Senior Practicum Foundations of Psychiatric Nursing
A nurse has been working with a battered woman who is being discharged and returning home with her husband. The nurse says, "All this work with her has been useless. She is just going back to him as usual." Which statement by a nursing colleague would be most helpful to this nurse?
"Her reasons for staying are complex. She can leave only when she is ready and can be safe." Explanation: The colleague needs to provide the nurse with information about spouse abuse. Giving information about reasons for staying is useful for decreasing the nurse's frustration. Although expressing empathy is appropriate, it does not help the nurse understand the client's needs and behaviors. Telling the nurse that there will be another chance is not helpful and fails to educate the other nurse about the dynamics of abuse. Although dependence is a problem, women who are abused can overcome this and leave if they have support, not criticism. Saying that abused women almost never leave does not help the nurse understand the client's needs and behavior.
The nurse is teaching an unlicensed assistive personnel (UAP) about the care of clients with self-mutilation. Which statement by the UAP would indicate teaching about self-mutilation has been effective?
"It is a way to express anger and rage." Explanation: Self-mutilation is a way to express anger and rage, commonly seen in clients with borderline personality disorder. It typically is a cry for help, an expression of intense anger, helplessness, or guilt. When a client is experiencing numbness or feelings of unreality, self-mutilation induces physical pain that validates the person's being alive because of the ability to feel the physical pain. Self-mutilation is not a means of getting what the person wants. It is not used as a form of manipulation, although it is often misinterpreted as such. Self-mutilation is a serious behavior that is harmful to the self and cannot be ignored.
While listening to a taped-report at shift change, one of the other team members remarks that "My mother lives near this client, and his yard is always full of junk." What should the nurse assigned to provide care to this client do in this situation?
Ask the team member what the purpose was in sharing the information. Explanation: The assigned nurse should determine if the comment has any relevance to the care of this client. Ignoring the comment or asking the team member to be quiet does not help determine if the comment was appropriate. Only information that has therapeutic value should be shared with other team members.
When should a nurse introduce information about the end of the nurse-client relationship?
During the orientation phase Explanation: Preparation for ending the nurse-client relationship should begin during the orientation phase, when realistic limits of the relationship are established. Termination should also be discussed as goals are achieved and the relationship nears an end. Although the nurse should remind the client when only one or two sessions remain, she must not wait until then to prepare the client for termination. The client's ability to tolerate the end of a relationship shouldn't dictate its timing. Because many clients have had negative experiences when ending relationships, the nurse may use termination of the nurse-client relationship to prepare the client for and work the client through positive termination experiences with others.
The campus health nurse is caring for a client after she was sexually assaulted. Which of the following intervention would be most beneficial for this client?
Explore the client's strengths and resources with her. Explanation: The goal of crisis intervention is to support clients to resume pre-crisis levels of functioning. Variables in a client's recovery include support and access to resources. Suggesting courses in martial arts could be a strategy, but more important for the client's adjustment would be helping the client identify strengths and resources that could give her support. Assessing for coping should include all client activity, not only negative coping behaviors. Agreeing with the client that she should move on would be giving advice, a nontherapeutic technique.
Which finding indicates that a client who has been raped will have future adjustment problems and need additional counseling?
Her parents show shame and suspicion about her part in the rape. Explanation: The potential for problems in adjusting after a rape will be increased when those around the victim treat her as though she is to blame for the rape, especially when she already may feel some guilt and shame about it. A rape victim is likely showing adjustment to her experience when she is upset about her experience, when she seeks out formerly ignored relatives and friends for support, or when she attempts to help other rape victims. A rape victim is likely showing adjustment to her experience when she is upset about her experience, when she seeks out formerly ignored relatives and friends for support, or when she attempts to help other rape victims. A rape victim is likely showing adjustment to her experience when she is upset about her experience, when she seeks out formerly ignored relatives and friends for support, or when she attempts to help other rape victims.
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?
Return to the car and call the police. Explanation: The nurse needs to consider his/her own personal safety in this situation and how he/she will be the most help to this family. The nurse needs to get some back-up support before entering the house due to the potential for violence. The nurse should not go into the home if his/her safety is in danger.
The treatment team recommends that a client take an assertiveness training class offered in the hospital. Which behavior indicates that the client is becoming more assertive?
The client asks his roommate to put away his dirty clothes after telling the roommate that this bothers him. Explanation: By requesting that the roommate respect his rights (asking the roommate to put the dirty clothes on the floor away after telling him that this bothers him), the client is asserting himself. Arriving late is commonly passive resistance and thus not an indicator that the client is becoming assertive. Asking the nurse to call is dependent behavior. Although asking the HCP is more assertive, the client is relying on the nurse's direction to do so.
What client behaviors would be most important for the nurse to consider in deciding to institute suicide precautions because of high-risk behavior?
The client recently attempted suicide with a lethal method. Explanation: A recent suicide attempt using a lethal method always indicates the need for suicide precautions. The client is at high risk for suicide, and his life must be protected and safety maintained. Having feelings of being in control of suicidal thoughts, worrying about a child's reaction, or expressing guilt and shame about a suicide attempt indicates a lower risk for suicide.
The nurse who uses self-disclosure should:
refocus on the client's experience as quickly as possible. Explanation: The nurse's self-disclosure should be brief and to the point so that the interaction can be refocused on the client's experience. Because the client is the focus of the nurse-client relationship, discussion shouldn't dwell on the nurse's experience.
Nursing care for a client after electroconvulsive therapy (ECT) should include:
assessment of short-term memory loss. Explanation: After ECT, the nurse must assess the client's short-term memory loss. The client might need to be reoriented. The client may get out of bed and eat as soon as he feels comfortable doing so.
A nurse is assessing a client at a mental health clinic who threatens suicide and describes having a plan. Which of the following should the nurse recognize as the priority goal for the client?
Working with the client to resolve the immediate crisis Explanation: The goal of crisis intervention is the resolution of an immediate problem. The client must learn to solve his/her own problems. Although some clients do enter long-term therapy or are admitted to an acute care facility, these are not the goals of crisis intervention.
A client with antisocial personality disorder smokes in prohibited areas and refuses to follow other unit and facility rules. The client persuades others to do his laundry and other personal chores, splits the staff, and will work only with certain nurses. The care plan for this client should focus primarily on:
consistently enforcing unit rules and facility policy. Explanation: Firmness and consistency regarding rules are the hallmarks of a care plan for a client with a personality disorder. Isolation is inappropriate and violates the client's rights. Power struggles should be avoided because the client may try to manipulate people through them. Behavior modification usually fails because of staff inconsistency and client manipulation.
A woman who was raped in her home was brought to the emergency department by her husband. After being interviewed by the police, the husband talks to the nurse. "I do not know why she did not keep the doors locked like I told her. I cannot believe she has had sex with another man now." The nurse should respond by saying:
"Let us talk about how you feel. Maybe it would help to talk to other men who have been through this." Explanation: The nurse should respond to the husband's needs and concerns and should offer support. Protecting or defending the wife against his criticism ignores the husband's needs.
The nurse meets with a client in the outpatient clinic who is suicidal and refuses to sign a "no suicide" contract. What should the nurse do next?
Arrange for immediate hospitalization on a locked unit. Explanation: The nurse should arrange for immediate hospitalization on a locked unit for the client who is suicidal and refuses to sign a "no suicide" contract. A psychiatric intensive care unit or locked unit is the appropriate setting and least restrictive environment to provide safety for a high-risk client. When clients are treated in an outpatient area, procedures must be in place for swift admission to an inpatient area that has a locked unit. The group home, a partial program, or a subacute unit would not provide the maximum safety that the client needs.
The stigma related to having a mental illness, especially a chronic illness, persists despite improvements in the management of illnesses and an increase in public education. Which view most perpetuates the stigma?
Clients can recover from mental illness if they have willpower. Explanation: Many still believe that recovery from mental illness is a matter of willpower—for example, "pull yourself up by your bootstraps" or "just get over it." This belief persists despite awareness that mental illness is can be hereditary and has a biochemical basis. Mental illness can be prevented only if there is early intervention. Clients cannot prevent it just by the desire to do so.
When working with clients in crisis, the nurse must be aware that crisis intervention differs from other forms of therapeutic intervention in that crisis intervention focuses on which concern(s)?
Determining immediate problems, as perceived by the client, with the short-term goal of problem solving Explanation: Focusing on the immediate problem and short-term goals to solve that problem are the priorities of the nurse dealing with crisis intervention work. Delving into the complete history is not the priority because it takes time away from resolving the immediate crisis. The client's role in the problem is not the goal of this sort of intervention, but rather of longer term therapy that would hopefully prevent future crises. This is also true for assisting the client to identify what sort of patterns exist in his/her problems.
A client reports losing his job, not being able to sleep at night, and feeling upset with his wife. The nurse responds, "You may want to talk about your employment situation in group today." The nurse is using which therapeutic technique?
Focusing Explanation: The nurse is using focusing by suggesting that the client discuss a specific issue. She didn't restate the question (restating technique) or ask further questions (exploring technique), and didn't make an observation.
A client in group therapy is restless. His face is flushed and he makes sarcastic remarks to group members. The nurse responds by saying, "You look angry." The nurse is using which technique?
Making observations Explanation: The nurse is using observation to give the client feedback about his behavior and attitude. A broad statement doesn't give feedback to the client. The nurse didn't ask the client to explain his actions (the clarifying technique) and didn't reassure him.
A client is irritable and hostile. He becomes agitated and verbally lashes out when his personal needs are not immediately met by the staff. When the client's request for a pass is refused by the healthcare provider, he utters a stream of profanities. Which statement best describes the client's behavior?
The client's anger is not intended personally. Explanation: Staff members sometimes are the recipients of a client's angry behavior because they are safe targets and are available for attack. The display of anger is rarely intended to be personal. Such behavior is not necessarily a sign of serious pathology but must be weighed in conjunction with other behaviors. An angry outburst is not an attack on a healthcare provider's skills. While not necessarily pathologic, the client's behavior is not a sign that his condition is improving.
A client is admitted to the inpatient psychiatric unit. He is unshaven, has body odor, and has spots on his shirt and pants. He moves slowly, gazes at the floor, and has a flat affect. When assessing the client on admission, the nurse should first ask the client:
if he is thinking about hurting himself. Explanation: The nurse's highest priority is to ask the client if he is thinking about hurting himself or to assess for suicide. Questioning the client about his sleep pattern, about recent stresses, and about his feelings regarding himself are all important areas of assessment for the depressed client, but they are not as immediate a priority as assessing the risk for suicide.
Which nursing intervention is the highest priority when a client is placed in restraints?
monitoring the client every 15 minutes Explanation: Safety of the client and staff is the utmost priority. Therefore, the client must be monitored closely and frequently, such as every 15 minutes, to ensure that the client is safe and free from injury. Assisting with nutrition and elimination, performing range-of-motion exercises on each limb, and changing the client's position every 2 hours are important after the safety of the client and staff is ensured by close, frequent monitoring.
A nurse is teaching self-esteem to a client. Which statements by the client would indicate understanding of the concept? Select all that apply.
-"I need to have consistent limits." - "Living in a critical environment is not good for me." - "I need to have healthy boundaries." Explanation: Self-esteem is how we value or feel worthwhile about ourselves. A variety of factors can aide a person in developing a healthier self-esteem. Here are a few. A structured lifestyle demonstrates acceptance and caring and provides a sense of security. A critical environment erodes a person's esteem. Inconsistent boundaries lead to feelings of insecurity and lack of concern. Physical discipline can decrease self-esteem. When the client starts to make decisions, this can help increase their self-esteem.
A psychiatric nurse in the emergency department is assigned to care for a group of clients. Which client should the nurse see first?
A client who states she was sexually assaulted an hour ago. Explanation: A rape or assault of any kind is a crisis situation, and the primary nursing focus should be safety for the client. In addition to the psychological crisis, the client could have physiologic injuries that need immediate medical attention. The client with a panic disorder does have acute symptoms of anxiety, but is not in crisis. The client off his/her medication and worsening depressive symptoms is a concern, but is not in immediate danger.
A nurse hears a client state, "I have 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?
The nurse must start the process to warn the client's husband. Explanation: Confidentiality must be broken if there are credible threats made against another person's safety. Confidentiality does not override the safety of other persons.
During therapy, a client on the mental health unit is restless and is starting to make sarcastic remarks to others in the therapy session. The nurse responds by saying, "you look angry." Which of the following communication techniques is the nurse using?
Making observations Explanation: The nurse has provided direct feedback as an observation to the client and the group. The nurse is not mirroring the behavior or seeking clarification or an explanation of the behavior. This is not an open-ended question. Making direct observations and providing feedback in this manner is useful in demonstrating attention and concern for group members as well as providing an external vantage point on behaviors exhibited in a group setting. While such a statement makes a space for later clarification, this statement itself if not a statement of clarification, it is simply an observation.
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?
Return to the car and call the police. Explanation: The nurse needs to consider his/her own personal safety in this situation and how he/she will be the most help to this family. The nurse needs to get some back-up support before entering the house due to the potential for violence. The nurse should not go into the home if his/her safety is in danger.
The treatment team recommends that a client take an assertiveness training class offered in the hospital. Which behavior indicates that the client is becoming more assertive?
The client asks his roommate to put away his dirty clothes after telling the roommate that this bothers him. Explanation: By requesting that the roommate respect his rights (asking the roommate to put the dirty clothes on the floor away after telling him that this bothers him), the client is asserting himself. Arriving late is commonly passive resistance and thus not an indicator that the client is becoming assertive. Asking the nurse to call is dependent behavior. Although asking the HCP is more assertive, the client is relying on the nurse's direction to do so.
An elderly client was prescribed lorazepam 1 mg three times a day to help calm her anxiety after her husband's death. The next day the client calls her daughter asking when she is picking her up to go to the graveside. The client says she has been walking up and down the driveway for the past hour waiting for her daughter. Noting the client's agitation, hyperactivity, and insistence, the daughter calls the nurse to report her mother's behavior. Which finding would the nurse suspect as the cause of the mother's behavior, and what action would she suggest?
The client is experiencing a paradoxical reaction to the lorazepam and should stop the new medication immediately. Explanation: Paradoxical responses to benzodiazepines are more common in children and the elderly than other age groups and generally occur at the beginning of treatment. Grief and depression in the elderly is more likely to result in fatigue and withdrawal than hyperactivity and agitation. Treatment with a sleeping medication chemically related to the benzodiazepines is likely to result in an increase rather than decrease in agitation symptoms in elderly clients. A medication interaction is possible, but less likely since most pharmacies screen for drug interactions when filling prescriptions.
In addition to teaching assertiveness and problem-solving skills when helping the client cope effectively with stress and anxiety, the nurse should also address the client's ability to:
use conflict resolution skills. Explanation: Because relationships inherently lead to stress and anxiety, conflict resolution skills are essential for solving relationship problems. Dealing with anger is more effective than suppressing it. Suppression is a mechanism that avoids the issue rather than solving it. Balancing a checkbook involves calculations, not coping skills. Following directions is a passive activity that reflects a lack of problem solving by the client.
The nurse in a psychiatric unit has formed a therapeutic relationship with a client with a borderline personality disorder. When the client is readmitted to the unit for a suicide attempt, the nurse exclaims to another staff nurse, "Why? Everything was going well. How could she do this to me?" What response by the staff nurse reflects an understanding of the client's borderline disorder?
"Clients with borderline disorder act out to relieve anxiety, and something must have provoked a great deal of anxiety. Explanation: It will be instructive for the emergency department nurse to share with the clinic nurse the rationale behind the client's self-inflicted injuries as a feature of her borderline personality disorder. Understanding professional boundaries is a vital nursing role. Reinforcing an over-helping relationship or boundary blurring would not be professional or instructive, and berating the client and his/her behaviors would not be professional.
A nurse is working with an adolescent who has reported low self-esteem. When developing a plan of care, the nurse considers the adolescent's psychosocial needs. Which of the following questions will best assist the nurse in assessing the adolescent's psychosocial development?
"How did you come to understand your feelings about yourself?" Explanation: According to Erik Erikson, the primary psychosocial task during adolescence is to establish a personal identity while overcoming role or identity confusion. The adolescent strives to attain a personal identity by becoming more independent from his family. Asking the adolescent client about his religious beliefs and ethnic background would not establish identity. Asking the teen what makes him think the things they do could make the teen defensive. An open-ended question that allows the adolescent to explore his thoughts and feelings is the best way to assist the teen in building identity.
In the process of dealing with the intense feelings about being raped, victims commonly verbalize that they were afraid they would be killed during the rape and wish that they had been. The nurse should decide that further counseling is needed if the client makes which statement?
"I get so angry at times that I have to have a couple of drinks before I sleep." Explanation: Use of alcohol reflects unhealthy coping mechanisms. The client's report of needing alcohol to calm down needs to be addressed. Survival is the most important goal during a rape. The client's acknowledging this indicates that she is aware that she made the right choice. Although suicidal thoughts are common, the statement that suicide is an easy escape but the client would be unable to do it indicates low risk. Fantasies of revenge, such as giving the death penalty to all rapists, are natural reactions and are a problem only if the client intends to carry them out directly.
A female client is admitted to a mental health unit with a diagnosis of depression and is participating in group sessions. She asks a male nurse if he is married or has a girlfriend. What is the best response by the nurse to maintain a therapeutic relationship?
"I'm curious about your question, but I want to know how you are feeling today." Explanation: Nurses must practice in a manner that is consistent with providing safe, competent, and ethical care. If the nurse shared personal information with the client, the nurse would have crossed the boundary of a therapeutic relationship and changed the focus of the discussion from a client focus to a social focus. It is very important in all areas of care, but especially in the mental health setting, that the relationship between the nurse and the client has very clear boundaries and is client focused. The other options are incorrect because they do not follow the principles of a therapeutic nurse-client relationship.
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:
"It's frightening to have new people on the unit. We're here to talk about things like being afraid." Explanation: The nurse needs to acknowledge the client's feelings. In doing so, the nurse helps the group accept a new member. Focusing on "everyone" and telling the client not to worry ignores the client's fears. Having the other group members introduce themselves places the focus on the other clients in the group and does not address the client's fears. Implying that getting to know someone will reduce the fear is false reassurance.
After teaching a group of students who are volunteering for a local crisis hotline, the nurse judges that further education about crisis and intervention is needed when a student makes which statement?
"Most people in crisis will be calling the line once every day for at least a year." Explanation: The concern that someone may call the crisis hotline every day for a year indicates that further understanding about crisis and crisis intervention is needed. A crisis situation is time-limited, typically resolving in 4 to 6 weeks if handled effectively. If a person calls the line daily for a year, that person has not been properly dealt with or is probably in a highly disorganized state requiring an alternative intervention. The nurse needs to further review and clarify the material presented. Callers are typically in pain, overwhelmed, and exhausted when they call. A crisis can help an individual cope better in the future if he learns to handle the situation.
Which client statement indicates that the client has gained insight into his use of the defense mechanism of displacement?
"Now when I am mad at my wife, I talk to her instead of taking it out on the kids." Explanation: Displacement refers to a defense mechanism that involves taking feelings out on a less-threatening object or person instead of tackling the issue or problem directly. Talking to his wife directly reflects insight into the client's use of the defense mechanism and his ability to overcome it. Not thinking about the weekend is suppression. Here, the client is focusing on the issue with the highest priority. Focusing on academic rather than athletic achievement is compensation, highlighting one's strengths instead of weaknesses. Not remembering the molestation is repression.
A client with depression has not responded to drug therapy. At a team conference, staff members recommend electroconvulsive therapy (ECT). Which statement should the nurse add when explaining the procedure to the client?
"This treatment has been proven to be effective, and we expect a positive outcome." Explanation: To emphasize the therapeutic value of ECT, the nurse should refer to it as a "treatment." Although ECT is the medically correct terminology, this term should not be used unless the client is familiar with it and comfortable with it. Referring to the procedure as ECT may cause the client to focus on the disturbing elements of this treatment. The client should be as involved as possible in the decision-making process and not just refer to the client's family as having made all the decisions.
A client is admitted for a surgical biopsy of a suspicious lump in his/her right breast. At the time the nurse arrives to take the client to surgery, the client is finishing a letter to his/her to children. The client tearfully tells the nurse, "I just want to leave this for my children in case anything goes wrong in the surgery." Which nursing response will be most therapeutic?
"What are you concerned about right now?" Explanation: The most therapeutic response is one in which the nurse reflects back to the client what the client has said and asks the client to reflect further. Making light of the client's worries about the biopsy does not help the client process his/her feelings or concerns. The client did not express questions about the biopsy; therefore calling the doctor is not appropriate at this time. Confronting the client about what the nurse feels is misplaced anxiety of the biopsy versus cancer would not be beneficial to the client and not therapeutic in these circumstances.
The client, who is dying from acquired immunodeficiency syndrome (AIDS), is admitted to the inpatient psychiatric unit because he attempted suicide. His close friend recently died from AIDS. The client states to the nurse, "What is the use of living? My time is running out." What is the nurse's best response?
"You are in a lot of pain. What are you feeling?" Explanation: The nurse recognizes the client's pain, hopelessness, and sense of loss related to his condition and the loss of his friend and encourages him to express his feelings. Giving the client permission to talk about his feelings of sadness, loss, and hopelessness and listening to him is an important nursing intervention for the dying client. Telling the client to make good use of his remaining time diverts attention from the content of the client's statements and blocks expression of feelings. "Do not give up" is a type of pep talk that ignores the client's feelings. Saying that life is precious and worth living ignores the client's needs and inhibits his expression of feelings.
The client, who is dying from acquired immunodeficiency syndrome (AIDS), is admitted to the inpatient psychiatric unit because he attempted suicide. His close friend recently died from AIDS. The client states to the nurse, "What is the use of living? My time is running out." What is the nurse's best response?
"You are in a lot of pain. What are you feeling?" Explanation: The nurse recognizes the client's pain, hopelessness, and sense of loss related to his condition and the loss of his friend and encourages him to express his feelings. Giving the client permission to talk about his feelings of sadness, loss, and hopelessness and listening to him is an important nursing intervention for the dying client. Telling the client to make good use of his remaining time diverts attention from the content of the client's statements and blocks expression of feelings. "Do not give up" is a type of pep talk that ignores the client's feelings. Saying that life is precious and worth living ignores the client's needs and inhibits his expression of feelings.
The nurse is performing an assessment on a client with a history of a dysfunctional family. Which findings should the nurse anticipate? Select all that apply.
- Unhealthy personal boundaries - Abuse and neglect Explanation: Healthy boundaries setting limits are established in childhood when parents provide consistent, supportive limits, and attention. In a dysfunctional family, the parents are unable to give the support, attention, care, discipline, and direction that children need in order to develop into mature adults. Often they are abused, emotionally or otherwise, or neglected. This leads to a poor self-concept and role confusion, the basis for unhealthy personal boundaries.
A nurse makes a home visit to a client who was discharged from a psychiatric hospital. The client is irritable and walks about her room slowly and gloomily. After 10 minutes, the nurse prepares to leave, but the client plucks at the nurse's sleeve and quickly asks for help rearranging her belongings. She also anxiously makes inconsequential remarks to keep the nurse with her. In view of the fact that the client has previously made a suicidal gesture, which intervention by the nurse should be a priority at this time?
Ask the client frankly if she has suicidal thoughts or plans. Explanation: Investigating the presence of suicidal thoughts and plans by overtly asking the client if she is thinking of or planning to commit suicide is a priority nursing action in this situation. Direct questioning about thoughts or plans related to self-harm does not give a person the idea to harm herself. Self-harm is an individual decision. Avoiding the subject when a client appears suicidal is unwise; the safest procedure is to investigate. It would be premature in this situation to outline alternative measures to suicide. Describing other clients who have attempted suicide is too indirect to be helpful and minimizes the client's feelings.
A nurse is coordinating care for a client admitted to the psychiatric unit after his/her fiancé was killed accidentally at his work site. Several weeks after the accident, the client is unable to sleep, eat, or work. Which of the following interventions would be most therapeutic for the client?
Assign the same staff as often as possible. Explanation: Traumatic stress can create symptoms such as an inability to sleep, eat, or work. The nurse can facilitate a trusting relationship with staff if the same staff can be assigned to him/her as often as possible. It is not realistic for the nurse to be able to anticipate and eliminate stress for the client. The nurse can discuss coping strategies for the client to deal with stress. Medication is practical for times of stress reactions, but does not give long-term solutions for stress responses. The nurse should encourage the client to talk about trauma at the client's own pace.
Which task may be delegated to a nursing assistant (unregulated care provider) in an acute care mental health setting?
Checking for sharp objects Explanation: A nursing assistant (unregulated care provider) may be assigned to search a client's luggage or room for potentially harmful objects, such as glass or sharp metal. A mental status assessment should be conducted by the nurse at the time of admission. Administering medication can't be delegated to an unlicensed (unregulated) person. A nurse or physician must discuss the treatment plan with the client.
The nurse is working with a client with depression in a mental health clinic. During the interaction, the nurse uses the technique of self-disclosure. In order for this technique to be therapeutic, which of the following steps must be a priority for the nurse?
Ensuring relevance to, and quickly refocusing upon, the client's experience Explanation: The nurse's self-disclosure should be brief and to the point so that the interaction can be refocused on the client's experience. Because the client is the focus of the nurse-client relationship, the discussion should not dwell on the nurse's own experience.
A 6-year-old client is diagnosed with attention deficit hyperactivity disorder (ADHD). When asking this client to complete a task, what techniques should the nurse use to communicate most effectively with him?
Obtain eye contact before speaking, use simple language, and have him repeat what was said. Praise him if he completes the task. Explanation: Because the client with ADHD is easily distractible, it is important to obtain eye contact before explaining the task. Simple language and having him repeat what he is told are necessary because of his age. Praise encourages the client to repeat the task in the future as well as building the client's self-esteem. A full explanation with verbal praise and a food reward is inappropriate because a food reward increases the chance that he will expect a physical reward for completing tasks. In addition, a full explanation might be too confusing for someone his age. Explaining consequences focuses on punishment, rather than praise. Although demonstration and imitation is an effective teaching method, rewarding with food fosters dependence on food reward for task completion.
When preparing to use seclusion as an alternative to restraint for a client who has not yet lost control, the nurse expects to use a room with limited furniture and no access to dangerous articles. What should the nurse also consider as critical for the safety of the client?
a security window in the door or a room camera Explanation: When using seclusion, the safety of the client is paramount. Therefore, staff must be able to see the client in seclusion at all times, such as through a security window in the door or with a room camera. Although outside access for dimming the lights to decrease stimuli may be appropriate, it is not critical for the client's safety. Having one staff member stay in a room alone with a potentially violent client is unsafe. A prescription for seclusion can be obtained before or after it is initiated.
During the mental status examination, a client may be asked to explain such proverbs as "Don't cry over spilled milk." The purpose of this is to evaluate the client's ability to think:
abstractly. Explanation: Abstract thinking is the ability to conceptualize and interpret meaning. It's a higher level of intellectual functioning than concrete thinking, in which the client explains the proverb by its literal meaning. Rational thinking involves the ability to think logically, make judgments, and be goal-directed. Tangential thinking is scattered, non-goal-directed, and hard to follow. Clients with such conditions as organic brain disease and schizophrenia typically can't conceptualize and comprehend abstract meaning. They interpret such statements as "Don't cry over spilled milk" in a literal sense, such as "Even if you spill your milk, you shouldn't cry about it."
The nurse understands that with the right help at the right time, a client can successfully resolve a crisis and function better than before the crisis, based primarily on which factor?
acquisition of new coping skills Explanation: Learning new coping skills is the major factor necessary for higher functioning. Better coping is likely to lead to regaining support systems, giving up dysfunctional coping, and awareness of how to prevent future crises.
A nurse must assess a client's judgment to determine his mental status. To best accomplish this, the nurse should have the client:
discuss hypothetical ethical situations. Explanation: The best way to assess a client's judgment is to discuss hypothetical ethical situations, such as "What would you do if you found a wallet that contained several credit cards and identification?" Interpreting proverbs tests thinking. Spelling words backward and counting by serial sevens test concentration.
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?
facilitating progressive review of the accident and its consequences Explanation: The nurse should facilitate progressive review of the accident and its consequences to help the client integrate feelings and memories and to begin the grieving process. Helping the client to evaluate her sister's behavior, telling the client to avoid details of the accident, or postponing the discussion of the accident until the client brings it up is not therapeutic and does not facilitate the development of trust in the nurse. Such actions do not facilitate review of the accident, which is necessary to help the client integrate feelings and memories and begin the grieving process.
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. The primary developmental task of the young adult is to develop intimacy with another person while making choices about relationships and career. Industry, a task associated with children ages 6 to 12, involves active socialization as the child moves from the family into society; much of the child's energy is focused on acquiring competency. Generativity is associated with middle age and is characterized by parental responsibility and concern for future generations. Developing trust is the task of the infant; it's accomplished when the infant receives adequate mothering and satisfaction of oral needs.
A nurse may use self-disclosure with a client if:
it achieves a specific therapeutic goal. Explanation: Self-disclosure (making personal statements about oneself) can be a useful nursing tool. However, a nurse should use self-disclosure judiciously and with a specific therapeutic purpose in mind. She should listen closely to the client and remember that the experiences of different people are sometimes similar but never identical. Using too many self-disclosures is unethical and can shift the focus from the client to the nurse. Self-disclosure that distracts the client from treatment issues doesn't benefit the client and may alienate the client from the nurse.
A mute client begins to express herself verbally on occasion. Which nursing action should be credited with helping a mute client express herself verbally?
making open-ended statements followed with silence Explanation: The best approach for a client who has difficulty expressing herself verbally is to use an undemanding, open-ended statement. When the client is ready to talk, the silences following the statement will give her the opportunity to do so. Asking the client direct questions may be too intimidating and yield only yes or no answers. Using hand signals is not likely to be effective. No one individual can know what another is experiencing, and it is rude to presume to know. It can lead to the client's anger or resentment.
The nurse who uses self-disclosure should:
refocus on the client's experience as quickly as possible. Explanation: The nurse's self-disclosure should be brief and to the point so that the interaction can be refocused on the client's experience. Because the client is the focus of the nurse-client relationship, discussion shouldn't dwell on the nurse's experience.
A 35-year-old man was experiencing martial discord with his wife of 4 years. When his wife walked out, he became angry, throwing things and breaking dishes. A friend talked him into seeking help at the local mental health center. Which question should the nurse ask initially to begin to assess this man's immediate problem?
"What led you to come in for help today?" Explanation: Beginning with an open-ended question that brings out the client's view of his situation and reasons for seeking treatment is the most neutral beginning and helps to gain the client's perception of events. Blaming the client for his problems is accusatory and nonproductive. A time for reviewing what could be done differently will come later.
A teenage client is a high school wrestler who fasts before every wrestling tournament and then binges immediately after the tournament. On the way to each tournament, the client walks rapidly up and down the bus aisle and spits repeatedly into a cup. Which of the following is the best initial intervention for this client?
Discuss secondary gains that are unconsciously driving the client's behavior. Explanation: Discuss secondary gains that are unconsciously driving the client's behavior as a first step in assessment and intervention. The client and his/her family need assistance to examine motives for this behavior and the extent of the behavior. The client first needs to discuss the altered behaviors and deal with the issue openly. Teaching the mother about nutrition appears to blame the mother and puts the responsibility for the problem solely on the her. Psychopharmacology may be helpful, but there is no specific medication for the treatment of eating disorders, and this is not indicated at this stage of the client's assessment and treatment. Calling the high school principal to report the wrestling coach would be inappropriate at this stage, although the parents may want to talk with the wrestling coach about their concerns.
When planning care for a client with schizophrenia, who lacks motivation to shower and dress, which outcome should the nurse expect the client to achieve by the end of 4 days?
Perform showering and dressing for herself. Explanation: By the end of 4 days, the client should be able to perform showering and dressing for herself. The client with schizophrenia commonly appears to be apathetic and lack initiative. Therefore, demonstrating the ability to complete the tasks indicates improvement. Although the client may be able to recognize, verbalize, or explain the need to shower and dress herself, she may be unable to do so because of the ambivalence associated with schizophrenia that impedes the client's ability to initiate and complete self-care. Therefore, evidence of improvement would be lacking.
The family members of the victims of a three-car accident have arrived at the emergency department. The wife of one accident victim is sitting away from the others and crying. Which action by the nurse would be best?
Sit next to the wife and offer her some tissues. Explanation: Conveying warmth, empathy, and support to the wife to encourage the release of feelings is a priority nursing action at this time. Leaving her alone to cry without offering help is inappropriate behavior by the nurse. Calling the healthcare provider for something to sedate the wife or asking the wife if she would like to speak to the social worker may be necessary and appropriate later.
A client who has had AIDS for years is being treated for a serious episode of pneumonia. A psychiatric nurse consult was arranged after the client stated that he was tired of being in and out of the hospital. "I am not coming in here anymore. I have other options." The nurse would evaluate the psychiatric nurse consult as helpful if the client makes which statements?
"I realize that I really do have more time to enjoy my friends and family." Explanation: Focusing on enjoying time with family and friends conveys a renewal of hope for the future and a decreased risk of suicide. Simply saying that no one wants him to commit suicide does not say he does not want to do it. Avoiding a transfer to a psychiatric unit does not mean he is no longer suicidal. Fear of not being successful with suicide usually is not a deterrent.
Which client statement indicates that the client has gained insight into his use of the defense mechanism of displacement?
"Now when I am mad at my wife, I talk to her instead of taking it out on the kids." Explanation: Displacement refers to a defense mechanism that involves taking feelings out on a less-threatening object or person instead of tackling the issue or problem directly. Talking to his wife directly reflects insight into the client's use of the defense mechanism and his ability to overcome it. Not thinking about the weekend is suppression. Here, the client is focusing on the issue with the highest priority. Focusing on academic rather than athletic achievement is compensation, highlighting one's strengths instead of weaknesses. Not remembering the molestation is repression.
A 5-year-old child exhibits signs of extreme restlessness, short attention span, and impulsiveness. Which intervention by the nurse would be therapeutic for this child?
Define behaviors that are acceptable and behaviors that are not permitted. Explanation: Children need to know what behaviors are acceptable and what behaviors are unacceptable. They feel more secure when limits are clear and when policies concerning their behavior are consistently enforced. Increasing sensory stimulation tends to increase hyperactive and impulsive behavior. Limiting opportunities to verbalize anger and frustration tends to increase stress and frustration for the child. Physical activities are needed to help the child expend energy, reduce anxiety, and increase self-worth.
A nurse is obtaining a history from a client. The client reports that he is a waiter. When asked about his work environment, the client says, "If customers confront me for not being attentive enough, I just spit on their food." The nurse suspects the client is prone to which type of behavior?
Passive-aggressive Explanation: This client exhibits a negative attitude and passive-aggressive behavior in response to word demands for adequate performance. Clients who are passive-aggressive won't confront or discuss issues with others but will go to great lengths to "get even." Obsessive-compulsive behavior involves rituals or rules that interfere with normal functioning. A person with a narcissistic personality has an exaggerated sense of self-worth. A person with a dependent personality is submissive and frequently apologizes and backs down when confronted.
The nurse is admitting a client with Borderline Personality Disorder. When planning care for this client, the nurse should give priority to which item?
Safety Explanation: Persons with Borderline Personality Disorder have a variety of difficult characteristics. Their impulsivity leads them to self-mutilation and sudden suicide attempts. This is the correct answer, as safety is always paramount. In splitting the client categorizes people as good or bad and tries to keep the bad from contaminating the good. Such a client may view a staff member as ideal and later devalue that person. Empathy is the nurse's attempt to understand and respond to a client's needs and feelings. In manipulation a person attempts to obtain needs in unacceptable ways.
A client with a self-inflicted gunshot wound in his arm is brought to the inpatient psychiatric unit from the emergency department. With his arm bandaged and in a sling, he is escorted to the unit by emergency department staff. A staff member states to the nurse, "He only hurt his arm, so he probably did it for attention." Which response by the nurse to the staff member would be most appropriate?
"All suicide attempts or acts of self-harm are very serious and indicate a cry for help." The nurse must always consider all suicide attempts as very serious. Even though the attempt may result in minimal injury, it is still a cry for help and an extremely dysfunctional method of coping. Discounting the injury minimizes the client's pain and disregards his intent. At some point a deeper conversation may be warranted, but the priority at this point is caring for the client rather than engaging in a what could be a lengthy conversation about the staff member's attitudes. To think of a suicide as a way to escape a serious problem or a means to gain attention is irresponsible and leads to unsafe nursing practice such as ignoring warning signs of suicide attempts.
A 74-year-old client receiving fluphenazine decanoate therapy develops pseudoparkinsonism, and is ordered amantadine hydrochloride. With the addition of this medication, the client reports feeling dizzy when standing. Which response by the nurse is best?
"When you change positions, do so slowly." Explanation: Both the fluphenazine decanoate and amantadine hydrochloride can have orthostatic hypotensive effects. Clients should be educated about this side effect especially in the elderly. Telling the client to change positions slowly will help ease the dizziness. If the dizziness is prolonged, the client should report those results to their practitioner. The client does not need a dose change or taken off the medication. The symptoms reported are orthostatic hypotensive effects not signs and symptoms of a stroke. The client could consider taking the medications at bedtime, but symptoms will likely persist. It would be safer to teach the client how to deal with symptoms as they occur.
During the conversation with the nurse, a victim of physical abuse says, "Let me try to explain why I stay with my husband." Which response would the nurse find inconsistent with the profile of a battered partner?
"The abuse adds spice to our relationship." Explanation: Saying that abuse "adds spice" suggests the woman actually enjoys the violent relationship and is inconsistent with the profile of victim of battery. Women are conditioned to be responsible for the family's well-being. This is often a motivation for a battered woman to stay in an abusive relationship. The victim believes that she can save the relationship and that her partner will change. Feelings of guilt surrounding issues such as these often influence an abused woman's decisions about staying with her partner. A woman's lack of job skills and financial resources may cause her to stay. Many women are injured or killed when they try to leave a violent relationship.
A nurse is instructing a client with bipolar disorder on proper use of lithium carbonate, the drug's adverse effects, and symptoms of lithium toxicity. Which client statement indicates that additional teaching is required?
'When my moods fluctuate, I'll increase my dose of lithium." Explanation: A client who states that he'll increase his dose of lithium if his mood fluctuates requires additional teaching because increasing the dose of lithium without evaluating the client's laboratory values can cause serious health problems, such as lithium toxicity, overdose, and renal failure. Clients taking lithium don't need to limit their sodium intake. A low-sodium diet causes lithium retention. A therapeutic lithium blood level indicates that the drug concentration has stabilized. The client demonstrates effective teaching by stating his lithium levels will be affected by foods that have a diuretic effect, such as watermelon, cantaloupe, grapefruit juice, and cranberry juice.
A nurse assesses a client with psychotic symptoms and determines that the client likely poses a safety threat and needs vest restraints. The client is adamantly opposed to this. What would be the best nursing action?
Contact the physician and obtain necessary orders. Explanation: If a nurse feels that a client needs to be restrained, the nurse should inform the physician and obtain necessary orders. The nurse should also discuss this with the client's family members and ask their opinion. Applying a wrist restraint instead of a vest restraint is inappropriate if a vest restraint is genuinely necessary. It would be inappropriate to delegate this aspect of care to a family member.
During an assessment interview, a depressed 15-year-old girl states that she "can't sleep at night." The nurse begins to explore factors that might contribute to this situation by asking if the girl is sexually active. The girl changes the subject. What should the nurse suspect based on the client's response to the assessment question?
Sexual abuse Explanation: Victims of sexual abuse commonly refuse to talk about the abuse or change the subject because they have been threatened by their abuser. Although there may be other explanations for the adolescent's inability to sleep at night, such as noise, anxiety, spiritual distress, pain, or other disturbances, adolescents are typically willing to discuss these factors as contributors to their inability to sleep. An adolescent with narcolepsy would experience brief periods of deep sleep followed by periods of feeling refreshed and wouldn't complain of being unable to sleep at night.
A psychiatric treatment team is planning care for a client who was involuntarily admitted for treatment of depression and suicide ideation. When planning the client's care, what legal parameters of care should the nurse be aware of?
The client is able to refuse medications. Explanation: Competent clients have the right to refuse medications. Even though the client is an involuntary admission, the client is competent and able to be involved in treatment planning. Because the client was admitted involuntarily, the client is not able to obtain release. The client who is legally declared incompetent is given a court-appointed guardian or representative who is responsible for giving consent. A client is considered to be competent unless the court has declared that the client is incompetent. The client who is incompetent is not able to give or refuse consent for treatment.
When planning the care for a client who is being abused, which measure is most important to include?
helping the client develop a safety plan Explanation: The client's safety, including the need to stay alive, is crucial. Therefore, helping the client develop a safety plan is most important to include in the plan of care. Being empathetic, teaching about abuse, and explaining the person's rights are also important after safety is ensured.
A client has been diagnosed with Avoidant Personality Disorder. He reports loneliness, but has fears about making friends. He also reports anxiety about being rejected by others. In a long-term treatment plan, in what order, from first to last, should the nurse list goals for the client? All options must be used.
- Talk with the client about his self-esteem and his fears. - Teach the client anxiety management and social skills. - Help the client make a list of small group activities at the center he would find interesting. - Ask the client to join one of his chosen activities with the nurse and two other clients. Explanation: The client needs a stepwise plan for developing a social life. He needs to first work on his self-esteem and reduce his fears of rejection before talking about how to decrease his anxiety and learning new social skills. Helping him chose interesting activities is important before suggesting an activity for him. Then he will be ready to try a structured activity with the nurse present for support and role modeling.
A nurse is teaching self-esteem to a client. Which statements by the client would indicate understanding of the concept? Select all that apply.
- "I need to have consistent limits." -"Living in a critical environment is not good for me." - "I need to have healthy boundaries." Explanation: Self-esteem is how we value or feel worthwhile about ourselves. A variety of factors can aide a person in developing a healthier self-esteem. Here are a few. A structured lifestyle demonstrates acceptance and caring and provides a sense of security. A critical environment erodes a person's esteem. Inconsistent boundaries lead to feelings of insecurity and lack of concern. Physical discipline can decrease self-esteem. When the client starts to make decisions, this can help increase their self-esteem.
An inpatient psychiatric nurse has received a report on her assigned clients. Which of the following clients should the nurse see first?
A client with schizophrenia who is suspicious of staff. Explanation: This client with schizophrenia has an illness with altered thought and sensory perception. The client is suspicious of others and without the ability to think clearly has the potential of being dangerous to self and others. This client is unstable and is the most important client for the nurse to assess. The client with anorexia is moving toward the goal of gaining weight. The client with alcohol withdrawal is nervous, which is an expected symptom as the client progresses though withdrawal, and would therefore not be a priority. The client who is anxious but stable enough to be discharged from the hospital is not the first priority.
Emergency restraints or seclusion may be implemented without a physician's order under which condition?
When a licensed practitioner will do a face-to-face assessment within 1 hour Explanation: In an emergency, a client who is a threat to himself or others may be restrained without an order. If restraints are initiated without an order the client must be assessed within 1 hour of application by a licensed, independent practitioner. Voluntary clients have the right to leave against medical advice. A minor should be treated the same way as an adult regarding restraints.
Parents tell a nurse that they have not met their goal of home management of their son with schizoaffective disorder. They report that the client poses a threat to their safety. Based on this information, what recommendation should the nurse make?
Evaluate the client for voluntary admission to a mental health facility. Explanation: A voluntary admission is the preferred approach because it involves having the client recognize existing problems and facilitates the client's involvement in treatment. Chemical restraints would violate the client's rights to freedom from the use of restraints and seclusion. The duty of care is a legal concept that applies only to the nurse-client relationship, not to family relationships. Respite care isn't an appropriate recommendation at this time. The nurse must address the safety issue and institute effective treatment and care. At a later time, it would be prudent for the nurse to talk with the client's family about caregiver burden and the option of using respite care.
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?
verbalization of feelings in an appropriate manner Explanation: Verbalizing feelings, especially feelings of anger, in an appropriate manner is an adaptive method of coping that reduces the chance that the client will act out these feelings toward others. The client's ability to verbalize feelings indicates a change in behavior, a crucial indicator of goal achievement. Although acknowledging feelings of anger and describing situations that precipitate angry feelings are important in helping the client reach her goal, they are not appropriate indicators that behavior has changed. Asking the client to list how anger has been handled in the past is helpful if the nurse discusses coping methods with the client. However, based on this client's history, this would not be helpful because the nurse and client are already aware of the client's aggression toward others.
A client is being admitted to a psychiatric outpatient program for counseling for his ongoing emotional symptoms. He is asked to rate the severity of his depression, anxiety, and anger. He states, "I do not have any anger any more. I lost my temper once and nearly hurt my wife. I never got angry again." In which order of priority from first to last should the principles related to anger be shared with this client? All options must be used.
- "Anger is a natural emotion occurring in all human relationships." -"Unexpressed anger has a negative effect on the human body and mind." - "Holding your anger inside contributes to your depression." - "You can learn effective ways to discuss anger with others and still maintain control." Explanation: The clients need to understand that anger is a normal emotion, but if not expressed can have negative effects on the body and mind. Then, the nurse begins to focus on the client's personal situation and help the client understand that holding anger in aggravates his depressive symptoms as well. One focus of outpatient counseling will be learning safe, effective ways to express anger.
When creating an educational program about safety, what information should the nurse include about sexual predators? Select all that apply.
-Child molesters pick children or teens over which they have some authority, making it easier for them to manipulate the child with special favors or attention. - Child molesters gain the child's trust before making sexual advances so the child feels obligated to comply with sex. -Child molesters often choose children whose parents must work long hours, making the extra attention initially welcomed by the child. - Child molesters maintain the secrecy of their actions by making threats if offering attention and favors fail or if the child is close to revealing the secret. Explanation: Child molesters prey on teens or children that they have some authority over. Though some child molesters have had difficult childhoods in which they may have been molested, having them recognize that is not enough to keep them from offending again. Once trust is established, molesters push for a more sexual relationship, which they justify by pointing out what they have done to help the child. Child molesters prey on lonely children or those who spend a lot of time at home alone due to a working parent. They initially show interest and assist the child and family by measures such as providing rides, money, and homework help. If the child tries to stop the sexual interaction or appears ready to tell someone, molesters will use threats to maintain the secret.
A client was brought to the unit and admitted involuntarily. During visiting the next day, the client's brother demands that the client be released immediately. The brother says he might have to hurt staff if the unit door is not opened. In which order of priority from first to last should the nursing actions be implemented? All options must be used.
- Calmly restate to the client and his brother that the client cannot be released without a health care provider's (HCP's) prescription. -Ask the client's brother to leave the unit quietly when he repeats his demands. -Quietly ask the other clients and visitors to move to another area of the unit with a staff member. - Call security officers to the unit for the protection of all on the unit. Explanation: The first step is to calmly present the reality that the client cannot be released at this time. Next, the brother should be asked to leave the unit quietly. When he does not, protecting the other clients and visitors is essential for their safety. (The staff member can help them process what is happening on the unit.) Calling security to the unit is a last resort when less restrictive measures have not worked. Calling them before setting limits with the brother and giving him a choice of actions will likely escalate the situation. Security can legally escort the brother off the unit and hospital grounds.
The widow of a client who successfully completed suicide tearfully says, "I feel guilty because I am so angry at him for killing himself. It must have been what he wanted." After assisting the widow with dealing with her feelings, which intervention is most helpful?
Refer her to a group for survivors of suicide. Explanation: The survivor of suicide, in this situation, would be referred to a group for survivors of suicide to help her with her feelings and to work through the grief reaction. This group provides support and understanding of what the individual is experiencing by members who are experiencing similar reactions, including anger and guilt. Depression and unresolved grief can occur when the survivor does not receive appropriate help. Counseling by a chaplain or individual therapy by the nurse may be appropriate in addition to referral to the group. Giving the survivor the suicide hotline number would be appropriate if the survivor herself were thinking about suicide.
