A nurse in an emergency mental health facility is caring for a group of clients. The nurse should identify that which of the following clients requires a
... [Show More] temporary emergency admission?
A. A client who has schizophrenia with delusions of grandeur
B. A client who has manifestations of depression and attempted suicide a year ago
C. A client who has borderline personality disorder and assaulted a homeless man with a metal rod
D. A client who has bipolar disorder and paces quickly around the room while talking to themselves
C
A client who is a current danger to self or others is a candidate for a temporary emergency admission
B is incorrect because clinical findings of depression do not constitute a clear reason for a temporary emergency admission unless the client is currently at risk for suicide
A nurse decides to put a client who has a psychotic disorder in seclusion overnight because the unit is very short-staffed, and the client frequently fights with other clients. The nurse's actions are an example of which of the following torts?
A. Invasion of privacy
B. False imprisonment
C. Assault
D. Battery
B
A civil wrong that violates a client's civil rights is a tort. In this case, it is false imprisonment, which is the confining of a client to a specific area (a seclusion room) if the reason for such confinement is for the convenience of the staff.
A client tells a nurse, "Don't tell anyone but I hid a sharp knife under my mattress in order to protect myself from my roommate, who is always yelling at me and threatening me." Which of the following actions should the nurse take?
A. Keep the client's communication confidential, but talk to the client daily, using therapeutic communication to convince him to admit to hiding the knife
B. Keep the client's communication confidential, but watch the client and his roommate closely.
C. Tell the client that this must be reported to the health care team because it concerns the health and safety of the client and others.
D. Report the incident to the health care team, but do not inform the client of the intention to do so.
C
The information presented by the client is a serious safety issue that the nurse must report to the health care team. Using the ethical principle of veracity, the student tells the client truthfully what must be done regarding the issue
A nurse is caring for a client who is in mechanical restraints. Which of the following statements should the nurse include in the documentation? (Select all that apply)
A. "Client ate most of their breakfast."
B. "Client was offered 8 oz of water every hr."
C. "Client shouted obscenities at assistive personnel."
D. "Client received chlorpromazine 15 mg by mouth at 1000."
E. "Client acted out after lunch."
B, C, D
The amount and frequency of fluids offered is objective data that should be documented when caring for a client in mechanical restraints.... blahblahblah basically all of these choices are objective data so you need to include it
A & E are incorrect because these aren't objective. How much is "most?" If it said "Client at 70% of breakfast" then it's right. "Acted out" also tells me nothing.
A nurse hears a newly licensed nurse discussing a client's hallucinations in the hallway with another nurse. Which of the following actions should the nurse take first?
A. Notify the nurse manager.
B. Tell the nurse to stop discussing the behavior.
C. Provide an in-service program about confidentiality.
D. Complete an incidence report.
B
The greatest risk to this client is an invasion of privacy through the sharing of confidential information in a public place. The first action to take is to tell the newly licensed nurse to stop discussing the client's hallucinations in a public location.
A charge nurse is conducting a class on therapeutic communication with a group of newly licensed nurses. Which of the following aspects of communication should the nurse identify as a component of verbal communication?
A. Personal space
B. Posture
C. Eye contact
D. Intonation
D
Intonation is the tone of one's voice and can communicate a variety of feelings
A nurse in an acute mental healthy facility is communicating with a client. The client states "I can't sleep. I stay up all night." The nurse responds, "You are having difficulty sleeping?" Which of the following therapeutic communication techniques is the nurse demonstrating?
A. Offering general leads
B. Summarizing
C. Focusing
D. Restating
D
Restating allow the nurse to repeat the main idea expressed.
A nurse is communicating with a client who was admitted for treatment of a substance use disorder. Which of the following communication techniques should the nurse identify as a barrier to therapeutic communication?
A. Offering advice
B. Reflecting
C. Listening attentively
D. Giving information
A
Offering advice to a client is a barrier to therapeutic communication that should be avoided. Advice tends to interfere with the client's ability to make personal decisions and choices
A nurse is caring for a client who has anorexia nervosa. Which of the following examples demonstrates the nurse's use of interpersonal communication?
A. The nurse discusses the client's weight loss during a health care team meeting.
B. The nurse examines their own personal feelings about clients who have anorexia nervosa.
C. The nurse asks the client about personal body image perception.
D. The nurse presents an educational session about anorexia nervosa to a large group of adolescents.
C
The nurse's one-on-one communication with the client is an example of interpersonal communication. [Show Less]