Mod 4 Psychosocial Alterations

Which step should be included in the care of a 13 year-old hospitalized child who has been abused?

Providing a caring environment that fosters the development of trust RATIONALE: the abused child usually requires long-term therapeutic support. The environment during the child's healing must be one in which trust and caring are provided for the child.

A client who is an alcoholic says to the nurse, "I'm taking milk thistle, so I can drink all I want and never get cirrhosis." Which statement by the nurse would be therapeutic?

" milk thistle is an herbal extract. It does seem to prevent liver damage and stimulate liver cell regeneration, but it can't prevent damage to other organs, like your brain."

A client who has twice attempted suicide says, "if people would just leave me alone and let me do what I want with my life, I can get on with what I want to do."Which response should the nurse give to the client?

" you've tried to end your life twice, yet you feel that everyone should let you do what you want to do?" RATIONALE:The therapeutic response is the one that offers reflection, which permits the client to observe the contact of what she is saying.

A client says to the nurse, "it's over for me -the whole thing is over." Which response by the nurse would be therapeutic?

"Let's talk more about your feeling that the whole thing is over for you. This is important, and I may need to share your feelings with other staff members." RATIONALE: The therapeutic response seeks clarification, employs paraphrasing, and inform the client that the nurse needs to share any information that requires crisis intervention with our staff members.

Which client is At the highest risk for suicide?

A 75 year old women with severe depression and disabling arthritis RATIONALE: an individual with a terminal or crippling illness is at high risk for suicide.

A nurse is assigned to care for a client experiencing a crisis. What is the appropriate initial nursing intervention for this client?

Providing authority and action RATIONALE: A crisis is an acute time limited state of disequilibrium resulting from situational, developmental, or societal sources of stress.

A client with schizophrenia and his parents are meeting with the nurse. One of the young man's parents says to the nurse, "we are stunned when we learned that our son had schizophrenia. He was no different than from his older brother when they were growing up. Now he's had another relapse, and we can't understand why he stopped his medication."Which response by the nurse is appropriate?

Asking the client, "How can we help you take your medicine or tell us when you're having problems so that your medication can be adjusted?" RATIONALE: The therapeutic response is the one in which the nurse models speaking directly to the client. This facilitates further assessment of the situation and helps elicit the cause of and motivations for the clients behavior for both the nurse and the family.

A client with schizophrenia says, "I'm away for the day... think we should play... or do we have feet of clay?" Which alteration in the clients speech does the nurse document?

Clang association RATIONALE: clang association is the meaningless rhyming of words in which the rhyming is more important than the context of the words.

A client with schizophrenia in the psychiatric inpatient unit is yelling, "the CIA is trying to kill me. I know they're plotting to kill me so they can overthrow the government." On the basis of this client statement, which clinical manifestation with the nurse document in the client record?

Evidence of persecutors delusions RATIONALE: A persecutory delusion is the false belief that one is being singled out for harm by others, generally in the form of a plot by other people against the client.

The moderate depressed client who was admitted to the mental health unit two days ago suddenly begins smiling and reports that the crisis is over. The client says to the nurse,"I'm finally cured." The nurse interprets his behavior as a cue to modify the treatment plan by taking which action?

Increasing the level of suicide precautions RATIONALE: A client is moderately depressed and has only been hospitalized for two days is very unlikely to have had such a dramatic cure. When a depressed mood suddenly lifts, it is likely that the client has made the decision to harm him/herself.

A heroin addict who overdoses on a drug is brought into the emergency department. The client is having seizures, and the nurse notes that his pupils are constricted. Which intervention does the nurse anticipate that the emergency department healthcare provider will prescribe?

Naloxone RATIONALE:An opiate antagonist such as naloxone would be prescribed to treat a heroin overdose to reverse central nervous system depression?

A nurse is admitting a client with a diagnosis of anorexia nervous to the mental health unit. Which characteristic is a hallmark of this disorder?

Personal relationships tend to become more superficial and distant. RATIONALE: as anorexia develops, personal relationships tend to become more superficial and distant. Social contacts are avoided because of the fear of being invited to eat and being discovered.

A mental health nurse is conducting the initial assessment of a client who weighs 325 pounds. The client confides that she was sexually molested at age 7 and began putting on weight there after. The nurse determines that the client symptoms are compatible with a somatization disorder and recalls that obesity for this client most likely represents which factor?

Protection from the risk of intimacy RATIONALE: client to become obese after a trauma such as the one described in the question maybe trying unconsciously to prevent themselves as unattractive as a means of protecting themselves from the danger of intimacy.

A nurse is participating in a care planning conference for a client with obsessive compulsive disorder. Which does the nurse expect to see as the focus of care?

Reducing the clients anxiety RATIONALE:The focus of care will be reducing the clients anxiety because OCD is a type of anxiety disorder. Group and recreational therapy may eventually reduce anxiety, but the focus should be primarily on anxiety reduction.

A client is admitted to the psychiatric unit after a serious suicide attempt involving drug overdose which is a priority nursing intervention?

Remain with the client at all times RATIONALE: drug overdose constitutes a serious suicide attempt. The plan of care must compromise actions that will promote the client safety.

A nurse is caring for a client who has been identified as a victim of physical abuse which action is priority as a nurse plans care for the client?

Removing the client from an immediate danger RATIONALE: whenever the abused client remains in the abusive environment, priority must be placed on determining whether the person is in any immediate danger and, if so, taking emergency action to remove the client from the situation.

A nurse is trying to D escalate aggressive behavior exhibited by a client with schizophrenia. Which nursing action would be contradicted in this situation?

Standing close to the client and telling the client that the behavior is unacceptable. RATIONALE: 2D escalate aggressive behavior, the nurse should maintain calm and non-aggressive posture.

A nurse is collecting data from a client in crisis and assessing the potential for self-harm. Which finding indicates that the client is at high risk for suicide?

The client has immediate plan for a suicide attempt RATIONALE: clients at high risk for suicide include those with a history of a dual diagnosis of mental illness and substance abuse, a personal or family history of suicide attempts, depression, alcoholism, and psychotic episodes.

A nurse collects data from an older client and monitors him for signs of abuse. Which psychosocial factor does the nurse recognize as placing a client at risk for abuse?

The client is completely dependent on family members for food and medicine. RATIONALE: abuse of the older client is sometimes a result of frustration on the part of adult children who find themselves caring for a dependent parents. Increasing demands by parents for care and financial support may cause resentment it may be perceived as burdensome. Signs and symptoms of depression do not specifically indicate abuse. A client who is independent or lives alone is generally not at risk for abuse.

A nurse employer and a mental health unit is reviewing the work schedule. At what time does the nurse expect that additional client safety precautions will be provided?

Weekends RATIONALE: because there is less availability of nursing staff on the weekends, risk to the client safety increases, necessitating extra attention on the part of staff. There is often less availability of staff during shift changes as well. The nurse should increase precautions at these times. The night shift is also a high risk time.

A client who is an alcoholic has been admitted to the mental health unit and states to the nurse, "the judge made me come in here. My blood alcohol level was the only 0.20% when the cop pulled me over in my car." Which statement by the nurse is most appropriate?

" this level means that you consumed several drinks of alcohol and would be experiencing depressed motor function of the brain. You would have been staggering and clumsy, and your judgment would have been impaired, but you seem to feel that the judge was unreasonable for sending you here." RATIONALE: in most states the legal alcohol limit is 0.08%. The most appropriate response is the one that teaches the client about his BAL and direct him to focus on his action and behaviors.

A client with schizophrenia exhibit confused and intelligible speech which nursing statement would be most therapeutic?

" this morning you are participating in the tree-decorating ceremony for the unit" RATIONALE: The most therapeutic technique for assisting a client who speech is confused and unintelligible is to emphasize what is happening in here and now and involve the client and simply reality-based activities.

A psychiatric nurse is playing a card game with a client in the room. The client states to the nurse, "the voice in my head is telling me that you're cheating." Which response by the nurse is therapeutic?

" I do not hear any voices. He has the voice said anything else?" RATIONALE: when caring for a client experiencing delusions or hallucinations, the nurse should listen to the client, present reality, and collect more data regarding the content of a delusion and/or hallucination.

A client says to the nurse, "I don't do anything right. I am such a loser." What is the appropriate response?

" you don't do anything right?" RATIONALE: The correct response allows the client to verbalize his feelings. With this response, the nurse can learn more about what the client really means.

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! I'm the one who's dying." Which response by the nurse would be most therapeutic?

" you're feeling angry that your family continues to hope for you to be cured." RATIONALE: reflection is a therapeutic communication technique in which the clients feelings are reinstated to validate what the client is saying.

The mother of a child who is taking methylphenidate hydrochloride tells the school nurse that she is administering an OTC cough syrup to her son. Which response by the nurse would be appropriate?

" I think that you should stop giving this medicine to your son until I can check into contact with the pharmacy." RATIONALE: when a client is taking methylphenidate hydrochloride, no OTC meds should be administered without the approval of the pharmacist or healthcare provider. Search meds could contain caffeine or pseudoephedrine, which must be avoided.

An acutely ill client with schizophrenia says to the nurse, "he keeps saying that he likes you, and I keep telling him you're married, but he won't listen, and I think he's going to get fresh with you." Once the nurse has determined that the client is hallucinating, which response to the client would be most appropriate?

" Try not to listen to the voices right now so that I can talk with you." RATIONALE: The appropriate statement by the nurse is the one that does not acknowledge the clients hallucinations.

A client with schizophrenia is attending a support group held by a clinic nurse and says to the nurse and the group, "I've been laid off from my job at the factory, and so have three other people, so I'll have to get a new job. For now, there's unemployment." Which statement by the nurse would be most therapeutic at this time?

" have other people in the group been filling the job crunch this week? When changes like this occur, it's best to increase the number of your appointments with me for a short time." RATIONALE: The nurse is leading a support group for schizophrenic clients, so it is important to address every group member when possible and not to single out one member for special attention

A client who delivered a baby four months ago says, "I keep thinking that this boy is some sort of demon. All he does is cry. It's as if I can't feed him enough or satisfy him in any way. My daughter never gave me this kind of trouble. I really can't stand it." Which statement by the nurse is most appropriate?

" have you been having any thoughts of hurting your baby?" RATIONALE: The most important statement is the one in which the nurse assesses the client for her risk of harming the baby.

A client with schizophrenia is seen seemingly talking to someone who isn't there. Which nursing statement would be most therapeutic initially?

" i've noticed your eyes darting back and forth, and I wondered whether you might be hearing voices." RATIONALE: The most therapeutic nursing statement is the one in which the nurse addresses the clients behavior and asks whether the client is hearing voices.

A postpartum client says to the nurse, "sometimes I hear voices telling me to kill my baby to save her all the heartache I've been through. Which statement by the nurse would be most therapeutic?"

" it is so good that you shared your feelings and thoughts with me. I'm going to help you get immediate attention for your voices." RATIONALE: The client is experiencing serious postpartum psychosis and command hallucinations. They require immediate medical attention and intervention for the protection of both the mother and her baby.

A client in a skeletal traction says to the nurse, "I can't get any help with my care! I called and called, but the nurses never answer my light. Last night one of them told me she had other patients besides me! I am very sick, but the nurses don't care!" Which response by the nurse would be therapeutic?

" it's hard to be in bed and have to ask for help. You call for a nurse who never seems to come?" RATIONALE: and the correct option, the nurse displays empathy while sharing perceptions. Sharing perceptions allow the client to validate the nurses understanding of what the client is feeling and thinking.

A nurse is participating in a care planning conference for a client who is being treated for psychosis. Which step would be included during the stable or discharge phase of treatment?

Keeping the client active with hobbies, exercise, and work RATIONALE: desired outcomes for a psychotic client during the stable or discharge phase of treatment include maintenance of a consistent sleeping pattern; avoidance of caffeine and alcohol; maintenance of daily and weekly routines, including enjoyable activities; and a regular medication schedule.

A nurse determines that a client whose son died in a car accident is at risk for self harm. Which intervention is most appropriate initially?

Making a no suicide contract with the client RATIONALE: The nurse would first plan to implement a no suicide contract when a client is at risk for self harm. The safety of the client is the priority.

A client arrives in the emergency department in a crisis state. The client demonstrates signs of profound anxiety and is unable to focus on anything but the object of the crisis and the impact on herself. The nurse plans to focus initial data collection on which matter?

The physical condition of the client RATIONALE:The initial priority in the nursing care of a client in a crisis state is to collect data on the physical condition, potential for self harm, and potential for harm to others.