Foundations & Practice of Mental Health Nursing
A nurse is caring for a client with generalized anxiety disorder. Which factor should be assessed to best determine the client's present status? 1. Memory 2. Behavior 3. Judgment 4. Responsiveness
Behavior
A nurse is speaking with a client who was sexually abused as a child. The client does not know what constitutes inappropriate touch by another person. What issue will have to be addressed with this client? 1. Increased libido 2. Phobic behavior 3. Boundary violations 4. Excessive aggression
Boundary violations Clients who have experienced childhood sexual abuse will have difficulty being aware of their personal boundaries and maintaining appropriate boundaries for themselves and others. Clients who have experienced childhood sexual abuse tend to have decreased, not increased, libidos. Phobic behavior, the irrational fear of an object or situation, is not necessarily a concern that the nurse should have for this client more than for other clients. Clients who have experienced childhood sexual abuse tend to internalize the abuse; they do not become outwardly or excessively aggressive.
A primary healthcare provider recently diagnosed attention deficit-hyperactivity disorder (ADHD) in a pediatric client. When working with the family of this child, what should the nurse initially assess about the parents? 1. History of the disorder 2. Relationship with each other 3. Attitudes about the diagnosis 4. Understanding of the treatment regimen
Attitudes about the diagnosis
A nurse is evaluating a young adult for evidence of achievement of the age-related developmental stage set forth in Erikson's developmental theory. What developmental crisis is associated with this age group? 1. Trust versus mistrust 2. Intimacy versus isolation 3. Industry versus inferiority 4. Generativity versus stagnation
Intimacy versus isolation The major task of young adulthood is centered on human closeness and sexual fulfillment; lack of love results in isolation. The trust-versus-mistrust stage is associated with infancy. The industry-versus-inferiority stage is associated with middle childhood (school age). The generativity-versus-stagnation stage is associated with middle adulthood.
What is the basic therapeutic tool used by the nurse to foster a client's psychological coping? 1. Self 2. Milieu 3. Helping process 4. Client's intellect
The Self The self is often the most important tool available to the nurse to help a client cope; to be therapeutic, the nurse must be present, actively listening, and attentive. The environment is important, but it is not the most basic tool. The nurse first must use the self before the helping process can begin. The client's intellect is not generally a therapeutic tool used by the nurse.
A client who had to be cut out of a car after a motor vehicle collision has no visible physical effects from the ordeal. The client responds to the emergency department nurse's questions factually in a soft voice with a composed manner. What does this behavior indicate? 1. The client is controlling the expression of feelings 2. The client has repressed the details of the accident 3. The client has blocked out the events of the last few hours 4. The client is experiencing the reorganization phase of the trauma experience
The client is controlling the expression of feelings The ability to respond to questions in a composed manner indicates that the client is using intellectualization and withholding feelings to maintain emotional control. Reorganization is a long-term process that starts several days or weeks after the trauma. The fact that the client is answering questions regarding the incident indicates that he or she is not engaging in repression or blocking out the accident.
A client who has been attending a day treatment facility for 1 month with the diagnosis of major depression is to be discharged in a week. Because the nurse and the client are aware of this, what is the most appropriate comment by the nurse? 1. "We have just a few sessions left. I'm really pleased at your progress." 2. "Your discharge date has been set for next week. That's wonderful news." 3. "We have five sessions remaining. We need to start making plans to end our sessions." 4. "I understand that your discharge is set for next week. I'm wondering how you feel about that."
"I understand that your discharge is set for next week. I'm wondering how you feel about that." Plans for termination that take emotional needs into account are best made after exploration of the client's thoughts and feelings about discharge. Noting that there are just a few sessions left and expressing pleasure at the client's progress acknowledges the future termination but focuses on the nurse's, not the client's, feelings. Noting that the client's discharge date has been set for next week and calling this wonderful news acknowledges the future termination but suggests that the client should feel wonderful about the discharge, which may or may not be true. Although noting that the client and nurse have five sessions remaining and that the two need to start making plans to end the sessions acknowledges the future termination, plans for termination should be made after a discussion of the client's emotional response to the pending discharge.
A client has had repeated hospitalizations for aggressive, violent behavior. While on the mental health service, the client becomes very angry, starts screaming at the nurse, and pounds the table. What is the priority nursing assessment at this time? 1. Range of expressed anger 2. Extent of orientation to reality 3. Degree of control over the behavior 4. Determination of whether the anger is justified
Degree of control over the behavior Degree of control over the behavior is the most important assessment because it will influence the nurse's intervention. Depending on the extent of the client's control, the nurse may or may not need assistance. It is not the degree of anger but instead the behavior it precipitates that is important to assess. The extent of orientation to reality may or may not influence the ability to control behavior. Anger is always justifiable to the client feeling the anger; the determination of whether the anger is justified will not help the nurse address the client's behavior.
A young adult client with schizophrenia is prescribed haloperidol. When the nurse administers the medication, the client asks, "What's this for?" The nurse responds that the medication has which effect? 1. Helps the client relax and think more clearly 2. Fights "the blues" and helps keep thoughts together 3. Maintains an even mood and controls the client's temper 4. Raises the client's seizure threshold by letting the client think more clearly
Helps the client relax and think more clearly Stating that the medication will help the client to relax and think more clearly is an accurate and concise explanation of the effects of haloperidol; it blocks postsynaptic dopamine receptors in the brain. Haloperidol is a neuroleptic; it does not alter mood. Haloperidol lowers, not increases, the seizure threshold.
A nurse is assigned to lead a relaxation group. Which techniques should the nurse incorporate? Select all that apply. 1. Meditation 2. Mental imagery 3. Token economy 4. Operant conditioning 5. Deep-breathing exercises
Meditation, Mental imagery, Deep-breathing exercises Meditation lowers heart and blood pressure rates, decreases levels of adrenal corticosteroids, improves mental alertness, and increases a sense of calmness and peace. Imagery is the internal experience of memories, dreams, fantasies, and visions that serves as a bridge connecting the body, mind, and spirit; its distractive ability decreases adrenal corticosteroids, promotes muscle relaxation, and increases a sense of calmness and peace. Deep breathing increases oxygenation and releases tension in the muscles of the neck, shoulders, and torso. Token economy is a behavioral theory that acknowledges acceptable behavior with a reward (token) that can be redeemed for something that has a perceived value (e.g., a desirable activity). Operant conditioning, a behavioral therapy, is the learning of a particular type of behavior followed by a reward.
What should be a priority of nursing care for a client with dementia resulting from acquired immune deficiency syndrome (AIDS)? 1. Frequent assessments for pain 2. Planning for remotivational therapy 3. Arranging for long-term custodial care 4. Providing basic intellectual stimulation
Providing basic intellectual stimulation Providing basic intellectual stimulation maintains, for as long as possible, the client's remaining intellectual functions by providing an opportunity to use them. Although pain syndromes can occur in clients with dementia resulting from AIDS, frequent pain assessment is not a priority; providing cognitive stimulation facilitates the use of nonpharmacologic treatments for pain management as long as possible. Remotivation is not always possible with extensive organic brain damage. There are no data to indicate that the client needs custodial care at this time.
During the admission procedure a client appears to be responding to voices. The client cries out at intervals, "No, no! I didn't kill him! You know the truth, tell that police officer! Please help me!" What is the most appropriate response by the nurse? 1. Listening attentively and assuming an expression of disbelief 2. Saying, "I want to help you. I realize that you must be very frightened." 3. Sitting quietly and refraining from responding to the client's statements 4. Saying, "Don't be so upset. No one is talking to you; those voices are part of your illness."
Saying, "I want to help you. I realize that you must be very frightened." Telling the client that help is available demonstrates an understanding of the client's feelings and encourages the client to share feelings, which is an immediate need. Assuming an expression of disbelief is judgmental and demeaning to the client. Sitting quietly and not responding to the client's statements will probably intensify the client's fears. Although telling the client not to be upset because no one is talking points out reality, it also gives a command that is unrealistic and closes the communication process.
