Saunders Ch 68 Foundations

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 response by the nurse demonstrates therapeutic communication? 1. "You have everything to live for" 2. "Why do you see yourself as a failure?" 3. "Feeling like this is all part of being depressed." 4. "You've been feeling like a failure for a while?"

4. "You've been feeling like a failure for a while?"

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. 1. Libel 2. Battery 3. Assault 4. Slander 5. False imprisonment

2. Battery 3. Assault 5. False imprisonment

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? 1. Fearfulness regarding treatment measures 2. Anger and aggressiveness directed towards others 3. An understanding of the pathology and symptoms of the diagnosis 4. A willingness to participate in the planning of the care and treatment plan

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

A client experiencing disturbed thought processes believes that his food is being poisoned. Which communication technique should the nurse use to encourage the client to eat? 1. Using open-ended questions and silence 2. Sharing personal preference regarding food choices 3. Documenting reasons why the client does not want to eat 4. Offering opinions about the necessity of adequate nutrition

1. Using open-ended questions and silence

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? 1. Providing a supportive environment 2. Examining intrapsychic conflicts and past issues 3. Emphasizing social interaction with clients who withdraw 4. Helping the client to examine dysfunctional thoughts and beliefs

4. Helping the client to examine dysfunctional thoughts and beliefs

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?" she is my best friend and is seen at your clinic every week." Which is the most appropriate nursing response? 1. "I cannot discuss any client situation with you." 2. "If you want to know about carol, you need to ask her yourself." 3. "Only because you're worried about a friend. I'll tell you that she is improving" 4. "Being her friend, you know she is having a difficult time and deserves her privacy"

1. "I cannot discuss any client situation with you."

A client is preparing to attend a Gamblers anonymous meeting for the first time. The nurse should tell the client that which is the first stop in this 12 step program? 1. Admitting to having a problem 2. Substituting other activities for gambling 3. Stating that the gambling will be stopped 4. Discontinuing relationships with people who gamble

1. Admitting to having a problem

A client admitted voluntarily for treatment of an anxiety disorder demands to be released from the hospital. Which action should the nurse take initially? 1. Contact the clients health care provider (HCP) 2. Call the clients family to arrange for transportation. 3. Attempt to persuade the client to stay "for only a few more days." 4. Tell the client that leaving would likely results in an involuntary commitment

1. Contact the clients health care provider (HCP)

A client is participating in a therapy group and focuses on viewing all team members as equally important in helping the clients to meet their goals. The nurse is implementing which therapeutic approach? 1. Milieu therapy 2. Interpersonal therapy 3. Behavior modification 4. Support group therapy

1. 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 should provide which intervention for this client? 1. Monitor closely for harm to self and others 2. Assist in completing an application for admission 3. Supply the client with written information about his or her mental illness 4. Provide an opportunity for the family to discuss why they felt the admission was needed.

1. Monitor closely for harm to self and others

The nurse is a mental health unit plans to use which therapeutic communication techniques when communicating with a client? Select all that apply 1. Restating 2. Listening 3. Asking the client "why?" 4. Maintaining neutral responses 5. Providing acknowledgment and feedback 6. Giving advice and approval of disapproval

1. Restating 2. Listening 4. Maintaining neutral responses 5. Providing acknowledgment and feedback

The nurse should plan which goals of the termination stage of group development? Select all that apply. 1. The group evaluates the experience 2. The real work of the group is accomplished 3. Group interaction involves superficial conversation 4. Group members become acquainted with one another 5. Some structuring of group norms, roles, and responsibilities takes place. 6. The group explores members' feelings about the group and the impending separation.

1. The group evaluates the experience 6. The group explores members' feelings about the group and the impending separation.

The nurse provides an educational sessions on client rights. Which statement by a member of the session demonstrates the best understanding of the nurses role regarding ensuring that each client's rights are respected? 1. "Autonomy is the fundamental right of each and every client" 2. "A clients rights are guaranteed by both state and federal laws" 3. "Being respectful and concerned will ensure that i'm attentive to my clients rights." 4. "Regardless of the client's condition, all nurses have the duty to value client rights"

3. "Being respectful and concerned will ensure that i'm attentive to my clients rights."

A client is 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? 1. "Have you shared your feelings with your family" 2. "I think we should talk more about your anger with your family." 3. "You're feeling angry that your family continues to hope for you to be cured?" 4. "You are probably very depressed, which is understandable with such a diagnosis."

3. "You're feeling angry that your family continues to hope for you to be cured?"

The nurse visits a client at home. The client states, "I haven't slept at all the last couple of nights." Which response by the nurse demonstrates therapeutic communication? 1. "I see." 2. "Really?" 3. "You're having difficulty sleeping?" 4. "Sometimes I have trouble sleeping too"

3. "You're having difficulty sleeping?"

The nurse is working with a client who despite making a heroic effort was unable to rescue a neighbor trapped in a house fire. Which client focused action should the nurse engage in during the working phase of the nurse-client relationship? 1. Exploring the client's ability to function 2. Exploring the clients potential for self-harm 3. Inquiring about the client's perception or appraisal of why the rescue was unsuccessful 4. Inquiring about and examining the client's feelings for any that may block adaptive coping

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

What is the most appropriate nursing action to help manage a manic client who is monopolizing a group therapy session? 1. Ask the client to leave the group for this session only 2. Refer the client to another group that includes other manic clients 3. Tell the client to stop monopolizing in a firm but compassionate manner. 4. Thank the client for the input, but inform the client that others now need a chance to contribute.

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