Senior Sem Quiz 5: Ch 64-68

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's having a difficult time and deserves her privacy.

1. I cannot discuss any client situation with you

the client is preparing to attend a gambler's anonymous meeting for the first time. the nurse should tell the client that which is the first step 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 is unwilling to go to his church because his ex-girlfriend goes there and he feels she will laugh at him if she sees him. because of this hypersensitivity to a reaction from her, the client remains homebound. the home care nurse develops a plan of care that addresses which personality disorder? 1. avoidant 2. borderline 3. schizotypal 4. obsessive-compulsive

1. avoidant

a client admitted voluntarily for treatment of an anxiety problem demands to be released from the hospital. which action should the nurse take initially? 1. contact the client's hcp 2. call the client's 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 result in an involuntary commitment

1. contact the client's hcp

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? 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 self harm or harm to others 2. assist in completing an application for admission 3. supply the client with written information about his or her mental health problem 4. provide an opportunity for the family to discuss why they felt the admission was needed

1. monitor closely for harm to self or others

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? 1. provide safety for the client and others on the unit 2. provide the clients on the unit with a sense of comfort and safety 3. assist the staff in caring for the client in a controlled environment 4. offer the client a less stimulating area in which to calm down and gain control

1. 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 should the nurse initially implement? 1. setting limits on the client's behavior 2. asking the client to leave the group session 3. asking another nurse to escort the client out of the group session 4. telling the client that they will not be able to attend any future group sessions

1. setting limits on the client's behavior

A client experiencing disturbed thought processes believes 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 planning the discharge of a client with chronic anxiety, which is the most appropriate maintenance goal? 1. suppress feelings of anxiety 2. identifying anxiety-producing situations 3. continuing contact with a crisis counselor 4. eliminating all anxiety frim daily situations

2. identifying anxiety-producing situations

A client diagnosed with delirium becomes disoriented and confused at night. Which intervention should the nurse implement initially? 1. move the client next to the nurses' station 2. use an indirect light source and turn off the television 3. keep the television and a soft light on during the night 4. play soft music during the night and maintain a well-lit room

2. use an indirect light source and turn off the television

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? 1. I don't believe this is true 2. The guards are not out to kill you 3. Do you feel afraid that people are trying to hurt you? 4. What makes you think the guards were sent to hurt you?

3. Do you feel afraid that people are trying to hurt you?

A manic client begins to make sexual advance towards 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 should the nurse implement? 1. Place the client in seclusion for 30 minutes. 2. Tell the client that the behavior is inappropriate. 3. Escort the client to their room, with the assistance of other staff. 4. Tell the client that their telephone privileges are revoked for 24 hours.

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

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

3. You're having difficulty sleeping?

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? 1. psychosis 2. repression 3. conversion disorder 4. disassociative disorder

3. conversion disorder

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? 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 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 client's 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

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?

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 toward 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

when a client is admitted to an inpatient mental health unit with a diagnosis of anorexia nervosa, a cognitive behavioral approach is used as a part of the treatment plan. the nurse plans to 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

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

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

A client is admitted to the mental health unit with a diagnosis of depression. the nurse should develop a plan of care for the client that includes which intervention? 1. encouraging quiet reading and writing for the first few days 2. identification of physical activities that will provide exercise 3. no socializing activities until the client asks to participate in milieu 4. a structured program of activities in which the client can participate

a structured program of activities in which the client can participate