When developing the plan of care for a client who is staying in his room
because he perceives that staff want to harm him, which outcome of care planning
... [Show More] is most realistic?
Within 2 days, the client will complete his activities of daily living. Within 3 days, the client will participate in recreation with other clients.
Within 5 days, the client will seek out staf f to talk about feelings.
Within 4 days, the client will demonstrate an absence of verbal aggression. Good work
A client was experiencing marital discord with a spouse of 4 years. When the
spouse walked out, the client became angry and began to throw things and break dishes. A friend talked the client into seeking help at the local mental health center. Which of these questions should the nurse ask initially to begin to assess this client's immediate problem?
"In hindsight, how might you have managed this situation differently?" "What led you to come in for help today?"
"Do you feel in control of yourself at this time?"
"What did you do to cause your spouse to leave?" Good work
A client with depression is ready for discharge from the hospital and tells the nurse, "It would be good for me if we could meet for coffee if I start feeling down again." Which statements indicate that the nurse understands the boundaries of the therapeutic relationship?
"Before you leave the hospital, I'll make sure you have information about the crisis center."
"That would be fine as long as we go to a public place. Where would you like to meet?"
"We could go to the gym together. Exercise can be very therapeutic for clients with depression."
"I often meet with people after they are discharged. Sometimes it's difficult to deal with situations after you leave the hospital."
Good work
While listening to a taped-report at shift change, one of the other team
members remarks that "My mother lives near this client, and his yard is always full of junk." What should the nurse assigned to provide care to this client do in this situation?
Ask the team member what the purpose was in sharing the information. Include the information in report for the next shift.
Ask the team member to be quiet.
Ignore the comment. Good work
The basis for building a strong, therapeutic nurse-client relationship begins
with a nurse's:
sincere desire to help others.
sound knowledge of psychiatric nursing.
self-awareness and understanding.
acceptance of others. Good work
A client with antisocial personality disorder smokes in prohibited areas and
refuses to follow other unit and facility rules. The client persuades others to do the client's laundry and other personal chores, splits the staff, and will work only with certain nurses. The care plan for this client should focus primarily on:
isolating the client to decrease contact with easily manipulated clients.
consistently enforcing unit rules and facility policy.
engaging in power struggles with the client to minimize manipulative behavior.
using behavior modification to decrease negative behavior by using negative reinforcement.
Good work
A 26-year-old is being treated for delirium due to acute alcohol intoxication.
The client is restless, does not want to stay seated, and has a staggering gait. What should the nurse do first?
Decrease stimuli by putting the client in bed with the room door closed.
Ask the client to sit in a chair next to the nurses' station. Place the client in a chair with a waist restraint.
Provide one-to-one supervision of the client until detoxification treatment can begin.
Good work
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 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." "My child doesn't like going to the doctor."
Good work
A client who has had AIDS for years is being treated for a serious episode of
pneumonia. A psychiatric nurse consult was arranged after the client stated, "I'm tired of being in and out of the hospital. I'm not coming in here anymore. I have other options." The nurse would evaluate the psychiatric nurse consult as helpful if the client makes which statements?
"If I talk about suicide, I'll be transferred to the psychiatric unit." "Nobody wants me to commit suicide."
"I realize that I really do have more time to enjoy my friends and family."
"I would probably screw up suicide anyway." Good work
A client is admitted to the emergency department after being sexually
assaulted. The nurse notes that the client is sitting calmly and quietly in the
examination room and recognizes this behavior as a protective defense mechanism. What defense mechanism is the client exhibiting?
denial intellectualization regression
displacement Good work
When caring for a client who was a victim of a crime, the nurse is aware that
recovery from any crime can be a long and difficult process depending on the meaning it has for the client. What should the nurse establish as a victim's ultimate goal in reconstructing his or her life?
getting through the shock and confusion
regaining a sense of security and safety resolving grief over any losses
carrying out home and work routines Good work
During periods of extreme stress a client may experience elevated blood
pressure, dilated pupils, and increased respirations. These unconscious responses originate in which part of the brain?
limbic system
reticular activating system somatic nervous system
hypothalamus Good work
A new client has just been admitted to an adolescent psychiatric inpatient
unit. The charge nurse and an unlicensed assistive personnel (UAP) are discussing the client's needs. The UAP says, "She is just showing off to try and get our sympathy. There is no need for her to cut herself. Why would adolescents want to do such a thing to themselves?" What response by the charge nurse would most help the UAP understand the client and her illness?
"She's not doing the cutting for attention since she always wears clothing that covers up her injuries, and further, she's not willing to talk about it."
"You don't understand her problems and don't take them seriously, so you shouldn't be allowed to work with her during her hospitalization."
"Perhaps you should transfer to another unit where you are able to have empathy for clients."
"It's hard to see a young person harm herself as she does, but she has serious family issues and doesn't know better ways to handle them, so we have to help her with that."
Good work
A client was talking with her husband by telephone, and then she began
swearing at him. The nurse interrupts the call and offers to talk with the client. She says, "I can't talk about that bastard right now. I just need to destroy something." What should the nurse do next?
Offer her a phone book to "destroy" while staying with her. Ask her to calm down or she will be restrained.
Urge her to talk with the nurse now.
Tell her to write her feelings in her journal. Good work
A family member visiting an acute care psychiatric unit approaches the
nurses' station and reports an elderly client walking in the hall without clothing. The nurse doesn't assist the client and suggests the family member inform the nurse assigned to that client. Which term describes the nurse's action?
compassionate sensitive organized
negligent Good work
Which probe should the nurse use to encourage client evaluation of his or
her own behavior?
"I can hear that it's still hard for you to talk about this." "What will it take to carry out your new plans?"
"So what does this all mean to you now?"
"What did you do differently with your coworker this time?" Good work
When developing the plan of care for a client with suicidal ideation, the nurse should address which priority issue?
stress
safety
self-esteem sleep
Good work
The nurse is planning care for a newly admitted client on the psychiatric unit.
Which action by the nurse is most important? To set limits with the client for behavior
To know how to solve the client's problems accurately
To establish trust and rapport by using the client's name and maintaining eye contact
To encourage the client to participate in recreational activities Good work
An adolescent girl 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?
giving a diuretic
giving naloxone IV
forcing fluids
inducing vomiting Good work
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.
Discuss the conversation directly with the other nurse.
Encourage the interaction with the client after discharge. Report the conversation to the nurse manager.
Good work
A mute client begins to express herself verbally on occasion. Which nursing
action should be credited with helping a mute client express herself verbally? making open-ended statements followed with silence
using hand signals to entice the client to communicate asking direct questions that draw the client out
expressing perceptions about what the client is experiencing Good work
Two unlicensed assistive personnel (UAP) are discussing which person is
responsible for taking the dirty linen bags into the utility room. One UAP approaches the charge nurse and complains about the other. Which action should the nurse employ?
Advise the UAP to be more tolerant of his coworker.
Urge the UAP to discuss the problem with his coworker. Tell the UAP to take care of the linen bags himself.
Take care of the linen bags to avoid further conflict. Good work [Show Less]