A nurse is conducting a counseling session with a client who has a substance use disorder. The client repeatedly ask personal questions about the nurse.
... [Show More] Which of the following actions should the nurse take?
Explain that this time is designated to focus on the client.
A nurse is preparing to apply restaurants on a client who is threatening to harm others and has not responded to lessen case of interventions. Which of the following actions should the nurse plan to take?
Document the clients behavior every 15 minutes while restraints are in place.
Community mental health nurse is planning strategies to address substance use my adolescence. Which of the following intervention should the nurse plan as a method of primary prevention?Community mental health nurse is planning strategies to address substance use my adolescence. Which of the following intervention should the nurse plan as a method of primary prevention?
Provide a presentation at area high school's and resisting peer pressure for substance use.
A nurse in an emergency department is caring for an 18 month old toddler who has a fractured left femur. What is the long statement by the toddler's parent should cause the nurse to suspect child abuse?
"My child was riding a bicycle and fell off."
A nurse is administering an oral sedative to a client who is receiving careful and involuntary admission. The client states, " I'm not taking any more medication." Which of the following actions should the nurse take?
Document the client refusal of the medication in the medical record.
A nurse is caring for a school age client who begins wetting the bed after finding out her parents are getting a divorce. The nurse should identify the client is exhibiting which is a fine defense mechanisms?
Regression
A nurse is caring for a client who is brought to the clinic by her adult son who states that his father recently died. The client repeatedly yells at her son stating, " Quit lying about your father!" The nurse should recognize that the client is demonstrating which of the following defense mechanisms?
Denial
A nurse is caring for a client called mental health counseling center. The client received a failing grade in the course and spends entire counseling session blaming the teacher. The nurse should recognize this behavior as example of which of the following defense mechanisms?
Projection
A nurse at a college campus health clinic is caring for a client who reports manifestations of bulimia nervosa. The client tells the nurse, " I know my eating binges and vomiting are not normal, but I cannot control it." Which of the following responses should the nurse make?
" You are feeling helpless about changing this behavior?"
A nurse is preparing to administer fluphenazine decanoate 12.5 mg subcutaneous. available is fluphenazine decanoate 25 mg/mL. How many mL should the nurse administer per dose?
0.5
A nurse is providing support for the parents of a child has a new diagnosis of a terminal brain tumor. The nurse should expect the parents to experience which of the following stages of grief?
Denial
A nurse is caring for a client who has depression. The nurse observes that the client has not come to breakfast and is still in bed. The client states, " I'm not worth your time. Leave me alone and go help someone else." which of the following responses should the nurse make?
" In other words, you seem to be saying that you feel unworthy of help."
A nurse is caring for a client has schizophrenia. The client states, " My internal organs have turned to stone." The nurse should document this finding as which of the following types of delusions?
Somatic
A nurse is establishing a therapeutic relationship with a client who has hallucinations. Which of the following actions should the nurse take during the orientation phase?
Identify the clients perception of the reason for therapy.
A nurse is assessing a client who has anorexia nervosa. The nurse should expect the client to display which of the following characteristics?
Possesses feelings of decreased self-worth
A nurse is planning reminiscence therapy for an older adult client. The nurse should identify which of the following goals for the client's therapy?
The client will gain increased self-esteem.
A nurse is caring for a client who reminds her of a negative person in her past. These memories cause the nurse to unconsciously displace negative feelings towards the client. The nurse should recognize that she is demonstrating which of the following behaviors?
Countertransference
A nurse is caring for a client has a new diagnosis of colon cancer. Shortly after the client received the diagnosis, the nurse enters the clients room and the client begins yelling, " I have received terrible care here and no one cares about me." The nurse should recognize that the client is demonstrating which of the following defense mechanisms?
Displacement
A nurse is caring for a client who has major depressive disorder and recently started taking an antidepressant. The nurse should identify which of the following client statements as the priority?
" I have it all figured out. Everything is going to be okay now."
A nurse in an emergency department is caring for a female client who has ecchymosis of the trunk and face. The client reports that her partner hit her, causing the injuries. When offered information about shelters for intimate partner violence, the client declines, stating, " I could never leave my husband because of my kids." Which of the following responses should the nurse make?
" The next time this occurs, what make you do that ensure your safety?"
A nurse is performing a mental health status assessment on an older adult client who has dementia. Which of the following questions should the nurse is ask to assess the client's remote memory?
" What year did you graduate from high school?"
A nurse in the pediatric emergency department is caring for four clients. The nurse should suspect possible abuse with which of the following clients?
A 9 month old infant who reportedly nearly drowned after climbing into the tub and turning on the water
A nurse is assessing a client who is experiencing moderate level anxiety. Which of the following findings should the nurse expect?
The client has difficulty concentrating
A nurse is caring for a client who has borderline personality disorder. The nurse enters the clients room and find the client cutting into his flash with a paper clip. After providing first aid, which of the following actions should the nurse take first?
Identify the clients feelings that lead to the south injurious behavior.
A nurse is caring for a client who attempted suicide and refuses to sign a no-suicide contract.Which of the following actions should the nurse take when implementing suicide precautions?
Place the client on one-to-one observation.
A nurse is caring for a client who is adolescent child died in a motor vehicle crash. The client is crying inconsolably. Which is the following actions should the nurse take?
Stay with the client and allow the client to cry.
A nurse is caring for a client who has depression and started taking porosity in one week ago. The client states the nurse," My family would be better off without me." What are the following responses should the nurse make?
" You sound upset. Are you thinking of hurting yourself?"
A nurse is admitting a client following care in the emergency department for an intentional overdose of opioids. The client states, " I feel so alone. No one can help me." Which of the following responses by the nurse is therapeutic?
" I would like to sit and talk with you."
A nurse in a mental health facility is reviewing confidentiality requirements with a newly licensed nurse. Which of the following statements by newly licensed nurse indicates an understanding of the information?
" I said keep information private even after a client dies."
A nurse at an acute mental health facility is caring for a client who has acute mania do you to bipolar disorder. At 0300, the client runs to the nurse's station and demands to see the provider immediately. Which of the following responses should the nurse make?
" you must be very upset about some thing to want to see your provider in the middle of the night."
A nurse is counseling a client who seems relaxed initially, but then becomes restless and begins ringing his hands. The nurse states that the client seems tense, and the client agrees. Which of the following statements should the nurse make?
" What were we discussing when you begin to feel uncomfortable?"
A nurse is planning care for a client who has thoughts of suicide. Which of the following goes to the nurse include in the clients plan of care?
The client agrees to notify staff member of thoughts of self-harm.
A nurse in a mental health clinic is caring for a client who has bipolar disorder and states," I no longer take my medication because I like the feeling of being manic."Which of the following responses by the nurse is an example of therapeutic communication?
"You feel better when you don't take your medication?"
A nurse is completing an admission assessment for an adolescent client who has depression. The nurse should identify which of the following findings as a priority?
The client gave his favorite possessions to his friends.
A nurse is caring for a client who has borderline personality disorder. The client has previously identified another nurse assess favorite stating, "He's the best nurse ever."When that nurse calls in sick, Which of the following statements indicates that the client is using splitting as a method of coping?
" He's the worst nurse that ever taken care of me."
A nurse in a mental health clinic is caring for a client who states, " I think I might have a problem with alcohol." Which of the following actions should the nurse take first?
Ask the client to complete a CAGE questionnaire.
A nurse received a call on a crisis intervention hotline from a client. Which of the following statements should the nurse identify as an overt statement indicating the clients risk for suicide?
" There's no point in living any longer."
A nurse is caring for a client who has dementia. The client states to the nurse, " Everyone wants to kill me."Which of the following responses should the nurse make?
" You must feel very frightened to think someone wants to hurt you."
A nurse enters a client's room and observes that the client is agitated and pacing rapidly. The client looks at the nurse and says, " Back off. Leave me alone." Which of the following statements should the nurse make?
" I will give you space if you calm down. Tell me what is causing you to feel so tense."
A nurse is caring for a client who has alcohol use disorder and is receiving treatment for alcohol withdrawal. The nurse reports hand tremors 12 hr after admission. Which of the following statements should the nurse make?
" The tremors or persist for a few days as you are withdrawing from alcohol." [Show Less]