The nurse is conducting discharge teaching for a client with schizophrenia who plans to
live in a group home. Which statement is most indicative of the
... [Show More] need for careful followup after discharge?
a. Crickets are a good source of protein.
b. I have not heard any voices for a week.
c. Only my belief in God can help me.
d. Sometimes I have a hard time sitting still - ANS-*C. Only my belief in God can help
me.*
The most frequent cause of increased symptoms in psychotic clients is non-compliance
with the medication regimen. If clients believe that "God alone" is going to heal them (C)
then they may discontinue their medication, so (C) would pose the greatest threat to this
client's prognosis. (A) would require further teaching, but is not as significant a
statement as (C). (B) indicates an improvement in the client's condition. (D) may be a
sign of anxiety that could improve with tx, but does not have the priority of (C).
A child is brought to the ER with a broken arm. Because of other injuries, the nurse
suspects the child may be a victim of abuse. When the nurse tries to give the child an
injection, the child's mother becomes very loud and shouts, "I won't leave my son! Don't
you touch him! You'll hurt my child!" What is the best interpretation of the mother's
statements? The mother is
a. regressing to an earlier behavior pattern.
b. sublimating her anger.
c. projecting her feelings onto the nurse.
d. suppressing her fear. - ANS-*C. projecting her feelings onto the nurse.*
Projection is attributing one's own thoughts, impulses, or behaviors onto another--it is
the mother who is probably harming the child and she is attributing her actions to the
nurse (C). The mother may be immature, but (A) is not the best description of her
behavior. (B) is substituting a socially acceptable feeling for an unacceptable one.
These are not socially acceptable feelings. The mother may be suppressing her fear (D)
by displaying anger, but such an interpretation cannot be concluded from the data
presented.
An elderly female client with advanced dementia is admitted to the hospital with a
fractured hip. The client repeatedly tells the staff, "Take me home. I want my Mommy."
Which response is best for the nurse to provide?
a. Orient the client to the time, place, and person.
b. Tell the client that the nurse is there and will help her.
c. Remind the client that her mother is no longer living.d. Explain the seriousness of her injury and need for hospitalization. - ANS-*B. Tell the
client that the nurse is there and will help her.*
Those with dementia often refer to home or parents when seeking security and comfort.
The nurse should use the techniques of "offering self" and "talking to the feelings" to
provide reassurance (B). Clients with advanced dementia have permanent physiological
changes in the brain (plaques and tangles) that prevent them from comprehending and
retaining new information, so (A, C, and D) are likely to be of little use to this client and
do not help the clients emotional needs.
A 27 y/o F client is admitted to the psychiatric hospital with a dx of bipolar disorder,
manic phase. She is demanding and active. Which intervention should the nurse include
in this client's plan of care?
a. Schedule her to attend various group activities.
b. Reinforce her ability to make her own decisions.
c. Encourage her to identify feelings of anger.
d. Provide a structured environment with little stimuli. - ANS-*D. Provide a structured
environment with little stimuli. [Show Less]