mental health EAQ
A nurse is speaking with a client who was sexually abused as a child. The client does not know what constitutes inappropriate touch by another person. What issue will have to be addressed with this client? 1 Increased libido 2 Phobic behavior 3 Boundary violations 4 Excessive aggression
Boundary violations Rationale: Clients who have experienced childhood sexual abuse will have difficulty being aware of their personal boundaries and maintaining appropriate boundaries for themselves and others. Clients who have experienced childhood sexual abuse tend to have decreased, not increased, libidos. Phobic behavior, the irrational fear of an object or situation, is not necessarily a concern that the nurse should have for this client more than for other clients. Clients who have experienced childhood sexual abuse tend to internalize the abuse; they do not become outwardly or excessively aggressive.
A client who appears dejected, barely responds to questions, and walks very slowly about the mental health unit tells the nurse in a barely audible voice that life is no longer worth living. What is the most therapeutic response to this statement by the nurse? 1 "Have you been thinking about suicide?" 2 "What could be so bad to make you feel that way?" 3 "We'll talk about your feelings after you've rested." 4 "Let's talk about something pleasant to make you feel better."
"Have you been thinking about suicide?" Rationale: It is important to determine whether the client is thinking about suicide; the direct approach is most effective. The response "What could be so bad to make you feel that way?" not only denies the client's feelings but also tells her that it is not right to feel that way. The response "We'll talk about your feelings after you've rested" indicates that the client's feelings do not have top priority. The response "Let's talk about something pleasant to make you feel better" denies the client's feelings and offers false reassurance.
A client is found to have a borderline personality disorder. What is a realistic initial intervention for this client? 1 Establishing clear boundaries 2 Exploring job possibilities with the nurse 3 Initiating a discussion of feelings of being victimized 4 Spending 1 hour twice a day discussing problems with the nurse
Establishing clear boundaries Rationale: Individuals with borderline personality disorder are impulsive and have difficulty identifying and respecting boundaries in relation to others. Exploration of this topic in a meaningful manner can be done only after an ongoing relationship has been established. Feeling victimized is a frequent theme among clients with this disorder; however, they rarely have the insight to initiate discussion of these feelings and usually show resistance when the topic is broached. An individual with a borderline personality disorder may not be able to spend this length of time having a meaningful discussion with the nurse; usually they are too impulsive to engage in consistent work until a therapeutic relationship has been established.
A client in the hyperactive phase of a mood disorder, bipolar type, is receiving lithium. A nurse sees that the client's lithium blood level is 1.8 mEq/L. What is the most appropriate nursing action? 1 Continuing the usual dose of lithium and noting any adverse reactions 2 Discontinuing the drug until the lithium serum level drops to 0.5 mEq/L 3 Asking the health care provider to increase the dose of lithium because the blood lithium level is too low 4 Holding the drug and notifying the health care provider (prescribing provider) immediately because the blood lithium level may be toxic
Holding the drug and notifying the health care provider (prescribing provider) immediately because the blood lithium level may be toxic Rationale: The lithium level should be maintained between 0.5 and 1.5 mEq/L. The lithium level is currently unsafe but does not need to drop to 0.5 mEq/L before being resumed. Continuing the drug and asking the health care provider to prescribe a higher dosage are both unsafe options.
In addition to hallucinating, a client yells and curses throughout the day. The nurse should: 1 Ignore the client's behavior 2 Isolate the client until the behavior stops 3 Explain the meaning of the behavior to the client 4 Seek to understand what the behavior means to the client
Seek to understand what the behavior means to the client Rationale: All behavior has meaning; before planning intervention, the nurse must try to understand what the behavior means to the client. Ignoring behavior does little to alter it and may even cause further acting-out. Isolation may increase anxiety and precipitate more acting-out behavior. The nurse cannot explain the meaning of the client's behavior; only the client can.
A young adult with a history of cognitive impairment and tonic-clonic seizures is admitted to a group home. Among the client's medications is a prescription for phenytoin (Dilantin) 125 mg by mouth three times a day. Phenytoin is supplied as an oral suspension of 25 mg/5 mL. How many milliliters of solution should the nurse administer for each dose?Record your answer using a whole number. __________ mL
The correct amount of solution to administer at each dose is 25 mL.
Which psychotherapeutic theory uses hypnosis, dream interpretation, and free association as methods to release repressed feelings? 1 Behaviorist model 2 Psychoanalytical model 3 Psychobiological model 4 Social-interpersonal model
Psychoanalytical model Rationale: The psychoanalytical model studies the unconscious and uses the strategies of hypnosis, dream interpretation, and free association to encourage the release of repressed feelings. The behaviorist model holds that the self and mental symptoms are learned behaviors that persist because they are consciously rewarding to the individual; this model deals with behaviors on a conscious level of awareness. The psychobiological model views emotional and behavioral disturbances as stemming from a physical disease; abnormal behavior is directly attributed to a disease process. This model deals with behaviors on a conscious level of awareness. The social-interpersonal model affirms that crucial social processes are involved in the development and resolution of disturbed behavior; this model deals with behavior on a conscious level of awareness.
A resident in a nursing home recently immigrated to the United States from Italy. How does the nurse plan to provide emotional support? 1 By offering choices consistent with the client's heritage 2 By ensuring that the client understands American beliefs 3 By assisting the client in adjusting to the American culture 4 By correcting the client's misconceptions about appropriate health practices
By offering choices consistent with the client's heritage Rationale: Adherence to a plan of care is enhanced by the nurse's providing choices consistent with the client's cultural beliefs and practices. The nurse's cultural or personal beliefs and biases should not influence or interfere with the implementation of appropriate care. Helping the client adjust to the American culture is not the priority at this time; care should be adapted to the client's needs and culture. The person's cultural practices should not be addressed unless they are detrimental to the person's health.
A young female client admitted to the trauma center after being sexually assaulted continues to talk about the rape. Toward what goal should the primary nursing intervention be directed? 1 Getting her involved with a rape therapy group 2 Remaining available and supportive to limit destructive anger 3 Exploring her feelings about men to promote future relationships 4 Providing a safe environment that permits the ventilation of feelings
Providing a safe environment that permits the ventilation of feelings Rationale: The client needs to be able to express her current feelings. Providing an environment in which she feels safe will encourage this expression of feelings. It is too soon after the assault to discuss this topic in a group. Although the nurse should be available and supportive, feelings of anger are usually not the initial response. It is too soon after the assault to discuss her feelings about men and future relationships.
A client has been prescribed lithium. What important nursing intervention must be implemented while this medication is being administered? 1 Restricting the client's daily sodium intake 2 Testing the client's urine specific gravity weekly 3 Regularly testing the level of the drug in the client's blood 4 Withholding the client's other medications for several days
Regularly testing the level of the drug in the client's blood Rationale: Lithium alters sodium transport in nerve and muscle cells and causes a shift toward intraneuronal metabolism of catecholamines. Because the range between therapeutic and toxic levels is very slim, the client's serum lithium level should be monitored closely. Sodium restriction may cause electrolyte imbalance and lithium toxicity. Testing the client's urine specific gravity weekly is not necessary or useful. Withholding the client's other medications for several days may or may not be necessary; it depends on what the client is receiving; also, it requires a health care provider's prescription.
An older client who lost a spouse 20 years ago comes to the community health center with a vague list of complaints and a brief life history. The couple's only child died at birth. The client lives alone and is able to perform all the activities of daily living. The client has had an active social life in the past but has outlived many friends and family members. What is an important question for the nurse to ask when taking this client's health history? 1 "Are you all alone?" 2 "How did your son die?" 3 "Do you still miss your spouse?" 4 "How do you feel about your life now?"
"How do you feel about your life now?" Rationale: The answer to "How do you feel about your life now?" will provide the nurse with an idea of the client's hopes and frustrations without being threatening or probing. "Are you all alone?" is probing and provides little information for the nurse to use in planning care. "How did your son die?" and "Do you still miss your spouse?" are both probing, disregard the client's present situation, and provide little information for the nurse to use in planning care.
Which statement by the client indicates to the nurse that the teaching about taking an antidepressant medication has been understood? 1 "I need to take every dose of my medication as prescribed." 2 "I need to discontinue the medication if I have side effects." 3 "I don't have to be concerned about taking my medications." 4 "I can double the dose of the medication if I still feel depressed."
"I need to take every dose of my medication as prescribed." Rationale: The client should be encouraged to follow the medical regimen to maximize response to drug therapy. The client needs further teaching. The health care provider should be notified of side effects. The drug should not be discontinued without the health care provider's supervision. The client should be concerned about taking the medication. The health care provider should make the decision to increase the dosage.
When speaking with a client who has schizophrenia, the nurse notes that the client keeps interjecting sentences that have nothing to do with the main thoughts being expressed. The client asks whether the nurse understands. How should the nurse reply? 1 "You aren't making any sense; let's talk about something else." 2 "Why don't you take a rest? We can talk again later this afternoon." 3 "I'd like to understand what you're saying, but you're too confused now." 4 "I'd like to understand what you're saying, but I'm having trouble following you."
"I'd like to understand what you're saying, but I'm having trouble following you." Rationale: "I'd like to understand what you're saying, but I'm having trouble following you" lets the client know that the nurse is trying to understand; it increases the client's feeling of self-esteem and points out reality. Clients with schizophrenia have problems with associative links, and these same problems will occur regardless of the topic. The statement "Why don't you take a rest? We can talk again later this afternoon" cuts off communication and tells the client that the nurse will speak only if the client's communication makes sense to the listener. "I'd like to understand what you're saying, but you're too confused now" cuts off communication and tells the client that the nurse will speak only if the client's communication makes sense to the listener.
A parent of a 13-year-old adolescent with recently diagnosed Hodgkin disease tells a nurse, "I don't want her to know about the diagnosis." How should the nurse respond? 1 "It's best for your child to know the diagnosis." 2 "Did you know that the cure rate for Hodgkin disease is high?" 3 "Would you like someone with Hodgkin disease to talk with you?" 4 "Let's talk about how you're feeling about your child's diagnosis."
"Let's talk about how you're feeling about your child's diagnosis." Rationale: Initiating a conversation about the client's feelings does not prejudge the parent; it encourages communication. Stating that it is best for the child to know the diagnosis disregards the parent's feelings and cuts off further communication. Asking the client about the cure rate may stop communication and does not recognize the parent's concerns. Offering to have someone with Hodgkin disease speak to the client is premature and does not recognize the parent's concerns.
During a group meeting a client tells everyone, "I'm about to be discharged from the hospital, and I'm afraid." What is the most appropriate response by the nurse facilitator? 1 "You ought to be happy that you're leaving." 2 "Maybe you're not ready to be discharged yet." 3 "Maybe others in the group have similar feelings that they would share." 4 "How many in the group feel that this member is ready to be discharged?"
"Maybe others in the group have similar feelings that they would share." Rationale: Stating that others in the group have similar feelings permits the client to see that these feelings are not unique and are shared by others. Stating that the client should be happy about leaving will make the client worry about not feeling happy. Stating that the client may not be ready to be discharged is a nonsupportive response to a realistic fear of leaving the safe hospital and going back to the "real world," where problems must be confronted. How the others feel about whether the client is ready to be discharged is irrelevant.
A client is dying. Hesitatingly, his wife says to the nurse, "I'd like to tell him how much I love him, but I don't want to upset him." Which is the best response by the nurse? 1 "You must keep up a strong appearance for him." 2 "I think he'd have difficulty dealing with that now." 3 "Don't you think he knows that without your telling him?" 4 "Why don't you share your feelings with him while you can?"
"Why don't you share your feelings with him while you can?" Rationale: It is difficult to work through a loss; however, encouraging the sharing of feelings helps both parties to feel better about having to let go. The response "You must keep up a strong appearance for him" impedes the work of acceptance of one's finality and the use of the remaining time to the best advantage. There is no evidence to suggest that the client cannot cope with these emotions; the response "I think he'd have difficulty dealing with that now" denies that this is a time for closeness and honesty. The response "Don't you think he knows that without your telling him?" is demeaning, closes off communication, and does not foster the expression of feelings.
During a group discussion regarding the unexpected suicide of a young female client who was on a weekend pass, one of the other clients stands up and shouts, "Oh, I know what you're all thinking. You think that I should've known that she was going to kill herself. You think I helped her plan this." What is the mosttherapeutic response by the group leader? 1 "Oh no! We all know you liked her." 2 "Don't you think you should tell us the truth?" 3 "Helping another person plan a suicide isn't healthy." 4 "You're upset because you think we're blaming you for her death?"
"You're upset because you think we're blaming you for her death?" Rationale: The statement "You're upset because you feel we're blaming you for her death?" puts the focus on feelings, not on a statement of what did or did not happen. The statement "Oh no! We all know you liked her" does not give the client the opportunity to explore feelings. Asking "Don't you think you should tell us the truth?" implies that the client may have had some part in causing another person's death. Saying that helping another person plan a suicide is not healthy closes the door to any further communication of feelings or fears.
While caring for a client, a nurse notes that the client has begun to create new words. What term does the nurse use to document this finding? 1 Neologism 2 Perseveration 3 Pressured speech 4 Tangential speech
Neologism Rationale: Neologism is the invention of new words with meanings understood only by the client. Perseveration is repetitive verbalizations or motions. Pressured speech is rapid speech with an urgent quality. Tangential speech is a tendency to digress from the original subject.
A nurse counseling a female client on the inpatient psychiatric unit responds to a statement made by the woman by stating, "I'm confused about exactly what is upsetting you. Would you go over that again, please?" The nurse is using: 1 Clarifying 2 Structuring 3 Confronting 4 Paraphrasing
Clarifying Rationale: Clarifying is an attempt to better understand the message intended by the client. It is utilized to gain a clearer understanding of what another person has stated. Structuring is an attempt to create order and thereby allow a client to become aware of problems. Confronting examines a discrepancy between what a person is saying and what a person does. It requires careful attention to nonverbal communication, as well as the discrepancies between the nonverbal and verbal message. Paraphrasing allows the speaker to share how one person perceives and hears another's information. The nurse is not paraphrasing but instead is attempting to better understand the client.
A male college student who is smaller than average and unable to participate in sports becomes the life of the party and a stylish dresser. What defense mechanism does the nurse determine that the client is using? 1 Introjection 2 Sublimation 3 Compensation 4 Reaction formation
Compensation Rationale: By developing skills in one area, the individual compensates for a real or imagined deficiency in another, thereby maintaining a positive self-image. Had the student incorporated the qualities of the college athlete, that would be introjection. Sublimation is related to unacceptable impulses that may pose a threat. This person is trying to make amends not for unacceptable feelings (reaction formation) but rather for a believed deficiency and an inadequate self-image.
Which relationship is of mostconcern to the nurse because of its importance in the formation of the personality? 1 Peer relationships 2 Sibling relationships 3 Spousal relationships 4 Parent-child relationships
Parent-child relationships Rationale: Children base their own worth on the feedback they receive from their parents. This sense of worth sets the basic ego strengths and is vital to the formation of the personality. Peer groups come later in a child's development, but the parent-child relationship is still the most important. Although sibling relationships are important, they are not as important as the parent-child relationship. Spousal relationships come later in life, after the basic personality has been formed.
After speaking with the parents of a child dying of leukemia, the practitioner gives a verbal do-not-resuscitate order but refuses to put it in writing. What should the nurse do? 1 Follow the order as given by the practitioner 2 Refuse to follow the practitioner's order unless the nursing supervisor approves it 3 Ask the practitioner to write the order in pencil on the child's chart before leaving the room 4 Determine whether the family is in accord with the practitioner while following hospital policy
Determine whether the family is in accord with the practitioner while following hospital policy Rationale: Determining whether the family is in accord with the practitioner while following hospital policy verifies family and practitioner agreement and uses institutional policy developed by the ethics committee. Neither the nurse nor the nursing supervisor should accept this inappropriate order. The order must be present in ink on the written record.
A nurse is planning to teach a client about self-care. What level of anxiety will best enhance the client's learning abilities? 1 Mild 2 Panic 3 Severe 4 Moderate
Mild Rationale: Mild anxiety motivates one to action, such as learning or making changes. Higher levels of anxiety tend to blur the individual's perceptions and interfere with functioning. Attention is severely reduced by panic. The perceptual field is greatly reduced with severe anxiety and narrowed with moderate anxiety.
A client who is taking lithium arrives at the mental health center for a routine visit. The client has slurred speech, has an ataxic gait, and complains of nausea. The nurse knows that these signs and symptoms are: 1 Related to a low lithium level 2 Associated with cyclic mood disorders 3 Often related to a therapeutic lithium level 4 Probably associated with a toxic level of lithium
Probably associated with a toxic level of lithium Rationale: The classic signs and symptoms of lithiumtoxicity include slurred speech, ataxia, nausea, and vomiting. When the lithium level is low the client presents with recurring signs and symptoms of the mood disorder. These are not signs and symptoms of a mood disorder. If the lithium level is within the therapeutic range, the client's mood is more stable; the client may experience gastrointestinal symptoms but will not experience slurred speech or an ataxic gait.
A 13-year-old girl is brought to the emergency department by her mother, who tells the nurse that she just found out that her daughter has been sexually abused by her grandfather for almost 2 years. What is the nurse's priorityintervention? 1 Keeping the family unit intact 2 Validating the truth of the child's accusations 3 Providing a safe, nonjudgmental environment 4 Securing psychiatric treatment for the grandfather
Providing a safe, nonjudgmental environment Rationale: Victims of sexual abuse need to feel safe and accepted when discussing their histories. The nurse's primary responsibility is toward the child, not the family. The story should initially be accepted as true. The nurse's primary responsibility is toward the child, not the grandfather.
What is most important for a nurse to have when working with families who are encountering problems? 1 Good memory for details 2 Common social background 3 Warm nature and loving personality 4 Sense of self and empathy for others
Sense of self and empathy for others Rationale: Awareness of one's strengths and limitations and the ability to place one's self in another's situation are essential for intervening effectively. A good memory for details is not a necessary characteristic for helping families with problems, and many times it is impossible to achieve; this is not a prerequisite for understanding. Although common social background may be helpful, it is not a priority. Although a warm nature and loving personality may be helpful, they are not priorities.
After several interactions with a client, the nurse at the mental health clinic identifies a pattern of withdrawal and nonparticipation in situations requiring communication with others. In which area should the nurse expect the client to have difficulty? 1 Personal identity 2 Social interaction 3 Sensory perception 4 Verbal communication
Social interaction Rationale: Characteristics of clients with problems with social interaction include avoidance of others, problematic patterns of interaction, and an inability to establish or maintain stable supportive relationships. Withdrawal from others is not a characteristic of individuals with difficulties involving personal identity. These clients usually exhibit an inability to distinguish between the self and nonself. Withdrawal from others is not a characteristic associated with clients who have alterations in sensory perception. A client with impaired sensory perception demonstrates altered processing of sensory stimuli and an exaggerated or distorted response to stimuli. Withdrawal from others is not a characteristic of clients who have difficulty communicating with others. A client who has problems communicating has a decreased ability to receive, process, or transmit communication.
A client with schizophrenia is taking benztropine (Cogentin) in conjunction with an antipsychotic. The client tells a nurse, "Sometimes I forget to take the Cogentin." What should the nurse teach the client to do if this happens again? 1 Take 2 pills at the next regularly scheduled dose. 2 Notify the health care provider about the missed dose immediately. 3 Take a dose as soon as possible, up to 2 hours before the next dose. 4 Skip the dose, then take the next regularly scheduled dose 2 hours early.
Take a dose as soon as possible, up to 2 hours before the next dose. Rationale: Taking a dose as soon as possible is the advised intervention when a dose is missed; interruption of the medication may precipitate signs of withdrawal such as anxiety and tachycardia. Taking 2 pills at the next regularly scheduled dose will provide an excessive amount of the medication at one time. Notifying the health care provider about the missed dose immediately is unnecessary. Skipping a dose is not advised if the next regularly scheduled dose is due within 2 hours.
A nurse is aware that a co-worker's mother died 16 months ago. The co-worker cries every time someone says the word "mother" and when the mother's name is mentioned. What does the nurse conclude about this behavior? 1 It is an expected response. 2 Most people cry when their mother dies. 3 The co-worker may need help with grieving. 4 The co-worker was extremely attached to the mother.
The co-worker may need help with grieving. Rationale: Crying is a release, but the individual should have developed effective coping mechanisms by this time. The co-worker may need help with the grieving process. Excessive crying 16 months after the death of a loved one is not an expected response. People express grief in a variety of ways, not necessarily by crying. Concluding that the co-worker was extremely attached to the mother is an assumption and is not a valid conclusion.
On which generally accepted concept of personality development should a nurse base care? 1 By 2 years of age the personality is firmly set. 2 The personality is capable of being modified throughout life. 3 The capacity for personality change decreases rapidly after adolescence. 4 By the end of the first 6 years of life the personality has reached its adult limitations.
The personality is capable of being modified throughout life. Rationale: New methods of coping with situations require modifications of approach and attitudes; hence personality is always capable of change. Certain personality traits are established by age 2, but not the total personality. The capacity for change exists throughout the life cycle. Accepting the theory that a personality has reached its adult limitations by age 6 denies the fact that the personality is capable of change throughout life.
