2204 Milieu Therapy - The Therapeutic Community, 2204 The Nursing Process in Psychiatric/Mental Health Nursing, 2204 Relationship Development, chapter 6 Cultural and Spiritual Concepts Relevant to Psychiatric/Mental Health Nursing, 2204 Ethical and L...

According to Peplau, which nursing intervention is most appropriate when the nurse is functioning in the role of a surrogate? A. The nurse functions as a nurturing parent in order to build a trusting relationship. B. The nurse plays cards with a small group of clients. C. The nurse discusses childhood events that may affect personality development. D. The nurse provides a safe social environment.

ANS: A According to Peplau, when a client is acutely ill, he or she may incur the role of infant or child while the nurse is perceived as the mother surrogate.

An adolescent client has problems expressing anger appropriately. Which nursing statement would encourage the client to set realistic goals? A. "What do you think needs to change about how you express anger?" B. "How did you feel after attending the anger management session?" C. "On a scale of 1 to 10, please rate your current level of anger." D. "What bothers you about the actions of others when you get angry?"

ANS: A In the planning phase of the nursing process, the nurse works with the client to identify expected outcomes for a plan individualized to the client or to the situation.

A client is recovering from abdominal surgery. In order to maximize the learning process prior to discharge teaching, which assessment should be performed by the nurse? A. Assessing the client's level of pain B. Assessing and documenting the client's vital signs C. Assessing skin turgor and hydration status D. Assessing incisional site for serosanguineous drainage

ANS: A Pain will distract the client and interfere with the learning process.

The nurse should recognize which acronym as representing problem-oriented charting? A. SOAPIE B. APIE C. DAR D. PQRST

ANS: A The acronym SOAPIE represents problem-oriented charting which reflects the subjective, objective, assessment, plan, implementation, and evaluation format. This type of charting identifies nursing diagnoses (client problems) on a written plan of care with appropriate nursing interventions described for each.

A community health nurse is planning a health fair at a local shopping mall. Which middle-class socioeconomic cultural group should the nurse anticipate would most value preventive medicine and primary health care? A. Northern European Americans B. Native Americans C. Latino Americans D. African Americans

ANS: A The community health nurse should anticipate that Northern European Americans, especially those who achieve middle-class socioeconomic status, place the most value on preventative medicine and primary health care. This value is most likely related to this group's educational level and financial capability. Many members of the Native American, Latino American, and African American subgroups value folk medicine practices.

Without authorization, a nurse administers an extra dose of narcotic tranquilizer to an agitated client. The nurse's coworker observes this action but does nothing for fear of repercussion. What is the ethical interpretation of the coworker's lack of involvement? A. Taking no action is still considered an unethical action by the coworker. B. Taking no action releases the coworker from ethical responsibility. C. Taking no action is advised when potential adverse consequences are foreseen. D. Taking no action is acceptable because the coworker is only a bystander.

ANS: A The coworker's lack of involvement can be interpreted as an unethical action. The coworker is experiencing an ethical dilemma in which a decision needs to be made between two unfavorable alternatives. The coworker has a responsibility to report any observed unethical actions.

A psychiatric nurse working on an inpatient unit receives a call asking if an individual has been a client in the facility. Which nursing response reflects appropriate legal and ethical obligations? A. Refusing to give any information to the caller, citing rules of confidentiality B. Refusing to give any information to the caller by hanging up C. Affirming that the person has been seen at the facility but providing no further information D. Suggesting that the caller speak to the client's therapist

ANS: A The most appropriate action by the nurse is to refuse to give any information to the caller. Admission to the facility would be considered protected health information (PHI) and should not be disclosed by the nurse without prior client consent.

9. A Native American client is admitted to an emergency department (ED) with an ulcerated toe secondary to uncontrolled diabetes mellitus. The client refuses to talk to a physician unless a shaman is present. Which nursing intervention is most appropriate? A. Assist the client in contacting a shaman of his choice. B. Explain to the client that "voodoo" medicine will not heal the ulcerated toe. C. Ask the client to explain what the shaman can do that the physician cannot. D. Inform the client that refusing treatment is a client's right.

ANS: A The most appropriate nursing intervention would be to facilitate meeting the client's need to have a shaman present. The nurse should understand that in the Native American culture, religion and health-care practices are often intertwined. The shaman, a medicine man, may confer with physicians regarding the care of a client. Research supports the importance of both health-care systems in the overall wellness of Native American clients.

What is the most essential task for a nurse to accomplish prior to forming a therapeutic relationship with a client? A. To clarify personal attitudes, values, and beliefs B. To obtain thorough assessment data C. To determine the client's length of stay D. To establish personal goals for the interaction

ANS: A The most essential task for a nurse to accomplish prior to forming a therapeutic relationship with a client is to clarify personal attitudes, values, and beliefs. Understanding one's own attitudes, values, and beliefs is called self-awareness.

The following outcome was developed for a client: "Client will list five personal strengths by the end of day 1." Which correctly written nursing diagnostic statement most likely generated the development of this outcome? A. Altered self-esteem R/T years of emotional abuse AEB self-deprecating statements B. Self-care deficit R/T altered thought processes C. Disturbed body image R/T major depressive disorder AEB mood rating of 2/10 D. Risk for disturbed self-concept R/T hopelessness AEB suicide attempt

ANS: A The nurse should determine that altered self-esteem and self-deprecating statements would generate the outcome to list personal strengths by the end of day 1. Self-care deficit, disturbed body image, and risk for disturbed self-concept would generate specific outcomes in accordance with specific needs and goals. The self-care deficit and risk for disturbed self-concept nursing diagnoses are incorrectly written.

Which client response should a nurse expect during the working phase of the nurse-client relationship? A. The client gains insight and incorporates alternative behaviors. B. The client and nurse establish rapport and mutually develop treatment goals. C. The client explores feelings related to reentering the community. D. The client explores personal strengths and weaknesses that impact behaviors.

ANS: A The nurse should expect that the client would gain insight and incorporate alternative behaviors during the working phase of the nurse-client relationship. The client may also overcome resistance, problem solve, and continually evaluate progress toward goals.

11. In what way should a nurse expect a traditional Asian American client to view mental illness? A. Mental illness relates to uncontrolled behaviors that bring shame to the family. B. Mental illness is a curse from God related to immoral behaviors. C. Mental illness is cured by home remedies based on superstitions. D. Mental illness is cured by "hot and cold" herbal remedies.

ANS: A The nurse should expect that traditional Asian Americans are most likely to view mental illness as uncontrolled behavior that brings shame to the family. It is often more acceptable for mental distress to be expressed as physical ailments.

A newly admitted client asks, "Why do we need a unit schedule? I'm not going to these groups. I'm here to get some rest." Which is the most appropriate nursing reply? A. "Group therapy provides the opportunity to learn and practice new coping skills." B. "Group therapy is mandatory. All clients must attend." C. "Group therapy is optional. You can go if you find the topic helpful and interesting." D. "Group therapy is an economical way of providing therapy to many clients concurrently."

ANS: A The nurse should explain to the client that the purpose of group therapy is to learn and practice new coping skills. A basic assumption of milieu therapy is that every interaction, including group therapy, is an opportunity for therapeutic intervention.

The following North American Nursing Diagnosis Association (NANDA) nursing diagnostic stem was developed for a client on an inpatient unit: Risk for injury. What assessment data most likely led to the development of this problem statement? A. The client is receiving electroconvulsive therapy (ECT) and is diagnosed with Parkinsonism. B. The client has a history of four suicide attempts in adolescence. C. The client expresses hopelessness and helplessness and isolates self. D. The client has disorganized thought processes and delusional thinking.

ANS: A The nurse should identify that a client receiving ECT and who is diagnosed with Parkinsonism is at risk for injury due to confusion and potential for falls. History of suicide and hopelessness would lead to the development of a risk for suicide nursing diagnosis. Disorganized thoughts and delusional thinking would lead to the development of an altered thought process nursing diagnosis.

12. Which cultural considerations should a nurse identify with Western European Americans? A. They are present-time oriented and perceive the future as God's will. B. They value youth, and older adults are commonly placed in nursing homes. C. They are at high risk for alcoholism due to a genetic predisposition. D. They are future oriented and practice preventive health care.

ANS: A The nurse should identify that most Western European Americans are present oriented and perceive the future as God's will. Older adults are held in positions of respect and are often cared for in the home instead of nursing homes.

A client requests information on several medications in order to make an informed choice about management of depression. A nurse should provide this information to facilitate which ethical principle? A. Autonomy B. Beneficence C. Nonmaleficence D. Justice

ANS: A The nurse should provide the information to support the client's autonomy. A client who is capable of making independent choices should be permitted to do so. In instances when clients are incapable of making informed decisions, a legal guardian or representative would be asked to give consent.

14. During the first interview with a man from Syria who has just lost his son in a car accident, in sympathy for the man's loss, the female nurse reaches out and hugs him. Which is an accurate evaluation of the nurse's action? A. The nurse's action should be evaluated as unacceptable due to breech of cultural norms. B. The nurse's action should be evaluated as empathetic, encouraging expression of feelings. C. The nurse's action should be evaluated as the technique of offering self. D. The nurse's action should be evaluated as inappropriate due to poor timing.

ANS: A The nurse's action should be evaluated as unacceptable due to breech of cultural norms. During communication, Arab Americans stand close together, maintain steady eye contact, and may touch the other's hand or shoulder but only between members of the same sex.

A client has made the decision to leave her alcoholic husband. She is feeling very depressed. Which nontherapeutic statement by the nurse conveys sympathy? A. "You are feeling very depressed. I felt the same way when I decided to leave my husband." B. "I can understand you are feeling depressed. It was a difficult decision. I'll sit with you." C. "You seem depressed. It was a difficult decision to make. Would you like to talk about it?" D. "I know this is a difficult time for you. Would you like a prn medication for anxiety?"

ANS: A The nurse's statement, "You are feeling very depressed. I felt the same when I decided to leave my husband," is a nontherapeutic statement that conveys sympathy. Sympathy implies that the nurse shares what the client is feeling and by this personal expression alleviates the nurse's distress

To promote self-reliance, how should a psychiatric nurse best conduct medication administration? A. Encourage clients to request their medications at the appropriate times. B. Refuse to administer medications unless clients request them at the appropriate times. C. Allow the clients to determine appropriate medication times. D. Take medications to the clients' bedside at the appropriate times.

ANS: A The psychiatric nurse promoting self-reliance would encourage clients to request their medications at the appropriate times. Nurses are responsible for the management of medication administration on inpatient psychiatric units; however, nurses must work with clients to foster independence and provide experiences that would foster increased self-esteem.

6. A Latino American man refuses to acknowledge responsibility for hitting his wife, stating instead, "It's the man's job to keep his wife in line." Which cultural belief may be associated with this client's behavior? A. Traditional Latino American families are male dominated with clear male-female role distinctions. B. Religious tenets of Latino American culture support the use of violence within a marriage. C. Latino American families are female dominated and the mother possesses ultimate authority. D. Marriage dynamics are controlled by dominant females in Latin American families.

ANS: A Traditional Latino American families are male dominated with clear male-female role distinctions and may impact the client's perception about whether or not striking his wife is physical abuse. The nurse should also recognize that cultural beliefs do no exempt one from adhering to state and federal laws with regard to assault and battery.

Which client statement may indicate a transference reaction? A. "I need a real nurse. You are young enough to be my daughter and I don't want to tell you about my personal life." B. "I deserve more that I am getting here. Do you know who I am and what I do? Let me talk to your supervisor." C. "I don't seem to be able to relate to people. I would rather stay in my room and be by myself." D. "My mother is the source of my problems. She has always told me what to do and what to say."

ANS: A Transference occurs when a client unconscientiously displaces, or "transfers," to the nurse feelings formed toward a person from the past.

A female nurse is caring for an Arab American male client. When planning effective care for this client, the nurse should be aware of which of the following cultural considerations? (Select all that apply.) A. Limited touch is acceptable only between members of the same sex. B. Conversing individuals of this culture stand far apart and do not make eye contact. C. Devout Muslim men may not shake hands with women. D. The man is the head of the household and women take on a subordinate role. E. Men of this culture are responsible for the education of their children.

ANS: A, C, D When planning effective care for this client, the nurse should be aware that limited touch within this culture is acceptable only between members of the same sex, that devout Muslim men may not shake hands with women, and that women are subordinate to the man, who is the head of household. Conversing individuals of this culture stand close together and maintain eye contact. Arab American women are responsible for the education of the children.

Which of the following nursing interventions fall within the standards of psychiatric-mental health clinical nursing practice for a nurse generalist? (Select all that apply.) A. Assist clients to perform activities of daily living. B. Consult with other clinicians to provide services for clients and effect system change. C. Encourage clients to discuss triggers for relapse. D. Use prescriptive authority in accordance with state and federal laws. E. Educate families about signs and symptoms of alcohol dependence and withdrawal.

ANS: A, C, E Assisting clients to perform daily living activities, encouraging clients to discuss triggers, and educating families are nursing interventions that fall within the standards of psychiatric clinical nursing practice for a nurse generalist. Psychiatric-mental health advanced practice registered nurses can consult with other clinicians and use prescriptive authority.

Which is an example of an intentional tort? A. A nurse fails to assess a client's obvious symptoms of neuroleptic malignant syndrome. B. A nurse physically places an irritating client in four-point restraints. C. A nurse makes a medication error and does not report the incident. D. A nurse gives patient information to an unauthorized person.

ANS: B A tort is a violation of civil law in which an individual has been wronged and can be intentional or unintentional. A nurse who physically places an irritating client in restraints has touched the client without consent and has committed an intentional tort.

A nurse is evaluating the effectiveness of teaching after instructing a group of clients on joint replacement. In the evaluation step of the nursing process, which learning domain is the most difficult to measure? A. Normative domain B. Affective domain C. Cognitive domain D. Psychomotor domain

ANS: B Affective knowledge is the most difficult to evaluate because of differences in values, cultures, and attitudes.

A client is assigned the nursing diagnosis of impaired social interaction R/T socio-cultural differences AEB client stating, "Although I'd like to, I don't join in because I don't speak the language so good." Which correctly written outcome addresses this client's problem? A. The client will collaborate with nursing staff to set specific goals by day 3. B. The client will participate in one group activity of choice by day 2. C. The client will express a desire to interact with others. D. The client will become increasingly independent by discharge.

ANS: B In the planning phase of the nursing process, the nurse works with the client to identify expected outcomes for a plan individualized to the client need or to the situation.

15. A nursing instructor is teaching about cultural characteristics. Which statement by the student indicates the need for further instruction? A. "All cultures communicate freely within their group." B. "All cultures embrace light therapeutic touch." C. "All cultures view the importance of timeliness differently." D. "All cultures display biological variations."

ANS: B Not all cultures embrace light therapeutic touch. In the Native American culture, if a hand is offered to another it may be accepted with a light touch; however, in the Asian culture, touching during communication has been historically considered unacceptable. This student statement indicates the need for further instruction.

During the implementation phase of the nursing process, a nurse is teaching an adult with a cochlear implant about medications. Which modification in the teaching plan would be the most appropriate for this client? A. Using repetition B. Speaking directly face-to-face C. Employing the use of sign language D. Providing large-print materials

ANS: B Speaking face-to-face is an appropriate way to teach individuals with alterations in hearing.

Within the nurse's scope of practice, which function is exclusive to the advance practice psychiatric nurse? A. Teaching about the side effects of neuroleptic medications B. Using psychotherapy to improve mental health status C. Using milieu therapy to structure a therapeutic environment D. Providing case management to coordinate continuity of health services

ANS: B The advanced practice psychiatric nurse is authorized to use psychotherapy to improve mental health. This includes individual, couples, group, and family psychotherapy. It is within the scope of practice of a registered psychiatric mental health nurse generalist to provide education, case management, and milieu therapy.

During a hiring interview, which response by a nursing applicant should indicate that the applicant operates from an ethical egoism framework? A. "I would want to be treated in a caring manner if I were mentally ill." B. "This job will pay the bills, and the workload is light enough for me." C. "I will be happy caring for the mentally ill. Working in Med/Surg kills my back." D. "It is my duty in life to be a psychiatric nurse. It is the right thing to do."

ANS: B The applicant's comment reflects an ethical egoism framework. This framework promotes the idea that decisions are made based on what is good for the individual and may not take the needs of others into account.

Which statement is most accurate regarding the assessment of clients diagnosed with psychiatric problems? A. Medical history is of little significance and can be eliminated from the nursing assessment. B. Assessment provides a holistic view of the client including biopsychosocial aspects. C. Comprehensive assessments can be performed only by advanced practice nurses. D. Psychosocial evaluations are gained by subjective reports rather than objective observations.

ANS: B The assessment of clients diagnosed with psychiatric problems should provide a holistic view of the client. A thorough assessment involves collecting and analyzing data from the client, significant others, and health-care providers that may include the following dimensions: physical, psychological, sociocultural, spiritual, cognitive, developmental, economic, lifestyle, and functional abilities.

In response to a student's question regarding choosing a psychiatric specialty, a charge nurse states, "Mentally ill clients need special care. If I were in that position, I'd want a caring nurse also." From which ethical framework is the charge nurse operating? A. Kantianism B. Christian ethics C. Ethical egoism D. Utilitarianism

ANS: B The charge nurse is operating from a Christian ethics framework. The imperative demand of Christian ethics is to treat others as moral equals by permitting them to act as we do when they occupy a position similar to ours. Kantianism states that decisions should be made based on moral law and that actions are bound by a sense of moral duty. Utilitarianism holds that decisions should be made focusing on the end result being happiness. Ethical egoism promotes the idea that what is right is good for the individual.

What is the main goal of the working phase of the nurse-client therapeutic relationship? A. Role modeling to improve interaction with others B. Resolution of the client's problems C. Using therapeutic communication to clarify perceptions D. Helping the client access outpatient treatment

ANS: B The goal of the working phase of the nurse-client therapeutic relationship is to resolve client problems by promoting behavioral change.

A client diagnosed with schizophrenia functions well and is bright, spontaneous, and interactive during hospitalization but then decompensates after discharge. What does the milieu provide that may be missing in the home environment? A. Peer pressure B. Structured programming C. Visitor restrictions D. Mandated activities

ANS: B The milieu, or therapeutic community, provides the client with structured programming that may be missing in the home environment. The therapeutic community provides a structured schedule of activities in which interpersonal interaction and communication with others are emphasized. In the milieu, time is also devoted to personal problems and focus groups.

A hungry, homeless client, diagnosed with schizophrenia, refuses to participate in an admission interview. A nurse streamlines the assessment, verbally assures safety, and provides a warm meal. What is the nurse promoting by these actions? A. Sympathy B. Trust C. Veracity D. Manipulation

ANS: B The nurse is promoting trust by streamlining the assessment, assuring safety, and providing a warm meal. Trust implies a feeling of confidence in that a person is reliable and sincere and has integrity and veracity. Trustworthiness is demonstrated though nursing interventions that convey a sense of warmth and caring to the client.

7. When working with clients of any culture, which action should a nurse avoid? A. Maintaining eye contact, based on cultural norms B. Assuming that all individuals who share a culture or ethnic group are similar C. Supporting the client in participating in cultural and spiritual rituals D. Using an interpreter to clarify communication

ANS: B The nurse should avoid assuming that all individuals who share a culture or ethnic group are similar. This action constitutes stereotyping and must be avoided. Within each culture, many variations and subcultures exist. Clients should be treated as individuals.

Which nursing diagnosis should a nurse identify as being correctly formulated? A. Schizophrenia R/T biochemical alterations AEB altered thought B. Self-care deficit: hygiene R/T altered thought as AEB disheveled appearance C. Depressed mood R/T multiple life stressors D. Developmental disability R/T early-onset schizophrenia AEB hallucinations

ANS: B The nurse should determine that the correctly written diagnosis would be Self-care deficit: hygiene R/T altered thought AEB disheveled appearance. The nursing diagnosis should describe the client's condition, facilitating the choice of interventions.

If an individual is "two-faced," which characteristic essential to the development of a therapeutic relationship should a nurse identify as missing? A. Respect B. Genuineness C. Sympathy D. Rapport

ANS: B The nurse should identify that genuineness is missing in the relationship. Genuineness refers to the nurse's ability to be open and honest and maintain congruence between what is felt and what is communicated. When a nurse fails to bring genuineness to the relationship, trust cannot be established.

Which client should a nurse identify as a potential candidate for involuntary commitment? A. A client living under a bridge in a cardboard box B. A client threatening to commit suicide C. A client who never bathes and wears a wool hat in the summer D. A client who eats waste out of a garbage can

ANS: B The nurse should identify the client threatening to commit suicide as eligible for involuntary commitment. The suicidal client who refuses treatment is a danger to self and requires emergency treatment.

What is the best rationale for including the client's family in therapy within the inpatient milieu? A. To structure a program of social and work-related activities B. To facilitate discharge from the hospital C. To provide a concrete demonstration of caring D. To encourage the family to model positive behaviors

ANS: B The nurse should include the client's family in therapy within the inpatient milieu to facilitate discharge from the hospital. Family members are invited to participate in some therapy groups and to share meals with the client in the communal dining room. Family involvement may also serve to prevent the client from becoming too dependent on the therapeutic environment.

How should a nurse prioritize nursing diagnoses? A. By the established goal of care B. By the life-threatening potential C. By the physician's priority of care D. By the client's preference

ANS: B The nurse should prioritize nursing diagnoses related to life-threatening potential. Safety is always the nurse's first priority.

A client diagnosed with paranoid schizophrenia becomes agitated when asked to play a game. The client responds, "Do you want to be my girlfriend?" Which nursing response is most appropriate? A. "You are upset now. It would be best if you go to your room until you feel better." B. "Remember, we have a professional relationship. Are you feeling uncomfortable?" C. "We have discussed this before. I am not allowed to date clients." D. "I think you should discuss your fantasies with your therapist."

ANS: B The nurse should promote the client's insight and perception of reality by confirming appropriate roles in the nurse-client relationship and identifying what is troubling the client in this situation.

Which nursing action demonstrates the role of the teacher in a therapeutic milieu? A. The nurse implements a self-affirmation exercise during a one-to-one client interaction. B. The nurse holds a group meeting to present common side effects of psychiatric medications. C. The nurse introduces the concept of fair play while playing cards with a group of clients. D. The nurse models adaptive and effective coping mechanisms with clients on the psychiatric unit.

ANS: B The nurse, in the role of teacher, identifies learning needs and provides information required by the client or family to improve the client's health.

A client diagnosed with schizophrenia is exhibiting nonverbal behaviors indicating that the client is hearing things that others do not. Which nursing diagnosis accurately reflects this client's problem? A. Altered thought processes B. Altered sensory perception C. Anxiety D. Chronic confusion

ANS: B The nursing diagnosis altered sensory perception accurately reflects the client's symptoms of hearing things that others do not. A nursing diagnosis describes a client's condition and facilitates the prescription of interventions. Delusional thinking, confusion, and disorientation are problems associated with the nursing diagnosis of altered thought processes.

Which phase of the nurse-client relationship begins when the individuals first meet and is characterized by an agreement to continue to meet and work on setting client-centered goals? A. Preinteraction B. Orientation C. Working D. Termination

ANS: B The orientation phase is when the individuals first meet and is characterized by an agreement to continue to meet and work on setting client-centered goals. There are four phases of relationship development: preinteraction, orientation, working, and termination.

What is the priority nursing action during the orientation (introductory) phase of the nurse-client relationship? A. Acknowledge the client's actions and generate alternative behaviors B. Establish rapport and develop treatment goals C. Attempt to find alternative placement D. Explore how thoughts and feelings about this client may adversely impact care

ANS: B The priority nursing action during the orientation phase of the nurse-client relationship should be to establish rapport and develop treatment goals. Rapport implies feelings on the part of both the nurse and the client based on respect, acceptance, a sense of trust, and a nonjudgmental attitude. It is the essential foundation of the nurse-client relationship.

What is the purpose when a nurse gathers client information? A. It enables the nurse to modify client behaviors related to personality disorders. B. It enables the nurse to make sound clinical judgments and plan appropriate client care. C. It enables the nurse to prescribe the appropriate medications. D. It enables the nurse to assign the appropriate Axis I diagnosis.

ANS: B The purpose of gathering client information is to enable the nurse to make sound clinical judgments and plan appropriate care. The nurse should complete a thorough assessment of the client including information collected from the client, significant others, and health-care providers.

Group therapy is strongly encouraged, but not mandatory, on an inpatient psychiatric unit. The unit manager's policy is that clients can make a choice about whether or not to attend group therapy. Which ethical principle does the unit manager's policy preserve? A. Justice B. Autonomy C. Veracity D. Beneficence

ANS: B The unit manager's policy regarding voluntary client participation in group therapy preserves the ethical principle of autonomy. The principle of autonomy presumes that individuals are capable of making independent decisions for themselves and that health-care workers must respect these decisions.

To effectively care for Asian American clients, a nurse should be aware of which cultural norm? A. Obesity and alcoholism are common problems. B. Older people maintain positions of authority within the culture. C. "Tai" and "chi" are the fundamental concepts of Asian health practices. D. Asian Americans are likely to seek psychiatric help.

ANS: B To effectively care for clients of the Asian American culture, the nurse should be aware that older people in this culture maintain positions of authority. Obesity and alcoholism are low among Asian Americans. The balance of "yin" and "yang," not "tai" and "chi," is the fundamental concept of Asian health practices. In the Asian culture, psychiatric illness is often believed to be out-of-control behavior and would be considered shameful to individuals and families.

The nurse-client therapeutic relationship includes which of the following characteristics? (Select all that apply.) A. Meeting the psychological needs of the nurse and the client B. Ensuring therapeutic termination C. Promoting client insight into problematic behavior D. Collaborating to set appropriate goals E. Meeting both the physical and psychological needs of the client

ANS: B, C, D, E The nurse-client therapeutic relationship should include ensuring therapeutic termination, promoting client insight into problematic behavior, collaboration to set appropriate goals, and meeting the physical and psychological needs of the client. The nurse's psychological needs should not be addressed within the nurse-client relationship.

When interviewing a client of a different culture, which of the following questions should a nurse consider asking? (Select all that apply.) A. Would using perfume products be acceptable? B. Who may be expected to be present during the client interview? C. Should communication patterns be modified to accommodate this client? D. How much eye contact should be made with the client? E. Would hand shaking be acceptable?

ANS: B, C, D, E When interviewing a client from a different culture, the nurse should consider who might be with the client during the interview, modifications of communication patterns, amount of eye contact, and hand-shaking acceptability. Given that cultural influences affect human behavior, its interpretation, and another person's response, it is important for nurses to understand the effects of these cultural influences to work effectively with diverse populations.

After a comprehensive assessment, correctly written nursing diagnoses developed for psychiatric clients may include which of the following components? (Select all that apply.) A. Medical judgments related to the psychiatric disorder B. Unmet client needs present at the moment C. Supporting data that validate the diagnosis D. Outcomes that will be targets for nursing interventions E. Statements of client problems of a functional nature

ANS: B, C, E A nursing diagnosis is a statement of a client's functional problem. An actual nursing diagnosis must include related to (R/T) and as evidenced by (AEB) statements. A risk for diagnosis does not contain AEB because there is only a potential for the problem, it does not as yet exist.

A nurse attends an interdisciplinary team meeting on an inpatient unit. Which of the following individuals are typically included as members of the interdisciplinary treatment team in psychiatry? (Select all that apply.) A. Respiratory therapist and psychiatrist B. Occupational therapist and psychologist C. Recreational therapist and art therapist D. Social worker and hospital volunteer E. Mental health technician and chaplain

ANS: B, C, E The interdisciplinary treatment team in a psychiatric inpatient setting consists of a psychologist, occupational therapist, recreational therapist, art therapist, mental health technician, and chaplain. In addition, a psychiatrist, psychiatric nurse, psychiatric social worker, music therapist, psychodramatist, and dietician participate in the interdisciplinary treatment team.

Which of the following are accurate descriptors of a therapeutic community? (Select all that apply.) A. The unit schedule includes unlimited free time for personal reflection. B. Unit responsibilities are assigned according to client capabilities. C. A flexible schedule is determined by client needs. D. The individual is the sole focus of therapy. E. A democratic form of government exists.

ANS: B, E In a therapeutic community, the unit responsibilities are assigned according to client capability and a democratic form of government exists. Therapeutic communities are structured and provide therapeutic interventions that focus on communication and relationship-development skills.

Because of cultural characteristics, in which of the following cultural groups would a nurse's assessment of mood and affect be most challenging? (Select all that apply.) A. Arab Americans B. Native Americans C. Latino Americans D. Western European Americans E. Asian Americans

ANS: B, E The nurse should expect that both Native Americans and Asian Americans might be difficult to assess for mood and affect. In both cultures, expressing emotions is difficult. Native Americans are encouraged to not communicate private thoughts. Asian Americans may have a reserved public demeanor and may be perceived as shy or uninterested.

How does a democratic form of self-government in the milieu contribute to client therapy? A. By setting punishments for clients who violate the community rules B. By dealing with inappropriate behaviors as they occur C. By setting community expectations wherein all clients are treated on an equal basis D. By interacting with professional staff members to learn about therapeutic interventions

ANS: C A democratic form of self-government in the milieu contributes to client therapy by setting the expectation that all clients should be treated on an equal basis. Clients participate in the decision-making and problem-solving aspects that affect treatment setting. The norms, rules, and behavioral limits are established by the staff and clients. All individuals have input.

17. Which cultural group is correctly matched with the disease process for which this group is most susceptible? A. African Americans are susceptible to lactose intolerance. B. Western European Americans are susceptible to malaria. C. Arab Americans are susceptible to sickle cell disease. D. Jewish Americans are susceptible to thalassemia.

ANS: C A number of genetic diseases are more common in the Arab American population, including sickle cell disease, tuberculosis, malaria, trachoma, typhus, hepatitis, typhoid fever, dysentery, parasitic infestations, thalassemia, and cardiovascular disease.

A client diagnosed with major depressive disorder states, "Why should I keep trying to get a job? I mess up everything I do." Which correctly written nursing diagnosis best reflects the content and mood themes in this client's statement? A. Hopelessness R/T poor job performance B. Risk for impaired adjustment R/T inadequate social skills AEB isolation C. Altered role performance R/T the fear of failure AEB not seeking employment D. Chronic low self-esteem R/T major depressive disorder AEB self-hatred

ANS: C An actual nursing diagnosis must include related to (R/T) and as evidenced by (AEB) statements. A risk for diagnosis does not contain AEB because there is only a potential for the problem, it doesn't as of yet exist. The client's statement indicates that role performance is altered due to the fact that fear of failure prevents seeking employment.

The nurse interviewed a client who was uncooperative, answered questions with minimal responses, and rarely made eye contact. Which is the most complete documentation of baseline data obtained during the interview? A. "Appears uncooperative. Exhibits characteristics of depression." B. "Maintains poor eye contact throughout interview process. Unable to answer interview questions due to depression." C. "States, 'I don't need to be here.' when discussing admission status. Maintains minimal eye contact and offers little data related to triggers for admission." D. "Unwilling to respond openly during interview."

ANS: C Documentation occurs in the implementation phase of the nursing process. All charting entries to the client's legal record should be objective and based on assessed data. Implications and generalizations should be avoided.

16. A nurse is preparing to establish a therapeutic relationship with a grieving family from China. Which nursing intervention would be considered most appropriate? A. Touch each member lightly, as this enhances the communication process. B. Direct questions to the young males of the family, as they maintain positions of authority. C. Avoid direct eye contact, as it implies rudeness. D. Remain objective and empathetic, as Asians express feelings freely.

ANS: C In the Asian culture, eye contact is often avoided, as it connotes rudeness and lack of respect.

The following clients are seen in the emergency department. The psychiatric unit has one remaining bed. The triage nurse should expect which client to be admitted? A. The client who is experiencing tremors and has a need for medication adjustment B. The client who is experiencing anxiety and a sad mood after separation from spouse C. The client who is a single parent and hears voices stating, "Kill your infant son" D. The client who argued with her boyfriend and inflicted a superficial cut on her arm

ANS: C In the assessment phase of the nursing process, the nurse collects comprehensive health data that are pertinent to the client's health or situation. These data are prioritized to meet client needs with an emphasis on safety.

A student nurse asks an instructor how best to develop nursing outcomes for clients. Which reply by the instructor most accurately answers the student's question? A. "Use the Nursing Interventions Classification (NIC) as a reference for nursing outcomes." B. "Look at your client's problems and set a realistic, achievable goal." C. "Use the Nursing Outcomes Classification (NOC) as a reference for nursing outcomes." D. "Copy your standard outcomes from a nursing care plan textbook."

ANS: C NOC is a comprehensive, standardized classification of client outcomes developed to evaluate the effects of nursing interventions.

Which client statement indicates that termination of the therapeutic nurse-client relationship has been handled successfully? A. "I know I can count on you for continued support." B. "I am looking forward to discharge, but I am surprised that we will no longer work together." C. "Reviewing the changes that have happened during our time together has helped me put things in perspective." D. "I don't know how comfortable I will feel when talking to someone else."

ANS: C Termination should begin in the orientation phase to minimize feelings of loss when the nurse-client relationship ends. Bringing a therapeutic conclusion to the relationship occurs when progress has been made toward attainment of mutually set goals.

A nurse moving out of state speaks to a client about the need to work with a new nurse. The client states, "You're the only one who can make me well." What does this client response indicate to the nurse? A. The client is using manipulation to receive secondary gain. B. The client is using the defense mechanism of denial. C. The client is having trouble terminating the relationship. D. The client is using "splitting" as a way to remain dependent on the nurse.

ANS: C Termination should begin in the orientation phase to minimize feelings of loss when the nurse-client relationship ends. When a client feels sadness and loss, behaviors to delay termination may become evident.

Which tool would be appropriate for a nurse to use when assessing mental acuity prior to and immediately following electroconvulsive therapy (ECT)? A. CIWA scale B. GGT C. MMSE D. CAPS scale

ANS: C The MMSE, or mini mental status exam, would be the appropriate tool to use to assess the mental acuity of a client prior to and immediately following ECT. The CIWA scale, or clinical institute withdrawal assessment scale, would be used to assess withdrawal from substances such as alcohol. The CAPS refers to the clinician-administered PTSD scale and would be used to assess signs and symptoms of PTSD. The GGT test is used to assess gamma-glutamyl transferase levels which may be an indication of alcoholism.

A nurse on an inpatient psychiatric unit implements care by scheduling client activities, interacting with clients, and maintaining a safe therapeutic environment. These actions reflect which role of the nurse? A. Health teacher B. Case manager C. Milieu manager D. Psychotherapist

ANS: C The milieu manager implements care by scheduling client activities, interacting with clients, and maintaining a safe therapeutic environment. Health teaching involves promoting health and a safe environment. Case management is utilized to organize client care so that outcomes are achieved. Psychotherapy involves conducting individual, couples, group, and family counseling.

Which data gathering technique is employed during the assessment phase of the nursing process? A. Asking the client to rate mood after administering an antidepressant B. Asking the client to verbalize understanding of previously explained unit rules C. Asking the client to describe any thoughts of self-harm D. Asking the client if the group on assertiveness skills was helpful

ANS: C The nurse should ask the client to describe any thoughts of self-harm during the assessment phase of the nursing process. Assessment involves collecting and analyzing data about the client that may include the following dimensions: physical, psychological, sociocultural, spiritual, cognitive, developmental, economic, lifestyle, and functional abilities. The other three options are employed during the evaluation phase of the nursing process.

What is being assessed when a nurse asks a client to identify name, date, residential address, and situation? A. Mood B. Perception C. Orientation D. Affect

ANS: C The nurse should ask the client to identify name, date, residential address, and situation to assess the client's orientation. Assessment of the client's orientation to reality is part of a mental status evaluation.

A client has undergone psychological testing. With which member of the interdisciplinary team should a nurse collaborate to review these results? A. The psychiatrist B. The psychiatric social worker C. The clinical psychologist D. The clinical nurse specialist

ANS: C The nurse should consult with the clinical psychologist to review psychological testing results for the client. Clinical psychologists can administer, interpret, and evaluate psychological tests to assist in the diagnostic process.

Northern European Americans value punctuality, hard work, and the acquisition of material possessions and status. A nurse should recognize that these values may contribute to which form of psychopathology? A. Dissociative disorders B. Alzheimer's dementia C. Stress-related disorders D. Schizophrenia-spectrum disorders

ANS: C The nurse should correlate Northern European American values, such as punctuality, hard work, and acquisition of material possessions, with stress-related disorders. Psychopathology may occur when individuals fail to meet the expectations of the culture.

A Latin American woman refuses to participate in an assertiveness training group. Which cultural belief should a nurse identify as most likely to have influenced this client's decision? A. Future orientation causes the client to devalue assertiveness skills. B. Decreased emotional expression makes it difficult to be assertive. C. Assertiveness techniques may not be aligned with the client's definition of the female role. D. Religious prohibitions prevent the client's participation in assertiveness training.

ANS: C The nurse should identify that the Latin American woman's refusal to participate in an assertiveness training group may be influenced by the Latin American cultural definition of the female role. Latin Americans place a high value on the family which is male dominated. The father usually possesses the ultimate authority.

Which client statement should a nurse identify as a typical response to stress most often experienced in the working phase of the nurse-client relationship? A. "I can't bear the thought of leaving here and failing." B. "I might have a hard time working with you. You remind me of my mother." C. "I really don't want to talk any more about my childhood abuse." D. "I'm not sure that I can count on you to protect my confidentiality."

ANS: C The nurse should identify that the client statement, "I really don't want to talk any more about my childhood abuse." reflects that the client is in the working phase of the nurse-client relationship. The working phase includes overcoming resistant behaviors on the part of the client as the level of anxiety rises in response to discussion of painful issues.

13. A nurse should recognize that clients who have a history of missed or late medical appointments are most likely to come from which cultural group? A. Northern European Americans B. Asian Americans C. Native Americans D. Jewish Americans

ANS: C The nurse should recognize that Native American clients might have a history of missed or late medical appointments. Many Native Americans are not ruled by the clock. The concept of time is casual and focused on the present.

Which statement regarding nursing interventions should a nurse identify as accurate? A. Nursing interventions are independent from the treatment team's goals. B. Nursing interventions are solely directed by written physician orders. C. Nursing interventions occur independently but in concert with overall treatment team goals. D. Nursing interventions are standardized by policies and procedures.

ANS: C The nurse should understand that nursing interventions occur independently but in concert with overall treatment goals. Nursing interventions should be developed and implemented in collaboration with other health-care professionals involved in the client's care.

A client diagnosed with schizophrenia refuses to take medication, citing the right of autonomy. Under which circumstance would a nurse have the right to medicate the client against the client's wishes? A. When the client makes inappropriate sexual innuendos to a staff member B. When the client constantly demands inappropriate attention from the nurse C. When the client physically attacks another client after being confronted in group therapy D. When the client refuses to bathe or perform hygienic activities

ANS: C The nurse would have the right to medicate a client against his or her wishes if the client physically attacks another client. This client poses a significant risk to safety and is incapable of making rational choices. The client's refusal to accept treatment can be challenged because the client is endangering the safety of others.

What should be the nurse's primary goal during the preinteraction phase of the nurse-client relationship? A. To evaluate goal attainment and ensure therapeutic closure B. To establish trust and formulate a contract for intervention C. To explore self-perceptions D. To promote client change

ANS: C The nurse's primary goal of the preinteraction phase should be to explore self-perceptions. The nurse should be aware of how any preconceptions may affect his or her ability to care for individual clients. Another goal of the preinteraction phase is to obtain available client information.

An angry client on an inpatient unit approaches a nurse stating, "Someone took my lunch! People need to respect others, and you need to do something about this now!" The nurse's response should be guided by which basic assumption of milieu therapy? A. Conflict should be avoided at all costs on inpatient psychiatric units. B. Conflict should be resolved by the nursing staff. C. Every interaction is an opportunity for therapeutic intervention. D. Conflict resolution should only be addressed during group therapy.

ANS: C The nurse's response should be guided by the basic assumption that every interaction is an opportunity for therapeutic intervention. The nurse can utilize milieu therapy to effect behavioral change and improve psychological health and functioning.

A client has a nursing diagnosis of Insomnia R/T paranoid thinking AEB midnight awakenings, difficulty falling asleep, and daytime napping. Which is a correctly written and appropriate outcome for this client's problem? A. The client will avoid daytime napping and attend all groups. B. The client will exercise, as needed, before bedtime. C. The client will sleep 7 uninterrupted hours by day four of hospitalization. D. The client's sleep habits will improve during hospitalization.

ANS: C The outcome "The client will sleep 7 uninterrupted hours by day four of hospitalization." is accurately written and an appropriate outcome to address the client problem of insomnia. Outcomes should be measurable, realistic, client-focused goals that include a time frame. Appropriate nursing interventions are guided by client outcomes.

As the client and nurse move from the orientation stage to the working stage of the therapeutic relationship, which is the nurse's most therapeutic statement? A. "I want to assure you that I will maintain your confidentiality." B. "A long-term goal for someone your age would be to develop better job skills." C. "Which identified problems would you like for us to initially address?" D. "I think first we need to focus on your relationship issues."

ANS: C When moving on a continuum from the orientation to working phase of the nurse-client relationship, identified goals are addressed through mutual therapeutic work to promote client behavioral change.

Which of the following characteristics of accurately developed client outcomes should a nurse identify? (Select all that apply.) A. Client outcomes are specifically formulated by nurses. B. Client outcomes are not restricted by time frames. C. Client outcomes are specific and measurable. D. Client outcomes are realistically based on client capability. E. Client outcomes are formally approved by the psychiatrist.

ANS: C, D The nurse should identify that client outcomes should be specific, measurable, and realistically based on client capability. Outcomes should be derived from the diagnosis and should include a time estimate for attainment. Outcomes are most effective when formulated cooperatively by the interdisciplinary team members, client, and significant others.

A nurse charts "Verbalizes understanding of the side effects of Prozac." This is an example of which category of focused charting? A. Data B. Problem C. Action D. Response

ANS: D "Verbalizes understanding of the side effects of Prozac." is an example of the response category of focused charting. The response is a description of the client's reaction to any part of medical or nursing care.

According to Peplau, which nursing action demonstrates the nurse's role as a resource person? A. The nurse balances a safe therapeutic environment to increase the client's sense of belonging. B. The nurse holds a group meeting with the clients on the unit to discuss common feelings about mental illness. C. The nurse monitors the administration of medications and watches for signs of "cheeking." D. The nurse explains, in language the client can understand, information related to the client's health care.

ANS: D According to Peplau, a resource person provides specific answers to questions usually formulated with relation to a larger problem.

An instructor overhears a student say, "That family seems to disagree more than agree. The family seems to be dysfunctional." To further assess the family's situation, which would be an appropriate instructor reply? A. "Families who disagree can be a challenge to the treatment team." B. "You seem very critical of the family. Do you believe that you are unable to help them?" C. "Let's bring the family in for an educational session to improve their communication." D. "What appears to trigger family disagreements?"

ANS: D In the assessment phase of the nursing process, the nurse collects comprehensive health data that are pertinent to the client's health or situation. In this situation, prior to intervening with this family, the nurse needs further information about the cause of family conflicts.

A client who has slept 6 hours the previous night reports this to the assigned psychiatric nurse. What should be the initial nursing action to address this situation? A. Provide warm milk and a backrub. B. Give a sleep medication. C. Hold a relaxation group before bedtime. D. Review the client's normal sleep pattern.

ANS: D In the assessment phase of the nursing process, the nurse collects comprehensive health data that are pertinent to the client's health or situation. In this situation, the nurse must initially determine the client's normal sleep patterns in order to evaluate if a true problem exists.

During an intake interview, which question would assist the nurse in gathering data about the client's judgment? A. "What brought you to the hospital? Do you know what day and season it is now?" B. "On a scale of 1 to 10, how would you rate your stress level?" C. "What does the phrase 'a rolling stone gathers no moss' mean to you?" D. "If you found a stamped, addressed envelope in the street, what would you do?"

ANS: D In the assessment phase of the nursing process, the nurse collects comprehensive health data that are pertinent to the client's health or situation. The nurse presents a situation that requires the client to make a judgment call and can assess appropriate judgment based on the client's action choice.

Which nursing response would be appropriately used in the evaluation phase of the nursing process? A. "If I were in your situation, I would not repeat a behavior that has caused problems." B. "What do you think needs changing, and what do you want to do differently?" C. "What exactly will it take to carry out your plan, and what else do you need to do?" D. "This new approach seems to work for you."

ANS: D In the evaluation phase of the nursing process, the nurse evaluates progress toward attainment of the expected outcomes.

When is self-disclosure by the nurse appropriate in a therapeutic nurse-client relationship? A. When it is judged that the information may benefit the nurse and client B. When the nurse has a duty to warn C. When the nurse feels emotionally indebted toward the client D. When it is judged that the information may benefit the client

ANS: D Self-disclosure on the part of the nurse may be appropriate when it is judged that the information may therapeutically benefit the client. It should never be undertaken for the purpose of meeting the nurse's needs.

In the role of milieu manager, which activity should the nurse prioritize? A. Setting the schedule for the daily unit activities B. Evaluating clients for medication effectiveness C. Conducting therapeutic group sessions D. Searching newly admitted clients for hazardous objects

ANS: D The milieu manager should search newly admitted clients for hazardous objects. Safety of the client and others is the priority. Nurses are responsible for ensuring that the client's safety and physiological needs are met within the milieu.

An involuntarily committed client is verbally abusive to the staff and repeatedly threatening to sue. The client records the full names and phone numbers of the staff. Which nursing action is most appropriate to decrease the possibility of a lawsuit? A. Verbally redirect the client, and then limit one-on-one interaction. B. Involve the hospital's security division as soon as possible. C. Notify the client that documenting personal staff information is against hospital policy. D. Continue professional attempts to establish a positive working relationship with the client.

ANS: D The most appropriate nursing action is to continue professional attempts to establish a positive working relationship with the client. The involuntarily committed client should be respected and has the right to assert grievances if rights are infringed.

A client on an inpatient unit angrily states to a nurse, "Peter is not cleaning up after himself in the community bathroom. You need to address this problem." Which is the appropriate nursing response? A. "I'll talk to Peter and present your concerns." B. "Why are you overreacting to this issue?" C. "You should bring this to the attention of your treatment team." D. "I can see that you are angry. Let's discuss ways to approach Peter with your concerns."

ANS: D The most appropriate nursing response involves restating the client's feeling and developing a plan with the client to solve the problem. According to Skinner, every interaction in the therapeutic milieu is an opportunity for therapeutic intervention to improve communication and relationship-development skills.

1. An African American youth, growing up in an impoverished neighborhood, presents in the emergency department with bruises to his face, chest, and arms. He appears to be upset, is speaking in a dialect that is difficult for the nurse to understand, and is standing within 6 inches of the nurse's personal space. What cultural consideration should a nurse identify as playing a role in this youth's behavior? A. African Americans frequently speak in different tongues when they are upset. B. Most African Americans have learned to be aggressive when they have to see a health professional. C. African Americans tend to use dialects and invasion of personal space to intimidate others. D. Some African Americans speak in a dialect that is different from standard English and tend toward smaller personal space than that of the dominant culture.

ANS: D The nurse needs to recognize that a tendency toward smaller personal space and the use of dialects different from Standard English are cultural variables and don't necessarily imply aggressive or disrespectful behavior.

An inpatient psychiatric physician refuses to treat clients without insurance and prematurely discharges those whose insurance benefits have expired. Which violation of an ethical principle should a nurse recognize in this situation? A. Autonomy B. Beneficence C. Nonmaleficence D. Justice

ANS: D The nurse should determine that the ethical principle of justice has been violated by the physician's actions. The principle of justice requires that individuals should be treated equally regardless of race, sex, marital status, medical diagnosis, social standing, economic level, or religious belief.

A nurse working on an inpatient psychiatric unit is assigned to conduct a 45-minute education group. What should the nurse identify as an appropriate group topic? A. Dream analysis B. Creative cooking C. Paint by number D. Stress management

ANS: D The nurse should identify that teaching clients about stress management is an appropriate education group topic. Nurses should be able to perform the role of client teacher in the psychiatric area. Nurses need to be able to assess a client's learning readiness. Other topics for education groups include medical diagnoses, side effects of medications, and the importance of medication compliance.

On which task should a nurse place priority during the working phase of relationship development? A. Establishing a contract for intervention B. Examining feelings about working with a particular client C. Establishing a plan for continuing aftercare D. Promoting the client's insight and perception of reality

ANS: D The nurse should place priority on promoting the client's insight and perception of reality during the working phase of relationship development. Establishing a contract for intervention would occur in the orientation phase. Examining feelings about working with a client should occur in the preinteraction phase. Establishing a plan for aftercare would occur in the termination phase.

Which is the best nursing action when a client demonstrates transference toward a nurse? A. Promoting safety and immediately terminating the relationship with the client B. Encouraging the client to ignore these thoughts and feelings C. Immediately reassigning the client to another staff member D. Helping the client to clarify the meaning of the current nurse-client relationship

ANS: D The nurse should respond to a client's transference by clarifying the meaning of the nurse-client relationship based on the current situation. Transference occurs when the client unconsciously displaces feelings toward the nurse about a person from the past. The nurse should assist the client in separating the past from the present.

Which statement should a nurse identify as correct regarding a client's right to refuse treatment? A. Clients can refuse pharmacological but not psychological treatment. B. Clients can refuse any treatment at any time. C. Clients can refuse only electroconvulsive therapy (ECT). D. Professionals can override treatment refusal if the client is actively suicidal or homicidal.

ANS: D The nurse should understand that health-care professionals can override treatment refusal when a client is actively suicidal or homicidal. A suicidal or homicidal client who refuses treatment may be a danger to self or others. This situation should be treated as an emergency, and treatment may be performed without informed consent.

10. When planning care for a Latino American client, the nurse should be aware of which cultural influence that may impact access to health care? A. The root doctor may be the first contact made when illness is encountered. B. The "yin" and "yang" practitioner may be the first contact made when illness is encountered. C. The shaman may be the first contact made when illness is encountered. D. The curandero may be the first contact made when illness is encountered.

ANS: D The nurse should understand that some Latino Americans may initially contact a curandero when illness is encountered. The curandero is the folk healer who is believed to have a gift from God for healing the sick. Treatments often include supernatural rituals, prayers, magic, practical advice, and indigenous herbs.

A mother notified that her child was killed in a tragic car accident states, "I can't bear to go on with my life." Which nursing statement conveys empathy? A. "This situation is very sad, but time is a great healer." B. "You are sad, but you must be strong for your other children." C. "Once you cry it all out, things will seem so much better." D. "It must be horrible to lose a child; I'll stay with you until your husband arrives."

ANS: D The nurse's response, "It must be horrible to lose a child; I'll stay with you until your husband arrives." conveys empathy to the client. Empathy is the ability to see the situation from the client's point of view. Empathy is considered to be one of the most important characteristics of the therapeutic relationship.

Which rationale by a nursing instructor best explains why it is challenging to globally classify the Asian American culture? A. Extremes of emotional expression prevent accurate assessment of this culture. B. Suspicion of Western civilization has resulted in minimal cultural research. C. The small size of this subpopulation makes research virtually impossible. D. The Asian American culture includes individuals from many different countries.

ANS: D The nursing instructor's best explanation is that the Asian American culture is difficult to classify globally due to the number of countries that identify with this culture. The Asian American culture includes peoples and descendents from Japan, China, Vietnam, the Philippines, Thailand, Cambodia, Korea, Laos, India, and the Pacific Islands. Within this culture there are vast differences in values, religious practices, languages, and attitudes.

Which expected client outcome should a nurse identify as being correctly formulated? A. Client will feel happier by discharge. B. Client will demonstrate two relaxation techniques. C. Client will verbalize triggers to anger by end of session. D. Client will initiate interaction with one peer during free time within 2 days.

ANS: D The statement "Client will initiate interaction with one peer during free time within 2 days." is an example of a correctly formulated expected outcome. Outcomes should be measurable, realistic, client-focused goals that include a time frame. Appropriate nursing interventions are guided by client outcomes.