Mental Health- Chapter 66
The nurse is conducting a group therapy session. During the session, a client diagnosed with ma- nia consistently disrupts the group's interactions. Which intervention would 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 at- tend any future group sessions
Answer: 1 Rationale: Manic clients may be talkative and can dominate group meetings or therapy sessions by their excessive talking. If this occurs, the nurse initially would set limits on the client's behavior. Initially, asking the client to leave the session or ask- ing another person to escort the client out of the session is inappropriate. This may agitate the client and escalate the cli- ent'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, agitat- ed, 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 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 con- trolled environment. 4.Offer the client a less stimulating area in which to calm down and gain control.
Answer: 1 Rationale: Safety of the client and other clients is the immedi- ate priority. The correct option is the only one that addresses the safety needs of the client as well as those of the other cli- ents.
A client is unwilling to go to church because the ex-spouse goes there and the client feels that the ex-spouse will laugh at the client. Because of this hypersensitivity to a reaction from the spouse, 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
Answer: 1 Rationale: The avoidant personality disorder is characterized by social withdrawal and extreme sensitivity to potential rejec- tion. The person retreats to social isolation. Borderline per- sonality disorder is characterized by unstable mood and self- image and impulsive and unpredictable behavior. Schizotypal personality disorder is characterized by the display of abnor- mal thoughts, perceptions, speech, and behaviors. Obsessive- compulsive personality disorder is characterized by perfec- tionism, the need to control others, and a devotion to work.
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 client. the 2.Ensure that the client knows that 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.
Answer: 1, 3, 4, 6 Rationale: 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 of exceeding the limits set; following through with the consequences in a nonpuni- tive manner; and assisting the client in identifying a means of setting limits on personal behaviors. Ensuring that the client knows that they are not in charge of the nursing unit is inap- propriate; power struggles need to be avoided. Enforcing rules by informing the client that they will not be allowed to attend therapy groups is a violation of a client's rights.
The nurse is caring for a client diagnosed with paranoid personality disorder who is experiencing disturbed thought processes. In formulating a nursing plan of care, which best intervention would the nurse include? 1. Increase socialization of the client with peers. 2. Avoid using a whisper voice 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.
Answer: 2 Rationale: Disturbed thought process related to paranoid per- sonality disorder is the client's problem, and the plan of care must address this problem. The client is distrustful and suspi- cious of others. The members of the health care team need to establish a 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 with this disorder.
A client diagnosed with delirium becomes disori- ented and confused at night. Which intervention would the nurse implement initially? 1)Move the client next to the nurses' station. 2)Use an indirect light source and turn off the tel- evision. 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.
Answer: 2 Rationale: Provision of a consistent daily routine and a low- stimulating environment is important when a client is disori- ented. Noise, including radio and television, may add to the confusion and disorientation. Moving the client next to the nurses' station may become necessary but is not the initial action.
When planning the discharge of a client with chronic anxiety, which is the most appropriate maintenance goal? 1. Suppressing feelings of anxiety 2. Identifying anxiety-producing situations 3. Continuing contact with a crisis counselor 4. Eliminating all anxiety from daily situations
Answer: 2 Rationale: 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.
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. Board games 4. Group exercise
Answer: 2 Rationale: 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 or are group activities and need to 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. The nurse plans care based on which mental health condition? 1. Psychosis 2. Repression 3. Conversion disorder 4. Dissociative disorder
Answer: 3 Rationale: A conversion disorder is the alteration or 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 con- flict. 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 rec- ognize reality, communicate, and relate to others is impaired, interfering with the person's ability to deal with life's demands. Repression is a coping mechanism in which unacceptable feel- ings are kept out of awareness. A dissociative disorder is a dis- turbance or alteration in the normally integrative functions of identity, memory, or consciousness.
The nurse is caring for a client just admitted to the mental health unit and diagnosed with catatonic stupor. The client is lying on the bed in a fetal posi- tion. Which 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 simple open- ended questions. 4. Take the client into the dayroom with other cli- ents to provide stimulation.
Answer: 3 Rationale: 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 establish- ment of interpersonal contact. The nurse facilitates communi- cation with the client by sitting in silence, asking simple open- ended questions rather than direct questions, and pausing to provide opportunities for the client to respond. Although overstimulation is not appropriate, there is no therapeu- tic 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." 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?"
Answer: 3 Rationale: It is 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 inappropriate.
A manic client begins to make sexual advances toward 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 would 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 assis- tance of other staff. 4.Tell the client that their telephone privileges are revoked for 24 hours.
Answer: 3 Rationale: The client is at risk for injury to self and others and should be escorted out of the dayroom. Seclusion is pre- mature 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.
The nurse is preparing a client with schizophrenia and 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 has a need for additional information? 1. "My medications will help my anxious feelings." 2. "I'll go to support group and talk about what I am feeling." 3. "When I have command hallucinations, I'll call a friend for help." 4. "I need to get enough sleep and eat well to help prevent feeling anxious."
Answer: 3 Rationale: 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 hallucina- tion, the nurse or health care counselor, not a friend, would be contacted to discuss whether the client has intentions for self-harm or to hurt others. Talking about auditory hallucina- tions can interfere with subvocal muscular activity associated with a hallucination. The client statements in the remaining options will aid in wellness but are not specific interventions for hallucinations, if they occur.
A client is admitted to the mental health unit with a diagnosis of depression. The nurse would develop a plan of care for the client that includes which intervention? 1)Encouraging quiet reading and writing for the rst few days 2)Identification of physical activities that will pro- vide 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
Answer: 4 Rationale: A client with depression often is withdrawn while experiencing difficulty concentrating, loss of interest or plea- sure, 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 offer little or no structure and stimulation.
