MENTAL HEALTH - Saunders

A client says to the nurse, "The federal guards were sent to kill me." Which is the best response by the nurse to the client's concern?

"Do you feel afraid that people are trying to hurt you?"

The nurse determines that the spouse of an alcoholic client is beneting from attending an Al-Anon group if the nurse hears the spouse make which statement?

"I no longer feel that I deserve the beatings my partner inflicts on me."

A client diagnosed with terminal cancer 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. After all, I'm the one who's dying." Which response by the nurse is therapeutic?

"It sounds as if you are feeling angry that your family continues to hope for you to be cured."

A client with a diagnosis of depression who has attempted suicide says to the nurse, "I should have died. I've always been a failure. Nothing ever goes right for me." Which therapeutic response would the nurse make?

"It sounds as if you've been feeling like a failure for a while."

The nurse visits a client at home. The client states, "I haven't slept at all the last couple of nights." Which therapeutic response would the nurse make?

"Tell me more about your sleep over the past few nights."

The nurse is conducting an initial assessment of a client in crisis. When assessing the client's perception of the precipitating event that led to the crisis, which is the most appropriate question?

"What leads you to seek help now?"

The nurse is preparing a client with schizophrenia and a history of command hallucinations for discharge by providing instructions on interventions for managing hallucinations and anxiety. Which statement in response to these instructions suggests to the nurse that the client has a need for additional information?

"When I have command hallucinations, I'll call a friend for help."

A depressed client on an inpatient unit says to the nurse, "My family would be better off without me." Which is the nurse's best response?

"You sound very upset. Are you thinking of hurting yourself?"

The nurse calls security and has physical restraints applied to a client who was admitted voluntarily when the client becomes verbally abusive, demanding to be discharged from the hospital. Which represents the possible legal ramifications for the nurse associated with these interventions? Select all that apply.

* Battery * Assault * False imprisonment

A client with a diagnosis of anorexia nervosa, who is in a state of starvation, is in a two-bed room. A newly admitted client will be assigned to this client's room. Which client would be the best choice as a roommate for the client with anorexia nervosa?

A client undergoing diagnostic tests

The nurse is creating a plan of care for a client in a crisis state. When developing the plan, the nurse would consider which factor?

A client's response to a crisis is individualized, and what constitutes a crisis for one client may not constitute a crisis for another client.

A client is admitted to the mental health unit with a diagnosis of depression. The nurse would develop a plan of care for the client that includes which intervention?

A structured program of activities in which the client can participate

A client is preparing to attend a Gamblers Anonymous meeting for the first time. The nurse would plan to tell the client that which is the first step in this 12-step program?

Admitting to having a problem

The home health nurse visits a client at home and determines that the client is dependent on drugs. During the assessment, which action would the nurse take to plan appropriate nursing care?

Ask the client about the amount of drug use and its effect.

The police arrive at the emergency department with a client who has lacerated both wrists. Which is the initial nursing action?

Assess and treat the wound sites.

A client is admitted to the mental health unit after an attempted suicide by hanging. The nurse can best ensure client safety by which action?

Assigning to the client a staff member who will remain with the client at all times.

The nurse is caring for a client diagnosed with paranoid personality disorder who is experiencing disturbed thought processes. In formulating a nursing plan of care, which best intervention would the nurse include?

Avoid using a whisper voice in front of the client.

A hospitalized client with a history of alcohol use disorder tells the nurse: "I am leaving now. I must go. I do not want any more treatment. I have things that I have to do right away." The client has not been discharged and is scheduled for an important diagnostic test to be performed in 1 hour. After the nurse discusses the client's concerns with the client, the client dresses and begins to walk out of the hospital room. What action would the nurse take?

Call the nursing supervisor.

A client admitted voluntarily for treatment of an anxiety problem demands to be released from the hospital. Which action would the nurse take initially?

Contact the client's primary health care provider.

A manic client begins to make sexual advances toward visitors in the dayroom. When the nurse firmly states that this is inappropriate and will not be allowed, the client becomes verbally abusive and threatens physical violence to the nurse. Based on the analysis of this situation, which intervention would the nurse implement?

Escort the client to their room, with the assistance of other staff

When a client is admitted to an inpatient mental health unit with the diagnosis of anorexia nervosa, a cognitive behavioral approach is used as part of the treatment plan. The nurse plans care based on which purpose of this approach?

Helping the client to examine dysfunctional thoughts and beliefs

The nurse is assessing a client who was admitted 24 hours ago for a fractured humerus. Which findings would alert the nurse to the potential for alcohol withdrawal delirium?

Hypertension, changes in level of consciousness, hallucinations

A moderately depressed client who was hospitalized 2 days ago suddenly begins smiling and reporting that the crisis is over. The client says to the nurse, "I'm finally cured." Based on the client's behavior and statement, which intervention would the nurse include in the plan?

Increasing the level of suicide precautions

The emergency department nurse is caring for an adult client who is a victim of family violence. Which priority information would be included in the discharge instructions?

Information regarding shelters

The nurse is working with a client who, despite making a heroic effort, was unable to rescue a neighbor trapped in a house re. Which client-focused action would the nurse plan to engage in during the working phase of the nurse-client relationship?

Inquiring about and examining the client's feelings for any that may block adaptive coping

The nurse is caring for a client who was admitted to the mental health unit recently for anorexia nervosa. The nurse enters the client's room and notes that the client is engaged in rigorous push-ups. Which nursing action is most appropriate?

Interrupt the client and offer to take the client for a walk.

A client is participating in a therapy group and focuses on viewing all team members as equally important in helping the clients meet their goals. The nurse is implementing which therapeutic approach?

Milieu therapy

When reviewing the admission assessment, the nurse notes that a client was admitted to the mental health unit involuntarily. Based on this type of admission, the nurse would provide which intervention for this client?

Monitor closely for harm to self or others.

The nurse is planning care for a client being admitted to the nursing unit who attempted suicide. Which priority nursing intervention would the nurse include in the plan of care?

One-to-one suicide precautions

The nurse observes that a client is pacing, agitated, and presenting aggressive gestures. The client's speech pattern is rapid, and affect is belligerent. Based on these observations, which is the nurse's immediate priority of care?

Provide safety for the client and other clients on the unit.

The nurse is conducting a group therapy session. During the session, a client diagnosed with mania consistently disrupts the group's interactions. Which intervention would the nurse initially implement?

Setting limits on the client's behavior

The nurse is caring for a client just admitted to the mental health unit and diagnosed with catatonic stupor. The client is lying on the bed in a fetal position. Which is the most appropriate nursing intervention?

Sit beside the client in silence with simple open ended questions.

What is the most appropriate nursing action to help manage a manic client who is monopolizing a group therapy session?

Thank the client for the input, but inform the client that others now need a chance to contribute.

Which behavior observed by the nurse indicates a suspicion that a depressed adolescent client may be suicidal?

The adolescent gives away a DVD and a cherished autographed picture of a performer.

The nurse is reviewing the assessment data of a client admitted to the mental health unit. The nurse notes that the admission nurse documented that the client is experiencing anxiety as a result of a situational crisis. The nurse plans care for the client, determining that this type of crisis could be caused by which event?

The death of a loved one

A client diagnosed with delirium becomes disoriented and confused at night. Which intervention would the nurse implement initially?

Use an indirect light source and turn off the television.

A client experiencing disturbed thought processes believes that the food is being poisoned. Which communication technique would the nurse use to encourage the client to eat?

Using open-ended questions and silence

The nurse is planning activities for a client diagnosed with bipolar disorder with aggressive social behavior. Which activity would be most appropriate for this client?

Writing

The nurse observes that a client with a potential for violence is agitated, pacing up and down the hallway, and making aggressive and belligerent gestures at other clients. Which statement would be most appropriate to make to this client?

"You seem restless; tell me what is happening."

A client is admitted with a recent history of severe anxiety following a home invasion and robbery. During the initial assessment interview, which statement by the client would indicate to the nurse the possible diagnosis of post-traumatic stress disorder? Select all that apply.

*"I keep reliving the robbery." *"I see that face everywhere I go." *"I might have died over a few dollars in my pocket."

The nurse has been closely observing a client who has been displaying aggressive behaviors. The nurse observes that the behavior displayed by the client is escalating. Which nursing intervention is most helpful to this client at this time? Select all that apply.

*Acknowledge the client's behavior. *Assist the client to an area that is quiet. *Maintain a safe distance from the client.

Which nursing interventions are appropriate for a hospitalized client with mania who is exhibiting manipulative behavior? Select all that apply.

*Communicate expected behaviors to the client. *Assist the client in identifying ways of setting limits on personal behaviors. *Follow through about the consequences of behavior in a nonpunitive manner. *Have the client state the consequences for behaving in ways that are viewed as unacceptable.

When planning the discharge of a client with chronic anxiety, which is the most appropriate maintenance goal?

Identifying anxiety-producing situations

A client is unwilling to go to church because the ex-spouse goes there and the client feels that the ex-spouse will laugh at the client. Because of this hypersensitivity to a reaction from the spouse, the client remains homebound. The home care nurse develops a plan of care that addresses which personality disorder?

Avoidant

A client is admitted to a medical nursing unit with a diagnosis of acute blindness after being involved in a hit-and-run accident. When diagnostic testing cannot identify any organic reason why this client cannot see, a mental health consult is prescribed. The nurse plans care based on which mental health condition?

Conversion disorder

The nurse employed in a mental health clinic is greeted by a neighbor in a local grocery store. The neighbor says to the nurse, "How is Carol doing? Carol is my best friend and is seen at your clinic every week." Which is the most appropriate nursing response?

"I cannot discuss any client situation with you."

A victim of a sexual assault is being seen in the crisis center. The client states, "I still feel as though the rape just happened yesterday," even though it has been a few months since the incident. Which is the most appropriate nursing response?

"Tell me more about the incident that causes you to feel as if the rape just occurred."

The spouse of a client admitted to the mental health unit for alcohol withdrawal says to the nurse, "I need to get out of this bad situation." Which is the most helpful response by the nurse?

"What do you nd difficult about this situation?"

The nurse is preparing to perform an admission assessment on a client with a diagnosis of bulimia nervosa. Which assessment findings would the nurse expect to note? Select all that apply.

*Dental decay *Loss of tooth enamel *Electrolyte imbalances

Which interventions are most appropriate for caring for a client in alcohol withdrawal? Select all that apply.

*Monitor vital signs. *Provide a safe environment. *Address hallucinations therapeutically. *Provide reality orientation as appropriate.

The nurse in the mental health unit plans to use which therapeutic communication techniques when communicating with a client? Select all that apply.

*Restating *Active listening *Maintaining neutral responses *Providing acknowledgment and feedback

The nurse would plan which goals for the termination stage of group development? Select all that apply.

*The group evaluates the experience. *The group explores members' feelings about the group and the impending separation.

On review of the client's record, the nurse notes that the admission was voluntary. Based on this information, the nurse plans care, anticipating which client behavior?

A willingness to participate in the planning of the care and treatment plan

A client with anorexia nervosa is a member of a predischarge support group. The client verbalizes an interest in buying new clothes, but expresses that money is limited. Group members have brought some used clothes to the client to replace the client's old clothes. The client believes that the new clothes are much too tight and has reduced personal caloric intake to 800 calories daily. How would the nurse evaluate this behavior?

Evidence of the client's disturbed body image

The nurse in the emergency department is caring for a young victim of sexual assault. The client's physical assessment is complete, and physical evidence has been collected. The nurse notes that the client is withdrawn, distracted, tremulous, and bewildered at times. How would the nurse interpret these behaviors?

Reactions to a devastating event