NSG382 Lippencott Practice
A severely dehydrated adolescent admitted to the hospital with hypotension and tachycardia undergoes evaluation for electrolyte disturbances. The client's history includes anorexia nervosa and a 20-lb (9.1-kg) weight loss in the past month. The client is 5′ 7″ (1.7 m) tall and weighs 80 lb (36.3 kg). Which nursing intervention takes highest priority? initiating caloric and nutritional therapy as ordered instituting behavioral modification therapy as ordered addressing the client's low self-esteem monitoring vital signs and weight regularly
A client with anorexia nervosa is at risk for death from self-starvation. Therefore, initiating caloric and nutritional therapy takes highest priority. Behavioral modification (in which client privileges depend on weight gain) and psychotherapy (which addresses the client's low self-esteem, guilt, anxiety, and feelings of hopelessness and depression) are important aspects of care but are secondary to stabilizing the client's physical condition. Monitoring vital signs and weight is important in evaluating nutritional therapy but doesn't take precedence over providing adequate caloric intake to ensure survival.
The nurse meets with a client in the outpatient clinic who is suicidal and refuses to participate in creating a suicide safety plan. What action should the nurse take next? Arrange for the client to be sent back to the group home. Refer the client to a partial program until the client is no longer suicidal. Arrange for immediate hospitalization on a locked unit. Arrange for admission to a subacute unit for 2 weeks.
A suicide safety plan is a written set of instructions to follow if a client begins to have self-harm thoughts. Plans are written by the client and care team when the risk for suicide is not considered high enough to warrant hospitalization. The nurse should arrange for immediate hospitalization on a psychiatric intensive care unit when the suicidal client refuses to help develop a safety plan. A psychiatric intensive care unit or locked unit is the appropriate setting and least restrictive environment to provide safety for a high-risk client. When clients are treated in an outpatient area, procedures must be in place for swift admission to an inpatient area that has a locked unit. The group home, a partial program, or a subacute unit would not provide the maximum safety that the client needs.
During the mental status examination, a client may be asked to explain such proverbs as "Don't cry over spilled milk." What type of thinking is being tested with this evaluaton? rational concrete abstract tangential
Abstract thinking is the ability to conceptualize and interpret meaning. It's a higher level of intellectual functioning than concrete thinking, in which the client explains the proverb by its literal meaning. Rational thinking involves the ability to think logically, make judgments, and be goal-directed. Tangential thinking is scattered, non-goal-directed, and hard to follow. Clients with such conditions as organic brain disease and schizophrenia typically can't conceptualize and comprehend abstract meaning. They interpret such statements as "Don't cry over spilled milk" in a literal sense, such as "Even if you spill your milk, you shouldn't cry about it."
A nurse is admitting a client with barbiturate use disorder. Which drug is most likely to increase the client's depression? methylphenidate cocaine amitriptyline hydrochloride amphetamine
Additive effects occur with concomitant use of CNS depressants, antihistamines, antidepressants, and antipsychotics. Amitriptyline is an antidepressant. Methylphenidate, cocaine, and amphetamine are classified as stimulants.
A client has been involuntarily committed to a hospital after being assessed as being dangerous to self or others. The client has lost which right? the right to refuse medications and treatments the right to send and receive uncensored mail freedom from seclusion and restraints the right to leave the hospital against medical advice
An involuntarily admitted client loses the right to leave the hospital until the condition is stable enough that the client no longer poses a danger to self or others. While hospitalized, the client retains all civil rights such as receiving mail, making phone calls, refusing treatment, and also receiving the least restrictive treatment. If the involuntarily admitted client refuses treatment once admitted, the client will be evaluated for the need to receive treatment against their wishes to decrease the risk for self-harm or harm to others.
A client is using biofeedback to manage pain. The nurse can explain to the client that biofeedback will enable the client to exert control over physiologic processes by which mechanism? regulating the body processes through electrical control shocking the client when an undesirable response is elicited monitoring the body processes for the therapist to interpret translating the signals of body processes into observable forms
Biofeedback translates body processes into observable signs so that the client can develop some control over certain body processes. Biofeedback does not involve electrical stimulation. The use of unpleasant stimuli such as electrical shock is a form of aversion therapy. Biofeedback does not involve monitoring body processes for the therapist to interpret; rather, it is a self-directed, self-care activity that reinforces learning because the client can see the results of their actions.
A 5-year-old child exhibits signs of extreme restlessness, short attention span, and impulsiveness. Which intervention by the nurse would be therapeutic for this child? Increase the child's sensory stimulation. Limit the child's opportunities to verbalize anger and frustration. Define behaviors that are acceptable and behaviors that are not permitted. Restrict the child's participation in physical activities.
Children need to know what behaviors are acceptable and what behaviors are unacceptable. They feel more secure when limits are clear and when policies concerning their behavior are consistently enforced. Increasing sensory stimulation tends to increase hyperactive and impulsive behavior. Limiting opportunities to verbalize anger and frustration tends to increase stress and frustration for the child. Physical activities are needed to help the child expend energy, reduce anxiety, and increase self-worth.
A nurse is caring for a client with schizoaffective disorder. The client is scheduled for the first round of electroconvulsive therapy (ECT). What is the priority nursing action post-ECT? withholding food and fluids for 12 hours maintaining bed rest for 8 hours performing a respiratory assessment assessing the client's skin for burns
ECT is used to reduce the severity of psychiatric symptoms by delivering an electrical stimulus to a client's brain. Prior to ECT, the client is given sedative medications. Priority assessments post-ECT should focus on airway, breathing, and circulation. The client may eat, drink, and get out of bed as soon as the client feels comfortable and vital signs (including level of consciousness) are within normal limits. Assessing the client's skin for burns is an appropriate nursing action; however, assessing breathing is the priority.
The nurse is caring for a client who has been a victim of intimate partner violence. Which statement by the nurse expresses empathy for this client? "Our staff will do the best they can to make you feel comfortable." "Do you have questions about what is happening?" "I am so sad to see you going through so much pain." "It must be difficult what you have been going through."
Empathy is a person's ability to understand what another person is going through and be objective at the same time. The nurse does not carry those feelings or that situation with them as in sympathy but is still able to relate to the person well. "It must be difficult what you have been going through" is such an example. It gives the client an opening to express any feelings regarding the abuse. "Our staff will do the best they can to make you feel comfortable" is a stereotypical response that does not empathize with the client. "Do you have questions about what is happening?" is a closed question and also a stereotypical question that nurses often ask when no other statement is known to them. "I am so sad to see you going through so much pain" is an example of a sympathetic response because the nurse is showing feelings of sadness over the client's situation.
A nurse is caring for a client diagnosed with body dysmorphic disorder. When the client verbalizes disapproval of the client's own physical features, the nurse should: encourage the client to talk about fears and stressful life situations. agree with the client's opinion that one of the client's physical features is awful. ignore the client's comment and talk about less-threatening issues. compliment the client's appearance.
Encouraging the client to discuss stressful life situations helps the client focus on the underlying issues. The client's preoccupation with a specific physical feature is a means of not coping with life. Ignoring the client doesn't address the underlying issue. Complimenting the client won't be helpful because the client won't be able to accept the compliment. Agreeing with the client reinforces the problem.
A client on the unit was placed in restraints because they became violent and threatened the safety of the staff and other clients on the unit. Attempts to de-escalate the client situation were ineffective. An emergency order was received for the use of restraints. The restraints were applied at 1805. A nurse assigned to provide care is monitoring the client closely and reporting to the health care provider that the client continues to demonstrate violent and threatening behavior. Based on the current guidelines for restraint use, the nurse would ensure that the health care provider renews the order for this restraint by no later than which time? 1930 2120 2205 2400
If a client has been restrained because of violent or self-destructive behavior that jeopardizes the client's physical safety or the safety of staff or others, the order for use of the restraint is valid for 4 hours and then must be renewed based on current guidelines. For this client, for whom the restraints were applied at 1805 and because the violent behavior continues, the order would need to be renewed by 2205. In addition, the health care provider, clinical psychologist, or other licensed independent practitioner responsible for the client's care must conduct an in-person evaluation within 1 hour of the initiation of restraint or seclusion.
The nurse is planning care for a client after being admitted in the emergency room for intimate partner violence. What would be the best action for the nurse? Teach client problem-solving techniques and structured activities. Use an insight-oriented analytic approach in the education. Send medication home to sedate the client. Use nondirective communication techniques, such as free association.
Individuals in crisis need immediate assistance. They are unable to solve problems and need structure and assistance in accessing resources. Clients in crisis do not need lengthy explanations or have time to develop insight on their own. Although clients in crisis might need medication, in most cases, support and direction can be most helpful. Free association like Freud's approach or Beck's thought and feelings approach are too complicated for the client to understand in their state of anxiety.
A client's coping has become dysfunctional enough to require admission to the hospital. The nurse expects that the client would be exhibiting what behaviors? objective and rational problem solving tension-reduction activities and then problem-solving anger management strategies with no problem-solving minimal functioning with new problems developing
Minimal functioning, which can cause new problems to develop, is a reflection of dysfunctional coping. The ability to objectively and rationally solve problems demonstrates adaptive coping. Tension-reduction activities demonstrate palliative coping. However, such activities alone do not solve problems; they must be followed by problem-solving. Anger management alone may prevent new problems, such as violence toward oneself or others, but it does not solve problems directly. It is considered maladaptive coping.
An adolescent is brought to the hospital emergency department in a state of unconsciousness after having swallowed "a bottle of pain pills" 45 minutes earlier. The pills are identified as oxycodone. A suicide note is found that asks for forgiveness. Which measure should the nurse be prepared to carry out when this client is admitted? forcing fluids giving a diuretic inducing vomiting giving naloxone IV
Naloxone is an opioid antagonist used as an antidote for opioid overdose.Forcing fluids is inappropriate because the client is unconscious.Giving a diuretic will not help eliminate the oxycodone.In an unconscious client, inducing vomiting is inappropriate.
A client who's taking antipsychotic medication develops a very high temperature, severe muscle rigidity, tachycardia, and rapid deterioration in mental status. What complication of antipsychotic therapy does the nurse suspect? agranulocytosis extrapyramidal effects anticholinergic effects neuroleptic malignant syndrome
Neuroleptic malignant syndrome is a rare but potentially fatal effect of antipsychotic medication. This condition generally begins with an elevated temperature and severe extrapyramidal effects. Agranulocytosis is a blood disorder. Symptoms of extrapyramidal effects include tremors, restlessness, muscle spasms, and pseudoparkinsonism. Anticholinergic effects include blurred vision, drowsiness, and dry mouth.
A client is admitted to a mental health unit with a diagnosis of depression and is participating in group sessions. The client asks a nurse if they are married or in a romantic relationship. What is the best response by the nurse to maintain a therapeutic relationship? "Group therapy is not the appropriate time to discuss my relationships." "It sounds as though you are interested in developing a relationship with me." "Tell me how you knew that I was not married or in a romantic relationship." "I'm curious about your question but I want to know how you are feeling today."
Nurses must practice in a manner that is consistent with providing safe, competent, and ethical care. If the nurse shared personal information with the client, the nurse would have crossed the boundary of a therapeutic relationship and changed the focus of the discussion from a client focus to a social focus. It is very important in all areas of care, but especially in the mental health setting, that the relationship between the nurse and the client has very clear boundaries and is client focused. The other options are incorrect because they do not follow the principles of a therapeutic nurse-client relationship.
A client is admitted to the psychiatric unit following a suicide attempt. The client experienced identity theft through the internet and states, "My savings, checking, and retirement accounts are empty. I have nothing left to pay my bills or buy food and medicines. The only thing left is to die." After 1 week, the nurse would conclude that the client's condition has improved upon hearing which statement(s)? Select all that apply. "I realize that I still can get monthly public assistance benefits." "I filed identity theft claims with the bank, my retirement account, and the government authorities." "I know all the actions I can take, but they take so much time and energy. I'm so tired." "With all the help I got here, I think I may be able to survive after all." "The staff has given me a lot of options, but I'm not sure they are even possible."
"I realize that I still can get monthly public assistance benefits." "I filed identity theft claims with the bank, my retirement account, and the government authorities." "With all the help I got here, I think I may be able to survive after all." Realizing financial resources and benefits will continue gives hope and decreases the risk for future suicide. Filing the claim forms may help regain some of the losses and shows the client is looking to the future. Lacking energy and motivation will inhibit taking positive actions and demonstrates the client has not been sufficiently helped as yet. Positive statements about survival also suggest the client has a new perspective. Not believing in the solutions will inhibit taking positive actions and demonstrates the client has not been sufficiently helped as yet.
The nurse is explaining the concept of poor personal boundaries to a client. Which statement by the client requires priority action by the nurse? "I understand that poor boundaries are unhealthy for me." "I understand that I should not share too much information with others." "I know that I should not try to control others." "I know that it is okay to expect others to fulfill my needs."
"I understand that poor boundaries are unhealthy for me." A person who has poor personal boundaries has difficulty discerning between self and others. Sometimes one becomes enmeshed in a relationship. The described behaviors indicate poor personal boundaries. The others indicate that the client has learned some aspects of a healthy relationship.
An experienced nurse is precepting a new nurse in a psychiatric emergency room and is discussing criteria for involuntary commitment. Which client would signal to the experienced nurse that the new nurse understands the criteria? the parent who leaves their minor children unattended and stays out all night snorting cocaine a client with schizophrenia who can manage activities of daily living but has grandiose delusions a person who threatens to kill their spouse of 38 years a person with depression who says they are tired of living and does not have a suicidal plan
One of the criteria for involuntary commitment is an emergency in which the client is a threat to themself or others. A parent might have a child removed from the home because of neglect but that doesn't meet the criteria for involuntary commitment. Many individuals with schizophrenia can learn to live with hallucinations and delusions and don't require hospitalization. To meet criteria for involuntary commitment, a depressed individual must have a suicide plan and be a direct threat to themself.
The nurse is admitting a client with Borderline Personality Disorder. When planning care for this client, the nurse should give priority to which item? safety splitting empathy manipulation
Persons with Borderline Personality Disorder have a variety of difficult characteristics. Their impulsivity leads them to self-mutilation and sudden suicide attempts. This is the correct answer, as safety is always paramount. In splitting the client categorizes people as good or bad and tries to keep the bad from contaminating the good. Such a client may view a staff member as ideal and later devalue that person. Empathy is the nurse's attempt to understand and respond to a client's needs and feelings. In manipulation a person attempts to obtain needs in unacceptable ways.
A nurse overhears a second nurse making plans to meet a hospitalized client for a drink after the client has been discharged. Which is the best action for the first nurse to take? Tell the client not to meet the nurse socially. Report the conversation to the nurse manager. Encourage the interaction with the client after discharge. Discuss the conversation directly with the other nurse.
Planning to meet a client for a social event while the client is still hospitalized could blur the boundaries of the therapeutic relationship. This could result in an unhealthy outcome for the client. The nurse should take the second nurse aside and point out that the behavior is inappropriate and not in the client's best interest. The other options do not demonstrate behavior that is consistent with the therapeutic nurse-client relationship.
An emergency department nurse is conducting an assessment interview with an older adult client. The client states, "I was so frightened when I fell while crossing the street." Which statement would be the best response? "That must have been frightening for you." "Why were you afraid on the street?" "Were you afraid because you were alone?" "You will feel less frightened tomorrow."
"That must have been frightening for you" acknowledges the client's experiences and is an empathetic response. "Why were you afraid on the street?" is asking a clarifying question but does not offer an empathetic response to the client. The statement, "Were you afraid because you were alone?" is a closed-ended question and therefore nontherapeutic. Finally, stating that the client will feel less frightened tomorrow is false assurance.
The nurse is planning an education for new nurses on psychiatric units. Which topic should be given priority? assault battery neglect breach of confidentiality
Psychiatric nurses know well the problem of stigma for those with a mental illness. The Code of Ethics for Nurses ensures the alleviation of stigma and discrimination toward those with mental illness. In the United States, RNs also know the importance of protecting a client's personal health information. In the United States, HIPAA (Health Insurance Portability and Accountability Act) requires health care workers to protect and keep private health information of clients and outlines penalties for any violations. Mental health and substance use disorder records are even more protective. Breach of confidentiality then, occurs when a nurse shares this information with another without the client's consent. Assault is an act that results in fear that one will be touched without consent. Battery involves nonconsensual touching of another person. Neglect is the failure to do what is deemed reasonable in a situation.
What is a generally accepted criterion of mental health? absence of anxiety self-acceptance ability to control others happiness
Self-acceptance is a generally accepted criterion of mental health and serves as the basis for healthy relationships with others. Some degree of anxiety is necessary to stimulate growth and adaptation. Self-control and self-direction — not the ability to control others — indicate mental health. Happiness, though desirable, isn't an effective indicator of mental health because even mentally healthy people may be unhappy when faced with such events as illness, loss, and death.
The most effective way for a nurse to set limits for a newly admitted client who puts out cigarettes on the floor of the designated smoking room is to: restrict the client's smoking to times when a staff member can supervise closely. encourage other clients to speak with this client about dirtying the floor. ask if the client puts out cigarettes on the floor at home. hand the client an ashtray and state that the client must use it or the client will not be allowed to smoke.
Setting limits is necessary to help clients behave in socially acceptable ways. By handing the client an ashtray and stating objectively that the client won't be allowed to smoke if the client doesn't use the ashtray, the nurse is setting limits on the client's behavior. Because this client is newly admitted, the nurse may need to restate these limits in a manner that shows disapproval of the behavior but doesn't reject the client as a person. A matter-of-fact, nonpunitive tone of voice is important. The nurse must stress that noncompliance will have consequences - in this case, a prohibition against smoking. The nurse can't bend the rules to accommodate the client. Encouraging other clients to deal with a new client isn't advisable. Asking if the client puts out cigarettes on the floor at home has no bearing on whether this behavior is acceptable in the hospital.
The nurse documents the initial care of a client who the nurse suspects is a victim of intimate partner violence. Which information would be most helpful for others to know when caring for the client? "States that they are not employed outside the home." "Seems fearful to discuss how bruises on their body were caused." "Asks that their spouse not be called at work, stating that the spouse is very busy." "Refuses a follow-up appointment, stating that they do not have time."
Stating that a client seems fearful to discuss what caused the bruises on their body is most helpful. A client being impacted by intimate partner violence (IPV) tends to conceal their situation because disclosure could be met with denial; minimization by their partner, friends, and relatives; and increased IPV by their partner. Documenting that the client is not employed outside the home does not help others caring for the client in relation to the needs of a person experiencing IPV Documenting that the client asks that their spouse not be called because they are very busy is important but not as important as the client's fear of disclosing the cause of the bruises. Documenting the client's refusal to follow up with their statement about not having time is less important than the client's fear of disclosing the cause of the bruises.
A client on the psychiatric-mental health unit has been deemed to be a high elopement risk. What is the nurse's most appropriate response? Ensure frequent and systematic supervision of the client. Advocate for the health care provider to prescribe temporary use of restraints. Ensure the client's room remains locked to protect the client's safety. Move the client's bed to a highly visible location such as a hallway.
Supervision is key to the prevention of elopement in high-risk clients. Elopement risk is not a valid reason for restraint use. Locking a client's room is a form of restraint. Supervision should take place without having to relocate the client to a public location, where privacy cannot be ensured.
A client's adult child says that their parent wore the same dirty, worn-out undergarments for 2 weeks. What should the nurse do to prevent further regression in the client's personal hygiene habits while they are in the hospital? Accept the client's need to go without bathing if they so desire. Make the client assume responsibility for their own physical care. Encourage the client to do as much self-care as they can. Do most of the client's physical care while letting them think they did it themself.
The best procedure for helping the client to remain independent and observe good hygiene habits is to encourage them to do as much self-care as they are capable of doing. For this client, it would be inappropriate to accept their poor personal hygiene habits. It would be impractical and unrealistic to expect the client to start taking care of all their hygiene needs. To do all of the client's hygienic care would cause further dependence, and it would be dishonest to care for the client while letting the client think they did it themself.
A client tells the nurse at the outpatient clinic that they do not need to attend groups because they are "not a regular like these other people here." How should the nurse respond to the client? "Because you're not a regular client, sit in the hall when the others are in group." "Your family wants you to attend, and they'll be very disappointed if you don't." "I'll have to mark you absent from the clinic today and speak to the health care provider about it." "You say you're not a regular here, but you're experiencing what others are experiencing."
The best response is "You say you're not a regular here, but you're experiencing what others are experiencing." This statement helps the client to identify factors that precipitate denial by helping them confront that which inhibits compliance. Denial is used to help a client feel better and more secure when a situation provokes a high level of anxiety and is threatening to the client. The statement "Because you are not a regular client, sit in the hall when the others are in group" agrees with and promotes denial in the client and interferes with treatment. The statement "Your family wants you to attend and they will be disappointed if you do not" causes the client to feel guilty and decreases their self-esteem. The statement "I'll have to mark you absent from the clinic today and speak to the health care provider about it" is punitive and threatening to the client, subsequently decreasing their self-esteem.
A 6-year-old child is brought to the walk-in clinic in their neighborhood for onset of symptoms of a urinary tract infection (UTI). The child is reluctant to give a urine specimen or to remove their clothing. Which one of these reports by the parent requires further investigation? "My child doesn't like going to the doctor." "My child has never had a UTI before." "I think my child drinks an adequate fluid intake throughout the day." "My child slept over at my friend's last night while I worked the night shift."
The child's symptoms of a UTI and their reluctance to undress and give a urine sample could be normal for the child's age, but the nurse needs to follow up with suspicion of sexual abuse due to the parent's statement about staying with their friend the night before. The child staying at their friend's house could make the child vulnerable to abuse, and the nurse must follow up with assessment of the child. The other responses would not signal to the nurse that there are potential issues associated with the symptoms of a UTI.
A client who is suspicious of others, including staff, is brought to the hospital wearing a wrinkled dress with stains on the front. The assessment also reveals a flat affect, confusion, and slow movements. Which goal should the nurse identify as the initial priority when planning this client's care? helping the client feel safe and accepted introducing the client to other clients giving the client information about the program providing the client with clean, comfortable clothes
The initial priority for this client is to help them overcome their suspiciousness of others, including staff, and thereby feel safe and accepted. Introducing the client to others, giving the client information about the program, and providing clean clothes are important, but these are of lower priority than helping the client feel safe and accepted.
A client diagnosed with antisocial personality disorder asks the nurse for an additional smoke break because of anxiety. Which response by the nurse is best? "I have a few minutes. I'll take you." "I'm sorry but I can't take you. I'm busy." "Smoking is harmful to your health. I don't want to contribute to your bad habits." "Clients are permitted to smoke at designated times. You have to follow the rules."
"Clients are permitted to smoke at designated times. You have to follow the rules." Consistency is essential when dealing with antisocial clients. They disregard social norms and don't believe the rules apply to them. Agreeing to give the client a smoke break would be detrimental to the client because it reinforces the client's acting-out behaviors. Saying the nurse is too busy avoids the client's attempt to manipulate. Telling the client that an extra smoke break is not allowed because smoking is harmful is inappropriate because the nurse is lecturing the client.
A client with a self-inflicted gunshot wound in their arm is brought to the inpatient psychiatric unit from the emergency department. With their arm bandaged and in a sling, the client is escorted to the unit by emergency department staff. A staff member states to the nurse, "They only hurt their arm, so they probably did it for attention." Which response by the nurse to the staff member would be most appropriate? "All suicide attempts or acts of self-harm are very serious and indicate a cry for help." "They really must not have wanted to kill themself, but they certainly injured their arm." "You seem to have some strong feelings about suicide attempts. Do you want to tell me about them?" "It was probably a way to escape a serious problem. The hospital is a safe and secure environment."
The nurse must always consider all suicide attempts as very serious. Even though the attempt may result in minimal injury, it is still a cry for help and an extremely dysfunctional method of coping. Discounting the injury minimizes the client's pain and disregards their intent. At some point, a deeper conversation may be warranted, but the priority at this point is caring for the client rather than engaging in what could be a lengthy conversation about the staff member's attitudes. To think of suicide as a way to escape a serious problem or a means to gain attention is irresponsible and leads to unsafe nursing practices such as ignoring warning signs of suicide attempts.
A client who is dying from AIDS is admitted to the inpatient psychiatric unit because they attempted suicide. Their close friend recently died from AIDS. The client states to the nurse, "What's the use of living? My time's running out." What is the nurse's best response? "Let's talk about making some good use of that time." "Don't give up. There could be a cure for AIDS tomorrow." "You're in a lot of pain. What are you feeling?" "Life is precious and worth living."
The nurse recognizes the client's pain, hopelessness, and sense of loss related to their condition and the loss of their friend and encourages them to express their feelings. Giving the client permission to talk about their feelings of sadness, loss, and hopelessness and listening to them is an important nursing intervention for the dying client. Telling the client to make good use of their remaining time diverts attention from the content of the client's statements and blocks expression of feelings. "Don't give up" is a type of pep talk that ignores the client's feelings. Saying that life is precious and worth living ignores the client's needs and inhibits their expression of feelings.
Following the failure of noninvasive interventions and de-escalation strategies, restraints have been prescribed for an aggressive client. When positioning the client, the nurse should prioritize which action? Maintain the head of the bed between 10 and 20 degrees. Ensure the client is secured and not able to shift their weight from side to side. Elevate the head of the bed unless contraindicated. Ensure the client's hand cannot touch their torso.
The nurse should keep the head of the bed elevated (more than 20 degrees), unless contraindicated, to prevent aspiration and other respiratory complications. There are no significant risks posed by the client being able to touch their torso or shift their weight.
A client who was raped in their home was brought to the emergency department by their spouse. After being interviewed by the police, the spouse talks to the nurse. "I don't know why my spouse didn't keep the doors locked like I said. I can't believe my spouse had sex with another person now." How should the nurse respond? "Let's talk about how you feel. Maybe it would help to talk to other people who have been through this." "Maybe the doors were locked, but the rapist broke in anyway." "Your spouse needs your support right now, not your criticism." "It wasn't consensual sex. Let's see if your spouse was physically injured."
The nurse should respond to the spouse's needs and concerns and should offer support. Protecting or defending the client against criticism ignores the spouse's needs.
The nurse manager on a psychiatric unit is reviewing the outcomes of staff participation in an aggression management program. What indicator would the nurse use to evaluate the effectiveness of such a program? fewer client injuries during restraint procedures a reduction of reports by clients' relatives fewer staff injuries during restraint procedures a reduction in the total number of restraint procedures
The primary goal of an aggression management program is to prevent violence. This goal is evidenced by a reduction in the total number of restraint procedures used or needed. Although fewer client and staff injuries are important, these goals are secondary to prevention. Reduction in the number of reports by clients' relatives is affected by more variables than just restraint procedures.
Which action demonstrates the role of the psychiatric nurse in primary prevention? handling crisis intervention in an outpatient setting visiting a client's home to discuss medication management conducting a postdischarge support group providing sexual education classes for adolescents
The psychiatric nurse participates in primary, secondary, and tertiary prevention activities. Primary prevention includes education programs that promote mental health and prevent future psychiatric episodes such as sexual education classes for adolescents. Secondary prevention involves treatment to reduce psychiatric problems (for example, handling crisis intervention in an outpatient setting, administering and supervising medication regimens, and participating in the therapeutic milieu). Tertiary prevention involves helping clients who are recovering from psychiatric illness; activities directed toward providing aftercare and rehabilitation are part of this role. Conducting a postdischarge support group is a tertiary prevention activity.
The nurse is teaching a group of unlicensed assistive personnel (UAP) new to psychiatry about balance in a therapeutic milieu. Which statement by a UAP indicates the need for further teaching? "Balance includes safe and effective treatment for all clients." "Controlling clients helps them feel more comfortable." "We don't fix clients, but we help them solve their problems." "We need to think of clients' rights as we provide care."
The statement, "Controlling clients helps them feel more comfortable," does not reflect an understanding of the concept of balance in a therapeutic milieu. Balance is the careful negotiation of the conflict between dependency and independency in a therapeutic milieu. Clients are dependent when admitted to care but are allowed and encouraged to become independent as they are able to assume responsibility for themself. Staff may find it easier to care for the client when they can control the client and may feel needed when the client is dependent on them. In a therapeutic milieu, staff do not solve the clients' problems for them. Rather, they work with the clients to gradually allow independent behaviors and decision-making. Understanding clients' rights, legal issues, and ethical concerns is crucial for the skilled use of balance.
While working with a client in the day room, a nurse notes that the client is becoming increasingly agitated. The client begins pacing around the room, hitting the wall with their fist and then knocking over a chair. Which action by the nurse would be appropriate? Tell the client to calm down or security will be called. Grab the client by the arm, and sit them down in a chair. Provide the client with clear and simple concrete choices. Forcefully tell the client that the nurse and staff are the ones in charge.
To de-escalate a potentially volatile situation, it is crucial to protect the safety of the client, staff, and visitors. It would be appropriate for the nurse to set limits with the client that are clear, simple, and enforceable because the client may not be able to focus on everything being said. The client should be offered respectful, concise choices and consequences. The nurse should respect the client's personal space by standing 1½ to 3 ft (46 to 91.5 cm) away from the escalating client, not physically handling them, and using nonthreatening communication. If the client continues to act out, the nurse should follow facility policy about notifying security.
