psychosocial integrity 3
When working with clients in crisis, the nurse must be aware that crisis intervention differs from other forms of therapeutic intervention in that crisis intervention focuses on which concern(s)?
Correct response: Determining immediate problems, as perceived by the client, with the short-term goal of problem solving Explanation: Focusing on the immediate problem and short-term goals to solve that problem are the priorities of the nurse dealing with crisis intervention work. Delving into the complete history is not the priority because it takes time away from resolving the immediate crisis. The client's role in the problem is not the goal of this sort of intervention, but rather of longer term therapy that would hopefully prevent future crises. This is also true for assisting the client to identify what sort of patterns exist in his/her problems.
Which would be most helpful when coaching a client to stop smoking? Review the negative effects of smoking on the body. Discuss the effects of passive smoking on environmental pollution. Establish the client's daily smoking pattern. Explain how smoking worsens high blood pressure.
Correct response: Establish the client's daily smoking pattern. Explanation: A plan to reduce or stop smoking begins with establishing the client's personal daily smoking pattern and activities associated with smoking. It is important that the client understands the associated health and environmental risks, but this knowledge has not been shown to help clients change their smoking behavior.
A client expresses to the nurse that he cannot get the mental support he needs to prepare himself to undergo treatment for leukemia. Which nursing diagnosis is most appropriate for the client? Spiritual distress Ineffective coping Disturbed body image Anxiety
Spiritual distress Explanation: The appropriate nursing diagnosis is spiritual distress. The client expresses concern that he does not have inner or psychological strength, which indicates a need for spiritual support to regain faith and strength. The client does not exhibit any abnormal behavior; therefore, ineffective coping is not the best diagnosis. Disturbed body image is also not suitable, because there is no mention of concern over appearance. Anxiety is always related to something unknown.
A nurse notices that a depressed client who has been taking amitriptyline hydrochloride for 2 weeks has become very outgoing, cheerful, and talkative. The nurse suspects that the client: is responding appropriately to the antipsychotic. may be experiencing increased energy and is at increased risk for suicide. is ready to be discharged from treatment. is experiencing a split personality.
Correct response: may be experiencing increased energy and is at increased risk for suicide. Explanation: As antidepressants take effect, an individual suffering from depression may begin to feel energetic enough to mobilize a suicide plan. Amitriptyline is an antidepressant, not an antipsychotic. The client shouldn't be discharged until his risk of suicide has diminished. His elevated mood is a response to the antidepressant, not an indication of a split personality.
A nurse is assessing a client suffering from stress and anxiety. The most common physiologic response to stress and anxiety is: sedation. diarrhea. vertigo. urticaria.
diarrhea
For a client with newly diagnosed cancer, the nurse formulates a nursing diagnosis of Anxiety related to the threat of death secondary to cancer diagnosis. Which expected outcome is appropriate for this client? "Client verbalizes feelings of anxiety." "Client doesn't guess at prognosis." "Client uses any effective method to reduce tension." "Client stops seeking information."
"Client verbalizes feelings of anxiety." Explanation: Verbalizing feelings is the client's first step in coping with the situational crisis. It also helps the health care team gain insight into the client's feelings, helping guide psychosocial care. An outcome in which the client doesn't guess at the prognosis is inappropriate because suppressing speculation may prevent the client from coming to terms with the crisis and planning accordingly. An outcome in which the client uses any effective method to reduce tension is undesirable because some methods of reducing tension, such as illicit drug or alcohol use, may prevent the client from coming to terms with the threat of death as well as cause physiologic harm. An outcome in which the client stops seeking information isn't appropriate because seeking information can help a client with cancer gain a sense of control over the crisis.
The nurse is assessing a 17-year-old client with a seizure disorder. A recent electroencephalograph monitoring showed seizure activity after the client stopped taking antiepileptic medication. Driving privileges were suspended for 6 months. The parents express concern because the teen has withdrawn from friends, shows difficulty completing school work, and spends increased time sleeping. Which of the following is the nurse's best response? "These behaviors are a normal part of adolescent growth and development." "Further evaluation is needed for a mood disorder." "Establish firm behavioral guidelines for the adolescent." "Has there been any talk about self-harm?"
"Further evaluation is needed for a mood disorder." Explanation: Adolescence is a time when clients may spend more time sleeping and when changes in mood occur. Abnormal changes include withdrawal from friends and favorite activities and difficulty completing tasks. The client should be evaluated for a mood disorder, such as situational depression.
The client with a diagnosis of schizophrenia is acutely psychotic and exhibits religious delusions and hallucinations, loose associations, and concrete thinking. When the nurse offers the client her medication, the client states, "I do not need that. God will heal me." The nurse should respond to the client by saying: "God helps those who help themselves." "God wants you to take your medicine." "God is important in your life, but the medicine will help you too." "This medicine will help clear your thoughts and decrease anxiety."
"God is important in your life, but the medicine will help you too." Explanation: Stating that God is important in the client's life recognizes the client's cognitive and perceptual disturbances and level of anxiety and acknowledges the client's message in a respectful and neutral manner, while adding that the medicine also will help, clearly and directly states the need for medication. Stating, "God helps those who help themselves" challenges the client. Stating, "God wants you to take your medicine" is deceitful. Stating, "Medicine will help clear your thinking and decrease anxiety" would be helpful to the client later when she is less acutely psychotic and anxious.
The client who has a history of angry outbursts when frustrated begins to curse at the nurse during an appointment after being informed that she will have to wait to have her medication refilled. Which response by the nurse is most appropriate? "You are being very childish." "I am sorry if you cannot wait." "I will not continue to talk with you if you curse." "Come back tomorrow and your medication will be ready."
"I will not continue to talk with you if you curse." Explanation: Stating, "I will not continue to talk with you if you curse," sets limits on the client's behavior and points out the negative effects of her behavior. Therefore, this response is most appropriate and therapeutic. The statement, "You are being very childish," reprimands the client, possibly causing the anger to escalate. The statement, "I am sorry if you cannot wait," fails to provide feedback to the client about her behavior. The statement, "Come back tomorrow and your medication will be ready," ignores the client's behavior, failing to provide feedback to the client about the behavior. It also shows poor nursing judgment because the client may need her medication before tomorrow or may not return to the clinic the following day.
A client with bleeding esophageal varices and cirrhosis of the liver due to alcoholism asks the nurse, "Will I survive and make it out of the hospital? One of my friends died from the same problem." What is the best nursing response to the question? "You'll be okay after the physician gets the bleeding under control." "That's a difficult question to answer, and this must be very frightening for you." "What makes you think you're not going to make it?" "Chronic alcoholism has serious consequences, and you may have the same outcome as your friend."
"That's a difficult question to answer, and this must be very frightening for you." Explanation: This answer is an honest response that acknowledges the client's fears and concerns, yet does not give false reassurance.
The client exhibits a flat affect, psychomotor retardation, and depressed mood. The nurse attempts to engage the client in an interaction but the client does not respond to the nurse. Which response by the nurse is most appropriate? "I will sit here with you for 15 minutes." "I will come back a little bit later to talk." "I will find someone else for you to talk with." "I will get you something to read."
"I will sit here with you for 15 minutes." Explanation: The most appropriate action is for the nurse to remain with the client even if the client does not engage in conversation with the nurse. A client with severe depression may be unable to engage in an interaction with the nurse because the client feels worthless and lacks the necessary energy to do so. However, the nurse's presence conveys acceptance and caring, thus helping to increase the client's self-worth. Telling the client that the nurse will come back later, stating that the nurse will find someone else for the client to talk with, or telling the client that the nurse will get her something to read conveys to the client that she is not important, reinforcing the client's negative view of herself. Additionally, such statements interfere with the client's development of a sense of security and trust in the nurse.
A clinic client with agoraphobia must go to a local laboratory to have blood drawn. The client is terrified, stating, "I know I can't handle being in the waiting room." What is the nurse's most therapeutic response? "You've come a long way in therapy. I'm sure you'll do just fine." "I'll arrange for you to be the first client and we'll talk about it afterward." "It sounds like you've had bad experiences having your blood drawn." "The procedure takes only a few minutes. Then you can go home."
"I'll arrange for you to be the first client and we'll talk about it afterward." Explanation: Scheduling the client as the first appointment and arranging to talk with him after having his blood drawn is a practical intervention that provides the client with the opportunity to express his feelings afterward. Referring to the client's progress in therapy or to the fact that the procedure doesn't take long discounts the client's feelings and blocks therapeutic communication. Referring to experiences associated with previous blood draws makes an assumption that doesn't address the client's current need for reassurance and security.
A nurse is caring for a 14-year-old adolescent who states, "No one understands me." Which of the following statements by the nurse best demonstrates empathy?
"It is difficult being a teenager. Tell me more." Explanation: Empathy is the ability to put oneself in another's place and experience a feeling as that person is experiencing it. The correct answer acknowledges the child's feelings and conveys an understanding without intimidating the child.
After teaching a group of students who are volunteering for a local crisis hotline, the nurse judges that further education about crisis and intervention is needed when a student makes which statement? "Callers to a crisis line use this service when they are overwhelmed and exhausted." "People use crisis hotlines when they are in the most pain and nothing is working for them." "Most people in crisis will be calling the line once every day for at least a year." "One benefit is that a person will know how to handle stressful situations better in the future."
"Most people in crisis will be calling the line once every day for at least a year." Explanation: The concern that someone may call the crisis hotline every day for a year indicates that further understanding about crisis and crisis intervention is needed. A crisis situation is time-limited, typically resolving in 4 to 6 weeks if handled effectively. If a person calls the line daily for a year, that person has not been properly dealt with or is probably in a highly disorganized state requiring an alternative intervention. The nurse needs to further review and clarify the material presented. Callers are typically in pain, overwhelmed, and exhausted when they call. A crisis can help an individual cope better in the future if he learns to handle the situation.
A nursing student and a charge nurse of a psychiatric unit are discussing the outcomes of clients with depression. Which of the following, if stated by the student, indicates that the student understands depression outcomes? "When an individual has depression, he/she will experience the problem all of their life." "Depression is situational. As long as the cause does not happen again, the depression should never happen again." "There are patterns with this illness. If a person has one depressive episode, he/she has a 60% chance of experiencing another." "All people are at risk of depression. Nine out of 10 people will have depression in their lives."
"There are patterns with this illness. If a person has one depressive episode, he/she has a 60% chance of experiencing another." Explanation: If a person has a depressive episode, there is a 60% chance of a second episode. Factors related to depression include gender, age, socioeconomic status, race, and marital status, but are not necessarily situational. A major depressive disorder can be recurrent and could be chronic, but does not have to be a lifelong issue. Depression can occur in up to 25% of women and up to 12% of men.
A laboring client at 28 weeks gestation is in preterm labor. Her husband gets very agitated with the situation and demands to know why this has happened. Which of the following immediate responses is most appropriate from the nurse? "Your wife seems to be coping just fine. She has managed very well today." "You and your wife have been through a lot with this pregnancy. Let's talk about this further." "You seem really stressed. Do you have any one to talk to about this?" "I know you are upset. However you need to put this in perspective for the sake of your wife and infant."
"You and your wife have been through a lot with this pregnancy. Let's talk about this further." Explanation: This response acknowledges the experience and provides the opportunity for the partner to discuss his feelings further in order to assist him. The other responses will either aggravate the situation or not acknowledge the feelings experienced by the family.
The client with a cognitive disorder tells the nurse, "Everyone is after me. They want to kill me." The nurse should respond: "You are frightened. This is a hospital and these people are staff members. You are safe here." "Why do you think someone wants to kill you?" "Tell me who do you mean when you say 'everyone' wants to kills you." "Do not worry, we will protect you. No one can come here to harm you."
"You are frightened. This is a hospital and these people are staff members. You are safe here." Explanation: The nurse does not argue with the client having delusions. The nurse addresses the client's underlying feeling and presents reality to promote the client's trust, comfort, and sense of reality. Asking why someone wants to kill the client challenges the client and further distances the client from reality. Asking the client to expand who he means by everyone does not help address reality. Indicating that staff will protect the client from others who intend to harm him validates the client's delusion, does not address the client's feeling, and may further confuse the client.
A nurse is coordinating outpatient care for a 38-year-old client who is homeless and has a history of chronic schizophrenia. Which one of the following interventions would be best for the nurse to suggest for this client? Job planning workshops at a local community college A mediator between the client and his/her family A life and social skills group Solitary games and activities
A life and social skills group Explanation: A client with a history of chronic schizophrenia is in need of learning activities of daily living, communication, and other social skill deficits caused by his/her chronic illness. A job-planning workshop is outside the client's capabilities at this time. The need for a family mediator is not indicated. Solitary games and activities would not build the social structure and skills necessary for this client's progress.
A client is being treated for alcoholism. After a family meeting, the client's spouse asks a nurse about ways to help the family deal with the effects of her husband's alcoholism. The nurse should suggest that the family join which organization? Al-Anon Make Today Count Emotions Anonymous Alcoholics Anonymous
Al-Anon Explanation: Al-Anon is an organization that assists family members in sharing common experiences and increasing their understanding of alcoholism. Make Today Count is a support group for people with life-threatening or chronic illnesses. Emotions Anonymous is a support group for people experiencing depression, anxiety, or similar conditions. Alcoholics Anonymous is an organization that helps alcoholics recover by using a 12-step program.
Which characteristic is most common among suicidal clients? Psychosis Remorse Frustration Ambivalence
Ambivalence Explanation: One of the characteristics most commonly shared by suicidal persons is ambivalence, an internal struggle between self-preserving and self-destructive forces. These doubts are expressed when a person threatens or attempts suicide and then tries to get help to save his life. When the possible consequences of suicide are discussed, such persons commonly describe life-related outcomes such as relief from an unhappy situation. Many people consider suicide an alternative to present circumstances, but they may not have considered the implications of no longer being alive. A psychotic person may or may not have suicidal tendencies. Remorse and anger may be associated with depression but aren't universally present in suicidal persons. Frustration isn't specifically associated with suicidal ideation.
A client with a history of suicidal thoughts and depression has just attended an outpatient day therapy group session. The nurse hears from the client that he/she plans to forgo lunch and the afternoon session, stating, "I just need to go home and have a nap." What would be the day therapy nurse's best response? Ask the client if he/she is angry. Remind the client that the program schedule will benefit the client only if he/she stays for the whole day. Ask the client if he/she is hungry or if he/she has not been enjoying the food at the outpatient program. Ask the client to sit for a few minutes to discuss missing the afternoon session.
Ask the client to sit for a few minutes to discuss missing the afternoon session. Explanation: The client is demonstrating a behavior that should be further assessed. The nurse should take the time to assess the client's thoughts, feelings, and behaviors. While the client may truly just need the rest, he/she may be upset, or employing a pattern of behavior that is part of the problem. Regardless, the nurse should investigate this and also assess for safety. Asking a closed question, such as "Are you angry?", would not assist this assessment, nor would it be therapeutic to focus on rules of the program or the client's interest or enjoyment of the food.
When a client expresses feelings of unworthiness, the nurse should respond by saying: "Your family loves you even if you feel unworthy." "Your feelings of being unworthy are just your imagination." "It would be best to try to forget the idea that you are unworthy." "As you begin to feel better, your feelings of unworthiness will begin to disappear."
Correct response: "As you begin to feel better, your feelings of unworthiness will begin to disappear." Explanation: When the client feels unworthy, she reflects low self-esteem. Presenting another set of facts in a manner that is accepting of the client but avoids a power struggle is helpful. Telling the client that her family still loves her is a type of pep talk that serves to block the client's emotional expression. Telling the client that her feelings are imaginary shows disapproval and may shame the client for having such feelings. Telling the client that she should try to forget ideas of unworthiness disregards her feelings and may be perceived as rejection.
A nurse is assessing a client with bulimia nervosa for possible substance abuse. What is the most important question for the nurse to ask this client? "What drugs have you used to manage your weight and appetite?" "What drugs have you used to help control anxiety?" "How would you describe your alcohol use?" "Do you participate in "pharm" parties?"
Correct response: "What drugs have you used to manage your weight and appetite?" Explanation: Some clients with bulimia nervosa use, or have a history of using, amphetamines to control their weight. This is the most important question, as it asks about medications related to the eating disorder and the potential medical complications. The use of alcohol and street drugs is common. Direct questions about medications used for anxiety will likely elicit a direct response. Similarly, asking for a description of alcohol use might yield information about the pattern of drinking. Participation in "pharm" parties indicates a high-risk behavior that should be addressed during treatment.
A client is in the withdrawn phase of catatonia due to schizophrenia. This is the client's first admission to an early psychosis program at an urban hospital. At present, the client is completely stuporous. What is the priority while giving care to the client during this phase of symptoms? Explain all physical care activities in simple, explicit terms as though expecting a response. Maintain a quiet atmosphere, speaking as little as possible to the client. Provide as much sensory stimulation as possible using conversation, radio, and television. Ask the client to do exactly the opposite of what is desired
Correct response: Explain all physical care activities in simple, explicit terms as though expecting a response. Explanation: A client in a stuporous state is not in a position to negotiate, discuss, or gather insight. At this stage of a psychotic experience, a client requires clear and simple explanations of all activities. Not speaking much would be confusing and increase anxiety, but excessive information and stimuli would also not benefit goal-directed activities.
The school nurse is discussing healthy eating strategies with a group of 8-year-old students. One student repeatedly makes comments of a sexual nature. The student seems to be preoccupied with sexual comments and is knowledgeable regarding a variety of sexual activities. Which of the following is the most crucial intervention for the nurse to take to manage the student's behavior?
Correct response: Investigate the possibility that the student may have been sexually abused. Explanation: When a child appears to be preoccupied with sexual comments and is knowledgeable regarding sexual activities, the nurse should suspect that the child may have been sexually abused and should explore the situation. The other options are possible, but the extent of this behavior is neither "typical," nor does it reflect one instance of viewing mature video content. The nurse should pursue and ensure the child's safety and investigate further.
An intoxicated client is admitted to the hospital for alcohol withdrawal. What should the nurse do to help the client become sober? Give the client black coffee to drink. Walk the client around the unit. Have the client take a cold shower. Provide the client with a quiet room to sleep in.
Correct response: Provide the client with a quiet room to sleep in. Explanation: The nurse should provide the client with a quiet room to sleep in. Alcohol is destroyed and oxidized in the body at a slow, steady rate. The rate of alcohol metabolism is not influenced by drinking black coffee, walking around the unit, or taking a cold shower. Therefore, it is best to have the client sleep off the effects of the alcohol.
A client changes topics quickly while relating past psychiatric history. This client's pattern of thinking is called looseness of association. flight of ideas. tangential thinking. circumstantial thinking.
Correct response: flight of ideas. Explanation: Flight of ideas describes a thought pattern in which a client moves rapidly from one topic to the next with some connection. Looseness of association describes a pattern in which ideas lack an apparent logical connection to one another. Tangential thoughts seem to be related but miss the point. A client who talks around a subject and includes a lot of unnecessary information is exhibiting circumstantial thinking.
The nurse is caring for a client with a panic attack. Which nursing intervention is most helpful for this client? Encourage the client to identify what precipitated the attack Encourage the client to verbalize any fears, feelings, or concerns Stay with the client and remaining calm, confident, and reassuring Encourage the client to learn relaxation techniques
Correct response: Stay with the client and remaining calm, confident, and reassuring Explanation: A panic-stricken client requires the assistance of a calm person who can provide support and direction. This approach is particularly important because the client already feels frightened and out of control. Having someone remain with the client helps prevent him from feeling isolated and deserted. Encouraging the client to verbalize any fears, feelings, or concerns or encouraging the client to identify what precipitated the attack is futile because the client's level of anxiety prevents him from focusing on precipitating factors. Also, encouraging the client to learn relaxation techniques is not possible at this time as the client is unable to learn new information when the anxiety level is at the panic level. Staying with the client is the best action for the nurse.
A client with major depression and suicidal ideation is suddenly calmer and more energetic. Which conclusion should the nurse reach? The client is improving. The client's medication dosage is too high. The client is overstimulated. The client is imminently suicidal.
Correct response: The client is imminently suicidal. Explanation: When a client with major depression and suicidal ideation displays a sudden elevation in mood, seems calmer, has more energy, and is more peaceful, the nurse should judge these behaviors as an indication that a suicide attempt is imminent. These symptoms may indicate relief from ambivalent thoughts about suicide and that the client has an immediate plan for killing himself.
A client is admitted to an inpatient psychiatric unit. After the assessment and admission procedures have been completed, the nurse states, "I'll try to be available to talk with you when needed and will spend time with you each morning from 10:00 until 10:30 in the corner of the dayroom." What is the rationale for communicating these planned nursing interventions? To attempt to establish a trusting relationship To provide a structured environment for the client To instill hope in the client To provide time for completing nursing responsibilities
Correct response: To attempt to establish a trusting relationship Explanation: Availability, reliability, and consistency are critical factors in establishing trust with a client. Being specific about the time and place of meetings helps establish trust, which is initially the main objective. Although important, structuring the environment and instilling hope aren't the primary tasks at this time. Arranging a regular meeting with the client allows the nurse to plan the workload but isn't the major reason for such scheduling.
A client with severe depression states, "My heart has stopped and my blood is black ash." The nurse interprets this statement to be evidence of which problem? hallucination illusion delusion paranoia
Correct response: delusion Explanation: A client with severe depression may experience symptoms of psychosis such as hallucinations and delusions that are typically mood congruent. The statement, "My heart has stopped and my blood is black ash," is a mood-congruent somatic delusion. A delusion is a firm, false, fixed belief that is resistant to reason or fact. A hallucination is a false sensory perception unrelated to external stimuli. An illusion is a misinterpretation of a real sensory stimulus. Paranoia refers to suspiciousness of others and their actions.
When assessing an aggressive client, which behavior warrants the nurse's prompt reporting and use of safety precautions? crying when talking about his divorce starting a petition to delay bedtime declining attendance at a daily group therapy session naming another client as his adversary
Correct response: naming another client as his adversary Explanation: The client exhibits aggression against his perceived adversary when he names another client as his adversary. The staff will need to watch him carefully for signs of impending violent behavior that may injure others. Crying about a divorce would be appropriate, not pathologic, behavior demonstrating grief over a loss. A petition to delay bedtime would be a positive, direct action aimed at a bothersome situation. Although declining to attend group therapy needs follow-up, there may be any number of unknown reasons for this action.
The nurse is assessing a client who has been admitted to the acute care facility. The client experiences an acute onset of altered level of consciousness and recent memory loss. Which of the following does the nurse anticipate the client will be evaluated for? Dementia Tertiary syphilis Delirium Depression
Delirium Explanation: Delirium presents as an acute process by which the client exhibits an alteration in level of consciousness, disorientation, and recent memory loss. It may be difficult to differentiate between dementia, delirium, and depression, as many of the clinical manifestations overlap. Dementia, tertiary syphilis, and depression are chronic states and do not manifest acutely.
The nurse is working with a highly culturally diverse group of mostly young adult clients who have substance abuse issues. Many clients in the group have had difficult social circumstances and experience relapses. What would be the most appropriate nursing intervention in dealing with these clients? Encourage motivation and confidence so that the clients can better deal with the triggers that cause them to repeat their behaviors. Demonstrate zero tolerance to relapse and provide a firm approach so the clients can repair character weaknesses now, while they are still young. Brainstorm and develop new coping strategies to share with the young adults weekly to keep a constant supply of options. Provide reassurance that the problem will resolve itself in time.
Encourage motivation and confidence so that the clients can better deal with the triggers that cause them to repeat their behaviors. Explanation: Provide confidence so that the clients have the ability to deal with the triggers that cause them to repeat their behaviors. Clients with multiple episodic occurrences of relapse are unable to adapt to the stressors but need support. Zero tolerance to relapse demonstrates an authoritarian attitude that the clients have a weakness in character. Providing reassurance that the problem will resolve itself in time does not motivate change. Providing coping strategies for the clients does not instill personal commitment to change.
A client reports losing his job, not being able to sleep at night, and feeling upset with his wife. The nurse responds, "You may want to talk about your employment situation in group today." The nurse is using which therapeutic technique? Restating Making observations Exploring Focusing
Focusing Explanation: The nurse is using focusing by suggesting that the client discuss a specific issue. She didn't restate the question (restating technique) or ask further questions (exploring technique), and didn't make an observation.
A client is being discharged after 3 days of hospitalization for a suicide attempt that followed the receipt of a divorce notice. Which client finding indicates to the nurse that the client is ready for discharge? Expresses a readiness for discharge. Has the names and phone numbers of two divorce lawyers. Has a list of support persons and community resources. Displays emotional stability.
Has a list of support persons and community resources. Explanation: The risk of suicide can persist for 2 to 3 months even after a crisis has abated. Therefore, it is important for the client to be able to verbalize information about appropriate support persons and community resources and to have this information readily available. Although the client may state that she is ready to be discharged, this is not the most reliable indicator. A divorce lawyer may not be appropriate at this point. At 3 days after a suicide attempt, emotional stability is not likely.
What question would the nurse ask to assess coping abilities of a family dealing with a chronic illness? How is your condition affecting your family members and their usual roles? Has your family been able to handle chronic illness management before? What is the best way your family resolves crisis situations? Does your family have the strength to deal with the changes and still support you through this difficult time?
How is your condition affecting your family members and their usual roles? Explanation: Clarification of the concerns the client has regarding the impact of the illness on the family is very important. This answer asks how members are affected. This is an important step before examining ways that the nurse might support the family during their period of adjustment. The other choices do not directly address the current situation and how the nurse can best assist the family
An 80-year-old woman who identifies herself as a devout Catholic has recently relocated to an assisted-living facility. The woman is pleased with most aspects of her new living situation, but laments the fact that she is no longer close to the church where she was in the habit of attending daily mass each morning. What nursing diagnosis may apply to this problem that the woman has identified? Impaired Religiosity Spiritual Distress Spiritual Pain Hopelessness
Impaired Religiosity Explanation: Impaired Religiosity encompasses the inability to participate in rituals of a particular faith tradition. Spiritual Distress involves the inability to integrate meaning and purpose in life, while Spiritual Pain involves angst over the nature and actions of a higher power. The woman's statements do not directly reflect an outlook of hopelessness.
Which nursing strategy would be effective in managing a client who has Alzheimer's disease and wanders? Encourage participation in activities such as board games. Discourage wandering by allowing the behavior at selected intervals. Involve the client in activities that promote walking. Promote safety by restricting the client in a geriatric chair.
Involve the client in activities that promote walking. Explanation: Supervised activities that promote walking are behavioral management strategies that help a client such as this. The client's cognitive and memory impairment would not be conducive to playing board games. Allowing the behavior at selected intervals would further encourage the client to wander. The client should not be restrained in a chair.
During a mental health assessment interview, a client does not make eye contact with the nurse. The nurse suspects this behavior is culturally based. What should the nurse do first in relation to this assumption? Accept this behavior because it is culturally based Observe how the client and the client's family interact with each other and with other staff members Read several articles about this cultural group and their behaviors Ask staff members of a similar cultural group about their habits and behaviors
Observe how the client and the client's family interact with each other and with other staff members Explanation: Assessing a client's interactions with others is a helpful way to determine the client's usual behavior patterns. This may also help a nurse determine what a behavior means to a client. Reading and consulting others about a cultural behavior pattern is useful only in assisting an understanding of an individual client after a nurse has had an opportunity to assess and observe the client directly. The nurse has to be able to assess and care for the client as an individual as well as a member of a cultural community.
Which of the following statements about religion and spirituality is most accurate? Religion is an organized system of spiritual beliefs. Religion and spirituality are synonymous. Spirituality is the behavioral manifestation of religious beliefs. Spirituality is a recently developed alternative to traditional religious belief.
Religion is an organized system of spiritual beliefs. Explanation: Spirituality may or may not include religion, which is a codified system of spiritual beliefs. The two terms are not interchangeable, and spirituality is not solely concerned with outward behavior. Spirituality is not necessarily an "alternative" to religion, nor is it a recent development.
Which term refers to the primary unconscious defense mechanism that blocks intense, anxiety-producing situations from a person's conscious awareness? Introjection Regression Repression Denial
Repression Explanation: Repression, the unconscious exclusion from awareness of painful or conflicting thoughts, impulses, or memories, is the primary ego defense. Other defense mechanisms tend to reinforce anxiety. Introjection is an intense identification in which one incorporates values or qualities of another person or group into one's own ego structure. Regression is a retreat, during a time of stress, to an earlier level of developmental behavioral. Denial is avoiding unpleasant realities by ignoring the
Prior to surgery for a modified radical mastectomy, the client is extremely anxious and asks many questions. Which approach offers the best guide for the nurse to answer these questions? Tell the client as much as she wants to know and is able to understand. Postpone discussing the client's questions with her until she is convalescing. Delay discussing the client's questions with her until her apprehension subsides. Explain to the client that she should discuss her questions first with the health care provider.
Tell the client as much as she wants to know and is able to understand. Explanation: An important nursing responsibility is preoperative teaching, and the most frequently recommended guide for teaching is to tell the client as much as she wants to know and is able to understand. Delaying discussion of issues about which the client has concerns is likely to aggravate the situation and cause the client to feel distrust. As a general guide, the client would not ask the question if she were not ready to discuss her situation. The nurse is available to answer the client's questions and concerns and should not delay discussing these with the client.
A client's partner tells the nurse that he will remain in the waiting room while the client is in labor. The client's sister has been chosen to be her birth companion. Which of the following responses from the nurse would be most appropriate? Encourage the partner to stay with the client because, as the baby's father, he is the best birth companion. Tell the partner that he will receive updates of the client's progress and be called as soon as the baby is born. Inform the client and her partner that only fathers can stay in the birthing room. Ask the client if she agrees with her partner's desire to stay in the waiting room.
Tell the partner that he will receive updates of the client's progress and be called as soon as the baby is born. Explanation: This statement respects the decision of the family and facilitates open communication among the nurse, the client, and the client's partner during labor and birth.
A nurse is caring for a client with end-stage testicular cancer who has been referred to hospice care. Which criterion indicates that the client requires more teaching about hospice care? The client doesn't want to discuss death around his girlfriend. The client entered a clinical trial through the National Cancer Institute. The physician orders weekly blood transfusions to be given at home. The client explains that he isn't ready to complete his will.
The client entered a clinical trial through the National Cancer Institute. Explanation: The client involved in a clinical trial needs additional teaching about hospice care. This treatment option suggests that the client isn't ready for palliative care, which is a criterion for hospice care. Preferring not to discuss death around the girlfriend and not feeling ready to complete a will are normal responses to the grieving process. Blood transfusions are considered palliative care.
A client is irritable and hostile. He becomes agitated and verbally lashes out when his personal needs are not immediately met by the staff. When the client's request for a pass is refused by the healthcare provider, he utters a stream of profanities. Which statement best describes the client's behavior? The client's anger is not intended personally. The client's anger is a reliable sign of serious pathology. The client's anger is an intended attack on the healthcare provider's skills. The client's anger is a sign that his condition is improving.
The client's anger is not intended personally.
A shy 12-year-old girl who must change school systems just before she begins junior high school begins cutting her arms to relieve the stress that she feels about leaving long-standing friends, having to develop new friendships, and meeting high academic standards in her new school. After she has been cutting for a few weeks, her parent discovers the injuries and takes her to a psychiatrist mental health provider who prescribes a therapeutic group at the local mental health center and medication to help decrease her anxiety. Which findings indicate that the girl had made appropriate progress toward recovery? Select all that apply. The girl indicates that she had joined three clubs at school and agreed to be an officer in one of them. The girl says she has developed a friendship with a girl in her class and one in her therapy group. The girl wears short-sleeved and/or sleeveless tops when the weather is warm. The girl's grades are good, and her hours of study are not excessive. The girl begins saying she must study hard so she can get into a good university.
The girl says she has developed a friendship with a girl in her class and one in her therapy group. The girl wears short-sleeved and/or sleeveless tops when the weather is warm. The girl's grades are good, and her hours of study are not excessive.
When the client tells the nurse that she believes that God's reality is personal and that God is the creator of all beings, the nurse determines the client is expressing Faith. Agnosticism. Atheism.
Theism. Explanation: Theism is the belief that God's reality is personal, without a body, perfect in all things, and creator and sustainer of the universe.
The nurse has recently accepted a position in a community with an ethnically and culturally diverse population. What action should the nurse first perform in order to enhance cultural competence? Thoughtfully reflect on the characteristics of his or her own culture. Make an effort to learn a language that is commonly spoken in the community. Ask several colleagues about the culture with which they most closely identify. Ask clients from varied ethnicities for suggestions on how to become more culturally aware.
Thoughtfully reflect on the characteristics of his or her own culture. Explanation: Cultural competence begins with self-awareness. This should precede efforts such as learning languages or inquiring about colleagues' cultures. The nurse should seek to better understand clients' cultures, but it would not be appropriate to ask clients for advice about becoming more culturally aware in general.
The client thinks he is being followed by foreign agents who are after secret papers in his briefcase. What thought process does this indicate? idea of reference idea of influence delusion of grandeur delusion of persecution
delusion of persecution Explanation: The client's thought process is best defined as a delusion of persecution. An idea of reference assumes that the remarks and behavior of others apply to oneself. An idea of influence refers to the belief that people or objects have control over one's behavior. A delusion of grandeur involves an exaggerated idea of one's importance or identity.
A client is remanded by the courts for psychiatric treatment. His police record, which dates to his early teenage years, includes delinquency, running away, auto theft, and vandalism. He dropped out of school at age 16 and has been living on his own since then. His history suggests maladaptive coping, which is associated with: antisocial personality disorder. borderline personality disorder. obsessive-compulsive personality disorder. narcissistic personality disorder.
antisocial personality disorder. Explanation: This client's history of delinquency, running away from home, vandalism, and dropping out of school is characteristic of antisocial personality disorder. This maladaptive coping pattern is manifested by a disregard for societal norms of behavior and an inability to relate meaningfully to others. In borderline personality disorder, the client exhibits mood instability, poor self-image, identity disturbance, and labile affect. Obsessive-compulsive disorder is characterized by a preoccupation with impulses and thoughts that the client realizes are senseless but can't control. Narcissistic personality disorder is characterized by a pattern of self-involvement, grandiosity, and demand for constant attention.
Which approach by the nurse would most likely foster a therapeutic relationship with a client who tries to manipulate people? strictness sympathy aloofness consistency
consistency Explanation: It is most important that the nurse maintain a consistent approach when dealing with the client who manipulates others. The nurse should set limits on the client's behavior and then consistently enforce these limits to help prevent manipulation. Strictness for its own sake is not appropriate with this client. Sympathy may feed into the client's manipulation. Aloofness will not help establish a therapeutic relationship.
A client admitted to the nursing unit with bipolar disorder, manic phase, is accompanied by his wife. The wife states that her husband has been overly energetic and happy, talking constantly, purchasing many unneeded items, and sleeping about 4 hours a night for the past 5 days. When completing the client's daily assessment, the nurse should be especially alert for which finding? exhaustion vertigo gastritis bradycardia
exhaustion Explanation: The client in the manic phase experiences insomnia, as evidenced by his sleeping only for about 4 hours a night for the past 5 days. The client experiencing an acute manic episode is not capable of judging the need for sleep. Therefore, the nurse should assess the amount of rest the client is receiving daily to prevent exhaustion. The development of vertigo, gastritis, or bradycardia typically does not result from acute mania.
A nurse is using drawing, puppetry, and other forms of play therapy while treating a terminally ill, school-age child. The purpose of these techniques is to help the child: internalize his feelings about death and dying. accept responsibility for his situation. express feelings that he can't articulate. have a good time while he's in the hospital.
express feelings that he can't articulate. Explanation: Children may not have the verbal and cognitive skills to express what they feel and may benefit from alternative modes of expression. A child should be allowed to express his feelings rather than internalize them. The child must also know that he isn't to blame for this situation. In the process of participating in play therapy, the child can also have fun, but that isn't the main goal of therapy.
A client with Alzheimer's disease mumbles incoherently and rambles in a confused manner. To help redirect the client's attention, the nurse should encourage the client to: fold towels and pillowcases. play cards with another client. participate in a game of charades. perform an aerobic exercise.
fold towels and pillowcases. Explanation: Folding towels and pillowcases is a simple activity that redirects the client's attention. Also, because this activity is familiar, the client is likely to perform it successfully. Cards, charades, and aerobic exercise are too complicated for a confused client.
A nurse is caring for a client who experiences false sensory perceptions that have no basis in reality. These perceptions are known as: delusions. hallucinations. loose associations. neologisms.
hallucinations. Explanation: Hallucinations are visual, auditory, gustatory, tactile, or olfactory perceptions that have no basis in reality. Delusions are false beliefs, rather than perceptions, that the client accepts as real. Loose associations are rapid shifts among unrelated ideas. Neologisms are bizarre words that have meaning only to the client.
When planning the care for a client who is being abused, which measure is most important to include? being compassionate and empathetic teaching the client about abuse and the cycle of violence explaining to the client the client's personal and legal rights helping the client develop a safety plan
helping the client develop a safety plan Explanation: The client's safety, including the need to stay alive, is crucial. Therefore, helping the client develop a safety plan is most important to include in the plan of care. Being empathetic, teaching about abuse, and explaining the person's rights are also important after safety is ensured.
Which activity by the mother offers the most support to the child during the first few days after surgery to repair a cleft lip? holding and cuddling the child helping the child play with some toys reading some of the child's favorite stories staying at the bedside and holding the child's hand
holding and cuddling the child Explanation: The mother should be encouraged to hold and cuddle her child to provide needed emotional support. Such activities as helping the child play with toys, reading stories, and staying with the child would not be contraindicated but do not offer as much emotional support as holding and cuddling.
The client states he washes his feet endlessly because they "are so dirty that I canot put on my socks and shoes." The nurse recognizes the client is using ritualistic behavior primarily to relieve discomfort associated with which feeling? intolerable anxiety depression ambivalence irrational fear
intolerable anxiety Explanation: The client with an obsessive-compulsive disorder has an uncontrollable and persistent need to perform behavior that helps relieve intolerable anxiety. In depression, the client feels extreme sadness. Depression is not alleviated by performing obsessive-compulsive actions. Ambivalence refers to two simultaneous opposing feelings. An irrational fear is called a phobia. Phobic behavior is associated with extreme avoidance behavior when confronted with the feared object, not with ritualistic behaviors.
A client with dementia must be temporarily hospitalized. The family wants to take proactive measures to assure the client does not experience further confusion. Which measure if suggested by the family would the nurse discourage? providing for uninterrupted sleep bringing familiar objects from home for the room keeping lights dimmed during daylight hours posting a calendar in the room
keeping lights dimmed during daylight hours Explanation: Clients with dementia are at risk for sudden decreases in their mental status when placed in unfamiliar settings. Keeping clients in a darkened room during the day simulates night and can disrupt the client's sleep wake cycle which exacerbates confusion. Providing for uninterrupted sleep helps maintain cognition. Bringing familiar objects from home makes the environment more comfortable and less strange. Clocks and calendars help keep the clients oriented to time.
A client in a long-term nursing care facility who decides to be placed on hospice care expresses to the nurse, "I have outlived my family and friends; I have lost hope and there is no need for me to continue on." What underlying client concerns would the nurse first address with this client? loneliness and feelings of isolation a sense of frustration and depression perceptions of survivor guilt and shame negative mood and mental illness
loneliness and feelings of isolation Explanation: At end-of-life when a person expresses a deep sense of loss, emptiness, and no hope for quality of life, it is frequently a reflection of severe loneliness and isolation. The client is experiencing more than frustration leading to depression, and survivor guilt is typically associated with a traumatic event. The current situation can negatively affect the client's mood, but it is not an indication of an incipient mental illness.
A client with a chronic mental illness has worked as a hotel maid for the past 3 years. She tells the nurse she is thinking of quitting her job because "voices on television are talking about me." The nurse should first: obtain information about the client's medication compliance. remind the client that hearing voices is a symptom of her illness with which she can cope. check with the client's employer about her work performance. arrange for the client to be admitted to a psychiatric hospital for a short stay.
obtain information about the client's medication compliance. Explanation: Symptom exacerbation is most often related to noncompliance with the prescribed medication regimen. Therefore, obtaining information about the client's compliance is the first priority. Helping the client recognize the symptoms and her ability to manage them is appropriate, but this is not the first priority. Checking with her employer is not appropriate and does not help the client with management of her illness. Hospitalization is not indicated because the client is still working and can talk about the symptoms.
A 15-year-old is a heavy user of marijuana and alcohol. When the nurse confronts the client about his drug and alcohol use, he admits previous heavy use in order to feel more comfortable around peers and achieve social acceptance. He says he has been trying to stay clean since his parents found out and had him seek treatment. When the nurse develops a plan of care with the client, what should be the highest priority to help him maintain sobriety? peer recognition that does not involve substance use support and guidance from his parents a strict no-drug policy at his high school the threat of legal charges if caught drinking or smoking marijuana
peer recognition that does not involve substance use Explanation: Peer acceptance and recognition is a very powerful force in the lives of adolescents, leading to positive or negative behavior depending on the child's peers. While the influence of parents remains strong, peer acceptance combined with the adolescent's desire for independence can lead to disobeying the parents. The sanctions provided at school and in the community by law enforcement will support those teens that have other support in their lives, but are generally not sufficient to prevent substance use in adolescents lacking support at home and with peers.
A client in the manic phase of bipolar disorder arrives at the outpatient psychiatric clinic. To help the client manage a manic episode, the nurse should suggest that she: go shopping with a friend. read a book in a quiet room. reorganize a kitchen cabinet. play a game with a few friends.
reorganize a kitchen cabinet. Explanation: Reorganizing a kitchen cabinet or painting a picture in a quiet environment are suitable outlets for this client's excess energy. Doing so transfers inappropriate aggressive drives into a constructive activity, which helps the client control her manic behavior. Going shopping is much too tempting an activity for this client, who can't control her behavior and is likely to overspend. During the manic phase, a client with bipolar disorder lacks the concentration needed to read a book. Playing a competitive game may be overly stimulating and could make the client more agitated.
A nurse plans to include the parents of a client with anorexia nervosa, in the client's therapy sessions. The nurse should anticipate that the parents will: tend to overprotect their child. have a history of substance abuse. maintain emotional distance from their child. alternate between expressing love for and rejection of their child.
tend to overprotect their child. Explanation: A client with anorexia nervosa typically comes from a family in which parents are controlling and overprotective and emphasize perfection and achievement. These clients use eating to gain control over one aspect of their lives. Parents of children with anorexia nervosa tend not to have a history of substance abuse, maintain emotional distance, or alternate between expressing love and rejection.
A client reports that before he leaves home to go anywhere, he counts the money in his wallet as many as 12 times. The nurse judges this behavior to indicate which client need? the need to channel excessive sexual energy into an appropriate habit the need to compensate for not having had enough money to spend as a child the need to avoid the embarrassment of having a shortage of funds on hand the need to channel emotions unacceptable to him with an acceptable activity
the need to channel emotions unacceptable to him with an acceptable activity Explanation: The dynamics of compulsive activity involve a defense against anxiety by persistently doing something to bind or reduce anxiety. This behavior occurs each time threatening thoughts occur that lead to increased anxiety. Believing that the client is channeling excessive sexual energy into an appropriate habit shows an incorrect understanding of the dynamics of the disorder. Judgment that the client counts money repeatedly to compensate for not having had enough money as a child or to avoid the embarrassment of running short is based on insufficient data and represents an oversimplification of the client's problem.
Which behavior if exhibited by a client with a depressive disorder should lead the nurse to determine that the client is ready for discharge? interactions with staff and peers sleeping for 4 hours at a time verbalization of feeling in control of self and situations statements of dissatisfaction over not being able to perform at work
verbalization of feeling in control of self and situations Explanation: The client who verbalizes feeling in control of self and situations no longer feels powerless to affect an outcome but realizes that one's actions can have an impact on self and situations. It is common for the client with depression to feel powerless to affect an outcome and to feel a lack of control over a situation. Although interacting with staff and peers is a positive action, the client could be conversing in a negative or nontherapeutic manner. Sleeping only 4 hours at a time is evidence of symptomatology and does not indicate improvement or recovery. Verbalizing dissatisfaction over not being able to perform at work indicates that the client is most likely focusing on shortcomings and powerlessness