Psychobiological Disorders
A hospitalized psychiatric client with the diagnosis of histrionic personality disorder demands a sleeping pill before going to bed. After being refused the sleeping pill, the client throws a book at the nurse. The nurse identifies this behavior as: 1 Exploitive 2 Acting out 3 Manipulative 4 Reaction formation
Acting out Acting out is the process of expressing feelings behaviorally. The action is not exploitive, because no evidence is provided to demonstrate that anyone has been used to get what the client wants. The action is not manipulative, because no evidence is provided to demonstrate that anyone has been influenced against his or her wishes. The action is not disguising unacceptable feelings by expressing opposite emotions.
An obviously upset client comes to the mental health clinic and, after pushing ahead of the other clients, states, "I had an argument with my daughter, and now I'm tense, and worried, and angry." What level of anxiety does the nurse determine that the client is experiencing? 1 Mild 2 Panic 3 Severe 4 Moderate
4 Moderate The client is focused on one part of reality but is unable to grasp the total picture; this situation reflects a moderate level of anxiety. Mild anxiety is the level at which the individual is cognizant of all aspects of reality but has a "jumpy feeling" and "butterflies in the stomach." Panic is the level at which the individual is no longer in contact with reality, is unable to make decisions, has impaired judgment, and is dysfunctional. Severe anxiety is the level at which individuals lose touch with reality and have a feeling of impending doom, which tends to immobilize them.
A client who is being admitted to the mental health unit with bipolar disorder is depressed, avoids eye contact, responds in a very low voice, and is tearful. What is most therapeutic for a nurse to say during the assessment interview? 1 "You'll get better faster if you let us help you." 2 "Hold my hand. I know that you're frightened. I won't let anyone harm you." 3 "I'm your nurse. I'll take you to the dayroom as soon as I get some information." 4 "I know this is difficult, but as soon as we're finished I'll take you to your room."
4 "I know this is difficult, but as soon as we're finished I'll take you to your room.""I know this is difficult, but as soon as we're finished I'll take you to your room." "I know this is difficult, but as soon as we're finished I'll take you to your room" recognizes the clients feelings and explains what is expected. "You'll get better faster if you let us help you" is threatening and constitutes false reassurance; it puts the responsibility on the client and does not permit expression of feelings. "Hold my hand. I know that you're frightened. I won't let anyone harm you" may lead the client to think that the environment is unsafe, which may increase insecurity and anxiety. Being with other people in a strange situation will add more stress to the new and already frightening experience of hospitalization.
Risk for assaultive behavior is highest in the mental health client who: 1 Uses profane language 2 Touches people excessively 3 Exhibits a sudden withdrawal 4 Experiences command hallucination
Command hallucinations are dangerous because they may influence the client to engage in behaviors that are dangerous to self or others. Although profane language, excessive touching of others, and withdrawn behavior may all be cause for concern, but none is as dangerous as command hallucinations.
A client is admitted to a long-term care facility and placed in a semiprivate room. After the second night on the unit the client's roommate reports that the client is masturbating at night and demands another room. What is the most appropriate intervention by the nurse? 1 Moving the roommate who made the report to another room 2 Providing the client who was masturbating with periods of private time 3 Telling the roommate that this is acceptable behavior and that the client has the right to engage in it 4 Informing the client who is masturbating that this behavior is inappropriate and should not continue
Correct2 Providing the client who was masturbating with periods of private time Masturbating is a healthy human sexual behavior. The client should be provided with private time. The client has the right to meet physical needs but should not impose the behavior on others. Moving the roommate to another room could be ineffective because this may happen with the client's future roommate. Telling the roommate that this is acceptable behavior and that the client has the right to engage in it does not address either client's needs.
A nurse raises three of four of the client's bedside rails at night. Which psychosocial outcome does the nurse hope to achieve through the use of side rails? 1 Prevent falls 2 Increase independence 3 Support a sense of security 4 Avoid an alteration in proprioception
Correct3 Support a sense of secur Because hospital beds are narrower than the beds clients sleep in at home, side rails often create a sense of security. The use of side rails to prevent falls relates to the client's physical status, not psychosocial status. The use of bedside rails may cause the client to feel more dependent. Bed rails are unrelated to proprioception, which is knowing the location of a body part when it is out of the field of vision.
A nurse approaches a depressed client who is sitting alone in the dayroom. What is the best nursing intervention? 1 "Do you mind if I talk to you?" 2 "May I sit with you for a while?" 3 "Call me if you'd like to talk with me." 4 "I'll be sitting with you for a while today."
"I'll be sitting with you for a while today." The response "I'll be sitting with you for a while today" makes it unnecessary for the client to make the decision and demonstrates that the client is worthy and important. "Do you mind if I talk to you?" "May I sit with you for a while?" and "Call me if you would like to talk." all require action that the client may be unable to take.
Electroconvulsive therapy (ECT) is a mode of treatment that is used primarily to treat: 1 Clinical depression 2 Substance abuse disorders 3 Antisocial personality disorder 4 Psychosis occurring in schizophrenia
Clinical depression ECT is used to treat clinical depression in clients who do not respond well to a trial of psychotropic medications or are so severely depressed that immediate intervention is needed. ECT is not used as a primary treatment for clients with substance abuse disorders, antisocial personality disorder, or schizophrenic psychosis.
A nurse is planning activities for a withdrawn client who is hallucinating. What is the most therapeutic activity for this client? 1 Going for a walk with the nurse 2 Watching a movie with other clients 3 Playing a board game with a group of clients 4 Playing a game of cards alone in the dayroom
Going for a walk with the nurse Walking with the nurse facilitates one-on-one interaction and the development of a trusting relationship. Watching a movie will allow the client to withdraw further. Playing a game with others is beyond the client's ability at this time. Playing cards alone will allow the client to withdraw further.
An extremely depressed client signed the consent for electroconvulsive therapy (ECT) but continues to express anxiety about the procedure. What is most important for a nurse to emphasize when discussing ECT with the client? 1 "The procedure may cause a headache." 2 "The procedure will make you feel better." 3 "You won't be left alone during the procedure." 4 "You will have periods of amnesia after the procedure."
You won't be left alone during the procedure The staff's presence provides continued emotional support and helps relieve anxiety. Although the client should be aware that headache may occur, it is not the priority information that should be discussed with the client. Also, a mild analgesic will be prescribed if a headache occurs. The treatments may not make the client feel better; this is false reassurance. Not all clients experience amnesia, and the amnesia is temporary; placing emphasis on amnesia will increase fear.
When a nurse sits next to a depressed client and begins to talk, the client responds, "I'm stupid and useless. Talk with the other people who are more important." Which response is most therapeutic? 1 "Everyone is important." 2 "Do you feel that you're not important?" 3 "Why do you feel that you're not important?" 4 "I want to talk with you because you are important to me."
"I want to talk with you because you are important to me." he response "I want to talk with you because you are important to me" is an expression of the nurse's positive thoughts about the client and lets the client know that the nurse is concerned. "Everyone is important" demonstrates the nurse's positive thoughts about all people and does not focus on the client specifically. Although the response "Do you feel that you are not important?" may promote verbalization of feelings, it does not communicate the nurse's positive regard for the client, which might support a more positive self-esteem. The client may not be aware of what has caused the feelings of insignificance and may not be able to answer the question "Why do you feel that you're not important?"
A client requiring surgery because of mitral valve incompetence is admitted to the hospital and states, "I need a new valve, with an oil change, too!" What is the nurse's most therapeutic response? 1 "You really don't need to hide your anxieties." 2 "You sure came to the right place for a valve job." 3 "I'm glad to see you're handling the situation well." 4 "I'm sure you have a great deal to ask about your surgery."
"I'm sure you have a great deal to ask about your surgery." "I'm sure you have a great deal to ask about your surgery" is a reflective response that fosters open lines of communication with the client. The response "You really don't need to hide your anxieties" puts the client on the defensive because it exposes the defensive behavior being used. The response "You sure came to the right place for a valve job" does not focus on the client's concern and cuts off further communication. The response "I'm glad to see you're handling the situation well" may be interpreted as a sarcastic response that may cut off further communication.
The parent of a child with a tentative diagnosis of attention deficit-hyperactivity disorder (ADHD) arrives at the pediatric clinic insisting on getting a prescription for medication that will control the child's behavior. What is best response by the nurse? 1 "It must be frustrating to deal with your child's behavior." 2 "Have you considered any alternatives to using medication?" 3 "Perhaps you're looking for an easy solution to the problem." 4 "Let me teach you about the side effects of medications used for ADHD."
"It must be frustrating to deal with your child's behavior." Stating that it must be frustrating acknowledges the parent's distress and encourages verbalization of feelings. Asking whether any alternatives have been considered is insensitive to the parent's feelings; it may be more appropriate later, when the parent's stress has diminished. Although the parent may be looking for an easy answer to the problem, this response is confrontational and may close off communication. Asking to teach the parent about the side effects of ADHD medications is insensitive to the parent's feelings; it may be more appropriate later if medication is prescribed and health teaching is started.
One morning a female client with the diagnosis of schizophrenia tells the nurse that she is Joan of Arc and is going to be burned at the stake. What is the most therapeutic response by the nurse? 1 "Tell me more about being Joan of Arc." 2 "We both know that you're not Joan of Arc." 3 "It seems like the world is a pretty scary place for you." 4 "You're safe here, because we won't let you be burned."
"It seems like the world is a pretty scary place for you." With the statement "It seems like the world is a pretty scary place for you" the nurse attempts to understand the symbolism, reflects and acknowledges the client's feelings, and helps preserve the client's integrity. The statement "Tell me more about being Joan of Arc" validates the client's delusion and does not test reality. The statement "We both know that you're not Joan of Arc" rejects the client's feelings and does not address the client's fears of being harmed; clients cannot be argued out of delusions. The statement "You're safe here, because we won't let you be burned" is false reassurance; the nurse cannot fully understand the symbolism and therefore cannot make this promise.
a nursing team holds a conference to develop goals for the care of a withdrawn, shy male client with low self-esteem who is afraid to talk to members of the opposite sex. Which objective should be given priority and documented in the client's plan of care? 1 "The client will increase his self-esteem." 2 "The client will understand his sexual disorder." 3 "The client will examine his feelings toward women." 4 "The client will increase his knowledge of sexual function."
"The client will increase his self-esteem." If the goal to increase the client's self-esteem is met, the client's relationship with others should improve in all aspects, including sexual. Increasing insight may be helpful but should not receive priority. The client may or may not have a sexual disorder. Examining his feelings toward women is not appropriate at this time; examining these feelings is nonproductive until the client's self-esteem improves. Increasing the client's knowledge of sexual function may be done, but improvement of self-esteem should receive priority.
An older client is brought to the hospital by a family member because of deep partial-thickness burns on the arms and hands. The client protests being hospitalized and asks, "Why can't I just go home and have my spouse care for me?" What is the best response by the nurse? 1 "You sound upset, but your health care provider knows best. You should do what is prescribed." 2 "Your spouse is very capable, but if your burns get infected, a family member can't give you the injections you will need." 3 "Your burns are more serious than you think, and we have specially trained people here just to take care of you." 4 "You may heal more slowly because of your age, and you may need the special care and equipment available in the hospital."
"You may heal more slowly because of your age, and you may need the special care and equipment available in the hospital." Many older clients have multiple health problems and are at a higher risk for infection because of a depressed immune system; the response "You may heal more slowly because of your age, and you may need the special care and equipment available in the hospital" provides information and addresses the fact that special care and equipment may not be available in the home. Although the response "You sound upset, but your health care provider knows best. You should do what is prescribed" addresses feelings, it does not provide information and promotes dependency and feelings of powerlessness and helplessness. The response "Your spouse is very capable, but if your burns get infected, a family member can't give you the injections you will need" is inaccurate; family members have been trained on how to give injections. The statement produces anxiety about an unpredictable future. Additionally, the competency of the spouse has not been assessed. The response "Your burns are more serious than you think, and we have specially trained people here just to take care of you" may increase anxiety and precipitate feelings of guilt regarding expectations being placed on the spou
One morning a client with the diagnosis of acute depression says to the nurse, "God is punishing me for my past sins." What is the best response by the nurse? 1 "Why do you think that?" 2 "God is punishing you for your sins?" 3 "You really seem to be upset about this." 4 "If you feel this way, you should talk to a member of the clergy."
"You really seem to be upset about this." "You really seem to be upset about this" focuses on the client's feelings rather than on the statement and serves to open a channel of communication. "Why do you think that?" asks the client to decide what is causing the feelings; most people are unable to explain why they feel as they do. Although paraphrasing may stimulate further communication, the statement does not focus on feelings. "If you feel this way, you should talk to a member of the clergy" does nothing to stimulate further communication; in fact, it tells the client to talk about feelings with someone else.
A disturbed client says, "The voices are saying that I killed my husband." What is the best response by the nurse? 1 "I just saw your husband, and he's doing fine." 2 "Tell me more about your concerns for your husband." 3 "We'll put you in a private room where you'll be safe." 4 "You seem to be having very frightening thoughts right now."
"You seem to be having very frightening thoughts right now." "You seem to be having very frightening thoughts right now" demonstrates that the nurse understands the client's feelings; reflection opens a channel for communication. The nurse cannot talk the client out of her delusions by pointing out reality. Focusing on delusional content only reinforces false beliefs. "We'll put you in a private room where you'll be safe" does not reflect the content of the client's statement.
A middle-age female client who has lost 20 lb over the last 2 months cries easily, sleeps poorly, and refuses to participate in any family or social activities that she previously enjoyed. What is the most important nursing intervention? 1 Providing the client with a high-calorie, high-protein diet 2 Reducing the client's crying episodes by setting firm, consistent limits 3 Assuring the client that she will regain her usual function in a short time 4 Allowing the client to externalize her feelings, especially anger, in a safe manner
1 Providing the client with a high-calorie, high-protein diet Allowing the client to externalize her feelings, especially anger, in a safe manner When a client exhibits adaptations related to depression, the greatest danger is self-inflicted injury when feelings, especially anger, are internalized. There are not enough data to show that the weight loss is the result of malnutrition. The client is unable to regulate her crying at this time. Assuring the client that she will regain her usual function in a short time is false reassurance and is not supportive of the client's feelings.
A depressed client is concerned about many fears that are upsetting and frightening and expresses a feeling of having committed the "unpardonable sin." What is the most therapeutic response by the nurse? 1 "Your family loves you very much." 2 "You do understand that you really aren't a bad person, right?" 3 "You know that these feelings are in your imagination and aren't true, right?" 4 "Your thoughts are just a part of your illness, and they'll change as you get better."
4 "Your thoughts are just a part of your illness, and they'll change as you get better." Telling the client that these thoughts are part of your illness and that they will change as the client gets better points out reality while accepting that the client believes that the feelings and thoughts are real. "Your family loves you very much" is false reassurance; there are no data about the client's family. The client does not know that he isn't a bad person; in fact, he believes the opposite to be true. "You know that these feelings are in your imagination and aren't true" is reality, but it is not a supportive response.
A client with depression has not responded to a tricyclic antidepressant and outpatient electroconvulsive therapy (ECT). The health care provider prescribes selegiline (Eldepryl), and the nurse teaches the client about food to be avoided while taking this medication. Which foods identified by the client allow the nurse to conclude that the instructions have been understood? Select all that apply. 1 Fresh fish 2 Aged cheese 3 Fried chicken 4 Chocolate drinks 5 Leafy vegetables
Aged cheese Chocolate drinks Foods containing tyramine can cause hypertensive crisis and should be eliminated from the diet. These foods include pickled herring, beer, wine, chicken livers, aged or natural cheese, caffeine, cola, licorice, avocados, bananas, and bologna. Chocolate in moderation is safe for some patients, but it does contain caffeine. Overripe fruits and caffeine have high levels of tyramine, which can cause dangerous hypertension in clients taking monoamine oxidase inhibitors (MAOIs). Also, large amounts of caffeine can increase blood pressure and should be avoided. There is no need to limit the intake of fish, chicken, or leafy vegetables while taking an MAOI
The nurse is caring for an 84-year-old man admitted with a diagnosis of severe Alzheimer dementia. In the admission assessment, the nurse notes that the client can no longer recognize familiar objects such as his glasses and toothbrush. The best term to describe this situation is: 1 Amnesia 2 Aphasia 3 Apraxia 4 Agnosia
Agnosia Agnosia is the term used to describe the loss of sensory ability to recognize familiar sounds and objects, as well as loved ones or even parts of the affected individual's body. Amnesia is the term for the impairment of memory both recent and remote. Aphasia is the term for the loss of language ability, which progresses with the disease. Apraxia is the term for the loss of purposeful movement in the absence of motor or sensory impairment. The individual is unable to perform purposeful tasks such as walking or putting clothing on properly.
An antipsychotic has been prescribed to be taken three times a day by a client who was admitted to the psychiatric service because of delusions and physical and verbal abuse of others. What client behavior demonstrates a therapeutic response to the medication? 1 Exhibits enthusiasm about the food in the hospital 2 Becomes aware of the behavior and its consequences 3 Begins to get involved with the activities of others on the unit 4 Remains preoccupied with the delusions but is less verbally abusive
Becomes aware of the behavior and its consequences As the therapeutic level is reached and maintained, the client's psychotic symptoms decrease and insight increases. Exhibiting enthusiasm about the food or beginning to get involved with the activities of others on the unit does not indicate that the client is responding therapeutically to the medication. Remaining preoccupied with the delusions but is less verbally abusive is an indication that the client is not responding to the medication.
A public health nurse is working with a family with three school-aged children as the unit of service. What should the nurse consider when caring for this family? 1 Certain members of the family may be capable of giving more support than the nurse. 2 Assessing each family member is not necessary to plan care for the family as a whole. 3 Family values are not as important as other factors regarding how assistance is perceived. 4 Helping the family requires separating health problems from other aspects of the family's life.
Certain members of the family may be capable of giving more support than the nurse. 2Family strengths must be identified and used by the nurse. It is necessary to assess each family member to plan care for the whole family. Family values, beliefs, and attitudes greatly influence perceptions. The family members and their problems must be viewed as an integrated whole.
A clinically depressed female client on a psychiatric unit of a local hospital uses embroidery scissors to cut her wrists. After treatment, when the nurse approaches, the client is tearful and silent. What is the best initial intervention by the nurse? 1 Note client's behavior, record it, and notify the practitioner. 2 Sit quietly next to the client and wait until she begins to speak. 3 Say, "You're crying. I guess that means you feel bad about attempting suicide and really want to live." 4 Comment, "I notice that you seem sad. Tell me what it's like for you and perhaps we can begin to work it out together."
Comment, "I notice that you seem sad. Tell me what it's like for you and perhaps we can begin to work it out together." Noting that the client seems sad and asking her to describe her feelings so the nurse and client can begin to work it out together recognizes feelings and behavior; it encourages the client to share feelings and promotes trust, which is essential for a therapeutic relationship. Although noting, recording, and notifying the practitioner of the client's behavior are important actions, they are not enough; nursing intervention with the client must be included. Without verbal encouragement, the depressed client will not respond to this intervention. Saying that because the client is crying she must feel bad about attempting suicide and really want to live assumes too much and may be inaccurate; an indirect approach should be used.
What is the best nursing intervention when the language of a client in the manic phase of a bipolar disorder becomes vulgar and profane? 1 Stating, "We don't like that kind of talk around here." 2 Ignoring it because the client is using it to gain attention 3 Recognizing that the behavior is part of the illness but setting limits on it 4 Responding, "We'll talk with you when you can speak in an acceptable way."
Correct3 Recognizing that the behavior is part of the illness but setting limits on it Recognizing the language as part of the illness makes it easier to tolerate, but limits must be set for the benefit of the staff and other clients. Setting limits also shows the client that the nurse cares enough to stop the behavior. "We don't like that kind of talk around here" shows little understanding or tolerance of the illness. Ignoring the behavior is a form of rejection; the client is not using the behavior for attention. "We'll talk with you when you can speak in an acceptable way" demonstrates rejection of the client and little understanding of the illness.
A 32-year-old woman is hospitalized with a diagnosis of a bipolar disorder, manic episode. She becomes loud and vulgar and disturbs the other clients. What is the best reaction by the nurse to this situation? 1 Telling her that she is bothering the other clients 2 Ignoring the vulgar talk because it is part of the illness 3 Segregating the client until this phase of her illness passes 4 Commenting that this kind of talk is not appreciated on the unit
Correct3 Segregating the client until this phase of her illness passes During the manic phase, when clients are unable to control their behavior, they should be protected from embarrassing themselves or harming others. These clients are unable to deal with others' feelings; the client's own feelings are primary at this time. Also, simply telling the client that her behavior is bothersome is too general to communicate which behaviors are dysfunctional. The client's behavior cannot be ignored because the client or others may be hurt if limits are not set. Stating that talk such as the client's is not welcome on the unit is critical of the client, who is unable to respond differently at this time.
A client with schizophrenia, paranoid type, is readmitted to the hospital at the insistence of the family. While exploring her feelings about the readmission, the client angrily shouts, "You're one of them. Leave me alone." How should the nurse respond? 1 "Try not to be afraid. I won't hurt you." 2 "I'm not one of them—I'm here to help you." 3 "Your family and the staff are trying to help you." 4 "I can see that you're upset. We can talk more later."
Correct4 "I can see that you're upset. We can talk more later." Acknowledging the client's feelings and offering an opportunity to talk in the future shows that the nurse cares and is not abandoning the client. Pursuing the topic while the client is angry may result in an escalation of the client's anger, jeopardizing the safety of the nurse and others. The nurse's telling the client that she is not one of "them" and that the client's family and staff are trying to help her requires trust on the part of the client, which may or may not be justified at this time; the client feels betrayed and is angry.
A client with a diagnosis of antisocial personality disorder is being discharged from the hospital. The client asks the nurse, "Can I have your phone number so I can call you for a date?" What is the best response by the nurse? 1 "We are not permitted to date clients." 2 "It is against my professional ethics to date clients." 3 "I'm glad you like me, but I can't give out my phone number." Correct4 "Our relationship is professional; therefore I will not see you socially."
Correct4 "Our relationship is professional; therefore I will not see you socially." Our relationship is professional; therefore I will not see you socially." "Our relationship is professional; therefore I will not see you socially" sets clear limits on the relationship and maintains a professional rather than a social role. "We are not permitted to date clients" shifts responsibility from the issue at hand to the institution. "It is against my professional ethics to date clients" avoids the real issue and shifts responsibility to the ethical code. "I'm glad you like me, but I can't give out my phone number" does not clarify the nature of the relationship as professional. Test-Taking Tip: Do not spend too much time on one question, because it can compromise your overall performance. There is no deduction for incorrect answers, so you are not penalized for guessing. You cannot leave an answer blank; therefore, guess. Go for it! Remember: You do not have to get all the questions correct to pass.
A psychologist has been a client on a mental health unit for 3 days. The client has questioned the authority of the treatment team, advised other clients that their treatment plans are wrong, and been disruptive in group therapy. What is the most appropriate nursing intervention? 1 Telling the other clients to disregard what the client is saying 2 Ignoring the client's disruptive behavior and waiting for it to subside 3 Restricting the client's contact with other clients until the disruptive behavior ceases 4 Accepting that the client is unable to control this behavior and setting appropriate limits
Correct4 Accepting that the client is unable to control this behavior and setting appropriate limits Clients who are out of control need to have limits set for them. The staff must understand that the client is not deliberately trying to disrupt the unit. Telling the other clients to disregard what the client is saying is demeaning the client in the eyes of the other clients and does not address the problem directly. Ignoring the client will not stop the disruptive behavior; also, the nurse has a responsibility to the other clients. Restricting the client's contact with other clients until the disruptive behavior ceases may be done as a last resort, but this approach should not be used until other alternatives have been explored.
A client has a diagnosis of schizoid personality disorder. During the assessment the nurse should expect the client's behavior to be: 1 Rigid and controlling 2 Dependent and submissive 3 Detached and socially distant 4 Superstitious and socially anxious
Detached and socially distant Clients with the diagnosis of schizoid personality disorder neither desire nor enjoy close relationships, prefer solitary activities, and demonstrate emotional coldness, detachment, and a flattened affect. Rigid and controlling behavior is typical of clients with the diagnosis of obsessive-compulsive personality disorder. Dependent and submissive behavior is typical of clients with the diagnosis of dependent personality disorder. Superstitious and socially anxious behavior is typical of clients with the diagnosis of schizotypal personality disorder.
A nurse is caring for a newly admitted, extremely depressed client. The most appropriate initial goal for the client is: 1 Setting realistic life goals 2 Developing trust in others 3 Expressing hostile feelings 4 Getting involved in activities
Developing trust in others Trust must develop before the nurse-client relationship can move toward the working phase of the relationship. There is nothing to indicate that the client has unrealistic goals. Expressing hostile feelings is a later goal; depressed clients find it difficult to express anger and hostility. Getting involved in activities is a later goal; depressed clients initially do not have the emotional or physical energy to get involved in activities.
A client's history demonstrates a pervasive pattern of unstable and intense relationships, impulsiveness, inappropriate anger, manipulation, offensive behavior, and hostility. The admitting diagnosis is borderline personality disorder. What does the nurse anticipate that this client may attempt to do? 1 Act out to intimidate others. 2 Cooperate with the staff to gain praise. 3 Divide the staff into opposing factions to gain self-esteem. 4 Remain removed from others to avoid interacting with them.
Divide the staff into opposing factions to gain self-esteem Attempts at dividing the staff are expected because the resulting effect creates a feeling of power and control. These individuals usually act out to discharge anxiety rather than to intimidate. Usually they comply or cooperate to prevent a feeling of abandonment rather than to gain praise. Although such clients may remain removed from others to avoid interacting with them occasionally, they have an unstable approach and their aloofness cannot be maintained.
An 84-year-old widow with dementia who had been living with her daughter before hospitalization is being discharged with a referral to the visiting nurse. When the nurse visits, the client is in bed sleeping at 10 am. Her daughter states that she gives her mother sleeping pills to stop her wandering at night. The nurse should: 1 Explore hiring a home health aide to stay with the client at night. 2 Discuss the possibility of having the client placed in a nursing home. 3 Suggest moving the client among family members on a monthly basis. 4 Empathize with the daughter but suggest that wrist restraints would be preferable. E
Explore hiring a home health aide to stay with the client at night. Exploring hiring a home health aide to stay with the client at night will reduce the need for sleeping pills, which frequently add to the older client's confusion. The family is not asking that the client be moved from the home; the nurse's focus should be helping reduce the confusion the client experiences at night, keeping the client safe, and easing the burden on the family. Continually changing a cognitively impaired client's environment and routine will increase confusion and anxiety. This client needs a consistent environment with a set daily routine of activities, which provides structure and comfort. Restraints add to the client's confusion and tend to worsen inappropriate behavior.
a client with the diagnosis of personality disorder with antisocial behavior is hospitalized. The client is openly discussing interpersonal difficulties with family members and the boss at work from whom he has stolen money. The client is facing criminal charges. Which behavior indicates that the client is meeting treatment goals? 1 Expression of feelings of resentment toward the employer 2 Discussion of plans for each of the possible outcomes of a trial 3 Expression of resignation about difficult relationships with his spouse and children 4 Discussion of the decision to file a grievance against the employer after discharge from the hospital
Expression of resignation about difficult relationships with his spouse and children Because the legal difficulties were a precipitating event for hospitalization, if the client can realistically examine the possible outcomes of the trial, then some benefit has been gained from the therapy. Freely expressing resentment and claiming victimization by the employer and authority figures do not show improvement or insight. The client has been discussing his problems since admission, so expressing resignation does not indicate the development of insight. Deciding to file a grievance indicates unrealistic planning and does not demonstrate the development of insight.
In an outpatient mental health clinic a nurse is working with a client who is beginning to address more effective ways to handle stressful situations. The best nursing action to include in the plan of care is to have the client: 1 Identify unhealthy habits that need to be altered. 2 Determine the benefits of a rehabilitation program. 3 Learn about the benefits of antianxiety medications. 4 Develop a consistent method for performing self-care.
Identify unhealthy habits that need to be altered. The identification of unhealthy habits or specific problems will allow the client to determine which additional coping skills need to be developed and practiced. A rehabilitation program is more appropriate for clients with psychotic or substance abuse disorders, not clients who are experiencing anxiety. Further assessment is required before initiation of the use of medication. Although a consistent method for performing self-care is important, it is not the priority.
A client who has been admitted with a diagnosis of schizophrenia says to the nurse, "Yes, it's March. March is Little Women. That's literal, you know." These statements illustrate: 1 Echolalia 2 Neologisms 3 Flight of ideas 4 Loosening of associations
Loosening of associations Loose associations are thoughts that are presented without the logical connections that are usually necessary for the listener to interpret the message. Echolalia is the purposeless repetition of words spoken by others or repetition of overheard sounds. Neologisms are new meaningless words coined by the client or new, unique meanings given to old words. Flight of ideas is the rapid skipping from one thought to another; these thoughts usually have only superficial or chance relationships.
When caring for clients who are demonstrating manic behavior, the nurse must constantly reassess these clients' physical needs. What characteristic about these clients makes this particularly important? 1 Will withdraw to their rooms if left alone 2 Have difficulty making their needs known 3 May gain too much weight from overeating 4 May become exhausted from excessive activity
May become exhausted from excessive activity The elated client expends a great deal of energy; dehydration, oxygen deficit, cardiac problems, and death may occur. The elated person does not withdraw from reality but continues to run headfirst into reality. The elated client has little difficulty verbalizing needs. The elated client usually does not take time to eat while expending a great deal of energy, so weight loss is the problem.
a nurse is caring for a group of depressed clients. What should the nurse attempt to provide? 1 A variety of stimuli 2 Many varied activities 3 Opportunities to make decisions 4 An uncomplicated daily schedule
Opportunities to make decisions Depression is usually both emotional and physical, so a simple, repetitive daily routine is the least stressful and least anxiety-producing. Too many stimuli will increase anxiety in a depressed client. A depressed client has limited interest in any activities; too many activities may increase anxiety. A depressed client may be incapable of making even simple decisions.
A nurse concludes that a client has successfully achieved the long-term goal of mobilizing effective coping responses when the client states that when he feels himself getting anxious he will: 1 Perform a relaxation exercise. 2 Get involved in some type of quiet activity. 3 Avoid the situation that precipitated the anxiety. 4 Examine carefully what precipitated the anxiety.
Perform a relaxation exercise. Perform a relaxation exercise. Relaxation techniques refocus energy and eventually ease physical and emotional stress. Getting involved in some type of quiet activity is not always possible; forced quiet activity may increase stress and anger rather than reduce it. Avoiding the situation that precipitated the anxiety is not always possible; stress can develop from a variety of feelings stimulated by many situations. What precipitated feelings of anxiety is not easy to identify; it is better to learn to deal with feelings once they develop.
A 32-year-old man is laughing loudly and making inappropriate comments to clients and staff on an inpatient psychiatric unit. Other patients are getting angry about his behavior and have asked him to leave the activity room, but he has refused to do so. The goal of the nurse in charge is to restore order and ease tension on the unit. In which situation may the nurse incur liability? 1 Reporting his behavior to his treatment team 2 Checking his prescriptions for a PRN medication to help to calm the client 3 Placing the client in seclusion only until he stops verbally attacking clients and staff 4 Bringing the client to a quiet area on the unit and encouraging him to discuss his thoughts and behavior
Placing the client in seclusion only until he stops verbally attacking clients and staff 4 It is unlawful for a client to be placed in seclusion simply because he is annoying or bothersome to other clients and staff. A nurse who places a client in seclusion for this reason may be held liable for the client's actions. Bringing the client to a quieter area to give him attention and allow ventilation of feelings may be helpful. It is appropriate for the nurse to report the behavior that is being observed to the client's treatment team. It is also appropriate to assess the client's record to see whether a PRN medication might be beneficial in calming the client's behavior.
A nurse is working with an adolescent client with conduct disorder. Which strategies should the nurse implement while working on the goal of increasing the client's ability to meet personal needs without manipulating others? Select all that apply. 1 Discuss how others can precipitate anxiety. Correct 2 Provide physical outlets for aggressive feelings. Correct 3 Establish a contract regarding manipulative behavior. Correct 4 Develop activities that provide opportunities for success. 5 Encourage the client to verbalize negative feelings to others.
Provide physical outlets for aggressive feelings. Correct 3 Establish a contract regarding manipulative behavior. Correct 4 Develop activities that provide opportunities for success. Channeling energy to healthy physical activities can decrease violent behavior. A behavioral contract is used to reinforce problem solving and encourage the use of social skills. Successful experiences improve the client's self-esteem and should decrease the manipulative behavior. Clients with conduct disorders tend to generate stress for others, not the other way around. Verbalization of negative feelings to others can often escalate and result in antisocial or acting out behavior.
A man is found to have paranoid schizophrenia, and the practitioner prescribes a typical antipsychotic medication. After taking the medication for 1 month the client comes to the clinic and says, "I feel stiff, my hands shake, and I started drooling." The picture illustrates the client's physical status observed by the nurse in the clinic. What extrapyramidal side effect does the nurse conclude has developed? 1 Dystonia 2 Akathisia 3 Tardive dyskinesia 4 Pseudoparkinsonism
Pseudoparkinsonism Pseudoparkinsonism has adaptations similar to those of Parkinson disease (e.g., shuffling gait, tremors, rigidity, bradykinesia). Pseudoparkinsonism, an extrapyramidal side effect of typical antipsychotics, can occur any time after initiation of therapy. Dystonia is muscle spasms of the face, tongue, head, neck, jaw, and back, usually causing exaggerated posturing of the head. Akathisia is exhibited by motor restlessness. Tardive dyskinesia is exhibited by facial, ocular, oral/buccal, lingual/masticatory, and systemic movements.
A nurse is assessing an older adult with the diagnosis of dementia. Which manifestations are expected in this client? Select all that apply. 1 Resistance to change 2 Inability to recognize familiar objects 3 Preoccupation with personal appearance 4 Inability to concentrate on new activities or interests 5 Tendency to dwell on the past and ignore the present
Resistance to change 2 Inability to recognize familiar objects 3 Inability to concentrate on new activities or interests 5 Tendency to dwell on the past and ignore the present Resistance to change is a clinical finding associated with dementia; these clients need structure and routines. An inability to recognize familiar objects (agnosia) is a typical cognitive dysfunction associated with dementia. A short attention span and little or no interest in new activities are typical of dementia. The past, rather than the threatening present, is where these clients feel comfortable. Clients with delirium, dementia, and other cognitive disorders rarely express any concern about personal appearance. The staff must meet most of these clients' personal needs.
A client with the diagnosis of schizophrenia refuses to get out of bed and becomes upset. What is the nurse's initial therapeutic response? 1 Requiring the client to get out of bed at once 2 Allowing the client to stay in bed for a while 3 Staying at the bedside until the client calms down 4 Giving the prescribed as-needed tranquilizer to the clien
Staying at the bedside until the client calms down Staying at the bedside until the client calms down provides support and security without rejecting the client or placing value judgments on behavior. Eventually limits will have to be set, but this is not the immediate nursing action. Allowing the client to stay in bed for the time being ignores the problem, and isolation may imply punishment. Although medication will calm the client, it does not address the problem.
A woman who gave birth to a second child 3 weeks ago is depressed and having difficulty caring for her children. At the end of the day both of the children are dirty, wet, and crying. The woman tells her husband that she "just can't take this anymore." The husband calls the women's health clinic and asks what he should do. What is the best response by the nurse? 1 Telling him that his wife may be suffering from depression and needs emergency care 2 Telling him that fatigue is expected and that his wife needs to take rest periods during the day 3 Reassuring him that his wife is experiencing postpartum blues that will lessen in several days 4 Advising him to make an appointment for his wife to see her practitioner if the problem continues
Telling him that his wife may be suffering from depression and needs emergency care The mother's inability to care for herself or her children is an ominous sign that postpartum depression is reaching a critical level. The woman needs immediate care to meet her needs and ensure the safety of the children. Between 10% and 15% of new mothers have postpartum depression within 4 weeks of the birth of an infant. Telling the husband that fatigue is expected and that his wife needs to take rest periods during the day ignores the severity of the situation. The client's behavior is indicative of postpartum depression, not postpartum blues. Approximately 80% of women experience postpartum blues ("baby blues"), which peak around the fifth postpartum day and usually subside by the 10th postpartum day. The condition is characterized by a combination of emotional lability, restlessness, depression, let-down feeling, fatigue, insomnia, anxiety, sadness, and anger. Advising the husband to make an appointment for his wife to see her practitioner if the problem continues ignores the severity of the situation.
A nurse is assigned to care for a client with the diagnosis of schizophrenia who is hallucinating. What is the first consideration in trying to establish a trusting relationship? 1 Family members must be included in the plan of care. 2 The client cannot be distracted from the hallucinations. 3 The client adamantly believes what is being experienced. 4 Electroconvulsive therapy should be explained in simple terms.
The client adamantly believes what is being experienced. Because the client believes the hallucinations, initially the nurse should validate the client's feelings, but not the experience of the hallucinations, to begin to build trust. Including family member's in the plan of care is not the priority; this may be done later with the client's permission. Distraction can help clients with schizophrenia pay less attention to hallucinations, but this is not done initially. Because electroconvulsive therapy usually is not that effective for schizophrenia, there is no reason to explain its use.
The mother's inability to care for herself or her children is an ominous sign that postpartum depression is reaching a critical level. The woman needs immediate care to meet her needs and ensure the safety of the children. Between 10% and 15% of new mothers have postpartum depression within 4 weeks of the birth of an infant. Telling the husband that fatigue is expected and that his wife needs to take rest periods during the day ignores the severity of the situation. The client's behavior is indicative of postpartum depression, not postpartum blues. Approximately 80% of women experience postpartum blues ("baby blues"), which peak around the fifth postpartum day and usually subside by the 10th postpartum day. The condition is characterized by a combination of emotional lability, restlessness, depression, let-down feeling, fatigue, insomnia, anxiety, sadness, and anger. Advising the husband to make an appointment for his wife to see her practitioner if the problem continues ignores the severity of the situation.
The mother's inability to care for herself or her children is an ominous sign that postpartum depression is reaching a critical level. The woman needs immediate care to meet her needs and ensure the safety of the children. Between 10% and 15% of new mothers have postpartum depression within 4 weeks of the birth of an infant. Telling the husband that fatigue is expected and that his wife needs to take rest periods during the day ignores the severity of the situation. The client's behavior is indicative of postpartum depression, not postpartum blues. Approximately 80% of women experience postpartum blues ("baby blues"), which peak around the fifth postpartum day and usually subside by the 10th postpartum day. The condition is characterized by a combination of emotional lability, restlessness, depression, let-down feeling, fatigue, insomnia, anxiety, sadness, and anger. Advising the husband to make an appointment for his wife to see her practitioner if the problem continues ignores the severity of the situation.
A nurse is accompanying a client with a diagnosis of anxiety disorder who is pacing the halls and crying. When the client's pacing and crying worsen, the nurse suddenly feels uncomfortable and experiences a strong desire to leave. What is the most likely reason for what the nurse is experiencing? 1 An empathic communication of anxiety 2 A fear of the client's becoming assaultive 3 A desire to go off duty after a busy workday 4 An inability to tolerate any more bizarre behavior
An empathic communication of anxiety Because anxiety can be an interpersonal experience, it is contagious; the nurse then has a strong urge to get away. A fear of the client's becoming assaultive is possible but not probable; the client is exhibiting anxiety, not hostility, at this time. The desire to go off duty should not suddenly make the nurse uncomfortable. There is no indication that this or any other behavior encountered has been bizarre.
A community health nurse is counseling an adolescent with bulimia nervosa. For which type of treatment should the nurse refer the client? 1 Family therapy 2 Supportive group therapy 3 Cognitive-behavioral therapy 4 Crisis intervention eclectic therapy
Cognitive-behavioral therapy Research indicates that cognitive-behavioral therapy is most effective in the treatment of bulimia nervosa. Although family therapy and supportive group therapy are both important and may be helpful, neither is the most effective therapy for clients with bulimia nervosa. Although many nurses use an eclectic model when conducting psychotherapy, the crisis model is not an effective therapy for clients with bulimia nervosa.
When a client who has a bipolar mood disorder is hyperactive, it is difficult to entice her to sit still long enough to eat a complete meal. The plan of care states, "Provide finger foods such as carrots, celery, and cheese sticks at 10 am, 2 pm, and 7 pm." Recent assessment of this client indicates that all of the food provided at mealtimes is being eaten but that snacks have been refused. The nursing staff should: 1 Change the plan, depending on evaluation findings. 2 Ask the client whether the finger foods should still be provided. 3 Continue the current plan so the client's nutritional status will improve. 4 Reassess the client's nutritional status in 1 week so changes can be made
Correct1 Change the plan, depending on evaluation findings Because the plan does not meet the client's needs, it should be changed. The client has already let the staff know that finger foods are not wanted. Continuing the plan will be frustrating for the client and the staff because the client's behavior indicates that snacks are not wanted. When the client's needs are not being met, the plan should be changed immediately.
What is the priority nursing intervention in the planning of nursing care for an adolescent client with anorexia nervosa? 1 Rewarding weight gain by increasing privileges 2 Discussing the importance of eating a balanced diet 3 Encouraging the client to include high-calorie foods in the diet 4 Focusing family therapy on the influence of the client's behavior on the family
Rewarding weight gain by increasing privileges
As a client who has just given birth examines her newborn, she notes a nevus vasculosus on her infant's mid thigh and becomes upset. How should the nurse respond? 1 "These areas usually spread and then regress." 2 "The mark is superficial and will fade in a few days." 3 "The mark is permanent, but it can be covered with clothes." 4 "The area may require surgical removal when your baby is a little older."
"These areas usually spread and then regress Spreading and then regressing is the usual pattern that a nevus vasculosus, which involves the dermal and subdermal layers, follows. Saying that the area will be covered by clothes gives little assurance. Surgical removal is not recommended.
When working with a client who is in an alcohol detoxification program, it is most important for the nurse to: 1 Support the client's need for nurture. 2 Address the client's holistic needs. 3 Discuss with the client the negative effects of alcohol. 4 Promote the client's compliance with the program through gentle prodding.
Address the client's holistic needs Clients who abuse alcohol characteristically have multiple nursing care needs, among them physiological, psychological, social and occupational. Although nurture is important, this client must learn self-reliance. Discussing with the client the negative effects of alcohol is probably an old story to this client and will have a minimal positive effect. Promoting the client's compliance with the program through gentle prodding will not provide an atmosphere that can help the client withstand the stress of the detoxification program.
One day the nurse and a young adult client sit together and draw. The client draws a face with horns and says, "This is me. I'm a devil." What is the best response by the nurse? Incorrect1 "I don't see a devil; why do you see a devil?" 2 "Let's go to the mirror to see what you look like." Correct3 "When I look at you I see a person, not a devil." 4 "You're not a devil; why do you talk about yourself like that?"
Correct3 "When I look at you I see a person, not a devil." The response "When I look at you, I see a person, not a devil" points out reality while attempting to let the client understand that the nurse sees the client as a person of worth. The statement "I don't see a devil; why do you see a devil?" asks the client to explain his feelings, which may be unrealistic. The client may indeed view himself as a devil. The statement "You're not a devil; why do you talk about yourself like that?" is a somewhat belittling response; it cuts off communication.
A female client with bipolar I disorder, manic episode, is admitted to the mental health unit of a community hospital. When developing an initial plan of care for this client, the nurse should plan to: 1 Increase her gym time. 2 Isolate her from her peers. 3 Encourage increased nutritional intake. 4 Reinforce her participation in unit programs.
Encourage increased nutritional intake The client in a manic episode of the illness often neglects basic needs; these needs are a priority to ensure adequate nutrition, fluid, and rest. The hyperactivity of mania creates an increased need for calories. Although the client needs to expend excess energy, physical exhaustion and dehydration are real possibilities during the manic episode of the illness. Isolating her from her peers is counterproductive and punitive. The client is unable to actively participate in group activities at this time.
A nurse develops a relationship with a client who has bipolar disorder with episodes of mania. The nurse concludes that their therapeutic interaction has entered the working stage when the client: 1 Identifies goals for the client-nurse interaction 2 Explores the effect of bipolar behavior on the family 3 Expresses ambivalence about meeting with the nurse 4 Informs the nurse that other family members are bipolar
Explores the effect of bipolar behavior on the family Acknowledging and exploring issues is part of the working phase of a therapeutic relationship. Formulating the purpose or goals of the therapeutic relationship is part of the orientation or introductory phase. The orientation or introductory phase of a therapeutic relationship involves tension and anxiety within an uncertain situation. Ambivalence is not an uncommon feeling. Having the client share the family history is a part of the orientation or introductory phase of a therapeutic relationship.
A 2-month-old infant is admitted to the pediatric unit for observation after an automobile collision. Family members are unable to stay. How can the nurse best provide psychological comfort for the infant? 1 Assigning the same nurse to the infant 2 Following a routine to which the infant is accustomed 3 Having the infant listen to the parents' voices over the phone 4 Ensuring that a staff member stays with the infant at all times
Following a routine to which the infant is accustomed Very young infants gain security from having their needs met consistently. Assigning one nurse to care for the infant is ideal but unrealistic. It is not critical at this age because the infant does not yet seek security from a significant caregiver. Although the infant may recognize the parents' voices, having the parents phone the child will not ensure psychological comfort. Consistent observation is adequate.
A nurse is counseling clients who are attending an alcohol rehabilitation program. Which substance poses the greatest risk of addiction for these clients? 1 Heroin 2 Cocaine 3 Nicotine 4 Marijuana
Nicotine Although polysubstance abuse is common, clients undergoing rehabilitation from alcohol dependence are most likely to use or develop a dependence on nicotine, another legal substance, than on an illegal substance such as heroin, cocaine, or marijuana.
A mother brings her 5-year-old daughter to the children's clinic after teachers report that the girl is disobedient and hostile. The child has a negative attitude and argues often with her teachers. At this time she has not violated the rights of other students. The mother reports that she has also noticed this behavior at home. The nurse suspects that the behavior described is associated with: 1 Anxiety disorder 2 Conduct disorder 3 Major depressive disorder 4 Oppositional defiant disorder
Oppositional defiant disorder Oppositional defiant disorder usually becomes evident before 8 years of age. Affected children do not violate the rights of others. They do not see themselves as defiant but feel that they are responding to unreasonable demands or situations. Conduct disorder is characterized by a pattern of behavior in which the rights of others and social norms or rules are violated. There is a lack of guilt or remorse for inappropriate behavior, and blame is placed on others. Children who are anxious or depressed may exhibit some disobedience during the school day but do not exhibit the argumentative and hostile behavior pattern seen with oppositional defiant disorder.
When intimate partner violence (IPV) is suspected, the nurse plays an important role as an advocate for the victim. The advocate role includes several important components. Select all that apply. 1 Planning for future safety 2 Normalizing victimization 3 Validating the experiences 4 Promoting access to community services
Planning for future safety Validating the experiences 4 Promoting access to community services Planning for the client's future safety needs, validating the client's experiences by letting the victim know that he or she is not alone, and promoting access to community services are all important roles of the nurse advocate. An advocate would not normalize the victimization by seeing the abuse as normal in the victim's relationship and failing to respond to the disclosure of the abuse.
What childhood problem has legal as well as emotional aspects and cannot be ignored? Correct1 School phobia 2 Fear of animals 3 Fear of monsters 4 Sleep disturbances
School phobia is a disorder that cannot legally be ignored for long because children must attend school. It requires intervention to alleviate the separation anxiety and promote the child's increasing independence. Fear of animals and monsters and sleep disturbances all require parents to comfort the child, to reorient the child to reality, and to help the child regain self-control. Legally there are no requirements mandating treatment for these common childhood problems.
A delusional client refuses to eat because she believes that the food is poisoned. What is the most appropriate initial nursing intervention? Correct1 Stating that the food is not poisoned 2 Tasting the food in the client's presence 3 Showing the client that other people are eating without being harmed 4 Telling the client that tube feedings will be started if she doesn't start eating
Stating that the food is not poisoned 2 Clients cannot be argued out of delusions, so the best approach is a simple statement of reality. Tasting the food in the client's presence is a form of entering into the client's delusions; the client may feel that only a particular part of the meal is free of poison. Showing the client that other people are eating without being harmed is trying to argue the client out of the delusion and will not work. The client can formulate a reason ("They have the antidote") to continue the false belief. Threats are always inappropriate nursing interventions.
After an emergency cesarean birth, the client tells the nurse that she was hoping for a "natural" childbirth but is glad that she and her baby are all right. Which postpartum phase of adjustment does this statement most closely typify? Correct1 Taking-in Incorrect2 Letting-go 3 Taking-hold 4 Working-through
Taking-in By discussing the experience, the client is bringing it into reality; this is characteristic of the taking-in phase. The client is not ready to assume the tasks of the letting-go phase until the tasks of the taking-in and taking-hold phases have been completed. The taking-hold phase is marked by an increased desire to resume independence. The working-through phase is not a separate phase of adjustment to parenthood; this is not relevant.
A client with schizophrenia is speaking made-up words that have no meaning to other people. What term should the nurse use to document these verbalizations? 1 Avolition 2 Echolalia 3 Anhedonia 4 Neologisms
neologisms Neologisms are unique words with personal meanings only to the client. Avolition is the lack of motivation associated with a reduced emotional expression (flat affect). Echolalia is parrotlike echoing of spoken words or sounds. Anhedonia is the loss of enjoyment in things that were formerly enjoyed.
When establishing a plan of care, the nurse should understand that a male client's delusion that he is an important government adviser is most likely related to: 1 A psychotic loss of touch with his real identity 2 An attempt at wish fulfillment created to manipulate others 3 A need to feel a sense of importance within his environment 4 An effort to compensate for feelings of depression about his problems
A need to feel a sense of importance within his environment The client is fearful and suspicious; the feeling of being in a powerful position helps the client cope with anxiety. The client is not out of touch with self-identity; the real identity has been given an important role. The client is not attempting to manipulate others. The client is compensating for feelings of inadequacy. The client is compensating for feelings of inadequacy, not depression about his problems.
A female client who is severely incapacitated by obsessive-compulsive behavior has been admitted to the mental health hospital. The client's compulsive ritual involves changing her clothing eight to 12 times a day. She continually asks the nurse for advice regarding her problems but then ignores it. This is an example of the conflict of: 1 Apathy versus anger 2 Trust versus mistrust 3 Intimacy versus isolation 4 Dependence versus independence
Dependence versus independence A conflict exists between wanting to be taken care of and wanting to be self-reliant; ambivalence fosters lowered self-esteem. Apathy versus anger do not relate to the behavior described; people usually do not alternate these emotions, which are at opposite ends of the spectrum. Trust versus mistrust is the developmental conflict of the infant, according to Erikson; it is not related to the behavior described. Intimacy versus isolation is the developmental conflict of the young adult, according to Erikson; it is not related to the behavior described.
At night an older client with dementia sleeps very little and becomes more disoriented. How can the nurse best limit this confusion resulting from sleep deprivation? 1 Shutting the client's door during the night 2 Applying a vest restraint when the client is in bed 3 Leaving a dim light on in the client's room at night 4 Administering the client's prescribed as-needed sedative medication
Leaving a dim light on in the client's room at night A small light in the room may prevent misinterpretation of shadows, which can heighten fear and alter the client's perception of the environment. A disoriented and confused client should be closely observed, not isolated. Restraints are a last resort; less restrictive interventions should be used first. Sedatives should be used sparingly in older adults because they may cause further confusion and agitation.
A client demonstrating manic behavior is elated and sarcastic. The client is constantly cursing and using foul language and has the other clients on the unit terrified. Initially the nurse should: 1 Demand that the client stop the behavior immediately. 2 Tell the client firmly that the behavior is unacceptable. 3 Ask the client to identify what is precipitating the behavior. 4 Increase the client's medication or get a prescription for another drug.
Tell the client firmly that the behavior is unacceptable. A firm voice is most effective; the statement tells the client that it is the behavior, not the client, that is upsetting to others. Demanding that the client stop the current behavior is a useless action; the client is out of control and needs external control. The client does not know what is precipitating the behavior, and asking the client will be frustrating for him. The dosage of the client's medication should be increased or a prescription for another drug should be obtained if the client does not respond to firm limit-setting.
A nurse is in the process of developing a therapeutic relationship with a client who has an addiction problem. What client communication permits the nurse to conclude that they are making progress in the working stage of the relationship? Select all that apply. 1 Describes how others have caused the addiction 2 Verbalizes difficulty identifying personal strengths 3 Expresses uncertainty about meeting with the nurse 4 Acknowledges the effects of the addiction on the family 5 Addresses how the addiction has contributed to family distress
Verbalizes difficulty identifying personal strengths 4 Acknowledges the effects of the addiction on the family 5 Addresses how the addiction has contributed to family distress Looking at one's strengths in addition to areas that need growth is difficult work, and sharing this difficulty demonstrates that the client is willing to work with the nurse to address personal issues. When he is willing to address cause and effect issues of personal behavior, the client is in the working phase of a therapeutic relationship. When people in a therapeutic relationship are able to address how their behavior affects others, they are taking the first step toward taking responsibility for their actions. The use of projection is a defense from taking responsibility for the addiction; this will impair the effectiveness of a working therapeutic relationship. Ambivalence about working with the nurse usually occurs during the introductory phase of the nurse-client relationship.
An older woman who has been a widow for 20 years comes to the community health center with a vague list of complaints. Her only child, a son, died at birth. She has lived alone since her husband's death and performs all of her own daily tasks of living. She had a very active social life in the past but has outlived many of her friends and family members. When taking this client's health history, it is important for the nurse to ask: 1 "Do you feel alone?" 2 "Do you still miss your husband?" 3 "What unfulfilled hopes do you have?" 4 "How did you feel when your son died?"
What unfulfilled hopes do you have?" The answer to "What unfulfilled hopes do you have?" will provide the nurse with an idea of the client's hopes and frustrations without being threatening or probing. "Do you feel alone?" "Do you still miss your husband?" and "How did you feel when your son died?" are all probing, disregard the client's complaints, and will provide little information for the nurse to use in the planning of care.
