Unit 7

Laboratory work is prescribed for a client who has been experiencing delusions. When the laboratory technician approaches the client to obtain a specimen of the client's blood, the client begins to shout, "You're all vampires. Let me out of here!" The nurse present at the time should respond by stating which?

"Are you fearful and think that others may want to hurt you?"

A patient comes up to you, and says, "I have a secret to tell you, promise me you won't tell anyone". What is an appropriate response by the nurse?

"I cannot promise to keep a secret"

The spouse of a client admitted to the hospital for alcohol withdrawal says to the nurse, "I should get out of this bad situation." The most helpful response by the nurse should be which?

"What do you find difficult about this situation?"

A client 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 therapeutic response should the nurse make to the client?

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

A client receiving lithium carbonate (Lithobid) complains of loose, watery stools and difficulty walking. The nurse should expect the serum lithium level to be which?

1.7 mEq/L

What should the nurse observe with tardive dyskinesia?

Abnormal movements and involuntary movements of the mouth, tongue, and face

The nurse is preparing a client for the termination phase of the nurse-client relationship. Which task should the nurse appropriately plan for this phase?

Assist in making appropriate referrals

What is milieu therapy?

Client involvement in goal setting

A client was admitted to a medical unit with acute blindness. Many tests are performed, and there seems to be no organic reason why this client cannot see. The nurse later learns that the client became blind after witnessing a hit-and-run car crash in which a family of three was killed. The nurse suspects that the client may be experiencing which?

Conversion disorder

A client in the psychiatric hospital states, "Let me out! There's nothing wrong with me! I don't belong here!" The nurse identifies this behavior as which?

Denial

The nurse is caring for a client with schizophrenia who states, "I decided not to take my medication because I realize that it really can't help me. Only I can help me." Which nursing response should be therapeutic?

Do you recall needing to be hospitalized because you stopped your medication?"

What is a would signal a toxic effect of haloperidol (Haldol)?

Excessive salvation

A client admitted to the hospital gives the nurse a bottle of clomipramine (Anafranil). The nurse notes that the medication has not been taken by the client in 2 months. Which behavior observed in the client would validate noncompliance with this medication?

Frequent hand washing with hot, soapy water

Following a group therapy session, a client approaches the nurse and verbalizes a need for seclusion because of uncontrollable feelings. The nurse reports the findings to the registered nurse (RN) and expects that the RN will take which action?

Get a written prescription from the health care provider (HCP) and obtain an informed consent

What is the purpose of behavioral therapy?

Help the client identify and examine dysfunctional thoughts and beliefs

The nurse receives a telephone call from a male client who states that he wants to kill himself and has a bottle of sleeping pills in front of him. Which would be the best response by the nurse?

Keep the client talking and signal to another staff member to send help to the client

What are appropriate nursing interventions for a patient going through alcohol withdrawal?

Monitor vital signs Provide a safe environment Address hallucinations therapeutically Provide reality orientation as appropriate

A tricyclic antidepressant is administered to a client daily. The nurse plans to alleviate the common side effects of the medication and includes which in the plan of care?

Offer hard candy or gum periodically

A patient waiting to be seen at the psychiatric clinic becomes combative and loud. What can the CNA do to for an appropriate nursing intervention?

Offer to take the client to an examination room until he or she can be treated

The nurse is assigned to care for a client experiencing disturbed thought processes. The nurse is told that the client believes that the food is being poisoned. Which communication technique should the nurse plan to use to encourage the client to eat?

Open-ended questions and silence

What are some therapeutic techniques?

Restating Listening Maintaing a neutral response Providing acknowledgment and feedback

If a patient in a psychiatric hospital is a voluntary admit, what kind of behavior should the nurse expect from the patient?

The client will be cooperative and participate in their treatment

A client is experiencing delusions of persecution. What type of delusion is this?

The false belief that one is being singled out for harm by others

A client with delirium becomes agitated and confused at night. What would be an appropriate nursing intervention?

Use a night light and turn off the television

A hospitalized client is started on phenelzine sulfate (Nardil) for the treatment of depression. At lunchtime, a tray is delivered to the client. Which food item on the tray should the nurse remove?

Yogurt