Module 4
A client says to the nurse, "I give you a lot of credit for what you do. I could never be a nurse or do anything that has to do with the medical profession — I have a panic attack whenever I see blood." Which type of phobia does the nurse identify from the client's statement? a) Acrophobia b) Agoraphobia c) Hematophobia d) Claustrophobia
c) Hematophobia RATIONALE: A phobia is a persistent, irrational fear of a specific object, activity, or situation that leads to an intense desire to avoid the object, activity, or situation. Hematophobia is the fear of blood. Acrophobia is the fear of heights. Agoraphobia is the fear of open spaces. Claustrophobia is the fear of enclosed spaces.
WHAT THERAPEUTIC NURSING INTERVENTION MAY REDIRECT A HYPERACTIVE, MANIC CLIENT? a) Suggesting that the client write a short story b) Having the client initiate group social activities on the unit c) Asking the client to guide other clients as they clean their rooms d) Encouraging the client to tear pictures out of magazines for a scrapbook
d) Encouraging the client to tear pictures out of magazines for a scrapbook Rationale: D Physical activity will help use some of the excess energy without requiring the client to make decisions or forcing other clients to deal with the behavior. A The client's extreme activity limits concentration or task completion. B The client may disrupt the unit because of the excess activity and bossiness associated with this disorder. C The client needs guidance and is not able to guide others.
The husband of a client who abuses alcohol tells a nurse at the mental health clinic that he is having a difficult time coping with his wife's behavior and that he is unsure how to deal with it. Which support group does the nurse suggest to the husband to help him deal with these issues? a) Al-Anon b) Narcotics Anonymous c) Alcoholics Anonymous d) Adult Children of Alcoholics
a) Al-Anon RATIONALE: Al-Anon is a support for spouses and friends of individuals with alcoholism. Narcotics Anonymous is a support group for individuals addicted to narcotics (opioids). Alcoholics Anonymous is a support group for recovering alcoholics. Adult Children of Alcoholics is a support group for adults who were reared in alcoholic homes.
Thomas undergoes amputation of the foot, has an uneventful recovery, and is discharged home. He is to receive home care visits from a visiting nurse and a physical therapist for rehabilitation measures, including preparation for a prosthesis. Angela, his wife, tells the visiting nurse that Thomas has been agitated and refuses to talk to anyone or allow any of his friends from the limousine company to visit him. During the home care visit, Thomas says to the nurse, "I can't drive my limousine! Life just isn't worth living anymore. Some days I wish I were dead." Which response should the nurse make first? a) "Are you having thoughts of suicide?" b) "Things will work out. It's just going to take some time." c) "Tell me why you don't want to talk to or see any of your friends." d) "Once you learn how to walk with the prosthesis, you'll feel better about yourself."
a) "Are you having thoughts of suicide?" RATIONALE: If the client makes a statement indicating a desire to end his or her life, the nurse must immediately validate the statement. The statement made by Thomas is one such overt verbal clue. Other such clues include "I can't take it any more" and "Everyone would be better off if I died." If a client makes such a statement, the nurse should specifically ask the client about his or her intention of committing suicide. Telling the client, "Things will work out" or "Once you learn to walk with the prosthesis, you will feel better" is nontherapeutic and provides false reassurance. Asking the client why he does not want to talk or see his friends may be appropriate at some point but, in light of Thomas' statement, is not the initial concern.
Thomas tells the nurse that even though he is upset about his situation, he sometimes says things that he doesn't really mean. The nurse talks to Thomas about counseling, and he agrees to speak with a crisis counselor. The nurse also talks to Thomas about a no-suicide contract, and Thomas agrees to sign one. Which statement should be included in the contract? a) "I will call my crisis counselor if I have any thoughts of harming myself." b) "If I start feeling that I want to kill myself, I will try to ignore the thought." c) "I will ask my wife to hide my medication if I have any thoughts of harming myself." d) "I will try to do something such as watching television or reading the newspaper if I have any thoughts of harming myself."
a) "I will call my crisis counselor if I have any thoughts of harming myself." RATIONALE: A no-suicide contract should provide an appropriate resource for the client in the event that the client experiences thoughts of self-harm. Calling the crisis counselor is the only option that is an appropriate resource for the client. Ignoring the thoughts does not provide a resource for the client; instead, it relies on the client to deal with the thoughts of self-harm. Placing the responsibility on the client's wife is an inappropriate intervention.
A client is admitted to the mental health unit with a diagnosis of obsessive-compulsive disorder. After the clinical intake assessment, the nurse observes that the client is repetitively wiping the furniture in her room with a facecloth and warm water. Which action should the nurse take initially? a) Allow the client to perform the repetitive act b) Stop the client from performing the repetitive act c) Help the client wipe the furniture while talking to her about her repetitive act d) Tell the client that it is not necessary to repetitively wipe the furniture because it has been thoroughly disinfected by the housekeeping staff
a) Allow the client to perform the repetitive act RATIONALE: Initially the nurse should not interfere with the repetitive act, as long as the act is not harmful, and the nurse should never ridicule the client's behavior. The client is performing the repetitive act to keep anxiety at a tolerable level. Also, the nurse should not attempt to argue with the client about the repetitive behavior, attempt to reason with the client and persuade him or her to stop the behavior, or reinforce the ritual by focusing attention on it and talking about it a great deal. With time, the nurse can begin to set limits on the client's behavior to modify the behavior.
A NURSE ENTERS A CLIENT'S ROOM, AND THE CLIENT IS DEMANDING RELEASE FROM THE HOSPITAL. THE NURSE REVIEWS THE CLIENT'S RECORD AND NOTES THAT THE CLIENT WAS ADMITTED 2 DAYS AGO FOR TREATMENT OF AN ANXIETY DISORDER AND THAT THE ADMISSION WAS A VOLUNTARY ADMISSION. WHICH OF THE FOLLOWING ACTIONS WOULD THE NURSE TAKE? a) Contact the physician. b) Call the client's family. c) Persuade the client to stay a few more days. d) Tell the client that discharge is not possible at this time.
a) Contact the physician. Rationale: Generally, the client seeks voluntary admission. Voluntary clients have the right to demand and obtain release. If the client is a minor, the release may be contingent on the consent of a parent or guardian. The nurse needs to be familiar with the state and facility policies and procedures. Many states require that the client submit a written release notice to the facility staff members, who re-evaluate the client's condition for possible conversion to involuntary status if necessary, according to criteria established by laws. The best nursing action is to contact the physician.
The nurse is developing a plan of care for a client admitted to the mental health unit with a diagnosis of dissociative amnesia. Which intervention should the nurse include in the plan? a) Encouraging the client to perform self-care activities b) Encouraging the use of dissociation to cope with stress and anxiety c) Orienting the client and frequently reminding him of events in his past d) Making all decisions for the client to prevent him from feeling overwhelmed
a) Encouraging the client to perform self-care activities RATIONALE: Dissociative amnesia refers to the client's inability to integrate memories. The memory loss serves the purpose of preventing anxiety. The client should be encouraged to do things for himself and to make decisions about routine tasks. This will enhance the client's self-esteem by reducing his sense of powerlessness. The nurse would not encourage the use of dissociation. Rather, the nurse would help the client see the consequences of using dissociation to cope with stress. Although the nurse would orient the client, flooding the client with information on past events is inappropriate. The nurse should encourage the client to make some decisions. This will increase the client's insight and help the client understand his own role in choosing behaviors.
Thomas, quite upset, begins to cry. He tells the nurse that he feels overwhelmed because of what his health care provider has told him and that he just doesn't know what to do or how he will manage without his foot. The nurse determines that Thomas is experiencing a situational crisis and which problem? a) Lack of control b) Inability to grieve c) Lack of family support d) Inability to think clearly
a) Lack of control RATIONALE: Thomas is expressing concern about how he will manage without his foot and therefore the problem he is experiencing is a lack of control over the current situation. There is no indication in that question that Thomas is unable or unwilling to acknowledge or mourn his loss. Additionally, there is no information in the question that indicates that Thomas lacks family support or is unable to think clearly.
A client in the inpatient mental health unit suddenly becomes violent, posing a threat to the safety of other clients and staff on the nursing unit. The nurse tries to use nonrestrictive interventions to deescalate the client's behavior, but these attempts are unsuccessful and the client's behavior escalates. Which action should the nurse take next? a) Obtain assistance from the nursing staff and place the client in seclusion b) Bring the client to his room and lock his door until hospital security arrives c) Ask the client to sign a consent form for the use of restraints (safety devices) and seclusion d) Call the client's psychiatrist and wait for a return call to obtain a prescription for restraints and seclusion
a) Obtain assistance from the nursing staff and place the client in seclusion RATIONALE: Client consent and a psychiatrist's written prescription are normally needed for the use of restraints and seclusion. In an emergency, a nurse may place a client in restraints or seclusion and obtain a written or verbal prescription from the health care provider as soon as possible thereafter. Federal law also requires the consent of the client unless an emergency situation exists in which an immediate risk of harm to the client or others can be documented. In most situations, a violent client cannot be reasoned with and is unlikely to sign a consent form on request. Locking the client in his room is a form of false imprisonment and could be physically harmful to the client.
A client with a history of panic disorder is brought to the emergency department complaining of dizziness, palpitations, and chest pain. The client states that he feels as if he is "going crazy." Which action should the nurse take first? a) Performing a physical assessment b) Calling the crisis intervention team c) Asking the client what brought on the panic attack d) Asking the unit secretary to obtain records of the client's previous hospitalizations
a) Performing a physical assessment RATIONALE: Panic attacks are a distinctive feature of panic disorder. Symptoms include dizziness, faintness, choking, palpitations, trembling, nausea or abdominal distress, numbness, chest pain, and the fear of dying or going crazy. The symptoms of panic disorder mimic a variety of medical conditions, so the nurse would first perform a physical assessment of the client to help rule out a medical problem. Once the client's physical needs have been attended to, other needs may be addressed. The nurse would then ask the client about the precipitant of the attack and obtain records of the client's previous hospitalizations. The crisis team may or may not be needed for intervention.
A client with a paranoid disorder refuses to eat because he believes that the food being served in the mental health unit is poisoned. Which response is an appropriate way for the nurse to defuse the client's delusional thoughts? a) Providing the client with food items in sealed containers b) Telling the client that he is safe now that he is in the hospital c) Setting firm limits and telling the client that the food is not poisoned d) Asking the client whether he would like to visit the hospital kitchen to watch the food being prepared
a) Providing the client with food items in sealed containers RATIONALE: A client with a paranoid disorder fears that others will exploit, harm, or deceive him or her, to the point of endangering the client's life. Adequate nutrition may be a problem with such clients. A common distortion or delusion is that food is poisoned, and the client may not eat as a result. In this situation, special foods should be provided in sealed containers to minimize the suspicion of tampering. The client should be allowed to prepare his or her own food, if possible. Although the nurse should assure the client that he or she is safe, this action alone will not eliminate the client's delusional thoughts. Likewise, inviting the client to visit the hospital kitchen to watch how the food is prepared and setting firm limits about discussion of food being poisoned will not help eliminate the client's delusional thoughts.
The nurse has provided the family of a client with Alzheimer's disease with guidelines for caring for the client at home. Which statement indicates the education has been effective? a) The family mentions encouraging physical activity during the day. b) The family members indicate they will dress the client to prevent client frustration. c) The family informs the nurse they will restrain the client at night if the client tends to wander. d) The family members agree they will feed the client to ensure that the client receives adequate nutrition.
a) The family mentions encouraging physical activity during the day. RATIONALE: Physical activity during the day should be encouraged for the client with Alzheimer's disease. Exercise will help the client sleep at night and reduce the likelihood of nighttime wandering. If the client wanders, safety measures (e.g., placing complex locks on doors or placing locks at the tops of doors) may be instituted. The client should perform all tasks within the capacity of his or her condition. This will help maintain the client's self-esteem and minimize further regression. Providing step-by-step instructions whenever necessary will help the client focus on small pieces of information and allows the client to perform at an optimal level. The client should not be restrained. Restraints can cause the client to become more terrified and agitated, until he or she is exhausted to a dangerous degree.
A week later, Thomas calls his crisis counselor. "I feel totally useless and I know my wife would be better off without me," he says, "but I promised to call you, because I signed that contract." The counselor evaluates the lethality of Thomas' suicide plan. Which of these methods are considered higher risk, or "hard," methods of suicide? Select all that apply. a) Using a gun b) Ingesting pills c) Slashing one's wrists d) Jumping from a high place e) Inhaling carbon monoxide
a) Using a gun d) Jumping from a high place e) Inhaling carbon monoxide RATIONALE: Lethality is how quickly or easily a person would die if he or she used that method to attempt suicide. Higher-risk, or hard, methods include using a gun, jumping from a high place, inhaling carbon monoxide, hanging, and staging a car crash. Lower-risk, or "soft," methods include slashing one's wrists, ingesting pills, and inhaling natural gas.
A client with depression who is scheduled to undergo electroconvulsive therapy (ECT) for the first time says to the nurse, "I'm nervous about this treatment. Someone told me there's a risk of electrocution." The nurse should make which response to the client? a) "Did your health care provider talk to you about this when you signed the informed consent?" b) "Electrocution is not a risk associated with this treatment. Let's discuss your concerns." c) "Electrocution can only happen during a thunderstorm. That's why we always check the weather report before starting a treatment." d) "The side effects of this treatment are minimal, so don't worry. Your health care provider can talk to you about them in greater detail if you'd like."
b) "Electrocution is not a risk associated with this treatment. Let's discuss your concerns." RATIONALE: Electroconvulsive therapy, or ECT, is a treatment in which a brief seizure is artificially induced in an anesthetized client by the passage of an electrical stimulus through electrodes applied to the client's head. The stimulus is generally adjusted to the lowest level of energy that will produce a seizure. While the client is being prepared for the treatment, it is important for the nurse to give the client the opportunity to express his or her feelings, including myths, about ECT. Clients may describe fears related to pain, dying of electrocution, suffering permanent memory loss, or experiencing impaired intellectual function. ECT is not associated with electrocution. Telling the client that electrocution can only happen during a thunderstorm is inaccurate and will instill additional fear in the client. Asking the client whether he or she has spoken with the health care provider regarding side effects avoids the client's concerns.
AN EXTREMELY ANXIOUS CLIENT ENTERS A CRISIS CENTER AND ASKS A NURSE FOR HELP. WHICH RESPONSE BEST REFLECTS THE NURSE'S ROLE IN CRISIS INTERVENTION? a) "Tell me what you have done to help yourself." b) "I will be here for you to help you figure things out." c) "I understand that in the past you have had problems." d) "Tell me about the things that are bothering you the most."
b) "I will be here for you to help you figure things out." Rationale: B Clients in crisis need assistance with coping; the nurse must be involved with problem solving. A, C, D Although a positive interview statement, this does not focus on the nurse's involvement with problem solving.
A NURSE IS WORKING WITH A MARRIED WOMAN WHO HAS COME TO THE EMERGENCY DEPARTMENT SEVERAL TIMES WITH INJURIES THAT APPEAR TO BE RELATED TO DOMESTIC VIOLENCE. WHILE TALKING WITH THE NURSE MANAGER, A NURSE EXPRESSES DISGUST THAT THE WOMAN RETURNS TO THE SAME SITUATION. WHAT IS THE NURSE MANAGER'S BEST RESPONSE? a) "She must not have the financial resources to leave her husband." b) "Most woman attempt to leave about six times before they are able to do so." c) "There is nothing the staff can do because people are free to choose their own life." d) "These women should be told how foolish they are to remain in their current situation."
b) "Most woman attempt to leave about six times before they are able to do so." Rationale: B Nurses who work with clients who are victims of partner abuse need to be supportive and patient. It takes time and several attempts for most victims to be able to leave abusive relationships. A This may or may not be true. There is not enough information to support this conclusion. C The staff can encourage the woman to make plans for addressing various potential events. Information about social services and telephone help lines can be beneficial. D The nurse should not resort to shaming women in this position because it will make them less likely to seek help.
A client who has been diagnosed as having an antisocial personality is hospitalized after being involved in a fight. Which interventions included in the plan of care are most crucial? Select all that apply. a) Encourage the client to place bets and play poker with other clients. b) Assess the client for thoughts of suicide and report these if they occur. c) Explain to the client that he will need to spend time in his room if he assaults others. d) Discuss with the client the need for him to refrain from hurting staff or other clients. e) Encourage the client to find contact information for those he has injured and to apologize.
b) Assess the client for thoughts of suicide and report these if they occur. c) Explain to the client that he will need to spend time in his room if he assaults others. d) Discuss with the client the need for him to refrain from hurting staff or other clients. RATIONALE: The person with an antisocial personality has a tendency to be aggressive and to ignore social expectations. The nurse should assess clients with a personality disorder for thoughts of suicide and report this if it occurs. By explaining consequences of behavior, the nurse sets clear limits on expectations and consequences. Playing poker and placing bets could increase the risk of the client hurting others. The client should not be encouraged to find contact information, because this increases the risk of the client hurting others. Clients with antisocial behavior do not experience true regret over actions taken.
Carl calls his wife, Jane, to tell her that he is undergoing treatment for his alcohol problem. Later that afternoon, Jane visits. During the visit, the nurse notes that Carl is anxious and confused and that he is experiencing tremors. The nurse suspects that Carl is experiencing alcohol withdrawal. Which action should the nurse take? a) Asking Jane to leave b) Implementing seizure precautions c) Planning to place Carl in the seclusion room d) Asking Carl for permission to apply restraints
b) Implementing seizure precautions RATIONALE: When a client demonstrates signs of alcohol withdrawal, careful assessment and appropriate medical and nursing interventions can prevent the more serious withdrawal reaction of delirium. The nurse would administer medication as prescribed and assess Carl frequently. The nurse would also implement seizure precautions because of the potential for seizures. Providing a quiet, nonstimulating environment and allowing a family member to stay with the client will minimize anxiety and confusion. Restraints and seclusion are used for a client who presents a threat to him- or herself or to others and is unable to control his or her behavior. Asking Carl for permission to apply restraints might increase his anxiety.
A client arrives at the clinic, extremely upset and crying, and asks to talk to someone. She tells the nurse that her husband has just told her that he wants a divorce because he is in love with someone else. The client says "I don't know what I'm going to do or how i'm going to deal with this. He was my whole life!" Which type of crisis does the nurse determine that the client is experiencing? a) Disaster b) Situational c) Maturational d) Adventitious
b) Situational RATIONALE: A situational crisis arises from an external rather than an internal source. Some examples of external situations that could precipitate a crisis include loss of a job, death of a loved one, a change in financial status, and divorce. A maturational crisis relates to developmental stages and associated role changes. An adventitious crisis relates to a crisis of disaster or an event that is not a part of everyday life.
A female client with anorexia nervosa is transferred to the mental health unit from a medical unit after being treated for an electrolyte imbalance. Which action does the nurse in the mental health unit plan to take to ensure adequate nutritional intake? a) Being supportive but feeding the client if she refuses to eat b) Staying with the client during mealtimes and encouraging the client to eat c) Telling the client that an intravenous line or a nasogastric tube will be inserted if she does not eat d) Asking the client to call the nurse when she is done eating so that her calorie intake and fluid intake can be calculated
b) Staying with the client during mealtimes and encouraging the client to eat RATIONALE: Anorexia nervosa is an eating disorder in which the individual experiences hunger but refuses to eat because of a distorted body image. It can lead to life-threatening physiological disorders. To ensure adequate nutrition, the nurse should stay with the client during meals and snacks, watch the client eat, and remain with the client for at least 1 hour after the meal. These actions will ensure that the client does not hide or throw away food or purge after the meal or snack. Feeding the client is an inappropriate action that will lead to a power struggle between the client and nurse. Telling the client that an intravenous line or nasogastric tube will be inserted if she does not eat is threatening the client. This is also an inappropriate action.
A CLIENT WITH A DIAGNOSIS OF ANTISOCIAL PERSONALITY DISORDER IS BEING DISCHARGED FROM THE HOSPITAL. THE CLIENT ASKS THE NURSE, "CAN I HAVE YOUR PHONE NUMBER SO THAT I CAN CALL YOU FOR A DATE." WHAT IS THE NURSE'S BEST RESPONSE? a) "We are not permitted to date clients." b) "It is against my professional ethics to date clients." c) "Our relationship is professional; therefore, I will not see you socially." d) "I'm glad you like me; however, I cannot give out my phone number."
c) "Our relationship is professional; therefore, I will not see you socially." Rationale: C This response sets clear limits on their relationship and maintains a professional rather than a social role. A This response shifts responsibility from the issue at hand to the institution. B This response avoids the real issue and shifts responsibility to the ethical code. D This response does not clarify the nature of the relationship as professional.
A COMMUNITY HEALTH NURSE VISITS A CLIENT AT HOME. THE CLIENT STATES, "I HAVEN'T SLEPT AT ALL THE LAST COUPLE OF NIGHTS." WHICH RESPONSE BY THE NURSE ILLUSTRATES A THERAPEUTIC COMMUNICATION TECHNIQUE FOR THIS CLIENT? a) "Go on." b) "Sleeping?" c) "You're having difficulty sleeping?" d) "Sometimes, I have trouble sleeping too."
c) "You're having difficulty sleeping?" Rationale: Option C uses the therapeutic communication technique of restatement. Although restatement is a technique that has a prompting component to it, it repeats the client's major theme, which assists the nurse to obtain a more specific perception of the problem from the client.
A 6-year-old child is brought to the school nurse's office because the child is complaining of abdominal pain. During assessment of the child, the nurse notes the presence of bruises on the child's abdomen and back, as well as several cigarette burns, and suspects child abuse. Which priority action should the nurse plan to take? a) Documenting the bruises b) Asking the child how long his parents have been abusing him c) Contacting child protective services and law enforcement d) Calling the parents to ask them how the child sustained the bruises and burn marks
c) Contacting child protective services and law enforcement RATIONALE: In a case of suspected child abuse, the nurse must make a report to child protective services and to law enforcement. The nurse would also provide accurate and thorough documentation of the child's bruises, but this is not the priority action. Asking the child how long he has been abused is inappropriate and may instill fear in the child. Determining how long the parents have been abusing the child is not the priority; neither is confronting the parents. Confrontation may anger the parents (if they are in fact the abusers), and they may take the child home before safety interventions can be initiated, putting the child at risk for further injury, especially if the parents believe that the child has told someone that he is the victim of abuse.
A survivor of sexual assault is brought to the emergency department by a neighbor. The nurse assists the client into a private examining room and conducts an interview with the client. The nurse explains the procedures for physical examination, and the client refuses the examination. Which action should the nurse take next? a) Obtaining a court order for the physical examination b) Telling the victim that the physical examination cannot be refused c) Encouraging the victim to discuss the reasons for refusing the physical examination d) Telling the victim that the physical examination must be performed to obtain evidence of the rape
c) Encouraging the victim to discuss the reasons for refusing the physical examination RATIONALE: The survivor of a sexual assault has the right to refuse a legal or a medical examination. Consent forms must be signed for photographs, pelvic examination, and any other procedures that might be needed to collect evidence and provide treatment. If the victim refuses the examination, it cannot be performed. Telling the victim that he or she must have the exam for evidence to be obtained, that the exam cannot be refused, and that a court order will be obtained for the exam are all inappropriate.
The nurse is conducting a group therapy session. One client with mania talks constantly, dominating the session and her behavior is disrupting group interaction. The nurse should take which initial action? a) Ask the client to leave the group session b) Ask another nurse to escort the client out of the group session c) Tell the client she needs to allow other clients in the group to talk d) Tell the client that she will not be allowed to attend future group sessions
c) Tell the client she needs to allow other clients in the group to talk RATIONALE: A manic client may be extremely talkative, dominating group meetings or therapy sessions. If this occurs, the nurse should initially set limits on the client's behavior. It is inappropriate initially to ask the client to leave the session or to ask another person to escort the client from the session, which could agitate the client and further escalate the client's behavior. Telling the client that she will not be allowed to attend future group sessions is also an inappropriate initial action. It violates a client's right to receive treatment and is a threatening action.
Police officers bring a victim of physical and emotional abuse to the emergency department. They tell the nurse that this is the client's fifth visit to the department in the last 4 months because of violent attacks by her husband. After assessing and treating the client's physical wounds, the nurse prepares to conduct an interview on the client. Which finding does the nurse expect to note while interviewing the client? a) The client has high self-esteem. b) The client is angry and aggressive. c) The client accepts the blame for the attack. d) The client is talkative, energetic, and anxious.
c) The client accepts the blame for the attack. RATIONALE: With each repeat of the violence patterns, the self-esteem of the victim erodes more and more. The victim either believes that the violence was deserved or accepts blame for it. This can lead to feelings of depression, hopelessness, dependency, depression, and powerlessness. High self-esteem, anger, aggressiveness, talkativeness, and displays of energetic or anxious behavior are not characteristics of an abuse victim.
A client with a diagnosis of severe depression is being treated in an inpatient mental health unit. Which observation by the nurse indicates an increased risk for suicide? a) The client is pacing the hallway. b) The client is sitting in her room, wringing her hands. c) The client gives her handmade sweater to her roommate. d) The client is sitting alone in the corner of the clients' lounge.
c) The client gives her handmade sweater to her roommate. RATIONALE: The nurse must be alert for clues indicating a risk for suicide in the client with depression. Behavioral changes, especially those that occur when the depression lifts and the client has more energy available with which to carry out a suicide plan, may indicate such a risk. Signs include giving away prized personal possessions, writing farewell notes, making out a will, and putting personal affairs in order. Pacing the hallway, wringing the hands, and sitting alone are all behaviors that may be noted in a client with depression, and although they cannot be ignored, they are not direct signs of an increased risk for suicide.
The nurse is planning activities for a client, hospitalized in the mental health unit, who is experiencing a moderate level of anxiety. Once the nurse has conducted a physical assessment, which activity is most appropriate for the client? a) Painting b) Drawing c) Walking d) Board games
c) Walking RATIONALE: Interventions for the client with moderate anxiety include providing outlets through which to work off excess energy and direct the client's attention outward. Physical activity can provide relief of built-up tension, increase muscle tone, and increase release of endorphins. Such activities include walking, table tennis, dancing, and exercising. Painting, drawing, and board games are sedentary activities.
The nurse, performing an assessment of a client, asks about the use of substances such as alcohol and drugs. The client tells the nurse that he has been using alcohol for a long time. Which question should the nurse ask to determine whether the client is physically dependent on alcohol? a) "Do people criticize your drinking?" b) "Have you ever felt guilty about drinking?" c) "Have you ever felt as though you should try to cut down on your drinking?" d) "Have you noticed that you have had to drink increasing amounts of alcohol?"
d) "Have you noticed that you have had to drink increasing amounts of alcohol?" RATIONALE: Tolerance is a need for increasing amounts of the substance to achieve the desired effect. It is a sign that the person is physically dependent on the substance. To determine whether the client is physically dependent on a substance, the nurse would ask the client whether he has noticed the need to drink increasing amounts of alcohol. The questions in the other options are related to a psychological dependence on alcohol.
A PHYSICIAN IS ADMITTED TO THE PSYCHIATRIC UNIT OF A COMMUNITY HOSPITAL. THE CLIENT, WHO WAS RESTLESS, LOUD, AGGRESSIVE, AND RESISTIVE DURING THE ADMISSION PROCEDURE, STATES, "I WILL TAKE MY OWN BLOOD PRESSURE." WHAT IS THE NURSE'S MOST THERAPEUTIC RESPONSE? a) "Right now you are just another client." b) "If you would rather, I'm sure you will do it correctly." c) "I will get the attendants to assist me if you do not cooperate." d) "I am sorry, but I cannot allow that because I must take your blood pressure."
d) "I am sorry, but I cannot allow that because I must take your blood pressure." Rationale: D This simply states facts without getting involved in role conflict. A-Being a physician is a big part of this client's self-esteem, and by this remark the nurse is threatening that self-esteem. B-This will confuse the client's role on the unit. A client who is a physician cannot be responsible for checking vital signs. C-Threats will make the situation worse and set the tone for future negative nurse-client interactions.
An employee from the dietary department is stocking the kitchen of a mental health unit. A client who is nearby says to the nurse, "The terrorists are here, and they're out to get me! They're putting anthrax in the sugar containers!" Which response should the nurse give to the client? a) "There aren't any terrorists in the kitchen." b) "No one is trying to hurt you. It's all in your mind." c) "You will scare the other clients if they hear you talking that way." d) "The person you saw is from the dietary department. He's here to stock the unit kitchen with food."
d) "The person you saw is from the dietary department. He's here to stock the unit kitchen with food." RATIONALE: When dealing with a client experiencing a delusion, the nurse should be open, honest, and reliable in interactions to ease the client's suspicion. The nurse should also present reality to the client. The nurse should avoid arguing about the content of the delusion, instead focusing on the feelings the delusion generates in the client. The nurse should not dwell on the delusion but instead should focus conversation on more reality-based topics.
A client is found to have post-traumatic stress disorder (PTSD) after witnessing a terrorist attack and seeing several people jump to their deaths from a burning building. The client, who is undergoing counseling, says to the nurse, "Those people who jumped were my friends and coworkers. The only reason I wasn't there is that it was my turn to get the coffee and doughnuts for everyone that morning. If I hadn't gone, I would have been with them. Maybe I could have helped." Which response should the nurse give to the client? a) "You just weren't meant to be there." b) "It was a horrible attack, and there wasn't anything anyone could do." c) "You need to think about the families of the victims and what they are dealing with." d) "You are not responsible for the attack but are responsible for learning how to cope with the trauma."
d) "You are not responsible for the attack but are responsible for learning how to cope with the trauma." RATIONALE: PTSD is precipitated by a specific overwhelming and devastating event. A positive outcome for the client is that the client will cope effectively with thoughts and feelings associated with the traumatic event. To help reduce the client's feelings of powerlessness and guilt, the nurse should note that the client was not responsible for the event. Stating that it was a horrible attack or that the client wasn't meant to be there does not help the client interpret the event or develop coping skills. Thinking about the families of victims and how they are dealing avoids addressing the client's thoughts and feelings.
A CLIENT WITH A DIAGNOSIS OF MAJOR DEPRESSION WHO HAS ATTEMPTED SUICIDE SAYS TO A NURSE, "I SHOULD HAVE DIED. I'VE ALWAYS BEEN A FAILURE. NOTHING EVER GOES RIGHT FOR ME." THE THERAPEUTIC RESPONSE TO THE CLIENT IS: a) "I don't see you as a failure." b) "You have everything to live for." c) "Feeling like this is all part of being ill." d) "You've been feeling like a failure for a while?"
d) "You've been feeling like a failure for a while?" Rationale: Responding to the feelings expressed by a client is an effective therapeutic communication technique. The correct option is an example of the use of restating. Options 1, 2, and 3 block communication because they minimize the client's experience and do not facilitate exploration of the client's expressed feelings.
A PSYCHOLOGIST HAS BEEN A CLIENT ON A MENTAL HEALTH UNIT FOR 3 DAYS. THE CLIENT HAS QUESTIONED THE AUTHORITY OF THE TREATMENT TEAM, ADVISED OTHER CLIENTS THAT THEIR TREATMENT PLANS ARE WRONG, AND HAS BEEN DISRUPTIVE IN GROUP THERAPY. WHAT IS THE NURSE'S MOST APPROPRIATE INTERVENTION? a) Tell the other clients to disregard what the client is saying. b) Ignore the client's disruptive behavior and wait until it subsides. c) Restrict the client's contact with other clients until the disruptive behavior ceases. d) Accept that the client is unable to control this behavior, and set appropriate limits.
d) Accept that the client is unable to control this behavior, and set appropriate limits. Rationale: D Clients who are out of control need controls set for them. The staff must understand that the client is not deliberately trying to disrupt the unit. A This is demeaning the client in the eyes of the other clients, and it does not address the problem directly. B Ignoring the client will not stop the disruptive behavior; the nurse has a responsibility to the other clients. C This may be a last resort taken to solve the problem but should not be used until other alternatives are explored.
A client who is hospitalized in a mental health unit has become argumentative and agitated, pacing the hallway. He suddenly begins to glare at another client and makes verbal threats. Which initial action should the nurse take? a) Telling the client that if he continues to make threats, he will be placed in seclusion b) Approaching the client, putting an arm around his waist, and asking what is bothering him c) Obtaining assistance from other members of the nursing staff and taking the client to his room d) Acknowledging the client's anger and providing the client options for dealing with his behavior
d) Acknowledging the client's anger and providing the client options for dealing with his behavior RATIONALE: To deescalate angry behavior, the nurse first ensures the safety of the client, other clients, and self. The nurse should acknowledge the client's anger, determine the client's need, and provide options to deal with the behavior. The nurse should also make the client aware of the consequences of his anger and violence. Threatening the client is a violation of his rights. The nurse should maintain a large personal space, use a nonaggressive posture, and avoid touching the client. The other options are incorrect.
A female client is brought to the emergency department by a neighbor after experiencing sudden paralysis in both arms. On assessing the client, the nurse discovers that the paralysis developed 2 days after the client's husband told her that he wanted a divorce. The client sighs and says, "Oh well, I guess I will eventually learn to live without my arms working." During the assessment, the nurse learns the client is a computer programmer and needs her hands to perform her work. Which action should the nurse undertake first? a) Requesting a psychiatric consult b) Contacting the crisis intervention team c) Conducting a thorough mental-health assessment d) Assessing the client for any physical basis for the paralysis
d) Assessing the client for any physical basis for the paralysis RATIONALE: A conversion disorder is a somatic symptom disorder in which a physical symptom appears when no organic cause exists. The most common conversion symptoms are blindness, deafness, paralysis, and inability to talk. Symptoms are not intentionally produced by the client and are directly related to conflict and increasing anxiety. This type of illness should never be dismissed as psychosomatic, and the nurse should initially plan to carefully assess the client to help rule out an organic cause for the paralysis. Requesting a psychiatric consult, contacting the crisis intervention team, and conducting a mental health assessment may be components of treatment, but they are not the first considerations.
A 16-year-old boy is brought to the emergency department by ambulance. The mother of the client tells the nurse that she called the ambulance because her son's behavior was bizarre and violent and because he was having hallucinations. The mother says that she is concerned because her son has been "hanging out with the wrong crowd" and she suspects that he has been "sniffing cocaine." During the assessment, which sign of cocaine intoxication should the nurse expect to note? a) Lethargy b) Bradycardia c) Hypotension d) Dilated pupils
d) Dilated pupils RATIONALE: Signs of cocaine intoxication include dilated pupils, tachycardia, hypertension, nausea and vomiting, and insomnia. Other effects include euphoria, impairment of judgment and social or occupational function, paranoia, delusions, and hallucinations, as well as the potential for violence.
During an interview, a client reveals having an interest in sexual activity with others of the same sex. Which nursing action is most appropriate? a) Asking the client why this activity is preferred. b) Asking the client how long this has been going on. c) Encouraging the client to discuss this with a minister. d) Encouraging the client to discuss how this affects overall health.
d) Encouraging the client to discuss how this affects overall health. RATIONALE: The nurse should encourage the client to discuss how this is affecting overall health. Asking the client "why" questions could cause the client to feel a need to defend their actions. It is not relevant to ask the client to explain how long this has been going on. Encouraging the client to discuss this with a minister is not appropriate because it suggests disapproval, not acceptance.
A client admitted to the mental health unit has a diagnosis of moderate depression. The nurse, formulating a nursing care plan, is concerned about the client's nutritional status. Which nursing interventions should be included in the care plan? Select all that apply. a) Weighing the client daily b) Filling out the menu for the client c) Restricting visitors during mealtimes d) Including the dietitian in meal planning e) Providing small high-calorie, high-protein snacks throughout the day
d) Including the dietitian in meal planning e) Providing small high-calorie, high-protein snacks throughout the day RATIONALE: The client with depression experiences anorexia, and poor nutrition puts the client at risk for illness, so maintaining adequate nutrition is crucial. The nurse should involve the dietitian in meal planning to ensure that the client is obtaining adequate nutrients. The client should be asked about food dislikes and provided with the opportunity to fill out the menu, because the client is more likely to eat foods he or she has selected. Small high-calorie, high-protein snacks and fluids should be offered frequently throughout the day and evening. Frequent small snacks are more easily tolerated than large plates of food when a client is anorexic. The client is weighed weekly (not daily) to monitor the nutritional status. Weighing the client daily is unnecessary. When possible, the nurse should encourage family or friends to remain with the client during meals. This intervention reinforces the idea that someone cares, may increase the client's self-esteem, and may serve as an incentive to eat.
A CLIENT WHOSE DEPRESSION IS BEGINNING TO LIFT REMAINS ALOOF FROM THE OTHER CLIENTS ON THE MENTAL HEALTH UNIT. HOW CAN A NURSE HELP THE CLIENT TO PARTICIPATE IN AN ACTIVITY? a) Find solitary pursuits that the client can enjoy. b) Speak to the client about the importance of entering into activities. c) Ask the health care provider to speak to the client about participating. d) Invite another client to take part in a joint activity with the nurse and the client.
d) Invite another client to take part in a joint activity with the nurse and the client. Rationale: D Bringing another client into a set situation is the most therapeutic, least-threatening approach. A At this point in time it is not therapeutic to allow the client to follow solitary pursuits; it will promote isolation. B Explanations will not necessarily change behavior. C This transfers the nurse's responsibility to the health care provider. (don't pass the buck!)
The nurse makes a routine scheduled visit to an older client and finds the client alone in his room while the client's son and daughter-in-law are enjoying a picnic in the back yard. When the nurse asks the client why he is not at the picnic with his family, the client tearfully responds, "My son told me to stay in my room because I make a mess of myself when I eat and I am a burden." Which action by the nurse is most appropriate? a) Telling the client that it is best that he stays in his room b) Telling the client that she will stay with him for a while so that he doesn't have to be alone c) Asking the client whether he would like to go home with her and spend the day at her house d) Recognize that emotional abuse is taking place and contact the local agency for older adult protective services
d) Recognize that emotional abuse is taking place and contact the local agency for older adult protective services RATIONALE: Socially isolating an individual is a form of emotional abuse. The nurse should contact the local agency for older adult protective services. Respite care and other stress relievers may be key interventions for an overburdened caregiver. Telling the client it is best to stay in his room, offering to sit with him so he won't be alone, and offering him to spend the day at the nurse's home are inappropriate actions and do not directly deal with the client's emotional abuse.
A CHILD TELLS THE SCHOOL NURSE, "MY FATHER HAS BEEN GETTING INTO BED WITH ME AT NIGHT AND TOUCHING ME." WHAT SHOULD THE NURSE DO NEXT? a) Ask the child to describe the touching. b) Tell the teacher to report any inappropriate behavior. c) Contact the father to come to the school immediately. d) Report the child's conversation to child protective services.
d) Report the child's conversation to child protective services. Rationale: D The nurse is legally responsible to report suspected child abuse to the appropriate child protection agency. The agency must assess the situation and intervene if necessary to protect the child. A Asking the child to describe the touching may cause more psychologic trauma; the nurse should listen and demonstrate concern. B The nurse does not need any more data to have a reasonable suspicion of child abuse. It must be reported. C Contacting the father may result in more abuse or in the child not reporting future abuse.
A client who is an alcoholic is brought to the hospital by his family because he has begun to exhibit signs of confusion and mental deterioration. After a physical examination, the health care provider determines that the client has Korsakoff syndrome. On the basis of this finding, what does the nurse expect the health care provider to prescribe? a) Ginkgo biloba b) A muscle relaxer c) Antiviral medication d) Thiamine (vitamin B1)
d) Thiamine (vitamin B1) RATIONALE: Korsakoff syndrome, a secondary dementia caused by thiamine (vitamin B1) deficiency, is associated with prolonged heavy ingestion of alcohol. Along with progressive mental deterioration, Korsakoff syndrome is marked by peripheral neuropathy, cerebellar ataxia, confabulation, and myopathy. Ginkgo biloga, a muscle relaxer, and antiviral medications are not used to treat Korsakoff syndrome. Although ginkgo biloba has been used to improve cognitive function in some clients, it should be used with caution in clients who consume alcohol.
The nurse, monitoring Carl closely for early signs of alcohol withdrawal, understands that these early signs begin: within which time frame? a) 3 days after the cessation of alcohol intake b) 48 hours after the cessation of alcohol intake c) 72 hours after the cessation of alcohol intake d) Within a few hours of the cessation of alcohol intake
d) Within a few hours of the cessation of alcohol intake RATIONALE: The early signs of alcohol withdrawal develop within a few hours after the client stops drinking or reduces alcohol intake. These signs peak after 24 to 48 hours and then rapidly disappear unless the withdrawal progresses to alcohol-withdrawal delirium.
