Psych Ch 7,8,10
A 17-year-old patient confides to the nurse that they have been thinking of ways to kill a peer. What response should the nurse give when the patient states, "you have to keep it a secret because its confidential information"?
"Issues of this kind have to be shared with the treatment team and your parents." Although adolescent patients request confidentiality, issues of sexual abuse, threats of suicide or homicide, or issues that put the patient at risk for harm must be shared with the treatment team and the parents.
Select the most critical question for the nurse to ask an adolescent who has threatened to take an overdose of pills.
"Do you have access to medications?"
Which statement shows a nurse has empathy for a patient who made a suicide attempt?
"You must have been very upset when you tried to hurt yourself."
A client tells the nurse, "I really feel close to you. You are like the friend I never had." The nurse can assess this statement as indicating the client may be experiencing which unconscious emotion?
Positive transference
What is the physiologic basis for the success of guided imagery?
β-Endorphin release raises the pain threshold.
Which response should the nurse provide a client who asks, "Why you need to conduct an assessment interview"?
"We will be able to form a relationship together where we can discuss the current problems and come up with goals and a plan for treatment." Some of the purposes of the assessment interview are to establish rapport, learn more about the presenting issues, and form mutual goals and a plan for treatment.
The nurse is conducting an admission interview with a client who was raped 2 weeks ago. When asked about the rape, the client becomes very anxious and upset and begins to sob. What should be the nurse's response to the client's reaction?
Acknowledge that the topic of the rape is upsetting and reassure the client that it can be discussed at another time when she feels more comfortable.
A nurse is about to interview an older client whose glasses and hearing aid were placed in the bedside drawer for safe keeping. Before beginning the interview, which nursing intervention that will best facilitate data collection?
Assist the client in putting on glasses and hearing aid.
A novice nurse tells a mentor, "I want to convey to my patients that I am interested in them and that I want to listen to what they have to say." Which behaviors will be helpful in meeting the nurse's goal? Select all that apply.
Assuming an open body posture and sometimes mirror imaging Using facial expressions to convey interest and encouragement Introducing self to a patient and identifying own role
The nurse is finding it difficult to provide structure and set limits for a client. The nurse should self-evaluate for which characteristic of a dysfunctional nurse-patient relationship?
Boundary blurring
A nurse interviews a patient abducted and raped at gunpoint by an unknown assailant. The patient says, "I can't talk about it. Nothing happened. I have to forget." What is the patient's present coping strategy?
Denial
A patient has a history of impulsively acting out anger by striking others. Select the most appropriate intervention for avoiding similar incidents.
Help the patient identify incidents that trigger impulsive anger.
What would a client experience during a progressive relaxation session?
Instruction in sequential tensing and relaxing of various muscle groups until the entire body is relaxed
What tool should the nurse use in assessing the amount of stress a client has experienced in the past year?
Life-Changing Event Questionnaire
Which entry in the medical record best meets the requirement for problem-oriented charting?
S: States, 'I feel like I'm ready to blow up.' O: Pacing hall, mumbling to self. A: Auditory hallucinations. P: Offer haloperidol (Haldol) 2 mg po. I: Haloperidol (Haldol) 2 mg po given at 0900. E: Returned to lounge at 0930 and quietly watched TV."
Self-help groups are useful for reducing stress because they provide the individual with the stress mediator that take what form?
Social support Self-help groups often provide a high level of social support. Members meet and are encouraged and sustained by others who share the same problem. None of the other options are expected to be provided by the self-help group format.
A 43-year-old client being seen in the mental health clinic states, "I have always been a practicing Jew, but in the past few months I am questioning everything. I just don't know if I believe in it anymore." Which of the following nursing diagnoses best describes the client's comment?
Spiritual distress The client is expressing distress regarding his religion and spiritual well-being.
Which rationale best explains why a nurse should be aware of personal feelings while working with a family experiencing family violence?
Strong negative feelings interfere with assessment and judgment.
What factor exerts the greatest influence on the degree to which various life events upset a specific individual?
The individual's perception of the event
