1. A nurse assesses a client at a community mental health facility using the SAD
PERSONS tool. The nurse knows that this tool provides which of the
... [Show More] following data
related to a client?
A.Current anxiety level
B.Problem-solving ability
C.Suicide potential
D.Mood disturbance - correct answersC
A.INCORRECT: SAD PERSONS is not a tool to provide data related to the client's
current anxiety level.
B.INCORRECT: SAD PERSONS is not a tool to provide data related to a client's ability
to problem solve.
C.CORRECT: SAD PERSONS is a tool that provides data related to a client's suicide
potential.
D.INCORRECT: SAD PERSONS does not provide data related to a client's mood
disturbance.
NCLEX® Connection: Psychosocial Integrity, Crisis Intervention
1. A nurse is assisting the parents of a school-age child who has oppositional defiant
disorder in identifying strategies to promote positive behavior. Which of the following is
an appropriate strategy for the nurse to recommend? (Select all that apply.)
A.Allow the child to choose consequences for negative behavior.
B.Use role playing to act out unacceptable behavior.
C.Develop a reward system for acceptable behavior.
D.Encourage the child to participate in school sports.
E.Be consistent when addressing unacceptable behavior. - correct answersC, D, E
A.IncOrrEct: The parents should set clear limits on unacceptable behavior.
B.IncOrrEct: The parents should focus on acceptable behavior and should demonstrate
this through modeling.
C.CORRECT: The parents should have a method to reward the child for acceptable
behavior.
D.CORRECT: The parents should encourage physical activity through which the child
can use energy and obtain success.
E.CORRECT: The parents should set clear limits on unacceptable behavior and should
be consistent.
NCLEX® Connection: Psychosocial Integrity, Behavioral Interventions
1. A nurse manager is discussing the care of a client who has a personality disorder
with a newly licensed nurse. Which of the following statements by the newly licensed
nurse indicates a need for further teaching?
A."I can promote my client's sense of control by establishing a schedule."
B."Self-assessment will help me cope with emotional reactions to client care."
C."I should practice limit-setting to help prevent client manipulation."
D."Maintaining professional boundaries is a priority of client care." - correct answersA
1. A. CoRRECT: Rather than establishing a schedule, the nurse should ask for the
client's input and offer realistic choices to promote the client's sense of control.
B. inCorrECt: Caring for a client who has a personality disorder can evoke an intense
emotional response by the nurse. Self-assessment assists the nurse to cope with these
reactions.
C. inCorrECt: When caring for a client who has a personality disorder, limit-setting is
appropriate to help prevent client manipulation.
D. inCorrECt: When caring for a client who has a personality disorder, the nurse should
always maintain professional boundaries.
NCLEX® Connection: Psychosocial Integrity, Behavioral Interventions
2. A client says, "I plan to commit suicide." Which of the following should be the nurse's
priority assessment?
A.Client's educational and economic background
B.Lethality of the method and availability of means
C.Quality of the client's social support
D.Client's insight into the reasons for the decision - correct answersB
A.INCORRECT: This is an appropriate action by the nurse. However, it is not the
priority.
B.CORRECT: The greatest risk to the client is self-harm as a result of carrying out a
suicide plan. Therefore, the priority assessment is to determine how lethal the method
is, how available the method is, and how detailed the plan is.
C.INCORRECT: This is an appropriate action by the nurse. However, it is not the
priority.
D.INCORRECT: This is an appropriate action by the nurse. However, it is not the
priority.
NCLEX® Connection: Psychosocial Integrity, Crisis Intervention
2. A nurse is caring for a client who has avoidant personality disorder. Which of the
following statements is expected from a client who has this type of personality disorder?
A."I'm scared that you're going to leave me."
B. "I'll go to group therapy if you'll let me smoke."
C."I need to feel that everyone admires me."
D."I sometimes feel better if I cut myself." - correct answersA [Show Less]