1. The nurse is informing the client about being diagnosed with cancer. Which is most likely going to be the client's initial reaction?:
... [Show More] Shock
explanation- Upon receiving the diagnosis of the disease, the client is most likely to be in a state of shock or disbelief. Shock is considered a universal reaction to loss. During this phase, the client is unable to accept the loss. Anger is most likely the next reaction. It is where the client would express anger toward God, family, and health care providers. Anxiety occurs when the client is waiting for the diagnosis and also when the client accepts the loss and starts feeling helpless. Once the client has accepted the loss, the client starts having negative feelings such as depression.
2. A client is crying continuously from having lost a friend in an accident. According to the tasks of grieving by Rando, which task of grief is expected to be accomplished next?: Recollect and reexperience
explanation-
The client is expressing grief (crying) for the friend's death, which indicates that the client is accomplishing the task of reaction. After this task, the client is likely to review memories related to the friend. This task of grief is referred to as the task of recollecting and reexperiencing. In the task of readjusting, the client begins to return to daily life after accepting the loss. In the task of reinvesting, the client accepts the changes that have occurred and starts forming new relationships and commitments.
3. A client with poorly controlled type 1 diabetes has just been informed that an amputation of the lower leg is required. The nurse can anticipate that the client will experience a reaction to the loss of which human need according to Maslow's hierarchy?: physiologic
explanation-
The client is about to experience physiologic loss of the lower right leg. The client is most likely to experience a reaction to this loss of human need according to Maslow's hierarchy. Safety loss refers to the loss of a safe environment such
as in domestic abuse, child abuse, or public violence. Loss of security and be- longing refers to the loss of loved ones. This loss can accompany the changes in relationships such as births, marriage, divorce, illness and death. The loss of self-actualization refers to potential life losses as a result of internal or external inhibition of the ability to strive toward fulfillment of individual potential.
4. The nurse is performing an initial psychological assessment on a client who has been rescued from a flood. Which question would be most important in helping determine the amount of support needed by the client?: "Have you thought about where you can stay right now?"
explanation-
The nurse should be determining the client's ability to solve problems with a psychological assessment. Asking if the client has been able to think about a possible solution to a living arrangement can help the nurse assess this. Once the nurse has an assessment of the client's problem-solving and coping skills, the nurse can plan further support needs. Asking about possessions is not a problem-solving question and neither is whether the client owns or rents the home. The nurse would want to explore the client's feelings but this would not necessarily give information on problem-solving or coping skills.
5. What does the nurse find on assessment of the thought processes of a client with obsessive-compulsive disorder (OCD)?: The obsessions become intense as the client tries to stop the behavior.
explanation- Clients with OCD do not willingly have obsessions or images, and their obsessions become more intense when they try to prevent them. Clients with OCD do not experience effects in memory or intellectual functioning. However, they have difficulty concentrating when the obsessions are strong. For most, the obsessions arise out of nowhere, during other activities.
6. A new client with a long-standing history of obsessive-compulsive disor- der (OCD) is describing to the nurse the complex ritual of locking and unlock- ing a door after entering a room alone. What is the nurse's most therapeutic response?: "The process you're describing sounds like it must require quite a bit of time and energy."
explanation-
Saying, "The process you're describing sounds like it must require quite a bit of time and energy" encourages the client to elaborate on the effect that the client's rituals have on the client's life. Rapport is likely to be harmed if the nurse focuses on "a problem that doesn't exist." Focusing on the prevalence of mental health disorders is likely to inhibit communication at this fragile, early stage of the nurse-patient relationship. Turing the tables by asking, "What would you say to me if I had similar rituals with locking and unlocking doors?" is not a recognized therapeutic technique.
7. The psychiatric mental health nurse has received a referral from a commu- nity health nurse regarding a client who appears to have hoarding disorder. When planning this client's care, the nurse should prioritize what consider- ation?: Promoting the client's safety in the home environment
explanation-
Safety is a paramount consideration for clients with hoarding disorder. Clients are not normally open to differentiating between necessary and unnecessary items.
Relaxation techniques are secondary to safety and there is not normally a need to involve law enforcement.
8. The nurse is caring for a client with obsessive-compulsive disorder (OCD). What are the expected outcomes for the client who has been stabilized by medication and behavior therapy?: Continue follow-up therapy as needed.
explanation-
Clients with OCD who have been stabilized by medication and behavior therapy may experience long-term difficulties in dealing with obsessive thoughts. These clients are encouraged to continue follow-up therapy. The expected outcome for clients in the stabilization phase of therapy is verbalizing knowledge of illness and treatment plan. In the immediate phase of therapy, clients should be able to list and review strengths and abilities with the nursing staff. These clients should also be able identify stresses and anxieties to enable the nurse to develop a plan of care.
9. The nurse is educating the client's family about compulsive behavior. The nurse is correct when making which statement?: The behavior neutralizes anxiety caused by obsessive thoughts.
explanation-
The client attempts to suppress or ignore the intrusive thoughts by indulging in ritualistic behavior. This behavior neutralizes the anxiety caused by obsessive thoughts. However, the thoughts and behaviors are not realistically connected. The client becomes agitated and anxiety levels increase when prompted to stop by external stimuli. The client has normal intellectual functioning and is not on the verge of insanity.
10. A client spends an hour cleaning and rearranging the client's desk prior to starting work after every break. This occurs about five to six times a day. How does the nurse rate the client according to the Yale-Brown Obsessive Compulsive Scale?: Severe [Show Less]