Saunders - Mental Health

An unlicensed assistive personnel (UAP) is assigned to work with the nurse to care for a client who is at risk for suicide. Which statement made by the UAP indicates to the nurse that the UAP understands suicide?

"Discussing suicide with a client is not harmful."

The nurse is caring for a client with schizophrenia who states, "I decided not to take my medication because I realize that it really can't help me. Only I can help me." Which nursing response would be therapeutic?

"Do you recall needing to be hospitalized because you stopped your medication?"

An adolescent who has been reported for drawing sexually explicit scenes in her school textbooks says to the psychiatric nurse, "I just felt like it." Which response is therapeutic for the nurse to make in order to assess abuse-related symptoms?

"I am concerned about you. Are you now or have you ever been abused?"

During a group meeting, a client diagnosed with posttraumatic stress disorder (PTSD) verbalizes difficulty with maintaining realistic behavior. Which response by the nurse would be therapeutic?

"I can see that you are upset about this. Let's talk about this some more."

The nurse is monitoring a client who is in seclusion. Which statement would indicate that the client is safe to come out of seclusion?

"I don't feel like hurting myself anymore."

The nurse is having a therapeutic discussion with a client and knows that which statements by the client should be immediately reported to the charge nurse? Select all that apply.

"I hid my silverware from dinner last night." "I know that by this time tomorrow all my troubles will be over."

While discharge planning for a female teenager with anorexia nervosa, the nurse suggests that the teenager attends a meeting of the local chapter of the National Association of Anorexia Nervosa and Associated Disorders. Which responses by the teenager indicate that she will likely be compliant with this suggestion? Select all that apply.

"I'm going to do whatever it takes to get better." "I'll go and participate as much as I can in the group discussions."

A client is being seen at the primary care clinic for her annual gynecological examination. Which client statements are most likely associated with potential intimate partner abuse? Select all that apply.

"My husband always brings me flowers and apologizes after he hits me." "I have bruises all over my body. I am frequently clumsy and fall a lot." "My boyfriend yells and accuses me of having an affair if I am late after work."

The nurse working in an urgent care center is interviewing a woman with vague somatic complaints. The client states that she was raped a few weeks ago but still feels "as if it just happened to me." The nurse should make which therapeutic response to the client?

"Tell me more about what happened that causes you to feel like the rape just occurred."

While the nurse is providing care, a client angrily reports to the nurse that the primary health care provider purposefully provided wrong information about her diagnosis and states, "The doctor lied to me." Which nursing response would likely be a barrier to further communication with the client?

"The primary health care provider would never lie to you."

The mother of 6-year-old twins says to the nurse, "My mother-in-law doesn't think our children should come to the funeral service for their grandfather. What do you advise?" Which response made by the nurse would be most appropriate?

"What do you and your husband believe is the right thing for your children?"

The nurse observes that a client with a potential for violence is agitated, pacing up and down in the hallway, and making aggressive and belligerent gestures at other clients. Which statement is appropriate to make to this client?

"What is causing you to become agitated?"

The nurse is gathering data from a client in crisis. When determining the client's perception of the precipitating event that led to the crisis, which is the most appropriate question to ask?

"What leads you to seek help now?"

The nurse is caring for an older adult client who has recently lost her husband. The client says, "No one cares about me anymore. All the people I loved are dead." Which response by the nurse is therapeutic?

"You must be feeling all alone at this point."

A client with lung cancer says to the nurse, "I'm sick and tired of my family telling me not to worry and that a cure will be discovered before I know it." Which response by the nurse is therapeutic?

"You're feeling angry that your family is hoping for a cure?"

A client with 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." The nurse should make which therapeutic response to the client?

"You've been feeling like a failure for a while?"

A confused and disoriented client is admitted to the psychiatric unit diagnosed with posttraumatic stress disorder (PTSD). The nurse initially plans to take which action with this client?

Accept the client as a person and make the client feel safe.

Which client is most likely at risk to become a victim of elder abuse?

A 90-year-old woman with advanced Alzheimer's disease

The nurse is assisting with creating a plan of care for the client in a crisis state. When developing the plan, the nurse should consider which about a crisis response?

A client's response to a crisis is individualized, and what constitutes a crisis for one person may not constitute a crisis for another person.

A client is unwilling to get out of the house for fear of "doing something crazy in public." Because of this fear, the client remains homebound except when accompanied outside by the spouse. The spouse asks the nurse, "what is the name of my wife's disorder?" Which answer should the nurse give to the spouse?

Agoraphobia

The wife of a client who abuses alcohol tells the nurse she cannot "do it alone" any longer and asks the nurse about the availability of any free support services for "people like me." The nurse refers the client's wife to which community group?

Al-Anon

A client with a diagnosis of a recurrent major depression, exhibiting psychotic features, is admitted to the mental health unit. In an attempt to create a safe environment for the client, the nurse designs a plan of care that deals specifically with which aspect of the client's disorder?

Altered thought processes

A client is scheduled to have electroconvulsive therapy (ECT). Which information should the nurse tell the client?

Amnesia of events occurring near the period of the therapy is common.

The nurse caring for a client with schizophrenia prepares to document which signs/symptoms exhibited by the client as negative? Select all that apply.

Avolition Anergia

A client is admitted to the psychiatric unit with a diagnosis of bipolar affective disorder and mania. The nurse identifies which signs/symptoms or behaviors as requiring immediate intervention?

Constant physical activity and poor oral intake

A client was admitted to a medical unit with acute blindness. Many tests are performed, and there seems to be no organic reason why this client cannot see. The nurse later learns that the client became blind after witnessing a hit-and-run car crash in which a family of three was killed. The nurse suspects that the client may be experiencing which diagnosis?

Conversion disorder

A client on the mental health unit is exhibiting distancing and does not speak to his/her family or visitors. Which are some other adverse relationship patterns? Select all that apply.

Cutoffs Conflict Over involvement

The nurse is monitoring a client with a history of opioid abuse for signs/symptoms of withdrawal. The nurse monitors this client for which signs/symptoms associated with opioid withdrawal?

Depression, high drug craving, fatigue with altered sleep (insomnia or hypersomnia), agitation, and paranoia

The nurse is caring for a client with severe depression. Which activity is appropriate for this client?

Drawing

A manic client announces to everyone in the dayroom that a stripper is coming to perform that evening. When the psychiatric nurse's aide firmly states that the client's behavior is not appropriate, the manic client becomes verbally abusive and threatens physical violence to the nurse's aide. Based on the analysis of this situation, the nurse determines that the appropriate action should be which intervention?

Escort the manic client to his or her room.

The nurse is assigned to assist in the care of a client with obsessive-compulsive disorder (OCD). The nurse should place priority on which action when planning care for this client?

Establish a trusting nurse-client relationship.

The nurse is caring for a client who has a history of opioid abuse and is monitoring the client for signs of withdrawal. Which observation is indicative of the signs/symptoms associated with withdrawal from opioids?

Fever, yawning, irritability, diaphoresis, and diarrhea

An older client is a victim of elder abuse, and the client's family has been attending weekly counseling sessions. Which statement by the abusive family member indicates that he or she has learned positive coping skills?

I feel better able to care for my father now that I know where to obtain assistance."

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?

Inquiring about the client's feelings that may affect coping

The nurse is caring for a client with seasonal affective disorder (SAD). Which type of therapy is considered a first-line treatment for this disorder?

Light therapy

The nurse is caring for a client who received electroconvulsive therapy (ECT) for a major depressive disorder. On data collection, the nurse notes that the client's blood pressure is elevated at 160/100 mm Hg. Based on this finding, which nursing action would be appropriate?

Notify the registered nurse.

An intoxicated client is brought to the emergency department by local police. The client is told that the primary health care provider (PHCP) 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 PHCP immediately. The nurse assisting to care for the client should take which appropriate nursing intervention?

Offer to take the client to an examination room until he or she can be treated.

The nurse is collecting data on a newly admitted client with conversion disorder. The nurse knows which voluntary motor or sensory function deficits might be present in this client? Select all that apply.

Paralysis Blindness Paresthesia Movement disorder

The nurse is assigned to care for a client being admitted to the nursing unit from the emergency department who attempted suicide by ingesting several sleeping pills. The nurse implements which priority action when the client arrives to the unit?

Place the client on one-to-one suicide precautions.

The nurse is assigned to care for a client who is suicidal. Which nursing intervention is appropriate for this client?

Provide authority, action, and participation.

A client is found to have rape-trauma syndrome. The nurse plans care for the client, knowing that rape-trauma syndrome is a condition that involves which?

Reexperiencing recollections of the trauma

The nurse is caring for a client with a somatic disorder and knows that which interventions would be most helpful to this client? Select all that apply.

Reinforce the client's problem-solving abilities. Assess "secondary gains" that the somatic illness provides the client.

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.

Restating Listening Maintaining neutral responses Providing acknowledgment and feedback

The nurse on the mental health unit is collecting data on a client diagnosed with obsessive-compulsive disorder (OCD). The nurse expects to note which behavioral characteristics of OCD? Select all that apply.

Rigidity Inflexibility Repetitive thoughts Ritualistic behavior

The nurse is caring for a client diagnosed with somatic symptom disorder who continuously complains of a severe headache. Which interventions are most appropriate when planning care for this client?

Shift the focus from the client's somatic concerns to feelings and coping skills.

Which nursing approach is important when administering an antianxiety agent to a client with acute, severe anxiety?

Stay with the client until the medication becomes effective.

The registered nurse has written an outcome statement of, "Client will feel less anxious by the end of session," for a client with generalized anxiety disorder. Which interventions should the licensed practical nurse use to assist this client in meeting this goal? Select all that apply.

Stay with the client. Administer anxiolytics medications if prescribed. Ensure the client is in an environment with little stimuli.

The nurse is reviewing the record of a client admitted to the mental health unit and notes that the client was admitted by voluntary status. The nurse makes which determination?

The client has the right to demand and obtain release from the hospital.

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, which would the nurse expect to note?

The client presents a harm to self.

A mother of a teenage client with an anxiety disorder is concerned about her daughter's progress during discharge. She states that her daughter "stashes food, eats all the wrong things that make her hyperactive," and "hangs out with the wrong crowd." While helping the mother prepare for her daughter's discharge, the nurse should make which suggestion?

The mother should restrict the amount of chocolate and caffeine products in the home.

A licensed practical nurse (LPN) is caring for a client with a diagnosis of schizophrenia. The LPN observes behaviors indicative of paranoia and reports these observations to the registered nurse (RN). The LPN assists the RN in developing a plan of care for the client and suggests inclusion of which intervention in the plan of care?

Avoid joking or laughing in the presence of the client.

The nurse is reading about the four different levels of anxiety. Which different categories distinguish and describe each level? Select all that apply.

Effects on problem solving Effects on perceptual field Physical and other defining characteristics

The psychiatric nurse knows that a therapeutic nurse-client relationship includes which specific goals and functions? Select all that apply.

Promoting self-care and independence Facilitating communication of distressing thoughts and feelings Helping clients examine self-defeating behaviors and test alternatives Assisting clients with problem solving to help facilitate activities of daily living

A client has been hospitalized and has participated in substance abuse therapy group sessions. The client has consented to participate in Alcoholics Anonymous (AA) community groups after discharge. Which statement by the client best indicates to the nurse that the client has assimilated therapy session topics and coping response styles and has processed information effectively for self-use?

"I'm looking forward to leaving here; I know that I will miss all of you. So, I'm happy and I'm sad, I'm excited and I'm scared. I know that I have to work hard to be strong and that everyone isn't going to be as helpful as you people."

The student nurse is learning about leadership and management. The student knows that which are the main styles of group leadership? Select all that apply.

Autocratic leader Democratic leader Laissez-faire leader

The nurse is collecting data from a newly admitted client recently diagnosed with borderline personality disorder. Which data provided by the client best supports the nurse's concern that the client is not using effective coping skills?

Driving under the influence (DUI) conviction resulted in a 1-year suspended license

A client who has just received a diagnosis of asthma says to the nurse, "This condition is just another nail in my coffin." Which response by the nurse is therapeutic?

"You seem very distressed over learning you have asthma."

The nurse is planning care for a client who is being hospitalized because the client has been displaying violent behavior and is at risk for potential harm to others. The nurse should avoid which intervention in the plan of care?

Assigning the client to a room at the end of the hall to prevent disturbing the other clients

The nursing instructor is helping students learn about bioethics, which is the study of specific ethical questions that arise in health care. The instructor reviews with the students which basic principles of bioethics? Select all that apply.

Autonomy: Respecting the rights of others to make their own decisions (e.g., acknowledging the client's right to refuse medication promotes autonomy) Beneficence: The duty to act to benefit or promote the good of others (e.g., spending extra time to help calm an extremely anxious client) Veracity: One's duty to communicate truthfully (e.g., describing the purpose and side effects of psychotropic medications in a truthful and non-misleading way) Fidelity (nonmaleficence): Maintaining loyalty and commitment to the client and doing no wrong to the client (e.g., maintaining expertise in nursing skill through nursing education) Justice: The duty to distribute resources or care equally, regardless of personal attributes (e.g., an ICU nurse devotes equal attention to someone who has attempted suicide as to someone who suffered a brain aneurysm)

The nurse in the psychiatric unit is reviewing the records of the clients admitted to the nursing unit. A client with a history of violent behavior approaches the nurse and demands immediate discharge from the hospital. The nurse notes that the client was voluntarily admitted to the psychiatric unit. Which is the appropriate nursing action?

Tell the client that the primary health care provider will be contacted regarding discharge.

The nurse employed in an emergency department is assisting in caring for an adult client who is a victim of family violence. The nurse reinforces which instruction to the victim in the discharge plan?

Information regarding the location of shelters

The nurse on a behavioral health unit is having a therapeutic discussion with a client and recognizes that which communication techniques would be nontherapeutic? Select all that apply.

Minimizing feelings Changing the subject Asking "why" questions

The nurse is working with a client who is delusional. The client says to the nurse, "The leaders of a religious cult are being sent to assassinate me." Which is the best response by the nurse?

"What makes you think that cult members are being sent to hurt you?"

A manic client is placed in a seclusion room after an outburst of violent behavior, including physical assault on another client. As the client is secluded, which action should the nurse perform?

Inform the client that she is being secluded to help regain control of herself.

A client who excessively uses alcohol and who is motivated to stop tells the nurse, "I know that there is a medication that can help people like me quit drinking." Which medication should the nurse explain is available for this purpose?

Disulfiram

A client is diagnosed with catatonic stupor. The client is lying on the bed, hidden under the sheets, with her body pulled into a fetal position. The nurse should take which appropriate action?

Sit beside the client in silence with occasional open-ended questions.

Milieu therapy is prescribed for a client on the psychiatric unit. The nurse knows that besides overcrowding on the unit, milieu characteristics conducive to violence include which factors? Select all that apply.

Poor limit setting Staff inexperience Provocative or controlling staff Arbitrary revocation of privileges

The nurse is assisting in conducting a group therapy session. During the session a client threatens to act out physically and states that he will punch another member of the group. Which is the appropriate nursing action?

Tell the client that he may talk about his anger but cannot act on it during the group session.

The nurse is assisting in conducting a group therapy session and a client with a manic disorder is monopolizing the group. The appropriate nursing action is which?

Suggest that the client stop talking and try listening to others.

The nurse in the mental health clinic hears a client yelling and threatening to hurt his sister. The nurse reports this episode to the mental health therapist. Which should the nurse anticipate the therapist to do? Select all that apply.

Identify the specific person being threatened. Take appropriate action to protect the identified victim. Assess and predict the client's danger of violence toward another.

The nurse working the evening shift is assisting clients in getting ready to go to sleep. A client diagnosed with obsessive-compulsive disorder (OCD) becomes upset and agitated and asks the nurse to sit down and talk. Which response by the nurse would be best at this time?

"I can see that you're upset. I'm willing to listen."

A client with delirium becomes agitated and confused at night. The best initial intervention by the nurse is which action?

Use a night light and turn off the television.

A female client with anorexia nervosa is a member of a support group. The client has verbalized that she would like to buy some new clothes, but her finances are limited. Group members have brought some used clothes for the client to replace her old clothes. The client believes that the new clothes were much too tight, so she has reduced her calorie intake to 800 calories daily. The nurse identifies this behavior as which finding?

Evidence of the client's altered and distorted body image

A client is diagnosed with schizophrenia. The nurse is asked to assist in preparing a nursing care plan for the client. Which is important for the nurse to understand when planning?

Until the client's thinking is cleared, the nurse may need to assist the client with grooming and nutrition.

The nurse is caring for a client who has bipolar disorder with aggressive social behavior. Which activity would be most appropriate initially for this client?

Writing