Treatment of Mental Health Disorders

Which approach would the nurse use to help a client with bipolar disorder who is aggressive and disruptive in group and social settings develop social skills? Facilitating one-on-one interactions Encouraging self-care with support Developing guidelines for seclusion Helping the client decrease activity level

Facilitating one-on-one interactions Rationale: The nurse would facilitate one-on-one interactions. A client who is aggressive in groups must begin socialization in one-on-one interactions that are less stimulating and distracting. Promoting self-care avoids addressing behaviors in group and social situations. Seclusion is always a last resort; the nurse does not want that to be the focus of the treatment. The client may not be able to decrease the activity at this time, and therefore it must be channeled appropriately.

Which therapeutic nursing intervention would redirect a hyperactive, manic client? Suggesting that the client write a short story Having the client initiate group social activities on the unit Asking the client to guide other clients as they clean their rooms Encouraging the client to tear pictures out of magazines for a scrapbook

Encouraging the client to tear pictures out of magazines for a scrapbook Rationale: The nurse would encourage the client to tear pictures out of magazines for a scrapbook. Physical activity will help the client expend some of the excess energy without requiring the client to make decisions or forcing other clients to deal with the behavior. The client's extreme activity limits capacity for concentration or task completion, like writing a short story. The client may disrupt the unit because of the excess activity and bossiness associated with this disorder if asked to initiate social activities on the unit. The client needs guidance and is not able to guide others on how to clean their rooms.

Which action would the nurse take before conducting an admission interview for a client with schizophrenia who has been violent in the past? Move to the client's side and sit down. Alert the assault response team about the client's history. Have two other staff members present when talking with the client. Enter the room with another staff member while remaining between the client and the door.

Enter the room with another staff member while remaining between the client and the door. Rationale: The nurse would enter the room with another staff member while remaining between the client and the door. Making sure to stay between the client and the door provides safety for the nurse and the other staff member, because it will enable them to make a rapid exit. Moving to the client and sitting down invades the client's territory and may precipitate an aggressive client response. Alerting the assault response team is premature; the team is alerted when a client is out of control, harming self or others, and cannot be managed by the staff on the unit. Having two other staff members present may be viewed by the client as confrontational and may precipitate an aggressive response.

Which response would the nurse make to parents of an adolescent with schizophrenia who tell the nurse that they are concerned about how to respond "if our child starts to act crazy"? Telling the parents how to respond to their child's bizarre behavior Assuring the parents that they are capable of controlling their child's behavior Referring the parents to a self-help group of parents with schizophrenic children Having the parents discuss mutual concerns with their child before the discharge date

Having the parents discuss mutual concerns with their child before the discharge date Rationale: The nurse would have the parents discuss mutual concerns with their child before the discharge date. Both the parents and their child should be included in a discussion so that concerns can be addressed openly; this increases trust and fosters a good relationship. Telling the parents how to respond to their child's bizarre behavior is not therapeutic. The nurse would teach, not tell, the parents based upon their concerns. Assuring the parents that they are capable of controlling their child's behavior is false reassurance. There is no evidence of the parents' ability to control their child's behavior. Referring the parents to a self-help group of parents with schizophrenic children may be useful for the family later, but it will not address the immediate problem of dealing with their concerns.

Which approach would the nurse use to help a severely depressed adolescent client accept the realities of daily living? Helping the client fulfill personal hygiene needs Encouraging the client to keep up with school studies Persuading the client to join the other clients in group activities Leaving the client alone when there appears to be a lack of interest in daily activities

Helping the client fulfill personal hygiene needs Rationale: The nurse would help the client fulfill personal hygiene needs. Assisting clients with grooming keeps them in contact with reality and allows them to realize that staff members care enough to help. Encouraging the client to keep up with school studies is not as important as grooming at this time and it is too overwhelming when the client is severely depressed. A one-on-one relationship is best initially before using group activities. The depressed client may withdraw even more if left alone when there appears to be a lack of interest in daily activities.

The client's hallucinations center on the theme of powerlessness. Which response would the charge nurse give to the primary nurse who tells the client, "You seem to be listening to something. Tell me what you hear"? Remind the nurse that once the content is known, there is no need to focus on the hallucinations, because doing so reinforces them. Give positive feedback for the nurse's attempt to explore the content of the client's hallucinations and reinforce the need to continue this approach. Recognize this as a positive intervention and help the nurse develop a plan of care that calls for a contract to refrain from acting on command hallucinations. Suggest to the nurse to use an open-ended approach and ask the nurse to discuss the correlation between positive behaviors observed and prescribed antipsychotics.

Remind the nurse that once the content is known, there is no need to focus on the hallucinations, because doing so reinforces them. Rationale: The charge nurse would remind the nurse that once the content is known, there is no need to focus on the hallucinations, because doing so reinforces them. Once the content of the hallucination is known and it is not a command to harm the self or others, focusing on the hallucinations is not therapeutic; recognizing feelings, pointing out reality, and learning to use strategies to push aside hallucinations are therapeutic. Giving positive feedback reinforces the nurse's inappropriate approach with the client; continuing this approach reinforces the value of the hallucinations, which is undesirable. This is a negative, not a positive, intervention. Also, there are no data to support the fact that the client is experiencing command hallucinations; the client hallucinations center on powerlessness. Clear, concise, direct communication is more desirable when clients are experiencing hallucinations, which are usually frightening; although positive behaviors are a response to antipsychotic medications, these should not be the primary focus of this supervisory session.

Which action would the school nurse take for a child who tells the nurse, "My father has been getting into bed with me at night and touching me"? Ask the child to describe the touching. Talk to the teacher about any inappropriate behavior. Contact the father to come to the school immediately. Report the child's conversation to child protective services.

Report the child's conversation to child protective services. Rationale: The nurse is legally responsible for reporting suspected child abuse to the appropriate child protection agency. The agency must assess the situation and intervene if necessary to protect the child. Asking the child to describe the touching may worsen the psychological trauma; the nurse would listen and demonstrate concern. The nurse does not need any more data from the teacher to have a reasonable suspicion of child abuse; the situation must be reported. Contacting the father may result in more abuse or in the child not reporting future abuse.

Which nursing intervention would be helpful in meeting the needs of an older adult with Alzheimer disease? Providing nutritious foods that are high in carbohydrates and protein Offering opportunities for choices in the daily schedule to stimulate interest Developing a consistent plan with a fixed time schedule to fulfill emotional needs Simplifying the environment as much as possible by limiting the need for decisions

Simplifying the environment as much as possible by limiting the need for decisions Rationale: Simplifying the environment as much as possible by limiting the need for decisions is the nursing intervention that would be helpful for a client with Alzheimer disease. Clients with this disorder need a simple environment. Because of brain cell destruction, they are unable to make choices or decisions. A well-balanced diet is important throughout life, not just during senescence; a diet high in carbohydrates and protein may be lacking in other nutrients such as fat. The client with dementia may be incapable of making choices; providing alternative choices will increase anxiety. Emotional needs must be met on a continuous basis, not just at fixed times.

The nurse discovers the client with antisocial personality disorder and visitors are smoking marijuana in the hall. Which response would the nurse make when the client responds, "I'm celebrating. I went to trial today and just got put on probation"? "You were lucky you just got probation, so don't get right back into trouble." "I understand your relief about the trial, but smoking pot is against the rules." "It's important that you and your friends join the other visitors in the dayroom." "If you can't follow the rules against drug use on the unit, your visiting privileges will be canceled."

"If you can't follow the rules against drug use on the unit, your visiting privileges will be canceled." Rationale: The nurse would respond with, "If you can't follow the rules against drug use on the unit, your visiting privileges will be canceled." This client needs firm, realistic limits set on behavior. This response permits the client to make the choice and clearly states the consequences of behavior. Clients with this diagnosis (antisocial) do not learn from past errors so saying, "You were lucky you just got probation, so don't get right back into trouble," will be ineffective and it is nontherapeutic. The response "I understand your relief about the trial, but smoking pot is against the rules," states the limits but does not inform the client of the consequences if the limits are broken. Clients with the diagnosis of antisocial personality disorder do not care about rules. The client and visitors will probably refuse to socialize with other clients and visitors and it is not appropriate at this time to send them to dayroom after smoking marijuana.

Which response would the nurse make to a client with agitation and mood swings who shouts, "I've been watching you for a few days. You think you're so perfect and good. I think you stink"? "Do you mean that I smell?" "You seem to be angry with me." "Wow, you're in a really bad mood." "I can't really be all that bad, can I?"

"You seem to be angry with me." Rationale: The nurse would say, "You seem to be angry with me." Observing that the client seems angry reflects on the client's feelings rather than focusing on the verbalization. Asking whether the client is referring to an odor changes the subject rather than on the feelings behind it. Stating that the client is in a bad mood dismisses the client and the client's feelings, belittling the client. Saying, "I can't really be all that bad, can I?" focuses the conversation on the nurse rather than the client's inappropriate behavior.

A client with a history of depression presents with multiple physical complaints and reports taking very high doses of vitamin D to "naturally" treat depression. Which symptoms might be explained by this vitamin toxicity? Select all that apply. One, some, or all responses may be correct. 1 Hunger 2 Confusion 3 Bone pain 4 Frequent urination 5 Malaise and fatigue

2, 3, 4, 5 Rationale: Vitamin D toxicity can result in confusion, bone pain, frequent urination, malaise, and fatigue. Vitamin D toxicity does not result in hunger but can cause loss of appetite.

Which rationale would be priority for recommending group activities for a client with persistent depressive disorder? A group can offer increased support. The client is comfortable in group settings. Exposure to group events will dispel the depression. Social stimulation from the group elevates the mood.

A group can offer increased support. Rationale: "A group can offer increased support" is the priority rationale for group activities. A persistent depressive disorder is chronic low-level depression that lasts longer than 2 years. Group activities provide an opportunity for socialization and support from others. It may or may not be true that the client is comfortable in group settings. Although many clients with persistent depressive disorder benefit from exposure to group activities, it will not dispel the chronic depression. Although social stimulation is beneficial, more treatment (medication and psychotherapy) will be needed to elevate the mood.

The home health nurse assesses the client with acquired immunodeficiency syndrome (AIDS) for which signs of altered mental health function associated with AIDS? Select all that apply. One, some, or all responses may be correct. 1 Delusions 2 Memory loss 3 Hopelessness 4 Hyperactivity 5 Paranoid thinking

1, 2, 3, 5 Clients with AIDS experience delusions, memory loss, hopelessness, and paranoid thinking. Changes in the neurological system can lead to alteration in thought patterns, causing delusional and paranoid thinking. Over time, AIDS affects the central nervous system and leads to neurological problems such as deterioration of memory. Feelings of hopelessness commonly occur in clients with AIDS because of the chronic nature of the disorder. Hyperactivity is a condition in which the client has too much energy; clients with AIDS experience a decrease in energy.

A client born as a male with the diagnosis of gender dysphoria has been dressing and functioning as a woman for 2 years and has decided to have sex-reassignment surgery. Place the following nursing interventions in order of priority. 1. Treating the client with respect 2. Investigating one's own feelings about sexuality 3. Encouraging the client to explore her feelings 4. Accepting the client's decision to have sex-reassignment surgery 5. Exploring ways in which the decision can be shared with significant others

2, 1, 3, 4, 5 Rationale: Because the self is the most important factor the nurse brings to the nurse-client therapeutic relationship, the nurse must understand personal feelings about issues surrounding this client's situation and needs by investigating one's own feelings about sexuality. This is part of the preorientation phase of a therapeutic relationship. In a therapeutic relationship, the client is the focus of care and the relationship should be based on respect by treating the client with respect. In an atmosphere of respect, the client is more likely to express feelings when she is encouraged to explore her feelings. The client considering sex-reassignment surgery should explore all alternatives. However, once the decision is made the nurse would support it by accepting the client's decision to have sex-reassignment surgery. After this important decision is made, the client may need assistance in informing significant others so the nurse would explore ways in which the decision can be shared with significant others.

Which feeling would the nurse be trying to prevent in other clients when the nurse sets limits on a client with bipolar disorder, manic episode, who has a superior, authoritative, and condescending manner? Angry Dependent Inadequate Ambivalent

Angry Rationale: The nurse is trying to prevent anger in other clients. A person with a condescending, superior attitude typically evokes feelings of anger in others and will increase their anxiety. It is unlikely that a condescending, superior attitude will produce feelings of dependency, inadequacy, or ambivalence in others.

Based upon the information in the chart, which action would be priority when an older adult presents to the clinic with reports of nausea, headache, and episodes of double vision during the past few days? Perform an in-depth cardiac assessment. Arrange for an ophthalmic consultation immediately. Initiate a conversation about the son's cancer diagnosis. Inquire when the client began therapy for hypertension.

Inquire when the client began therapy for hypertension Rationale: Based upon the information in the chart, which action would be priority when an older adult presents to the clinic with reports of nausea, headache, and episodes of double vision during the past few days?

A father states that his adolescent is not putting forth an effort at school, while the child's mother states, "It's not his fault that his grades are slipping. I've been distracted lately." Which communication problem would the nurse identify after hearing the parents' view on their child's academic performance? Blaming Placating Distracting Generalizing

Placating Rationale: Placating is to appease or pacify, which is described here. Blaming is putting the responsibility for failures, errors, or negative consequences on another. Distracting is the introduction of irrelevant details into problematic issues. Generalizing refers to the use of global statements such as "always" and "never" instead of dealing with specific problems and areas of conflict.

Which parameter would be most important for the nurse to identify after physically assessing a sexually abused female who states, "I've got to talk to someone or I'll go crazy. I shouldn't have dated him"? Support system Sexual background Ability to relay the facts Childhood relational memories

Support System Rationale:Identification of a client's support system and relationships is a priority if the victim is to be helped after the immediate crisis is over. Sexual background and ability to relay the facts may eventually be of value, but at this time they are irrelevant in the assessment of the client's current condition and needs. Childhood relational memories are not a priority at this time; they may become relevant later in therapy. In the immediate crisis, support is most important.

The nurse is working with a client who is crying and very upset. The client states, "I don't want to talk about it; it is too painful." Which question would the nurse ask to obtain the most information about the client's safety? "Is there anyone I can notify of your condition?" "Have you ever thought about going to a safe house?" "Do you feel that your life is in danger where you live?" "Do you belong to any churches in the area that could help?"

"Do you feel that your life is in danger where you live?" Rationale: The nurse would ask about safe living conditions to determine if the client feels his or her life is in danger in the home. The questions regarding asking about notifying someone of the client's condition and about church membership will assess situational support systems. Asking about going to a safe house would be appropriate if the client is found to be in actual danger.

Which approach would the nurse take for a client with Alzheimer disease who is fearful and anxious about being admitted? Exploring the reasons for the client's concerns Reassuring the client with the presence of same staff members Initiating the program of various planned interactions and activities Explaining the purpose of the unit with why admission was necessary

Reassuring the client with the presence of same staff members Rationale: Reassuring the client with the presence of same staff members is the approach the nurse would take. The client needs constant reassurance, because forgetfulness blocks previous explanations; presence of the same staff members serves as a continual reminder. This client will be unable to explain the reasons for concerns because of the dementia. Too many varied activities will increase anxiety in a client with Alzheimer disease. Clients with dementia need simple, structured, routine environments and activities. This client will not remember the explanation from one moment to the next.

Place these nursing assessment questions in the appropriate order to best ensure safety for a client with suicidal ideations. 1. "What is your plan for killing yourself?" 2. "Are you thinking about hurting yourself?" 3. "How would you get what you need to end your life?" 4. "Have you decided on a plan to harm yourself?"

2, 4, 1, 3 Rationale: The nurse would ask the questions in the following order: (1) "Are you thinking about hurting yourself?" (2) "Have you decided on a plan to harm yourself?" (3) "What is your plan for killing yourself?" and (4) "How would you get what you need to end your life?" The initial action is to determine whether the client intends to commit suicide. The second step is to determine whether the client has made the intention specific by planning a method of suicide. The third step is to determine to what extent the client has decided on the details of the act of suicide. Finally, it is necessary to determine whether the client has the means to actually complete the plan.

An older client who has been taking lorazepam for several years is scheduled for a procedure that requires the client to be awake for the duration. The client has a history of violence and hypotension. Which antipsychotic medication is appropriate to administer to the client during the procedure? Select all that apply. One, some, or all responses may be correct. Loxapine Risperidone Haloperidol Perphenazine Olanzapine IM Chlorpromazine

Haloperidol Perphenazine Rationale: Haloperidol and perphenazine are the most appropriate medications. Loxapine is available only through a restricted program and would not be suitable for this client. Risperidone can cause hypotension with reflex tachycardia and carries a risk of stroke among older adult clients. Olanzapine IM should be avoided with lorazepam and also raises the risk of stroke in older adults. Chlorpromazine is very sedating.