EXAM 2
A young woman who has been divorced twice says to the nurse, "I've decided not to date men ever again! It never works out for me. Now I'm left with two children to bring up." Which nursing response would be therapeutic?
" Divorce is hard to go through. Tell me what difficulties you feel you will face raising your children."."
The wife of a client who is dying says to the nurse, "I am able to take off the 6 months from work our doctor feels that my husband will live, but what if he lives beyond that time?" Which therapeutic response should the nurse make?
"Are there other options for you in taking work leave? Perhaps you could simply reduce your work hours at first so that you can extend your compassionate leave."
A 74-year-old widower of 3 months says to the nurse, "When my wife died, I lost my love and my best friend. Everyone I cared about is dead. We both were only children, and we had no kids. I'm more than ready to go when the time comes." Which nursing response should the nurse make?
"Are you thinking of ending your life because your time has come?"
A 52-year-old client is admitted to the hospital for surgery to treat lung cancer. The client says to the nurse, "I was an alcoholic for 15 years, and now that I'm 25 years sober, I'm being punished." Which statement by the nurse would be therapeutic?
"Because you seem to be blaming yourself unnecessarily, perhaps we can talk about your illness and what you can expect after surgery."
A young widow of 18 months says to the nurse, "I'm going to need a babysitter, because I'm going on a blind date at my brother and sister-in-law's house. They fixed me up, but I think it may be too soon." Which statement by the nurse would be therapeutic?
"By the end of a year, most people are able to renew their interest in other people and activities."
A client who is undergoing psychiatric counseling calls a nurse on a hotline, crying, and states, "My priest assaulted me when I was an altar boy, and my dad just found out. He's got a gun, and he's driving over to the church rectory. I don't know what to do." Which response by the nurse is most appropriate initially?
"Call the priest immediately and tell him to lock the doors until the police arrive. I'll call the police."
A client who delivered a baby 4 weeks ago says, "I'm feeling as if I'm hanging on by a thread to keep my wits about me." Which statement by the nurse would be therapeutic?
"Can you share with me more specifically how you feel that you're hanging on by a thread? Are you having thoughts of hurting yourself?"
A female victim of incest says to the nurse, "I've had tons of therapy but still can't let my fiancé get too close. He knows I've been sexually abused by my dad and older brother, but I'm wondering whether I'll ever be able to lead a normal sexual life." Which statement by the nurse would be therapeutic?
"Can you share with me some of the strategies you've been using?"
A client who was formerly a workaholic has lost his job and is being supported financially by his wife. The client says to the nurse, "I know that my wife is disappointed in me, but I can't seem to get a job doing what I've done for 25 years. Why should I take a low-level job when she's able to support us financially?" Which response by the nurse would be therapeutic?
"Can you tell me a little more about this?"
A 35-year-old recently divorced parent of twins comes to the intake office of the psychiatric clinic for the first time with a possible diagnosis of generalized anxiety disorder. The client says to the nurse, "My mother always called me a worrywart like my nana, so I guess I come by my problems naturally. I keep worrying about things I can't change, like my divorce, and blaming myself when I know I'm not the only one responsible for the divorce." Which nursing statement would be therapeutic?
"Can you tell me more about the worrying and blaming you are experiencing?"
A 32-year-old married woman who recently gave birth to her first child by cesarean section says, "My husband and I worry about our baby all the time. We did everything right, yet he had so many problems at birth." Which statement by the nurse would be therapeutic?
"Can you tell me more about the worrying? What's been happening since you brought your baby home?"
A 35-year-old client says to the nurse, "I got divorced less than a year after getting married. I left the Navy SEALs shortly after I joined. Now I teach in the air marshal program to avoid being recalled for war, but I'd really like to quit. I start something, am great at it, then get bored and move on. I date, but I'm still living at home. I never seem to be on my own like other guys my age." Which response by the nurse is most appropriate?
"Can you tell me more about your marriage and relationships? If you leave home, what do you fear will happen?"
A client with an anxiety disorder who has been prescribed an antibiotic for otitis media asks the nurse, "Why'd the doctor tell me not to discontinue the antibiotic until the pills are gone?" Which response by the nurse is appropriate?
"Completing the prescription ensures that the infection will be resolved."
An older adult client who is dying says to the nurse, "My son is 40 years old, but he works in a very poorly paying job and is always borrowing money from me. I don't know how he's going to manage without me." Which response by the nurse would be therapeutic?
"Could you share your feelings with your son just as you have with me?"
A 45-year-old client says to the nurse, "Since I left my wife and children, I can hardly make ends meet between child support and trying to support myself. I don't know why I bother going to work when my wife and kids take just about everything I make." Which nursing statement would be therapeutic?
"Do you feel that child support is designed to help children, not punish spouses who leave?"
A client in halo traction says to the nurse, "I can't get used to this contraption. I can't see properly on the side, and I keep misjudging where everything is." Which response by the nurse is therapeutic?
"Halo traction involves many difficult adjustments. Practice scanning with your eyes after standing up, before you move."
A client with schizophrenia attending a support group held by a clinic nurse says to the nurse and the group, "I've been laid off from my job at the factory, and so have 300 other people, so I'll have to get a new job. For now, there's unemployment." Which statement by the nurse would be most therapeutic at this time?
"Have other people in the group been feeling the job crunch this week? When changes like this occur, it's best to increase the number of your appointments with me for a short time."
A client who delivered a baby 4 months ago says, "I keep thinking that this boy is some sort of demon. All he does is cry. It's as if I can't feed him enough or satisfy him in any way. My daughter never gave me this kind of trouble. I really can't stand it." Which statement by the nurse is most important?
"Have you been having any thoughts of hurting your baby?"
A 62-year-old woman says, "Since my husband retired, 4 months ago, he's started playing golf 24/7, so after rearing our children alone while my workaholic husband ran his business I'm suddenly a golf widow." Which response by the nurse is appropriate?
"Have you shared your feelings with your husband?"
A client who was employed as a corporate manager before being laid off says to the nurse, "My wife thinks that I should work in a menial job to maintain our lifestyles until I find another job as a corporate manager, but I don't feel I should have to humiliate myself like that." Which nursing response would be therapeutic?
"Have you shared your feelings with your wife?"
A 16-year-old client says, "My dad thinks I'm evil, but we get into fights because I let things build up. He never has any time for me because he's always glued to the TV. He doesn't even look at me when he talks." Which statement by the nurse encourages the client to use assertive behavior with his father?
"Have you tried saying that directly to your dad? For example, you could say, 'I notice that you watch television when I'm telling you things that are important to me.'"
A client with schizophrenia says to the nurse, "I keep getting these thoughts and hearing voices. They worry and consume me so that I can't always stop myself like my health care provider told me to." Which intervention would the nurse suggest as a distraction technique?
"Have you tried to count back from 100 or listen to music?"
A client in the mental health unit tells the nurse, "My husband makes all the decisions about money, but I'm the one who's making the money now, not him. He needs to back off, but he's always directing every decision we make." Which nursing response would be the most therapeutic?
"How do you feel the money decisions could best be handled in your household?"
A 12-year-old client who has been reported for drawing sexually explicit scenes in her textbooks during class says to the psychiatric nurse, "I just felt like it." Which response by the nurse would be therapeutic and aid assessment of abuse-related symptoms?
"I am concerned about you. Are you being or have you ever been abused?"
The family of a client who is being discharged after trying to kill himself with one of his father's guns asks for a family meeting with the nurse to discuss their son's situation. Which statement by the nurse would be the most therapeutic start to the meeting?
"I am going to begin by talking in general terms about your son's return home and some of the things that might happen. I can suggest measures that might be helpful, and then you can ask questions."
A 61-year-old client whose two sons and daughter-in-law died in a nightclub fire says to the nurse, "We were going to retire early, but now we are the only ones who can care for our two grandchildren." Which response by the nurse would be therapeutic?
"I am sorry you've had so many losses."
The nurse is teaching assertiveness training to a client with anger-management issues. Which client statement indicates the client is able to assertively confront someone?
"I can ask for private time to talk and point out the facts without being accusatory, then determine areas of mutual misunderstanding and request the changes I need."
Family members awaiting the outcome of a suicide attempt are tearful. Which response by the nurse would be most therapeutic to the family at this time?
"I can see that you are worried."
A client says to the nurse, "I'm really phobic about flying, so my husband and I always drove or took the train everywhere. Now he's been offered a big job in Europe, and if I don't get over this and fly with him, he says we're done. I'll be left to bring up our three children by myself." Which statement by the nurse would be therapeutic?
"I can teach you strategies to help master your panic. An antianxiety medicine would also help you."
A psychiatric nurse is playing a card game with a client in the day room. The client states to the nurse, "The voice in my head is telling me that you're cheating." Which response by the nurse is therapeutic?
"I do not hear any voices. Has the voice said anything else?"
A client with mania who tends to be manipulative says angrily, "You had better let me out of here, or I'm going to call my lawyer. My boss has good friends with the owners of this tin-pot place you call a 'mind holism respite.'" Which statement by the nurse would be most therapeutic?
"I know that you feel that you're doing your very best right now, but you are yelling. Take some time out and some deep breaths, and I'll speak to you in half an hour."
The mother of a child who is taking methylphenidate hydrochloride(HCL) tells the school nurse that she is administering an over-the-counter (OTC) cough syrup to her son. Which response by the nurse would be appropriate?
"I think that you should stop giving this medicine to your son until I can check its content with the pharmacy."
Which statement made by a client with anorexia nervosa would indicate to the nurse that treatment has been effective?
"I went out to lunch today with my cousin."
The nurse is evaluating the coping skills of a client with a diagnosis of depression. Which statement indicates to the nurse the need to help the client learn and appropriately use these skills?
"I won't ever be depressed again."
In planning the care of a client dying of cancer, the nurse seeks to have the client verbalize acceptance of his impending death. Which statement indicates to the nurse that this goal has been met?
"I'd like to have my family here when I die."
The nurse is monitoring a client who is in seclusion. The nurse determines that it is safe for the client to come out of seclusion when the client makes which statement?
"I'm no longer a threat to myself or others."
The nurse is talking to a client whose spouse died 10 months ago. Which statement by the client indicates successful mourning?
"I'm planning a trip to England next fall to tour the mansions and their gardens."
A client with schizophrenia is seen seemingly talking to someone who isn't there. Which nursing statement would be most therapeutic initially?
"I've noticed your eyes darting back and forth, and I wondered whether you might be hearing voices."
A dying client with agoraphobia says to the nurse, "I've been unable to leave this house without tremendous effort for so long, and now it doesn't matter." Which statement by the nurse would be therapeutic?
"It doesn't matter? Can you share your feelings with me?"
During a nursing interview, a client says, "My daughter was murdered in her apartment, and her estranged husband called to tell me. I can't stop myself from wondering whether he killed her, but the police have ruled him out as a suspect." Which response by the nurse would be therapeutic?
"It feels terrible to lose a daughter."
A postpartum client says to the nurse, "Sometimes I hear voices telling me to kill my baby to save her all the heartache I've been through." Which statement by the nurse would be most therapeutic?
"It is so good that you shared your feelings and thoughts with me. I'm going to help you get immediate attention for your voices."
The young nurse has just completed postmortem care of a 16-year-old client who died of cancer. The nurse says to the nurse manager, "I never get sick, and this client kept telling me that he couldn't remember not being ill. I feel terrible and so bad for him and about what he went through." Which statement by the nurse manager would be therapeutic?
"Let's go for coffee and talk about this some more, shall we? We're both due for our coffee breaks."
The nurse is caring for an older adult client who says, "I don't want to talk with you — you're only a nurse. I'll wait for my health care provider." Which response by the nurse would be therapeutic?
"So you're saying that you want to talk to your health care provider?"
The wife of a dying man is ignoring his rapid physiological decline and imminent death. She continues with her usual activities, exhibits inability to remember what others have just told her, and misses important appointments. Which therapeutic statement should the nurse make to the wife?
"It isn't unusual for family to suffer from anticipatory grief when a loved one is dying."
A client who was recently admitted to the mental health unit has a history of paranoia. When the meal tray is delivered, the client refuses to eat and tells the nurse that someone is poisoning the food. Which statement by the nurse is appropriate?
"It must be frightening to you. Has something made you feel that your food is poisoned?"
A client says to the nurse, "I've started a journal because my health care provider suggested it, and I'm writing about the things that bother me each day. Sometimes I dictate my feelings and what happened during the day into a recorder and write them up before I go to bed — and, do you know, they seem silly to me then. Is this helping me?" Which response by the nurse would be appropriate?
"It seems that people who write in their journals and can share traumatic events improve their self-awareness."
The client says to a nurse, "Do you know that after 24 years of marriage I still serve my husband breakfast in bed? After all I do for him, he still doesn't treat me well. He should treat me better." Which nursing response is appropriate?
"It seems that you feel that your husband could treat you well just as you treat him."
A survivor of a nightclub fire that killed more than 100 people says to the nurse, "It should have been me. How come I got out and they didn't?" Which response by the nurse is appropriate?
"It seems that you're blaming yourself for something that was beyond your control."
During a mental health intake interview, a young adult client who lives with his family rent free says, "I'm tired of not being able to offer my friends a beer just because my folks don't believe in taking a drink socially." Which nursing response would be therapeutic?
"It seems that your parents expect you to follow their rules when you live under their roof."
A 56-year-old client says to the nurse, "I'm a guidance counselor at the middle school, and the kids like to come to see me for help, but I just found out from my wife that my 22-year-old daughter is a lesbian, and now I'm the one who needs advice. How am I supposed to accept that? She was the boy we didn't have, and I made a tomboy of her by taking her to baseball games with me. Is that why she's gay?" Which statement by the nurse would be therapeutic?
"It sounds like you and your daughter were very close but she kept her sexual orientation from you."
A client in skeletal traction says to the nurse, "I can't get any help with my care! I call and call, but the nurses never answer my light. Last night one of them told me she had other patients besides me! I'm very sick, but the nurses don't care!" Which response by the nurse would be therapeutic?
"It's hard to be in bed and have to ask for help. You call for a nurse who never seems to come?"
A client who is an attorney says to the clinic nurse, "I'm worried about my wife. She's been so distant and disorganized since our son died of leukemia 4 months ago. She never suggests that we go out or take our other children anywhere. Is this normal, or do I need to get her to a doctor?" Which statement by the nurse would be therapeutic?
"It's normal, but by the end of a year you can expect that your wife is improving and able to redirect her energy. Have you expressed your concerns to her?"
A client says to the nurse, "My health care provider wants me to start keeping a journal every day about what's happening in my job." Which response by the nurse is appropriate?
"Journal-keeping that identifies what seems to cause a strain in a person's life is a good way of improving one's health."
The nurse is caring for a bereaved man with acquired immunodeficiency syndrome (AIDS) who lost his twin brother in a rock-climbing accident a month ago. Which statement by the client should cause the nurse to be concerned?
"Lately I've been feeling that life isn't that great."
The husband of a terminally ill client says to the nurse, "My company went bankrupt, my son is a drug addict, my daughter is an alcoholic, and now this! My doctor wants me to try some stress reduction because my blood pressure is up. Whose wouldn't be? I've tried music and relaxation, but they don't work." Which statement by the nurse would be therapeutic?
"Let's talk more about what has been helpful to you in the past."
A client says to the nurse, "It's over for me — the whole thing is over." Which response by the nurse would be therapeutic?
"Let's talk more about your feeling that the whole thing is over for you. This is important, and I may need to share your feelings with other staff members."
On the initial visit to the mental health clinic, a client says to the nurse, "When I married my husband, more than 30 years ago, he was a big, handsome, competent professional who never wanted me to work and was so loving. Well, two kids later he's a slob who gambles and loses one job after another. Now I'm the breadwinner and he's content to be a shiftless town joke." Which statement by the nurse would be therapeutic?
"Many things have happened to you and your husband. Sounds as if you've both been struggling for some time. Would you like to have him come in with you to talk with me about all of this?"
An alcoholic client says to the nurse, "I'm taking milk thistle, so I can drink all I want and never get cirrhosis." Which statement by the nurse would be therapeutic?
"Milk thistle is an herbal extract. It does seem to prevent liver damage and stimulate liver cell regeneration, but it can't prevent damage to other organs, like your brain."
The nurse performing a lethality assessment asks the client whether he is thinking of suicide. Which statement by the client would be of most concern to the nurse?
"No, I wasn't, but I am now, thanks to you."
A 68-year-old client whose husband died 2 months ago says to the nurse, "I'm having trouble sleeping lately, even though I don't nap in the daytime. I've been using warm milk without any results." Which statement by the nurse would be therapeutic?
"One of the things that I've found has helped others is a small snack with your warm milk before sleep and a moderate increase in walking during the day. Is that something you could try?"
A client says to the nurse, "My doctor tells me that I need to start progressive muscle relaxation(PMR) to ease my stress, but I just can't get the hang of it." Which response by the nurse would be most helpful?
"PMR requires training sessions. Let's check into classes that you can attend to learn the technique."
A client says to the nurse, "My doctor says he thinks I'm ready to taper off my pain medication, but the new painkiller he prescribed doesn't relieve my pain the way the other pill did. I get pain when I try to do things." Which nursing response would be most supportive to the client?
"Perhaps if I medicate you about a half-hour before you plan to start your daily activities, the medicine will be more effective."
As the nurse prepares to interview a client being admitted to the mental health unit, the client says, "I asked my family to bring me in here to talk to someone, but now I don't know where to begin." Which response by the nurse would be most helpful?
"Perhaps you can start by sharing some of your most recent concerns."
A client says to the nurse, "I was cheating on my lover because I need the thrill of seeing someone new, and now my lover has left me to go live with this other woman. I know that this other woman wants more than friendship from my lover, and I can't make my lover see that I love her and that my affairs are meaningless. I don't want to lose her, but I can't stop cheating, because I need the thrill it brings." Which statement by the nurse would be therapeutic?
"Perhaps your task is not to make your lover see that your dalliances are meaningless but to look at your own behavior and determine what you would like or not like to be different."
A 79-year-old client, recently widowed, says to the nurse, "My wife kept up our condominium single-handedly, and now my kids expect me to cook and clean for myself. I'm not lazy, but I don't know how to cook and I've burnt myself twice just frying up what was supposed to be bacon and eggs. I'm so frustrated and I've already lost 10 lb (4.5 kg) this month." Which initial nursing statement should the nurse make to the client?
"Seems as if you feel lost without your wife and maybe a bit ignored by your children."
A client says to the nurse, "I've been following my diet and taking my medication. What else do you want to talk about today?" Which response would be most helpful during the working phase of the therapeutic alliance?
"Some people have added exercise to diet and medication therapy and gotten positive results. Do you think that this would work for you?"
A client whose husband died 2 months ago says to the nurse, "After church, I visit my husband's grave and talk to him. It comforts me, but my daughter thinks I'm morbid and crazy and is upset with me because I don't want to meet her for coffee after church like I used to." Which statement by the nurse would be therapeutic?
"Sounds as if you have had difficulty letting your husband go from your life. What would happen if you visited his grave less frequently?"
The 45-year-old husband of a client with breast cancer who just died says to the nurse, "If our doctor had operated sooner, my wife would be alive now." Which statement by the nurse would be therapeutic?
"Sounds as if you're feeling angry and pretty helpless right now."
A dying client says to the nurse, "How do I tell my parents that I am dying of AIDS ?" Which statement by the nurse would be therapeutic?
"Sounds as if you're thinking that it's time for you to tell your parents about your disease."
A university professor meeting with the mental health nurse for his weekly therapy session says, "I have a very intelligent student who keeps disrupting my classroom by bragging, and all I want to do is say, 'OK, you're great and you know it all! Now shut up!' But I just don't want to be rude." Which statement by the nurse is therapeutic?
"Sounds like you feel pretty helpless, yet you are the professor here."
A victim of sexual assault is being seen in the crisis center. The client states that she still feels "as though the assault just happened," even though it has been a few months since she was attacked. Which supportive statement should the nurse make to the client?
"Tell me more about why you feel like the assault just occurred."
A client who is experiencing suicidal thoughts says to the nurse, "It just doesn't seem worth it anymore. Why shouldn't I just end it all?" Which statement should the nurse use to gather additional data from the client?
"Tell me what you mean by that."
A client who is experiencing suicidal thoughts says to the nurse, "Life is just not worth it anymore." What is the appropriate initial response?
"Tell me what you mean by that."
A client who is an alcoholic, and has been sober for 8 months asks the nurse, "Do you think I should add individual therapy to my treatment plan?" Which response by the nurse would be therapeutic?
"The best time to add individual therapy seems to be after 2 to 5 years of sobriety. Individuals vary, though, and it may be that you are asking because you feel ready to work on your issues."
The parents of an adopted child schedule an appointment at a psychiatric clinic, and when they arrive the nurse conducts an initial assessment. One of the parents says to the nurse, "We need to speak to a psychiatrist about our adopted daughter. Could you please get one for us?" Which intervention by the nurse would be therapeutic?
"The doctors here feel that clients are best served when I conduct the initial assessment, after which the psychiatrist will see you with complete information."
The wife of an alcoholic client says to the nurse, "I can't afford to bail my husband out of this mess. Our business is filing for bankruptcy, and the Internal Revenue Service has posted a notice of auction on our home." Which statement by the nurse would be therapeutic?
"The lack of money has stopped you from saving your husband? It sounds like you need to help yourself right now. What do you think?"
A client says to the nurse, "What does my psychiatrist mean when she says that my illness is biologically based?" Which nursing statement would be the most informative?
"There are many possible physical causes of mental illness, and they include problems in the brain."
A single mother whose son was suspended from school for carrying a gun into the school, says to the nurse, "I know he has no dad, but I've brought him up to know better, and anyway, where did he get the stupid gun? What should I do? He just won't listen to me." Which nursing response would be helpful at this time?
"There is quite a bit that you can do. Let's talk about what you're already doing first."
A client who is an alcoholic, has been admitted to the mental health unit states to the nurse, "The judge made me come in here. My blood alcohol level was only 0.20% when the cop pulled me over in my car." Which statement by the nurse is most appropriate?
"This level means that you consumed several drinks of alcohol and would be experiencing depressed motor function of the brain. You would have been staggering and clumsy and your judgment would have been impaired, but you seem to feel that the judge was unreasonable for sending you here."
A 2-year-old child has injuries consistent with child abuse and the nurse is interviewing the child's parent. Which statement by the parent indicates the possibility of child abuse?
"When I tell my child to do something, I don't expect to have to repeat myself."
The parent of a 25-year-old man who has just been found to have a left frontal brain tumor says to the nurse, "At the local hospital, our doctor thought that his headaches were nothing and prescribed an analgesic. If I hadn't insisted on a CT scan, no one would have found the tumor." Which statement by the nurse would be therapeutic?
"You and your son are having a very trying time. What's happened since your son's diagnosis?"
A client with schizophrenia exhibits confused and unintelligible speech. Which nursing statement would be most therapeutic?
"This morning you are participating in the tree-decorating ceremony for the unit."
A client in a retirement center rings the night alarm and says to the nurse, "Look at this old man! He keeps breaking into my apartment! You've got to get him to stay out of here so I can sleep." Which statement by the nurse would be most therapeutic?
"This must be very troubling to you, but I can't see the old man. Perhaps I could stay with you for an hour or so while you try to rest."
An acutely ill client with schizophrenia says to the nurse, "He keeps saying that he likes you, and I keep telling him you're married, but he won't listen, and I think he's going to get fresh with you." Once the nurse has determined that the client is hallucinating, which response to the client would be most appropriate statement?
"Try not to listen to the voices right now so that I can talk with you."
A client says to the nurse, "I came in to see you because I've been off my medication for 4 years but I feel as though I may be getting depressed again. I've been despondent again and thinking I should have ended it. That's why I'm here to get help." Which response by the nurse would be therapeutic?
"Well, it's been more than 4 years, so you've done really well. Sounds like you're right about getting depressed again, though. Can you tell me what's been happening with you lately?"
A health care provider (HCP) tells a client that she has cancer, that her illness is terminal, and that she has a 6-month prognosis. After the health care provider leaves the client's room, which therapeutic statement should the nurse make to the client?
"What did your HCP tell you about your condition? Can you tell me what you're thinking about?"
A young adult client says to the nurse, "All my friends are married and have children. I can't seem to meet anyone, and I know I'll never be happy until I meet someone I can care about enough to marry." Which statement by the nurse would assist the client in reframing the situation?
"You can't seem to meet someone that you care about? You can still find enjoyment in friendships, work, books, and other things as well."
A client says to the nurse, "I don't do anything right. I'm such a loser." What is the appropriate response?
"You don't do anything right?"
The widow of a man who was killed a week ago in a hit-and-run accident while walking the family dog says, "I should have just let the dog run in the backyard or gone with my husband. Our own parish priest hit my husband and finally surrendered to the police. He brought a lawyer with him because he's worried about himself, not my husband. I hate him so much, my stomach hurts." Which nursing statement would be therapeutic?
"You not only lost your husband but also learned it was at the hands of someone you looked up to."
The nurse is talking to a client with depression when the client says, "I don't know why my son turned out like he did. I never thought that he would rob a bank! I don't know what I did wrong. I know that he didn't grow up with a father, but I gave him everything. I wish I could start over and do things differently." Which response by the nurse would be therapeutic?
"You seem to be feeling regret."
The nurse is caring for a 39-year-old client who has experienced a cerebral vascular accident(stroke). The client is recently widowed, is very active physically, and has two young sons. The client says to the nurse, "I don't know what my sons will do if anything permanent happens to me. We have no other relatives, even on my late wife's side." Which of the following nursing responses would be therapeutic?
"You seem to be feeling very troubled."
A client says to the nurse, "I have to do everything. My family can't plan or organize anything. My wife just wants to go out and socialize. My grown son and his wife live with us. They never do anything around the house but 'their' stuff, because they say they pay rent. We really need their rent money since I lost my job. My wife could work but she says 'it's too late to start over' for her. Well, that's what I'm doing—more work at far less money." Which response by the nurse would be therapeutic?
"You seem to be going through quite a lot recently. I'd like to hear more from you about your concerns. Would your family come in and talk with us?"
The nurse employed in a home care agency is assigned a recently widowed client. When the nurse arrives at the client's home, the ordinarily immaculate house is in chaos and the client is disheveled, with the odor of alcohol on his breath. Which statement by the nurse would be therapeutic?
"You seem to be having a very difficult time."
A recently widowed client says, "I lived my whole life for my husband and children. Now he's dead and my daughter and son have each married and moved across the country. They hardly ever call or visit. It's just that there's really nothing much for me to do." Which response by the nurse to the client is appropriate?
"You seem to be identifying some issues in your life that are troubling, and you sound very down right now."
The mental health home care nurse says to the client, "Do you feel ready to try attending a group session at the clinic?" The client shakes his head. Which nursing statement would be therapeutic?
"You seem to be saying no. Would you tell me more about your reluctance?"
A client says to the nurse, "I've ruined my life. I left college with only a few credits to go. I keep telling myself that I'm going to make it as a writer, but I'll be a loser and a nothing for the rest of my life." Which response by the nurse is therapeutic?
"You seem to be saying that your choices are final and that you've lost any other opportunities."
A client who has expressed suicidal ideation in the past says to the nurse, while shuffling several documents in an effort to organize them, "Well, I'm feeling so much better now since I got organized. My lawyer wrote my will and durable power of attorney." Which response by the nurse is most appropriate?
"You talk about getting organized. Are you thinking of killing yourself?"
A client says to the nurse, "I'm going to die, and I wish my family would stop hoping for a cure! I get so angry when they carry on like this! I'm the one who's dying." Which response by the nurse would be most therapeutic?
"You're feeling angry that your family continues to hope for you to be cured."
An adolescent client says, "I'm just a burden to my folks. They wish I'd never been born. My dad told me he had to marry Mom because she got pregnant." Which response by the nurse would be therapeutic?
"You're feeling that your folks didn't want you, but they chose to marry and have you."
A client in group therapy says to the two nurses conducting the group, "You two are great at psychoanalyzing us, but what about you two? Do you have trouble being assertive with your bosses or the doctors like we do?" Which statement by one of the nurses would be most therapeutic?
"You're interested in talking with us about our assertiveness, but this group is for all of you here to help you to deal with problems more effectively."
A 45-year-old fireman says to the nurse, "I've worked at some fires recently that were just devastating, but last week was the worst. I carried this little girl from a fire — she was badly burned and lived just a few minutes after I brought her out, and she said to me, 'Tell my mom and Rudy I love them both very much.' Her mom told me that Rudy is their dog, and he just mopes around the house since the little girl died. I keep thinking about her and just don't know if I can go on." Which response by the nurse would be therapeutic?
"You're questioning your job because you're upset about the little girl you tried to save. Work stress can be treated and help you cope better. It is so important for you to seek treatment."
A 25-year-old client says to the nurse, "I got my degree in criminal justice. I graduated first in my class from the police academy and had just started as a patrolman when my partner and I responded to a domestic violence call in the most rural part of our patrol area. Someone started shooting at us, and I'm terrified. Maybe I'm not right for this job." Which statement by the nurse would be therapeutic?
"You're saying that because you felt afraid in a violent situation, you may not be right for the job?"
The wife of a victim of a gas explosion says, "It's not bad enough that I've been left alone to care for two children — now the company is denying our claim for compensation and we have to join a class action suit to get my husband's pension." Which statement by the nurse would be therapeutic?
"You're saying that being left a widow with children is difficult enough, but now you've got to fight for your benefits."
A client who recently lost his hand in a workplace accident says to the nurse, "I don't know how I'm going to support my family with a plastic hand. I might as well be dead." Which nursing response would be therapeutic?
"You're saying that you feel useless without your hand?"
A client who witnessed her husband being shot and killed in an incident of road rage says to the nurse, "It's been 3 months now, and I still can't drive my car without acting crazy. My sister says I grip the wheel like I'm glued to it. I can't merge with traffic until it's almost completely clear, and I'm parking a mile from in the mall when there's plenty of parking close to the building." Which statement by the nurse would be therapeutic?
"You're seeking help appropriately, and there are many things you can do to get comfortable behind the wheel again. You've returned to driving, but remember, you're still grieving. It's normal to still feel this way."
A client with major depression says to the nurse, "I should have died. I've always been a failure." Which response by the nurse is therapeutic?
"You've been feeling like a failure for some time now?"
A student calls the campus crisis hotline and tells the nurse, "I went out to a sorority party last week and drank too much. Someone raped me, but when I told my folks about it, they acted like it was my fault. I feel so dirty and used." Which statement by the nurse would be most therapeutic?
"You've had an awful experience, but it's not your fault that it happened. Can you come in and talk to me about it in more detail?"
A client says to the nurse at the mental health clinic, "My husband and sister-in-law both have terminal illnesses, and my family thinks that because I'm a nurse I should be able to handle everything." Which nursing response would be therapeutic?
"You've seen your loved ones dealing with some troubling events recently. Sounds as if you feel that your family expects more from you than from others in the family because you're a nurse."
A client who has twice attempted suicide says, "If people would just leave me alone and let me do what I want with my life, I could get on with what I want to do." Which response should the nurse give to the client?
"You've tried to end your life twice, yet you feel that everyone should let you do what you want to do?"
The slightly overweight mother of a morbidly obese 11-year-old girl says, "My family health care provider is wild over my daughter's weight gain. He says she's not eating correctly and is too sedentary, and now she's at risk for diabetes. He says the sugar in her blood was up this month. It's all my fault because I eat the wrong things, too, and I never get off the couch." Which statement by the nurse would be therapeutic in easing the client's self-blame?
"Your daughter has a serious problem, but there are many successful programs that you can join with her to lose weight and improve your overall lifestyle."
A client who is a health care provider says to the nurse, after receiving a diagnosis of terminal lung cancer, "All my life I took care of my clients, and now my family is taking care of me." Which statement is a therapeutic nursing response?
"Your family is caring for you now."
A client with depression says to a nurse, "Why is my family meeting with you? Are you telling them about me?" Which response by the nurse would be therapeutic?
"Your family is learning about depression and how best to help you so that they can be supportive of you. We do not talk about you or anything confidential about you."
A client says to the nurse, "I'm worried about my husband. He's talking about ending it all since his law practice dropped off and his son by his late first wife died of a drug overdose — but he's too intelligent to hurt himself, isn't he?" Which response by the nurse is appropriate?
"Your husband is displaying behaviors that indicate a risk for self-harm."
A client's son and daughter were killed during a fellow student's murderous rampage at their high school 9 months ago. The client says to the nurse, "My wife and I just feel empty and exhausted. I can't believe that I had a vasectomy after our son and daughter were born because we wanted to give them both whatever they needed. We have college funds for both of them that they'll never use now." The nurse should make which appropriate statement to the client?
"Your loss touches me so. How truly devastated you both must be. Can you share what things you have been doing to grieve?"
The parents of a 20-year-old who was killed while driving drunk say to the nurse, "We're so devastated, but we are also angry that she would drink and drive when we told her over and over not to." Which statement by the nurse would be therapeutic?
"Your sadness over losing your daughter is mixed with anger at her driving while intoxicated."
A client whose adolescent son committed suicide by hanging himself in the family's garage says to the nurse, "The coroner just informed us that our son had AIDS." Which response to the client by the nurse is appropriate?
"Your son was keeping a very troubling diagnosis to himself. I am so sorry. No matter how close and loving children are to their parents, some children just aren't able to confide in their parents."
A nurse is caring for a patient whose spouse has died. How does the nurse determine that a client who has lost a spouse has successfully completed the tasks of mourning? Select all that apply.
-Reporting that sleeping alone is so hard now -Purchasing a smaller car she is comfortable driving -Placing a picture of her husband on the bedside stand -Heard explaining to family that illness "took" her husband
The nurse determines that a client whose son died in a car accident is at risk for self-harm. Which intervention is most appropriate initially?
Making a "no suicide" contract with the client
Which client is at the highest risk for suicide?
A 75-year-old woman with severe depression and debilitating arthritis
An adolescent client has graduated high school and is preparing to leave home to attend college. The adolescent is distressed about this life change. The nurse plans to implement crisis interventions, knowing that this situation is characteristic of which type of crisis?
A maturational crisis
The nurse observes that a client is pacing back and forth. The nurse asks the client how she is feeling, and the client responds by telling the nurse that she feels "out of control!" Which intervention is most appropriate initially to maintain a safe environment?
Moving the client to a quiet room and talking about her feelings
A client has just been admitted to the mental health unit with a diagnosis of obsessive-compulsive disorder (OCD). The nurse observes the client for compulsive behavior involving which repetative element?
Actions
A client with schizophrenia and his parents are meeting with the nurse. One of the young man's parents says to the nurse, "We were stunned when we learned that our son had schizophrenia. He was no different than from his older brother when they were growing up. Now he's had another relapse, and we can't understand why he stopped his medication." Which response by the nurse is appropriate?
Asking the client, "How can we help you to take your medicine or to tell us when you're having problems so that your medication can be adjusted?"
The nurse developing a plan of care for a client whose spouse recently died, determines the client has a problem with dysfunctional grieving. Which priority intervention does the nurse incorporate into the plan?
Assessing the client's risk for violence toward self and others
During a one-to-one nurse-client session, the client plays with her pack of cigarettes and says, "I just get a couple of DVDs and watch movies so I won't have to look at my husband or talk to him." Which coping mechanism does the nurse recognize in the client's behaviors?
Avoidance
The home care nurse makes a new-baby visit to a young husband and wife. The visit takes two-and-a-half hours because the parents are so detailed in giving information and asking questions of the nurse. Which intervention by the nurse would be therapeutic?
Blocking out more time for the next visit and scheduling a follow-up visit as soon as possible to assess how they are coping and gauge their level of anxiety
The home care nurse makes a visit to a client with a diagnosis of depression. The nurse finds the client unconscious on the floor, with an empty bottle of a prescribed tricyclic antidepressant lying near the client. What action must the nurse take immediately?
Calling an ambulance
A client with schizophrenia says, "I'm away for the day ... but don't think we should play or do we have feet of clay?" Which alteration in the client's speech does the nurse document?
Clang association
A client tells the nurse, "I am a queen. I'm mean, and I gleam." The nurse recognizes this as an example of which speech pattern?
Clang associations
The nurse in the emergency department is helping care for a young female survivor of sexual assault. The client's physical assessment is complete, and physical evidence has been collected. The nurse notes that the client is withdrawn, confused, and, at times, physically immobile. The nurse interprets these behaviors as which type of reaction?
Common reactions to a devastating event
A 24-year-old client with schizophrenia says, "I was in college and suddenly I was hearing voices telling me I was no good and that I should jump off the bridge by our college. My parents came and got me when I called them. We thought that I had inadvertently taken drugs at a party or something. My psychiatrist says that if I can improve, I can return to college next semester." Which guideline does the nurse plan to incorporate into teaching of the client and family about self-care on the client's return to college?
Compliance with the treatment regimen, immediate reporting of any relapse signs, avoidance of alcohol and drugs, and living a balanced lifestyle
A client with the diagnosis of schizophrenia is unable to speak, although nothing is wrong with the organs of communication. The nurse plans care knowing that this condition is referring to which aspect of the disorder?
Mutism
A person who has overdosed on heroin is brought into the emergency department. The client is having seizures, and the nurse notes that his pupils are constricted. Which intervention does the nurse anticipate that the emergency department health care provider will prescribe?
Naloxone
The nurse is caring for a hospitalized client with an alcohol abuse disorder. In reviewing the client's discharge outcomes, the most positive outcome is that the client states that he or she will perform which action?
Continue to attend Alcoholics Anonymous meetings
The nurse is preparing a discharge plan for a client who has attempted suicide. The nurse understands that the plan of care should have which focus?
Contracts and immediate available crisis resources
A client who has been admitted to a surgical unit with a diagnosis of cancer is scheduled for surgery in the morning. When the nurse enters the room and begins the surgical preparation, the client states, "I'm not having surgery — you must have the wrong person! My test results were negative. I'll be going home tomorrow." Which defense mechanism should the nurse recognize that the client is using?
Denial
The nurse sees a nursing assistant talking in an unusually loud voice to a client with delirium. Which action should the nurse take?
Determining that the client is safe, calmly asking the nursing assistant to join you outside the room, and informing the nursing assistant of the observation
The new nurse employee is developing a plan of care, with the registered nurse, for a client who recently received a diagnosis of acquired immunodeficiency syndrome (AIDS) and is experiencing difficulty adjusting to the illness. The registered nurse should suggest revision of which intervention for this client?
Discouraging social networking to prevent the spread of infection
The nurse is providing information to a group of nursing staff members about caring for suicidal clients. What should the nurse tell the group?
Discussing suicide with a client is not harmful
The mother of a 3-year-old child tells the nurse that her child hit her doll after the mother scolded her for picking the neighbors' flowers. Which defense mechanism used by the child does the nurse identify in the mother's report?
Displacement
A client with schizophrenia in the psychiatric inpatient unit is yelling, "The CIA is trying to kill me. I know they're plotting to kill me so they can overthrow the government." Based on the client's statement, which clinical manifestation should the nurse document in the client record?
Evidence of persecutory delusions
A single mother whose only son died 2 months ago says to the nurse, "I've been bothered at work with thoughts of my son. Suddenly I'll think of something awful I said to him years ago or some punishment I gave him because he'd been bad." Which plan should the nurse include in caregiving?
Explaining that bereaved persons often describe intrusive thoughts of negative experiences with the deceased and then increasing the frequency of nurse-client visits.
The nurse is preparing a care plan for a client with obsessive-compulsive disorder (OCD). Which should be the nurse's primary focus?
Goals and objectives
The nurse brings a meal tray to a client with psychosis in his hospital room. The client refuses the meal and says, "I'm not eating any more poisoned food while I'm vacationing here. I'm starting on a fast to stay healthy and alive." Which nursing intervention would be most appropriate initially?
Having the client eat with other clients in the community dining room
A client is severely injured, sustaining a full-thickness circumferential burn to the left leg, after passing out as a result of drinking alcohol and falling into a fire while on a camping trip. In report, the nurse is told that the client has just signed consent for amputation of the limb and that the procedure is scheduled for tomorrow. While caring for the client, the nurse notes that the client is upset and withdrawn. What is the most appropriate nursing action at this time?
Reflecting back to the client that he appears upset
The nurse is caring for a 15-year-old girl who has been hospitalized. The client tells the nurse that she had her hair styled just like her young math teacher, whom she admires. Which defense mechanism should the nurse recognize that the client is using?
Identification
A client who was admitted to the mental health unit 1 month ago with agoraphobia is cooperative, shares with peers, and makes appropriate suggestions during group discussions. Which is most consistent with the client's behavior?
Improvement
A client with schizophrenia is admitted to the inpatient psychiatric unit. The client is exhibiting clang associations, word salad, and loose associations. Which problem does the nurse recognize that the client is experiencing?
Inability to communicate effectively
A client with moderate depression, who was admitted to the mental health unit 2 days ago, suddenly begins smiling and reports that the crisis is over. The client says to the nurse, "I'm finally cured." The nurse interprets this behavior as a cue to modify the treatment plan in which manner?
Increasing the level of suicide precautions
The nurse is working with an older client who has been hospitalized and the client's family to formulate a plan for discharge. In guiding the discussion with the client and family, which living arrangement should the nurse promote?
Independently but close to their children
The nurse is explaining the plan of care to family members of an older client with a diagnosis of depression. Which explanation should the nurse provide to the client and family members?
Indications of dementia may be present in an older client with depression
A resident of a long-term care facility who has Alzheimer's disease becomes agitated when a group of children comes to sing and dance at the facility and tries to take one of the children to her room. Which should the nurse consider when approaching the client about this behavior?
Individuals with Alzheimer's disease have difficulty tolerating excessive stimulation and changes in routine.
The nurse preparing to admit a client with obsessive-compulsive disorder (OCD) to the mental health unit observes the client for certain characteristic behaviors. Which characteristic behavior will the nurse likely observe?
Inflexibility
The nurse is working with a new nurse employee who has been closely observing a client who has been displaying aggressive behaviors and notes that the client's aggressiveness is escalating. The new nurse employee has developed a plan of care for the client. The nurse realizes the new nurse employee requires additional instruction if which aspect is included in the plan of care?
Initiating confinement measures
A client is going to receive instruction in biofeedback technique to lower his stress level. The client asks the nurse to describe this technique. What should the nurse tell the client?
It is a therapeutic modality that enables an individual to monitor skin temperature, muscle activity, heart rate, blood pressure, and other bodily functions, then learn to control these physiologic responses to stressful or challenging events
A nursing student is assigned to work in the emergency department to assist victims after a tornado. The student says to the nurse in charge, "I don't know how to help these parents. Their son was just decapitated by a flying piece of glass, and they won't leave him. They did mention that they are Catholic." Which intervention does the nurse suggest for inclusion in a plan of immediate care for the family?
Joining the family and, after they have been able to be with their son for some time, helping them relinquish their son's body to the nurses
The nurse plans outcomes for a client who is being treated for psychosis. Which step would be included during the stable or discharge phase of treatment?
Keeping the client active with hobbies, exercise, and work
A client and her newborn have undergone human immunodeficiency virus (HIV) testing, and the results for both clients are positive. The news is devastating, and the mother is crying. What is the appropriate nursing action at this time?
Listen quietly while the mother talks and cries
The nurse is preparing to provide nursing unit information to a client who does not speak English who is being admitted to the mental health unit. Which action is best for the nurse to take to ensure that the client understands the information?
Obtaining a hospital interpreter to communicate with the client
The nurse is admitting a client with a diagnosis of anorexia nervosa to the mental health unit. The nurse is likely to note which aspect of the disorder?
Personal relationships tend to become more superficial and distant.
A client is admitted to the medical-surgical unit of a hospital, and suicide precautions are taken until the client can be admitted to the psychiatric unit. Which nursing intervention should the nurse implement?
Placing the client in a semiprivate room, providing plastic utensils for eating, and keeping an arm's distance from the client at all times
A male client reports difficulty concentrating, outbursts of anger, and a feeling of being keyed up all the time and states that peer relations are poor. He then tells the nurse that the symptoms started after his best friend was killed in the terrorist attack at the World Trade Center. The nurse plans the client's care, as the client is likely experiencing which disorder?
Post-traumatic stress disorder
The nurse working in a mental health unit reads a client's medical record and notes documentation that the client has been experiencing flashbacks. The nurse interprets this as a classic sign of which disorder?
Post-traumatic stress disorder
The nurse notes that a client being admitted to the inpatient mental health unit uses avoidance and denial to cope with stress. Which positive stress response will the nurse plan to focus on when working with the client?
Problem-solving
The mental health nurse is conducting the initial assessment of an client who is obese. The client confides that she was sexually molested at age 7 and began putting on weight thereafter. The nurse determines that the client's symptoms are compatible with a somatization disorder and recalls that obesity for this client most likely represents which?
Protection from the risk of intimacy
Which step should be included in the care of a 13-year-old hospitalized child who has been abused?
Providing a caring environment that fosters the development of trust
The nurse is assigned to care for a client experiencing a crisis. What is the appropriate initial nursing intervention for this client?
Providing authority and action
The nurse coordinates the use of hospice care to visit a dying client who will be going home with his family. Which is a function of hospice services that the nurse should tell the family?
Providing bereavement support to the family after the client's death
A young adult client who is dying says to the nurse, "I keep asking my wife what I can do for her and our daughter before I die, but she refuses to tell me." Based on the client's statement, what is the appropriate nursing intervention?
Talking with both the client and his wife about the importance of expressing their feelings and how to do it in healthy ways
A client is admitted to the psychiatric unit after a serious suicide attempt involving a drug overdose. What is the priority nursing intervention?
Remain with the client at all times
A client with obsessive-compulsive disorder who continually cleans her room with paper towels becomes enraged with her roommate for throwing the package of paper towels into the waste basket, begins to yell, and slaps the roommate. Which action would the nurse take first?
Removing both clients to safe locations
A client is admitted to the psychiatric inpatient unit and suicide precautions are instituted. Which intervention should the nurse implement?
Removing perfume, shampoo, and other toiletries from the client's room
The nurse is caring for a client who has been identified as a survivor of physical abuse by a family member. Which action is the priority as the nurse plans care for the client?
Removing the client from any immediate danger
A client is scheduled to undergo electroconvulsive therapy (ECT). Which client concern is of the highest priority?
Risk for impaired breathing
A client in a mental health unit gets into a fight with another client over the use of the public telephone on the unit. The client is accused of making two telephone calls and staying on the telephone for 1 hour. Which intervention by the nurse would be most therapeutic?
Saying to the clients, "You may each use the phone for 10 minutes. I will time the calls for both of you. Do you both agree to abide by my decision?"
A client with schizophrenia arrives for a scheduled appointment with the mental health nurse. The nurse notes that the client's hygiene is poor and that the client is having difficulty concentrating on what the nurse is saying and responding appropriately. Which nursing intervention would be most appropriate?
Saying, "I notice that you don't seem to be caring for yourself. Are you taking your medication?"
The nursing instructor enters a classroom to begin class and finds two students yelling and physically assaulting each other. Which intervention by the instructor would be most appropriate?
Telling the class to go to the nursing laboratory at once, then asking a student to tell the nursing secretary to have security come to the classroom, and asking the students who are fighting to stop fighting and take their seats
A client experiencing homelessness, with an antisocial disorder, is brought to the emergency department by the police after disturbing customers in a department store. The client says to the nurse, "I need to be hospitalized. It's getting cold out, and I need a warm bed. If you don't get me into a hospital, I'll jump off a bridge." Which nursing intervention would be therapeutic?
Sending the client to a shelter that will provide temporary housing if he signs a contract agreeing not to attempt suicide
A woman is brought to the emergency department after an assault. She presents with complaints of dizziness, dyspnea, visual disturbance, and motor tension with hyperactivity. Which level of anxiety does the nurse recognize in the client's presentation?
Severe
A nurse notices a client's glaring eyes during a conversation with the client. The client then begins to fidget and gets up to pace around the room. Which action by the nurse would be beneficial?
Sharing the observation with the client and helping the client recognize and acknowledge his or her feelings
A client with schizophrenia says, "I feel like I'm rotting away inside and all of my organs are rusting." Which type of delusion does the nurse identify in the client's statement?
Somatic
A client with a history of multiple somatic complaints involving several organ systems has no evidence of organic pathologic conditions. It is important for the nurse planning care for this client to understand that the client is afflicted with which disorder?
Somatization disorder
The nurse is teaching a group of new employees ways to deescalate aggressive behavior exhibited by a client with schizophrenia. After the course employees state several actions they would take if a client with schizophrenia became increasingly aggressive. Which comment causes the nurse to realizes further instruction is required?
Standing close to the client and telling the client that the behavior is unacceptable
A client brought to the emergency department by the police after being mugged is extremely agitated, trembling and hyperventilating. What is the appropriate initial nursing action?
Staying with the client
The nurse is working with a new nurse employee who is creating a care plan for an adolescent is returning home after an acute psychiatric hospitalization for a suicide attempt. The nurse should suggest a revision of the plan of care if the new nurse includes which intervention?
Suggesting that the client's mother quit her job
The nurse caring for a client with schizophrenia is assessing the client's ability to control distorted thought processes. Which finding indicates a positive outcome?
The client can identify the recurrence of hallucinations, can refrain from responding to them, and reports a significant decrease in the incidence of hallucinations.
The nurse is reading the medical record of a client who has a diagnosis of moderate anxiety and notes that the health care provider has documented that the client exhibits eustress. Based on this information, which finding would the nurse expect to encounter while assessing the client?
The client engages in purposeful movement.
The nurse is collecting data from a client in crisis and assessing the potential for self-harm. Which finding indicates that the client is at high risk for suicide?
The client has an immediate plan for a suicide attempt.
The nurse collects data from an older client and monitors him for signs of abuse. Which psychosocial factor does the nurse recognize as placing the client at risk for abuse?
The client is completely dependent on family members for food and medicine.
The nurse working in the emergency department is performing an initial assessment on a client, and notes many physical injuries. The nurse suspects family-related violence. Which finding is specific to this type of violence?
The client lives with one of their children and requires extensive assistance with activities of daily living.
The nurse reviews the nursing care plan of a client being seen in the mental health clinic and notes that the client is experiencing dysfunctional grieving after losing his spouse. Which is the appropriate outcome for the treatment plan for this client?
The client plans to attend a community grief group.
A client comes to the mental health clinic after losing all of his personal belongings in a hurricane. The client tells the nurse that the loss of his possessions is his fault because he didn't prepare for the storm. The nurse determines that the client is coping ineffectively and develops goals with the client. Which goal requires revision because it is not realistic?
The client will stop blaming himself for the loss of his belongings.
The nurse working with a survivor of sexual assault , is developing a plan of care for the client. Which short-term initial goal is most appropriate?
The client will verbalize her feelings about the event.
A client who has been referred for group therapy asks the nurse about the therapy. The nurse tells the client that this type of therapy is focused on which purpose?
The development of interpersonal skills
The nurse employed in an emergency department is assisting in caring for an adult client who is a survivor of family violence. Which priority instruction does the nurse include in the discharge plan?
The locations of shelters
A client arrives in the emergency department in a crisis state. The client demonstrates signs of profound anxiety and is unable to focus on anything but the object of the crisis and the impact on herself. The nurse plans to focus the initial assessment on which client factor?
The physical condition of the client
A 30-year-old client says to the nurse, "I want to die. I think about it a lot, but I don't know how in the world to do it." Based on the client's statement, what does the nurse determine?
The risk for suicide exists and continued assessment is needed
The nurse employed in a mental health unit is reviewing the work schedule. At what time does the nurse expect that additional client safety precautions will be provided?
Weekends
A furious and aggressive client is put in restraints and told that the restraints will be removed once the she regains control. At which time is removal of the restraints by the nurse appropriate?
When no acts of aggression are observed in the hour following the release of two extremity restraints
The client is the wife of a former workaholic who now has not worked in years, refusing to get a job or help with chores around the house. The man watches television and snacks all day. The client tells the nurse that her husband now weighs more than 300 lb (136 kg) and expects her to support him. The client states, "I keep saying everything will be fine. It will be if he keeps up these bad health habits, because they'll kill him, and then I would be free and wouldn't have to deal with his obnoxious behavior." Which negative stress response does the nurse recognize in the client's behavior?
Wishful thinking
