Psychosocial Integrity
Which statement would demonstrate to the nurse the highest risk for suicide or self-directed injury? 1. "I can't do anything right anymore." 2. "I am not sure what to do anymore." 3. "I just cannot take this loneliness anymore." 4. "No one cares about me."
3. Correct: This statement indicates that the person cannot tolerate the current situation. The client is at risk for harm self.
A frightened client comes to the nurses' station during the night and reports hearing the voice of the devil speaking to them. Which response by the nurse is priority? 1. "Could you have overheard the staff talking at the desk?" 2. "I will get you some medication for anxiety." 3. "What did the voice tell you? " 4. "You do not have to worry about this. You are safe."
3. Correct: The most important thing the nurse needs to find out is what the voice was telling the client. This is a safety issue. The nurse needs to know if the voice was telling the client to harm themselves or others.
A nurse on a psychiatric unit overhears an unlicensed assistive personnel (UAP) tell a client who is very restless and continually pacing, "I am going to put you in restraints if you do not go to your room and sit down." The nurse should inform the UAP that this comment could lead to which legal action being taken against the UAP? 1. Assault 2. Battery 3. False imprisonment 4. Invasion of privacy
1. Correct: Assault is an act that results in a person's genuine fear and apprehension that he or she will be touched without consent.
A client is seen in the clinic for recurrent unexplained, vague stomach pain over the past 5 years. A complete client evaluation has not identified a physical reason for the symptoms. The client tells the nurse, "The doctor thinks the pain in my stomach is psychosomatic. But the pain is so bad some times that I can't function!" What is the nurse's most appropriate response? 1. "The pain you feel is real." 2. "The primary healthcare provider is right. Your pain is not real." 3. "Let me get you an appointment with the psychiatrist." 4. "Don't worry. Everything will be ok."
1. Correct: Pain is real even if it is psychological pain. The client is expressing anxiety and stress through stomach pain. The nurse should use a therapeutic communication technique that is client centered and empowers the client.
A client experiencing a manic episode tells the night nurse, "If you do not go to bed with me, I am going to have you fired." What is the nurse's best response? 1. "That is inappropriate behavior. You will have to go to your room if you say that again." 2. "You've got to be kidding! You can't get me fired for not sleeping with you." 3. "I don't want to hear that again! Don't ever say that again." 4. "I can see that you need attention, but this is not the way to get it."
1. Correct: Set limits on manipulative behaviors. Explain what is expected and what the consequences are if limits are violated. The nurse needs to set limits on and control dangerous behavior.
The nurse is caring for a client diagnosed with paranoid personality disorder. Which interventions would be appropriate for the nurse to initiate? SATA 1. Develop a trusting relationship. 2. Be honest when communicating with the client. 3. Encourage the client to participate in group therapy. 4. Encourage the client to clean the day room daily. 5. Give clear explanations of procedures beforehand.
1., 2. & 5. Correct: This disorder is characterized by distrust and suspicion towards others. The nurse should use open communication techniques to increase the client's trust in the nurse. Clear explanations of procedures will decrease the anxiety of the client.
Which interventions are most appropriate for the nurse to provide for the client diagnosed with late onset Alzheimer's disease? SATA 1. Make sure the client's room is dark at bedtime to ensure sleep. 2. Offer fluids every 2 hours during the day and restrict fluids after 6 pm. 3. Teach client to dress self within 30 minutes. 4. Speak loudly and clearly while looking into the client's face. 5. Store frequently used items within easy reach of the client.
2. & 5. Correct: Offering fluids every 2 hours during the day and restricting fluids after 6 pm will ensure adequate hydration but will also minimize nighttime wetness, incontinence, and having to get up frequently at night. Storing frequently used items within easy reach helps to ensure client safety.
Which comments made by the nurse indicate an understanding of confidentiality as it relates to mental illness? SATA 1. "Client approval is needed prior to talking with family members." 2. "My computer screen is left open for the next nurse to chart." 3. "Client situations can be discussed in the care planning meeting." 4. "Discussion about clients while in the elevator is prohibited." 5. "In the home setting, I can be more casual in discussing client information with others."
1., 3., & 4. Correct. The nurse should be the client advocate and protect the client's confidential information. A client's personal data and identifiable health information should be shared only with persons approved by the client.
A nurse is attempting to develop trust with a psychiatric client exhibiting concrete thinking. Which nursing intervention would promote trust in this individual? SATA 1. Attend an activity with the client who is reluctant to go alone. 2. Allow the client to break an insignificant rule. 3. Consider client preferences when possible in decisions concerning care. 4. Provide a blanket when the client is cold. 5. Provide food when the client is hungry.
1., 3., 4. & 5. Correct: Trust is demonstrated through nursing interventions that convey a sense of warmth and care to the client. These interventions are initiated simply, concretely, and directed toward activities that address the client's basic needs for physiological and psychological safety and security. Concrete thinking focuses thought processes on specifics, rather than generalities, and immediate issues, rather than eventual outcomes. Examples of nursing interventions that would promote trust in an individual who is thinking concretely include such things as: providing a blanket when the client is cold, providing food when the client is hungry, keeping promises, being honest, providing a written, structured schedule of activities, attending activities with the client who is reluctant to go alone, being consistent in adhering to unit guidelines, and taking the client's preferences, requests, and opinions into consideration when possible in decisions concerning care.
The nurse is talking with the spouse of a client who has alcoholism and determines that the spouse is exhibiting co-dependent behavior. What comment by the spouse confirms this behavior? 1. "I frequently tell my spouse that drinking alcohol is ruining our relationship." 2. "I go and pick my spouse up from the bar when not home by midnight." 3. "I do not go out drinking with my spouse, and will not drink at home either." 4. "I have told my spouse that I am willing to attend a counseling session when my spouse wants to stop drinking."
2. Correct: The spouse is attempting to please the alcoholic client. Codependent people are people pleasers, and they make excuses for others. The spouse is enabling the client to continue to drink. The spouse may feel keeping the client from driving while intoxicated will keep people safe.
A nurse is caring for a client in an outpatient clinic. The client lost her husband of 51 years three months ago. Which findings support that the client is experiencing normal grief reactions rather than clinical depression? SATA 1. The client is experiencing anhedonia. 2. The client states, "I have good and bad days." 3. The client smiles at the nurse while talking about her grandchild. 4. The client has a persistent state of dysphoria. 5. The client states, "I am having fewer crying spells."
2., 3. & 5. Correct: A client going through a normal grieving process will experience a mixture of good and bad days. The client can enjoy their family. The client experiences moments of pleasure and cries less.
During evening rounds, the nurse discovers that a violent client with a history of threats against a former girlfriend cannot be located. The client's personal belongings are missing. Based on recent threats of violence against the girlfriend, what is the nurse's initial action? 1. Look for the client quietly to maintain confidentiality. 2. Notify the local police to organize a search party. 3. Initiate the missing client protocol. 4. Complete an "Against Medical Advice" (AMA) form on the client's elopement.
3. Correct. Since the client is missing and is considered to be a risk to himself or others, the missing client protocol is immediately implemented. An organized and escalating search for the client will occur.
A client, diagnosed with schizophrenia, tends to spend most of the time in bed and is very uncomfortable when other clients are in the day area of the unit. What activity would be most therapeutic for the nurse to initiate with this client? 1. Watching TV with two other clients in the day room. 2. Watching TV alone in a conference room. 3. Spending time in brief one on one interactions with the nurse. 4. Sitting in the day-room away from other clients.
3. Correct: The interaction with the nurse can keep the conversation reality based and provide interaction with someone. Clients with schizophrenia may be very withdrawn and need the presence of the nurse.
The nurse is contributing to the plan of care for a client with severe anxiety and new onset panic attacks following the loss of a spouse. Which factor is most important to recommend for the plan of care? 1. Available support system 2. Perception of the situation 3. Desire to return to work 4. Coping mechanisms
4. Correct. The plan of care for a client in crisis involves a complex combination of factors to achieve a positive outcome. However, the most important consideration is the client's own coping skills. Treatment and subsequent recovery is more successful when the client has the coping skills and is able to participate in the recovery process.
Which nursing intervention is likely to be most helpful in providing adequate nutrition while the client is in the acute phase of mania? 1. Sit with the client during meals and encourage the client to eat all foods on the tray. 2. Assess the client's food preferences and provide only those foods for the client at meal time. 3. Allow the client to eat in the dining room with other clients. 4. Provide high protein, high calorie snacks to the client between meals.
4. Correct: Having nutritious foods available between meals may help to increase the client's food intake. Nutritious intake is required on a regular basis to compensate for increased caloric requirements due to the hyperactivity during the manic phase.