Test 5 Fundamentals
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 nurse's station. 2. Use an indirect light source and turn off the TV 3. Keep the TV and a soft light source on during the night 4. Play soft music during the night, and maintain a well-lit room.
2. Provision of a consistent daily routine and low stimulating environment is important when a client is disoriented. Noise, including radio and television, may add to the confusion and disorientation. Moving the client next to the nurse's station may become necessary but is not the initial action.
A manic client begins to make sexual advances towards visitors in the day-room. 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. The client is at risk for injury to self and others and should be escorted out of the dayroom. Seclusion is premature in this situation. Telling the client that the behavior is inappropriate has already been attempted by the nurse. Denying privileges may increase the agitation that already exists in this client.
Which nursing interventions are appropriate for a hospitalized client with mania who is exhibiting manipulative behavior? Select ALL that apply. 1. Communicate expected behaviors to the client. 2. Ensure that the client knows they are not in charge of the nursing unit. 3. Assist the client in identifying ways of setting limits on personal behaviors. 4. Follow through about the consequences of behavior in a nonpunitive manner. 5. Enforce rules by informing the client that they will not be allowed to attend therapy groups. 6. Have the client state the consequences for behaving in ways that are viewed as unacceptable.
1, 3, 4, 6. Interventions for dealing with the client exhibiting manipulative behavior include setting clear, consistent, and enforceable limits on manipulative behaviors; being clear with the client regarding the consequences in a nonpunitive manner; and assisting the client in identifying means of setting limits on personal behaviors. Ensuring that the client knows that he or she is not in charge of the nursing unit is inappropriate; power struggles need to be avoided. Enforcing rules and informing the client that he or she will not be allowed to attend therapy groups is a violation of the patient's rights.
The nurse is conducting a group therapy session. During the session, a client diagnosed with mania consistently disrupts the group's interactions. Which nursing 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. Manic clients may be talkative and can dominate group meetings or therapy sessions by their excessive talking. If this occurs, the nurse initially should set limits on the clients behavior. Initially, asking the client to leave the session or asking another person to escort the client out of the session is inappropriate. This may agitate the client and escalate the client's behavior further. Barring the client from group sessions is also an inappropriate action because it violates the client's right to receive treatment and is a threatening action.
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, what is the nurse's IMMEDIATE PRIORITY of care? 1. Provide safety for the client and other clients 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 to calm down in and gain control.
1. Safety of the client and other clients is the priority. The correct option is the only one that addresses the safety needs of the client as well as those of the other clients.
The nurse is caring for a client who is experiencing disturbed thought processes as a result of paranoia. In formulating nursing interventions with the members of the health care team, what BEST instruction should the nurse provide to the staff? 1. Increase socialization of the client with peers. 2. Avoid laughing or whispering in front of the client. 3. Begin to educate the client about social supports in the community. 4. Have the client sign a release of information to appropriate parties for assessment purposes.
2. Disturbed thought process related to paranoia is the client's problem, and the plan of care must address this problem. The client is experiencing paranoia and is distrustful and suspicious of others. The members of the health care team need to establish rapport and trust with the client. Laughing or whispering in front of the client would be counterproductive. The remaining options ask the client to trust on a multitude of levels. These options are actions that are too intrusive for a client who is paranoid.
When planning the discharge of a client with chronic anxiety, the nurse directs the goals at promoting a safe environment at home. Which is the MOST APPROPRIATE maintenance goal? 1. Suppressing feelings of anxiety. 2. Identifying anxiety producing situations. 3. Continued contact with a crisis counselor. 4. Eliminating all anxiety from daily situations.
2. Recognizing situations that produce anxiety allows the client to prepare to cope with anxiety or avoid a specific stimulus. Counselors will not be available for all anxiety producing situations and this option does not encourage the development of internal strengths. Suppressing feelings will not resolve anxiety. Elimination of all anxiety from life is impossible..as well too.
A client is unwilling to go out of the house for fear of "making a fool of myself in public." Because of this fear, the client remains homebound. Based on these data, which mental health disorder is the client experiencing? 1. Agoraphobia 2. Social phobia 3. Claustrophobia 4. Hypochondriasis
2. Social phobia is a fear of situations in which one might be embarrassed or criticized, such as the fear of speaking, performing, or eating in public. The person fears making a fool of oneself. Agoraphobia is a fear of open spaces and the fear of being trapped in a situation in which there may not be an escape. Claustrophobia is a fear of closed spaces. Clients with hypochondriacal symptoms focus their anxiety on physical complaints and are preoccupied with their health.
The nurse is planning activities for a client diagnosed with bipolar disorder with aggressive social behavior. Which activity would be MOST APPROPRIATE for this client? 1. Chess 2. Writing 3. Ping pong 4. Basketball
2. Solitary activities that require a short attention span with mild physical exertion are the most appropriate activities for a client who is exhibiting aggressive behavior. Writing (journaling), walks with staff, and finger painting are activities that minimize stimuli and provide a constructive release for tension. The remaining options have a competitive element to them and should be avoided because they can stimulate aggression and increase psychomotor activity.
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. Which condition will be the focus of this consult? 1. Psychosis 2. Repression 3. Conversion disorder 4. Dissociative disorder
3. A conversion disorder is the alteration of loss of a physical function that cannot be explained by any known pathophysiological mechanism. A conversion disorder is thought to be an expression of a psychological need or conflict. In this situation, the client witnessed an accident that was so psychologically painful that the client became blind. Psychosis is a state in which a person's mental capacity to recognize reality, communicate, and relate to others is impaired, interfering with the person's abilities to deal with life's demands. Repression is a coping mechanism in which unacceptable feelings are kept out of awareness. A dissociative disorder is a disturbance or alteration in the normally integrative functions of identity, memory, or consciousness.
The nurse is caring for a client diagnosed with catatonic stupor who is lying on the bed in a fetal position. What is the MOST APPROPRIATE nursing intervention? 1. Ask direct questions to encourage talking. 2. Leave the client alone so as to minimize external stimuli. 3. Sit beside the client in silence with the occasional open-ended questions. 4. Take the client into the dayroom with the other clients so that they can help watch him."
3. Clients who are withdrawn may be immobile and mute and may require consistent, repeated approaches. Communication with withdrawn clients requires much patience from the nurse. Interventions include the establishment of interpersonal contact. The nurse facilitates communication with the client by sitting in silence, asking open-ended questions rather than direct questions, and pausing to provide opportunities for the client to respond. While over-stimulation is not appropriate, there is no therapeutic value in ignoring the client. The client's safety is not the responsibility of other clients.
A client says to the nurse, "The federal guards were sent to kill me." What is the BEST nursing response 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. It is the most therapeutic for the nurse to empathize with the client's experience. The remaining options lack this connection with the client. Disagreeing with delusions may make the client more defensive, and the client may cling to the delusions even more. Encouraging discussion regarding the delusion is appropriate.
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.
4. A client with depression often is withdrawn while experiencing difficulty concentrating, loss of interest or pleasure, low energy, fatigue, and feelings of worthlessness and poor self-esteem. The plan of care needs to provide successful experiences in a stimulating yet structured environment. The remaining options are either too "restrictive" or off little or no structure and stimulation.
The nurse is preparing a client with a history of command hallucinations for discharge by providing instructions on interventions for managing hallucinations and anxiety. Which statement in response to these instructions suggests to the nurse that the client understands the instructions? 1. "My medications aren't likely to make me anxious." 2. "I'll go to support group and talk so that I don't hurt anyone." 3. "It's not likely that I'll get anxious or hear things if I get enough sleep and eat well." 4. "When I begin to hallucinate, I'll call my therapist and talk about what I should do."
4. The risk for impulsive and aggressive behavior may increase if a client is receiving command hallucinations to harm self or others. If the client is experiencing a hallucination, the nurse should ask the client whether he or she has intentions to hurt him-or herself or others. Talking about auditory hallucinations can interfere with subvocal muscular activity associated with hallucination. The client statements in the remaining options will aid in wellness, but are not specific interventions for hallucinations, if they occur.
