with your family?" 4."Do you ever feel that you really need a drink to calm your nerves?"
Answer: 2."How do you feel when you haven't had a drink all day?" Rationale: Physical dependency results in withdrawal symptoms; therefore, the option addressing that topic is the priority question. An increase in alcohol consumption may be an indicator of alcohol tolerance. Alcohol abuse is described as being willing to continue the use of alcohol regardless of the problems doing so causes. Needing a drink to calm the nerves is an indicator of a psychological dependency.
The nurse has been closely observing a client who has been displaying aggressive behaviors. The nurse observes that the behavior displayed by the client is escalating. Which nursing intervention is most helpful to this client at this time? (Select all that apply) 1.Initiate confinement measures. 2.Acknowledge the client's behavior. 3.Assist the client to an area that is quiet. 4.Maintain a safe distance from the client. 5.Allow the client to take control of the situation.
Answer: 2.Acknowledge the client's behavior. 3.Assist the client to an area that is quiet. 4.Maintain a safe distance from the client. Rationale: During the escalation period, the client's behavior is moving toward loss of control. Nursing actions include taking control, maintaining a safe distance, acknowledging behavior, moving the client to a quiet area, and medicating the client if appropriate. To initiate confinement measures during this period is inappropriate. Initiation of confinement measures, if needed, is most appropriate during the crisis period.
Which behavior in a client with schizophrenia demonstrates the client's cognitive inability to appropriately process data from external stimuli? 1.The client remains in the same physical position for hours. 2.The client is convinced that the curtains are actually ghosts. 3.The client looks for a cat when someone says, "It's raining cats and dogs." 4.The client repeatedly asks, "Can you see my dead sister over by the door?
Answer: 2.The client is convinced that the curtains are actually ghosts. Rationale: A delusion is a personal belief that is the product of dysfunctional processing of information derived from external reality. This cognitive processing dysfunction is the basis of schizophrenia. Catatonia is a stuporous state that renders the client incapable of physical movement. Magical thinking is a result of concrete thinking that causes the client to interpret a statement literally. Hallucinations are the result of distortions in perceptions of the senses, but they are not reliant on internal or external stimuli
The husband of an alcohol-dependent wife says, "If anyone had said I'd be henpecked, I'd have called them a liar, but now I realize that I'm codependent." Which statement by the nurse would be therapeutic? 1."Did you know that more people identify with just what you are saying?" 2."Which of the features that describe codependence caused you to recognize that?" 3."Can you tell me more about that? You see yourself as being codependent with your wife?" 4."Have you discussed your feelings with your wife? What does your wife think about what you've said?"
Answer: 3. "Can you tell me more about that? You see yourself as being codependent with your wife?" Rationale: This question describes the husband of an alcohol-dependent wife who is developing awareness of his codependency. Codependency consists of an individual's becoming preoccupied with the needs and concerns of another to the exclusion of his or her own needs. The therapeutic statement seeks clarification and summarizes and focuses the client on his own concerns and discoveries. When the nurse provides a social response that is nontherapeutic, it does not focus on the client's feelings. Intellectual questioning does not facilitate expression of feelings. Asking questions that are off-focus from the client's feelings are nontherapeutic because they constitute probing. The nurse will gather this information, but by gaining the trust of the client, not by probing.
The nurse working in a detoxification unit is admitting a client for alcohol withdrawal. The client's spouse states, "I don't know why I don't get out of this rotten situation." Which response by the nurse addresses the spouse's concerns? 1."This is not a good time to make that decision." 2."What would your spouse think about your decision?" 3."What aspects of this situation are the most difficult for you?" 4."You seem to have a good grip on this situation. You probably should get out."
Answer: 3. "What aspects of this situation are most difficult for you?" Rationale: The most helpful response is one that encourages the spouse to explore the problem and problem-solve. The correct response should not disregard or redirect focus away from the spouse's concern. The nurse should appear neither to disagree nor agree with the spouse. Giving advice implies that the nurse knows what is best and can also foster dependency.
The nurse is creating a plan of care for a client who was experiencing anxiety after the loss of a job. The client is now verbalizing concerns regarding the ability to meet role expectations and financial obligations. What is the priority nursing problem for this client? 1.Anxiety 2.Unrealistic outlook 3.Lack of ability to cope effectively 4.Disturbances in thoughts and ideas
Answer: 3. Lack of ability to cope effectively Rationale: Lack of ability to cope effectively may be evidenced by a client's inability to meet basic needs, inability to meet role expectations, alteration in social participation, use of inappropriate defense mechanisms, or impairment of usual patterns of communication. Anxiety is a broad description and can occur as a result of many triggers; although the client was experiencing anxiety, the client's concern now is the ability to meet role expectations and financial obligations. There is no information in the question that indicates an unrealistic outlook or disturbances in thoughts and ideas.
The emergency department nurse is caring for a client who has been identified as a victim of physical abuse. In planning care for the client, which is the priority nursing action? 1.Adhering to the mandatory abuse-reporting laws 2.Notifying the caseworker of the family situation 3.Removing the client from any immediate danger 4.Obtaining treatment for the abusing family member
Answer: 3. Removing the client from any immediate danger Rationale: Whenever an abused client remains in the abusive environment, priority must be placed on ascertaining whether the client is in any immediate danger. If so, emergency action must be taken to remove the client from the abusing situation. Options 1, 2, and 4 may be appropriate interventions, but are not the priority.
A client diagnosed with depression shares with the outpatient clinic nurse, "I lost my job this week and can't pay my rent. My daughter is my only family, but I don't want to burden her with my problems." Which response by the nurse would effectively address the client's concern? 1."Let's talk about the circumstances that caused you to lose your job." 2."There are homeless shelters available for people who are experiencing this exact situation." 3."Wouldn't you want to know if your daughter was having difficulties so you could help if you could?" 4."Being homeless would allow us to admit you to the hospital so you will have a place to eat and sleep."
Answer: 3."Wouldn't you want to know if your daughter was having difficulties so you could help if you could?" Rationale: The therapeutic communication technique is clarification that attempts to put vague ideas into words. It helps the client to view the explicit correlation between the client's feelings and actions. Asking why a client lost a job is not directly related to the client's feelings and concerns. Offering to provide a homeless shelter or to commit the client to the hospital does not address the issue at hand and places the client's concerns and feelings on hold.
A client diagnosed with terminal cancer 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 response by the nurse is therapeutic? 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."You are probably very depressed, which is understandable with such a diagnosis."
Answer: 3."You're feeling angry that your family continues to hope for you to be cured? Rationale: Restating is a therapeutic communication technique in which the nurse repeats what the client says to show understanding and to review what was said. While it is appropriate for the nurse to attempt to assess the client's ability to discuss feelings openly with family members, it does not help the client to discuss the feelings causing the anger. The nurse's direct attempt to expect the client to talk more about the anger is premature. The nurse would never make a judgment regarding the reason for the client's feeling; this is nontherapeutic in the one-to-one relationship.
A client asks the nurse about the meaning of behavioral therapy. Which description describes the purpose of behavioral therapy? 1. Fosters positive behavioral change 2.Develops structure and organizes time 3.Creates insight into maladaptive behavior 4.Decreases stress through relaxation training
Answer: 1. Fosters positive behavioral change Rationale: The purpose of behavioral therapy is to create effective changes in behavior. Developing structure and organizing time describe aspects of milieu management. Insight is a useful outcome of psychotherapy but does not always result in behavior change. Relaxation training is a treatment modality effective for reducing stress.
The nurse is discussing discharge and outpatient follow-up plans with a client hospitalized for depression. Which statement demonstrates the client's use of a defense mechanism and would indicate the need for follow-up treatment? 1."I don't think I can do this on my own. I still need help coping with things. I know I need to keep working with staff, even now that I'm going home." 2."This has been the hardest thing I've ever had to deal with. I've made progress in learning how to communicate, especially with my family. It's hard to tell them when I need help." 3."I really tried to listen to what people said in the group sessions. Sometimes it was hard, but I think we really helped each other. I think I've learned it's all right to get disappointed sometimes." 4."I was really depressed about not getting the promotion I was promised. Looking back on it, the pay raise wouldn't have been worth the huge increase in responsibility. It's just as well; it all worked out in the end."
Answer: 4. "I was really depressed about not getting the promotion I was promised. Looking back on it, the pay raise wouldn't have been worth the huge increase in responsibility. It's just as well; it all worked out in the end." Rationale: Rationalization is substituting acceptable reasons for actual reasons for behavior. In the correct option the client is rationalizing and is minimizing the response to loss. The remaining options indicate that the client is reviewing and evaluating certain valued perceptions of the treatment process before discharge.
Laboratory work is prescribed for a client who has been experiencing delusions. When the nurse approaches the client to obtain a specimen of blood, the client begins to shout, "You're all vampires. Let me out of here!" Which nursing response addresses the client's anxiety? 1."What makes you think that I am a vampire?" 2."I'll leave and come back later for the specimen." 3."Do you remember discussing the lab work earlier?" 4."It must be frightening to think that others want to hurt you."
Answer: 4. "It must be frightening to think that others want to hurt you." Rationale: The correct option helps the client focus on the emotion underlying the delusion but does not argue with it. Avoid statements that place the client in a position that requires a response. Attempting to avoid the situation will not address the client's anxiety. The incorrect responses may cause the client to hold the delusion more strongly.
A client with a diagnosis of depression who has attempted suicide says to the nurse, "I should have died. I've always been a failure. Nothing ever goes right for me." Which response by the nurse demonstrates therapeutic communication? 1."You have everything to live for." 2."Why do you see yourself as a failure?" 3."Feeling like this is all part of being depressed." 4."You've been feeling like a failure for a while?"
Answer: 4. "You've been feeling like a failure for a while?" Rationale: Responding to the feelings expressed by a client is an effective therapeutic communication technique. The correct option is an example of the use of restating. The remaining options block communication because they minimize the client's experience and do not facilitate exploration of the client's expressed feelings. In addition, use of the word why is nontherapeutic because clients frequently interpret why questions as accusations. Why questions can cause resentment, insecurity and mistrust.
As discharge approaches, the client has been quiet and withdrawn when interacting with the nurse. Which interpretation should the nurse make about the client's behavior? 1.An indication of the need for antidepressants 2.An inability of the client to terminate from the nurse 3.An indication of the need for additional therapy sessions 4.A normal behavior that can occur during the termination period
Answer: 4. A normal behavior that can occur during the termination phase Rationale: In the termination phase of a relationship, it is normal for a client to demonstrate a number of regressive behaviors. Typical behaviors include the return of symptoms, anger, withdrawal, and minimizing the relationship. The behavior that the client is experiencing is normal during the termination phase and does not necessarily indicate the need for hospitalization, additional sessions, or antidepressants.
A client is admitted to the mental health unit with a diagnosis of depression. The nurse should develop a plan of care for the client that includes which intervention? 1.Encouraging quiet reading and writing for the first few days 2.Identification of physical activities that will provide exercise 3.No socializing activities until the client asks to participate in milieu 4.A structured program of activities in which the client can participate
Answer: 4. A structured program of activities in which the client can participate Rationale: A client with depression often is withdrawn while experiencing difficulty concentrating, loss of interest or pleasure, low energy, fatigue, and feelings of worthlessness and poor self-esteem. The plan of care needs to provide successful experiences in a stimulating yet structured environment. The remaining options are either too "restrictive" or offer little or no structure and stimulation.
A client admitted 72 hours ago with a diagnosis of depression presents for breakfast today appropriately dressed and well groomed, and appears to be calm and relaxed, yet more energetic than before. Which initial action should the nurse take after noting this client's behavior? 1.Institute the unit's suicide precaution protocol. 2.Alert the client's psychiatrist of these changes immediately. 3.Notify the staff of these observations at today's team meeting. 4.Ask the client directly about the presence of any suicide-related thoughts.
Answer: 4. Ask the client directly about the presence of any suicide-related thoughts. Rationale: A sudden improvement in a depressed client's mood may indicate that the client has decided to commit suicide. The most direct way to validate the nurse's impression is to ask the client directly about suicidal ideation or plans. The other options are not the most appropriate initial nursing intervention.
A client is withdrawn, immobile and mute. Which appropriate action should the nurse take? 1.Encourage talking. 2.Leave the client alone. 3.Provide stimulation from other clients. 4.Occasionally ask open-ended questions.
Answer: 4. Occasionally ask open-ended questions Rationale: Clients who are withdrawn may also be immobile and mute. These clients require consistent, repeated approaches to establish interpersonal contact. The nurse facilitates communication with the client by sitting in silence and asking open-ended questions, with pauses to provide opportunities for the client to respond. This approach to communication with clients who are withdrawn requires much patience from the nurse. The remaining options are not appropriate nursing interventions.
During a nursing interview, a client says, "My daughter was murdered. I can't help wondering if her husband killed her, but he's been eliminated as a suspect." Which statement is a therapeutic nursing response? 1."I agree. What do you want to bet he did it?" 2."Have you shared your concerns with the police?" 3."I don't think that you should blame yourself one little bit." 4."It feels terrible to lose a daughter. Your suspicions are only natural."
Answer: 2."Have you shared your concerns with the police?" Rationale: The correct option addresses the subject of the client's statement. Avoid options that identify the process of agreeing with the client. The option of telling the client not to blame themselves is not directly related to the subject of the client's statement.