ATI Learning Systems - Mental Health 1

1 ATI Learning Systems - Mental Health 1 1. A nurse is caring for a client who has borderline personality disorder. The nurse enters the client’s room and finds the client cutting his flesh with a paper clip. After providing first aid. Which of the following actions should the nurse take FIRST? A) Encourage the client to discuss feelings about his self-injurious behavior during group therapy. B) Fill out an incident report for risk management about the client's self-injurious behavior. C) Document the client's self-injurious behavior in his medical record. D) Identify the client's feelings that led to the self-injurious behavior. Rationale Encourage the client to discuss feelings about his self-injurious behavior during group therapy. The nurse should encourage the client to participate in group therapy or a support group to discuss feelings about self-injurious behavior; however, there is another action that the nurse should take first. Fill out an incident report for risk management about the client's self-injurious behavior. The nurse should complete an incident report about the self-injurious behavior; however, there is another action that the nurse should take first. Document the client's self-injurious behavior in his medical record. The nurse should document the self-injurious behavior in the client's medical record; however, there is another action that the nurse should take first. Identify the client's feelings that led to the self-injurious behavior. The nurse should apply the nursing process priority-setting framework. The nurse can use the nursing process to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify the provider of a change in the client's status, she must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with knowledge to make an appropriate decision. Therefore, the first action the nurse should take is to assist the client to identify events or feelings that led to his selfinjurious behavior. 2.A nurse is assessing a client who is experiencing moderate-level anxiety. Which of the following findings should the nurse expect? A) The client has a heightened perceptual field. B) The client has difficulty concentrating. C) The client reports shortness of breath. D) The client reports a sense of impending doom. The client has a heightened perceptual field. The nurse should expect a client who is experiencing mild anxiety to have a heightened perceptual field; however, the perceptual field becomes narrowed as the anxiety increases to a moderate level. The client has difficulty concentrating. The nurse should expect the client who has moderate-level anxiety to have difficulty concentrating and focusing. This lack of concentration increases as the anxiety level escalates. The client reports shortness of breath. 2 The nurse should expect severe somatic complaints, such as shortness of breath, for a client who is experiencing a panic level of anxiety. The client reports a sense of impending doom. The nurse should expect a sense of impending doom for a client experiencing a severe level of anxiety. 3. A nurse in a pediatric ED is caring for four clients. The nurse should suspect possible abuse with which of the following clients? A) 14 m.o. toddler who has recently learned to walk and has many bruises on bony prominences in various stages of healing. B) 9 m.o. infant who reportedly nearly drowned after climbing into the tub and turning on the water. C) 6 y.o. toddler who has a fracture of the tibia and fibula, which reportedly occurred while riding a bicycle. D) 3 y.o. toddler who has burns in a splash pattern over the face and chest, reportedly sustained when a tablecloth was pulled, spilling a teapot. A 14-month-old toddler who has recently learned to walk and has many bruises on bony prominences in various stages of healing Toddlers have recently mastered walking and experience many falls and collisions. Because the bruises are in various stages of healing and are located over bony prominences, this likely indicates falling on several occasions. A 9-month-old infant who reportedly nearly drowned after climbing into the tub and turning on the water The nurse should identify that, while a 9-month-old might have the ability to climb into the tub, it is unlikely that he could turn the water on. The nurse should suspect possible abuse because the reported cause of the accident seems inconsistent with the developmental abilities of most 9-month-old infants. A 6-year-old toddler who has a fracture of the tibia and fibula, which reportedly occurred while riding a bicycle Fractures can be caused by physical abuse, but this 6-year-old child is learning to ride a bicycle. This injury is consistent with having a fallen off of a bicycle. A 3-year-old toddler who has burns in a splash pattern over the face and chest, reportedly sustained when a tablecloth was pulled, spilling a teapot The history is consistent with the injury. Toddlers frequently help pull themselves up by pulling on objects that might be unstable. The splash of burns would occur from the head downward. 4. 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 ask to assess the client’s remote memory? A) What year did you graduate from high school? B) What is your favorite childhood memory. C) What did you have for supper yesterday? D) What is today's date? Rationale "What year did you graduate from high school?" When assessing a client’s remote memory, the nurse should ask questions that determine the client’s ability to remember things from the distant past. The nurse should ask questions that can be validated to ensure that the information is correct. "What is your favorite childhood memory?" 3 When assessing the client’s memory, the nurse should ask questions that can be validated. The client could use confabulation to develop an answer about childhood memories; therefore, this question does not accurately assess the client’s remote memory. "What did you have for supper yesterday?" The nurse should ask questions about the past few days when assessing the client’s recent memory. "What is today's date?" The nurse should ask the client about the current date when assessing the client’s orientation. 5. A nurse in the ED is caring for female pt who has ecchymosis of the trunk and face, client reports her partner hit her, causing the injuries. when offered info about shelters for IPV the client declines stating, I could never leave my husband because of my kids" Appropriate response? A. "Aren't you worried about the safety of your children?" B. "Can you identify your behaviors that provoke your partner?" C. "The next time this occurs, what might you do to ensure your safety?" D "You need to remove yourself and your children from the abusive situation." Rationale "Aren't you worried about the safety of your children?" The nurse should avoid making responses that are judgmental and might make the client defensive about her abilities as a mother to protect her children. "Can you identify your behaviors that provoke your partner?" The nurse should avoid making responses that imply that the client is somehow to blame for the abuse. "The next time this occurs, what might you do to ensure your safety?" The nurse should use the therapeutic communication technique of encouraging formulation of a plan of action. With this technique, the nurse encourages the client to explore alternative actions to ensure her safety if abuse occurs in the future. The nurse should assist the client to develop a safety plan, which includes information about shelters, so that she has the information if she chooses to leave in the future. "You need to remove yourself and your children from the abusive situation." The nurse should avoid offering an opinion or advice, which is a nontherapeutic communication technique that blocks further dialogue with the client. 6. A nurse is caring for a client who has a major depressive d/o and recently started taking an anti-depressant. The nurse should ID which of the following client statements as the priority? A) I hate being so helpless. I can't even manage my own finances anymore. B) At group therapy today, I wanted to leave. I didn't feel like being with other people. C) I have it all figured out. Everything is going to be okay now. D) I don't feel like showering. I'd rather just stay in bed today. Rationale "I hate being so helpless. I can't even manage my own finances anymore." The nurse should identify that an inability to perform tasks and low self-esteem are expected findings of depression. The nurse should explore this statement further and plan interventions to raise the client’s self-esteem; however, there is another statement that the nurse should address first. "At group therapy today, I wanted to leave. I didn't feeling like being with other people." 4 The nurse should identify that social withdrawal is an expected finding of depression. The nurse should explore this statement further and encourage participation in group therapy; however, there is another statement that the nurse should address first. "I have it all figured out. Everything is going to be okay now." The nurse should apply the safety and risk reduction priority-setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow’s hierarchy of needs, the ABC prioritysetting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. Therefore, the nurse should identify that this client statement is the priority because it indicates a possible plan for suicide. This reaction is possible after starting an antidepressant, when the client gains the energy to act upon suicidal thoughts. "I don't feel like showering. I'd rather just stay in bed today." The nurse should identify that neglect of personal hygiene and withdrawal are expected findings of depression. The nurse should explore this statement further and encourage personal hygiene; however, there is another statement that the nurse should address first. 7. A nurse is caring for a client who has a new dx of colon cancer. Shortly after the client receives the dx the nurse enters the client's 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? A. Denial B. Displacement C. Reaction formation D. Projection Rationale Denial The nurse should identify denial as the refusal to accept reality and to act as if a painful event, thought, or feeling does not exist. Displacement The nurse should identify displacement as the redirection of thoughts, feelings, and impulses from an object that causes to anxiety to a safer, more acceptable one. In this scenario, the client is redirecting his anxiety about the diagnosis to the staff that is providing care. Reaction formation The nurse should identify reaction formation when the client exhibits a behavior or emotion that is the opposite of what the client actually feels. Projection The nurse should identify projection when the client attributes undesired impulses to another. 8. 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? A) Suppression B) Countertransference C) Transference D) Assertiveness. 5 Rationale. Suppression The nurse demonstrates suppression through the conscious denial of a disturbing feeling. Countertransference The nurse demonstrates countertransference by unconsciously attributing feelings, positive or negative, about another towards the client. Transference The client demonstrates transference through the unconscious displacement of feelings towards the nurse. Assertiveness The nurse demonstrates assertiveness through communication and the expression of feelings without denying those of others. 9. A nurse is planning reminiscence therapy for an older adult client. The nurse should ID which of the following goals for client therapy? A) The client will gain increased self-esteem. B) The client will maintain orientation to place and time. C) The client will independently perform ADLs. D) The client will achieve optimal sensory stimulation. Rationale The client will gain increased self-esteem. The nurse should use reminiscence therapy to assist the client in reflecting on past experiences. This review of the client’s life is intended to increase the client’s selfesteem and attain ego integrity. The client will maintain orientation to place and time. The nurse should use reorientation strategies to assist the client in achieving and maintaining orientation. The client will independently perform ADLs. The nurse should promote independence in ADLs for a client who has a self-care deficit. The client will achieve optimal sensory stimulation. The nurse should promote sensory stimulation for a client who has diminished sensory perception. 10. A nurse is assessing a client who has anorexia nervosa. expect the client to display which characteristics? A) Refuses to participate in physical exercise activities. B) Possesses feelings of decreased self-worth. C) Preoccupied with concerns about personal health. D) Avoids discussion of food. Rationale Refuses to participate in physical exercise activities The nurse should expect the client who has anorexia nervosa to participate in a rigorous exercise routine to promote increased weight loss. Possesses feelings of decreased self-worth The nurse should expect the client who has anorexia nervosa to have an altered sense of self-image and self-identity. The client often bases feelings of self-worth on body weight; therefore, feelings of self-worth are often decreased because the client views herself as overweight. Preoccupied with concerns about personal health 6 The nurse should expect the client who has anorexia nervosa to have medical complications due to decreased body weight and malnutrition. The client who has anorexia nervosa is focused on weight without regard to personal health consequences. Avoids discussion of food The nurse should expect the client who has anorexia nervosa to be obsessed with thoughts of food despite the personal restrictions on intake. 7 11. 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? A) Identify the client's perception of the reason for therapy. B) Ask the client to provide a detailed description of the hallucinations. C) Assist the client with the development of problem-solving skills. D) Explore the client's relationship with family members. Rationale. Identify the client's perception of the reason for therapy. In the initial, orientation phase of the nurse-client relationship, the nurse should establish rapport and confidentiality with the client. The nurse should assess the client’s beliefs about the reason for therapy. Ask the client to provide a detailed description of the hallucinations. The nurse should gather further data, including a detailed assessment of the client’s hallucinations, during the working phase of the therapeutic nurse-client relationship. Assist the client with the development of problem-solving skills. The nurse should assist the client with the development of problem-solving skills during the working phase of the therapeutic nurse-client relationship. Explore the client's relationship with family members. The nurse should gather further data, including an assessment of the client’s family relationships, during the working phase of the therapeutic nurse-client relationship. 12. A nurse is caring for a client who has schizophrenia. the client states, "My internal organs have turned to stone." The nurse should document this finding as which type of delusion? A) Somatic B) Reference C) Persecutory D) Grandiose Rationale. Somatic The nurse should identify that the client is experiencing a somatic delusion. Clients experiencing a somatic delusion believe that a body part is no longer functioning in a realistic or expected manner. Reference The nurse should identify that a client who has a delusion of reference believes that occurrences in the environment are about or because of him. Persecutory The nurse should identify that a client who has a persecutory delusion believes that someone or something wants to intentionally harm him. Grandiose The nurse should identify that a client who has a grandiose delusion believes that he is superior or more important than others. 8 13. A nurse is caring for a client who has depression. The nurse observes the client has not come to breakfast and is still in bed. The client states, "I am not worth your time, leave me alone and go help someone else." Which of the following responses should the nurse make? A) Many people feel this way when they first start treatment. B) In other words, you seem to be saying that you feel unworthy of help. C) You'll feel better once you get up and have some breakfast. D) I disagree with your feeling that you are not worth my time. Rationale. "Many people feel this way when they first start treatment." The nurse should avoid using nontherapeutic communication that minimizes the client’s feelings. "In other words, you seem to be saying that you feel unworthy of help." The nurse should use the therapeutic technique of paraphrasing to clarify the client’s statement and promote further communication. "You'll feel better once you get up and have some breakfast." The nurse should avoid using nontherapeutic communication that provides false reassurance. "I disagree with your feeling that you are not worth my time." The nurse should avoid using nontherapeutic communication that offers disapproval of the client’s feelings. 14. A nurse is providing support for the parents of a child who has a new dx of a terminal brain tumor. The nurse should expect the parents to experience which of the following of grief FIRST? A) Denial B) Bargaining C) Anger D) Depression. Rationale Denial Evidenced-based practice indicates the nurse should first expect the parents to experience denial. Denial is the first stage of grief and is followed by anger, bargaining, depression, and finally acceptance. Bargaining The nurse should expect the parents to eventually experience the bargaining stage of grief; however, there is another stage of grief that the nurse should expect first. Anger The nurse should expect the parents to eventually experience the anger stage of grief; however, there is another stage of grief that the nurse should expect first. Depression The nurse should expect the parents to eventually experience the depression stage of grief; however, there is another stage of grief that the nurse should expect first. 9 15. A nurse is preparing to admin fluphenazine decanoate 12.5 mg subcutaneous. Available is fluphenazine decanoate 25mg/mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.) 0.5 mL Desired Over Have STEP 1: What is the unit of measurement the nurse should calculate? mL STEP 2: What is the dose the nurse should administer? Dose to administer = Desired 12.5 mg STEP 3: What is the dose available? Dose available = Have 25 mg STEP 4: Should the nurse convert the units of measurement? No STEP 5: What is the quantity of the dose available? 1 mL STEP 6: Set up an equation and solve for X. mL Desired x Quantity/Have = X 12.5 mg x 1 mL/25 mg = X mL 0.5 mL = X STEP 7: Round if necessary. 16. a nurse at a college campus health clinic is caring for a client who reports manifest 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? A) Why do you think you are experiencing these behaviors of binges and vomiting? B) Are other students in your dorm also experiencing this behavior? C) You are feeling helpless about changing this behavior? D) You know you must stop because you are endangering your health. Rationale "Why do you think you are experiencing these behaviors of binges and vomiting?" The nurse should avoid the nontherapeutic use of a "why" question, which can promote a defensive client response and block further communication. "Are other students in your dorm also experiencing this behavior?” The nurse should avoid the use of a closed-end question that takes the focus off of the client. "You are feeling helpless about changing this behavior?" The nurse should use the therapeutic communication technique of restating when responding to the feelings the client has expressed. Restating focuses on the main idea of the client’s statement and helps the client understand and explore personal behaviors. "You know you must stop because you are endangering your health." The nurse should avoid offering premature advice, which implies that the nurse knows what is best for the client and blocks communication and the client’s use of independent problem solving. 10 17. A nurse is caring for a client at a college mental health counseling center. The client received a failing grade in a course and spends the entire counseling session blaming the teacher. The nurse should recognize this behavior as an example of which defense mechanism? A) Projection B) Dissociation C) Undoing D) Compensation Rationale Projection The nurse should identify that a client is using projection when unconsciously transferring unacceptable feelings, thoughts, or traits in oneself onto another person. This response is maladaptive because it prevents the client from accepting responsibility for personal performance in school. Dissociation The nurse should recognize that the client is not using the defense mechanism of dissociation, which results in the client’s compartmentalization of undesirable personal attributes. Undoing The nurse should recognize that the client is not using the defense mechanism of undoing, which results in the client’s attempt to make up for an unacceptable action. Compensation The nurse should recognize that the client is not using the defense mechanism of compensation, which results in the client’s attempt to focus on a strength to compensate for a perceived weakness. 18. 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 defense mechanisms? A) Denial B) Identification C) Introjection D) Sublimation Rationale Denial The nurse should recognize that the client is demonstrating denial through her belief that her son is lying about her partner’s death. Identification Identification is taking on the characteristics of another person. Introjection Introjection is adopting the values and beliefs of another person. Sublimation Sublimation is the conversion of unacceptable drives into socially sanctioned activities. 11 19. A nurse is caring for a school-age client who begins wetting the bed after finding out that her parents are getting a divorce. The nurse should ID that the client is exhibiting which of the defense mechanisms? A) Regression B) Projection C) Repression D) Splitting Rationale Regression The nurse should identify that regression represents a dysfunctional attempt to reduce anxiety and conflict by returning to less mature behaviors that help the client better tolerate the anxiety. Projection Projection is the unconscious rejection of unacceptable features in oneself by attributing them to others. Repression Repression is the unconscious removal of thoughts or memories from one’s awareness. Splitting Splitting is the inability to integrate the positive and negative qualities of oneself or others into a combined idea. 20. A nurse is admin an oral sedative to a client who is receiving care following an involuntary admission. The client states I’m not taking any more medication. Which of the following actions should the nurse take? A) Administer the medication by another route B) Refer the client's refusal to the facility's ethics committee. C) Inform the client that, due to her involuntary admission, she cannot refuse a sedative. D) Document the client's refusal of the medication in the medical record. Rationale Administer the medication by another route. It is beyond the nurse’s scope of practice to administer a medication by a route other than what was prescribed by the provider. Refer the client's refusal to the facility's ethics committee. The client’s refusal of medication is a legal rather than an ethical issue. The nurse should recognize the client’s right to refuse medication and collaborate with the provider to meet the client’s needs. Inform the client that, due to her involuntary admission, she cannot refuse a sedative. The nurse should be aware of the client’s rights regarding an involuntary admission. This is incorrect information to provide the client. Document the client's refusal of the medication in the medical record. The nurse should respect the client’s right to refuse medication, even if the client is receiving treatment due to an involuntary admission. The nurse should document this refusal in the medical record and assess the reasons for the client’s refusal. 12 21. A nurse in an ED is caring for an 18-month-old toddler who has a fractured left femur. Which of the following statements by the toddler’s parent should cause the nurse to suspect child abuse? A) My child fell down the stairs. B) My child was riding a bicycle and fell of. C) My child slipped out of the highchair. D) My child climbed up on a chair and it tipped over. Rationale "My child fell down the stairs." The nurse should identify that 18-month-old toddlers are at a high risk for accidental injury due to falls because of increased mobility and curiosity; therefore, this report by the parent does not indicate child abuse. "My child was riding a bicycle and fell of." The nurse should suspect possible child abuse in response to this statement because an 18-month-old toddler is not expected to have the developmental ability to ride a bicycle. "My child slipped out of the highchair." The nurse should identify that 18-month-old toddlers are at a high risk for accidental injury due to falls because of increased mobility and curiosity; therefore, this report by the parent does not indicate child abuse. "My child climbed up on a chair and it tipped over." The nurse should identify that 18-month-old toddlers are at a high risk for accidental injury due to falls because of increased mobility and curiosity; therefore, this report by the parent does not indicate child abuse. 22. A community mental health nurse is planning strategies to address substance use by adolescents. Which of the following interventions should the nurse plan as a method of primary prevention? A) Offer substance use treatment options for adolescents from low-income households. B) Encourage the use of random testing for substance use for adolescents participating in extracurricular activities. C) Educate high school teachers about how to detect the manifestations of substance use. D) Provide a presentation at area high schools on resisting peer pressure for substance use. Rationale Offer substance use treatment options for adolescents from low-income households. Planning interventions that help stop or decrease substance use is an example of tertiary prevention. Ensuring that adolescents, regardless of income, have treatment options can decrease the overall incidence of substance abuse. Encourage the use of random testing for substance use for adolescents participating in extracurricular activities. Planning interventions that promote early detection of substance use is an example of secondary prevention. Encouraging the use of random testing for substance use allows for early detection and for the nurse to refer adolescents for treatment. Educate high school teachers about how to detect the manifestations of substance use. Planning interventions that promote early detection of substance use is an example of secondary prevention. Educating teachers about the manifestations of substance use allows for early detection and for the nurse to refer adolescents for treatment. 13 Provide a presentation at area high schools on resisting peer pressure for substance use. Planning interventions that prevent the onset of substance use is an example of primary prevention. By providing information to adolescents on methods to resist peer pressure for substance use, the nurse can help prevent the substance use from occurring. 23. A nurse is preparing to apply wrist restraints on a client who is threatening to harm others and has not responded to less invasive interventions. Which of the following should the nurse plan to take? A) Obtain a PRN prescription for restraints from the client's provider. B) Visually observe the client every 10 min until restraints are removed. C) Ensure that three fingers can fit between the restraint and the client's wrist. D) Document the client's behavior every 15 min while restrains are in place. Rationale Obtain a PRN prescription for restraints from the client's provider. The nurse should obtain a prescription for restraints from the provider; however, this prescription is legally required to be current and specific to the client’s present needs rather than PRN. Visually observe the client every 10 min until restraints are removed. The nurse should plan to have constant one-to-one observation by staff while the client is in restraints. Ensure that three fingers can fit between the restraint and the client's wrist. The nurse should ensure that two fingers can fit between the restraints and the client’s wrist. This safety check ensures adequate circulation while maintaining the effectiveness of the restraint. Document the client's behavior every 15 min while restraints are in place. The nurse should plan to document the client’s behavior every 15 min while restraints are in place. This frequent documentation meets the legal requirement for use of restraints; helps provide for prompt identification of complications related to restraint use; and helps ensure that restraints are removed as soon as possible, depending on the client’s behavior. 24. A nurse is conducting a counseling session with a client who has substance use d/o. The client repeatedly asks personal questions about the nurse. Which of the following actions should the nurse take? A) Explain that this time is designated to focus on the client. B) Answer the personal inquiry questions matter-of-factly. C) Tell the client that interest in someone besides himself is an indication of improvement. D) Request that personal questions be asked after the counseling session is over. Rationale Explain that this time is designated to focus on the client. The nurse should understand the difference between a therapeutic nurse-client relationship and a social relationship. The nurse should explain to the client that the counseling session time is designated to focus on the client and resolution of his problems. Answer the personal inquiry questions matter-of-factly. The nurse should avoid answering personal questions, which promotes a social, rather than therapeutic, relationship. 14 Tell the client that interest in someone besides himself is an indication of improvement. The nurse should understand that personal inquiries do not indicate improvement for a substance use disorder and can inhibit the therapeutic relationship. Request that personal questions be asked after the counseling session is over. The nurse should avoid answering personal questions, which promotes a social, rather than therapeutic, relationship. By requesting that personal questions wait until after the session, the nurse is indicating to the client that it is appropriate to ask personal questions, just not at this time. 15 25. 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 precaution? A) Assign the client to a private room. B) Request that the dietary department provides the client with finger foods. C) Place the client on one-to-one observation. D) Keep the door to the client's room closed. Rationale Assign the client to a private room. The nurse should avoid placing the client in a private room, where there is an increased opportunity for the client to harm himself. Request that the dietary department provide the client with finger foods. The nurse should provide the client with plastic rather than metal utensils to decrease the risk for self-harm; however, it is not necessary to provide finger foods. Place the client on one-to-one observation. The nurse has both a legal and professional responsibility to provide a safe environment for the client who is at risk for suicide. The client who is at high risk for suicidal behavior requires constant one-to-one observation to ensure safety. Keep the door to the client's room closed. The nurse should avoid closing the door to the client’s room, which gives the client an increased opportunity to harm himself. 26 A nurse is caring for a client whose adolescent child died in a motor vehicle crash. the client is crying inconsolably. Which of the following actions should the nurse take? A) Suggest that the client call the facility's chaplain. B) Provide a quiet place for the client to be alone. C) Stay with the client and allow the client to cry. D) Express sympathy for the client's loss. Rationale Suggest that the client call the facility's chaplain. The nurse should avoid offering advice, which is a nontherapeutic communication technique. The nurse can offer to contact the chaplain or support persons but should not assume that the client will find it beneficial. Provide a quiet place for the client to be alone. The nurse should identify that a client in crisis needs to feel safe and is at risk for selfharm; therefore, the nurse should not leave him alone at this time. Stay with the client and allow the client to cry. The nurse demonstrates respect for the client and his feelings by staying with him. The use of silence is a therapeutic communication technique and allowing the client to cry is therapeutic during times of grieving. Express sympathy for the client's loss. The nurse should use empathy rather than sympathy to promote a therapeutic nurseclient relationship. 16 27. A nurse is caring for a client who has depression and started taking paroxetine one week ago. The client states to the nurse, "My family would be better off without me." Which of the following responses should the nurse make? A) Why do you feel your family would be better off without you? B) Many people feel this way when they are depressed. C) You sound upset. Are you thinking of hurting yourself? D) Your medication hasn't started working yet. Then you'll be feeling differently. Rationale "Why do you feel your family would be better off without you?" The nurse should avoid asking a "why" question, which blocks communication by promoting a defensive client reaction. "Many people feel this way when they are depressed." This response exemplifies the nontherapeutic communication block of using a cliché. Telling the client that "many people feel this way" minimizes and takes the focus off of the client’s feelings. "You sound upset. Are you thinking of hurting yourself?" This response exemplifies the therapeutic communication technique of showing empathy. Telling the client, "You sound upset," focuses on the client’s feelings, which is a demonstration of therapeutic communication. In addition, the nurse addresses the possibility of suicidal ideation by asking the client directly whether or not she has an intent to harm herself. "Your medication hasn't started working yet. Then you'll be feeling differently. " This response exemplifies the nontherapeutic communication block of giving false reassurance. While the nurse is correct that antidepressant medications often take up to 3 weeks to take effect, there is no guarantee that the client will feel better at that time. 28. A nurse is admitting a client following care in the ER for an intentional O/D (overdose) of opioids. The client states, "I feel so alone, no one can help me." Appropriate response? A) Let's finish your admission and then talk about your feelings. B) How come you feel that no one can help you when you are receiving help now? C) Why do you feel that no one can help you? D) I would like to sit and talk with you. Rationale "Let's finish your admission and then talk about your feelings." The nurse should avoid using nontherapeutic communication that changes the focus away from the client’s feelings and blocks further communication. "How come you feel that no one can help you when you are receiving help now?" The nurse should avoid using nontherapeutic communication that makes a value judgment on the client’s feelings and blocks further communication. "Why do you feel that no one can help you?" The nurse should avoid using nontherapeutic communication that asks the client a "why" question, which promotes a defensive client response. "I would like to sit and talk with you." The nurse should use the therapeutic communication technique of offering one’s self to demonstrate caring and interest in the client and the client’s feelings. 17 29. A nurse in a mental health facility is reviewing confidentiality requirements with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates understanding of the information? A) I am legally required to notify a client's employer about a substance use disorder. B) If a client is involuntarily committed, I can discuss information with the client's next of kin. C) I can discuss a client's treatment with others as long as they are employees of the facility. D) I should keep information private even after a client dies. Rationale "I am legally required to notify a client's employer about a substance use disorder." The nurse should be aware that it is a breach of the client’s confidentiality to disclose information to an employer without her consent. "If a client is involuntarily committed, I can discuss information with the client's next of kin." The nurse should be aware that it is a breach of the client’s confidentiality to disclose information to the next of kin without her consent. This protection of the client’s privacy applies to clients who are receiving treatment voluntarily or involuntarily. "I can discuss a client's treatment with others as long as they are employees of the facility." The nurse should be aware that it is a breach of the client’s confidentiality to disclose information to other employees unless they are directly involved in the client’s care and the information is needed to carry out the client’s treatment plan. "I should keep information private even after a client dies." The nurse should be aware that a client’s right to privacy continues even after death. 30. A nurse at an acute mental health facility for a client who has acute mania due to bipolar d/o. At 0300 the client runs to the nurse’s station and demands to see the provider immediately. Appropriate response? A) Your request is unreasonable. We cannot call your provider at 3:00 in the morning. B) If you can calm down for 5 minutes, then I will call your provider for you. C) Calm down, go back to your room, and come back in 15 minutes and we'll talk about how you're feeling. D) You must be very upset about something to want to see your provider in the middle of the night. Rationale "Your request is unreasonable. We cannot call your provider at 3:00 in the morning." The nurse should avoid using nontherapeutic communication that indicates disapproval and blocks further communication. Depending on the client’s needs, it might be necessary for the nurse to contact the client’s therapist regardless of the time. "If you can calm down for 5 minutes then I will call your provider for you.” The nurse should clearly state expectations for the client’s behavior and avoid bargaining with the client, which can result in power struggles. "Calm down, go back to your room, and come back in 15 minutes and we'll talk about how you're feeling." The nurse should promptly address the client’s concerns and should avoid giving several directions at once, which can be confusing and difficult to follow for a client who is experiencing acute mania. 18 "You must be very upset about something to want to see your provider in the middle of the night." The nurse should respond to the client’s concern with empathy, which shows concern for the client’s feelings and offers an opportunity for the client to clarify the situation. 19 31. A client is hospitalized with schizophrenia. During a conversation with a nurse, the client seems relaxed initially, but then becomes restless and begins wringing his hands. The nurse states that the client seems tense, and the client agrees. Appropriate response? A) Did I say something wrong that made you feel tense? B) Do you often feel tense when you are talking to a Health care provider HCP? C) What were we discussing when you began to feel uncomfortable? D) It is ok to feel nervous during out counseling sessions. Rationale "Did I say something wrong that made you feel tense?" The nurse should avoid using closed-ended questions that block client communication. "Do you often feel tense when you are talking to a health care provider?" The nurse should avoid using closed-ended questions that block client communication. "What were we discussing when you began to feel uncomfortable?" The nurse should use the therapeutic technique of focusing, which promotes discussion about a specific topic. This technique helps identify the cause of the client’s feelings and promotes further communication. "It is ok to feel nervous during our counseling sessions." The nurse should avoid providing approval for and assuming the cause of the client’s feelings. These responses are nontherapeutic and block client communication. 32. A nurse is planning care for a client who has thoughts of suicide. Goals for nurse in the client’s plan of care? A) The client will identify positive aspects of others. B) The client agrees to notify a staf member of thoughts of self-harm. C) The client will engage in an independent diversional activity. D) The client will not verbalize thoughts or feelings related to suicide. Rationale The client will identify positive aspects of others. The nurse should assist the client to identify positive aspects about himself to improve the client’s sense of self-worth. The client agrees to notify a staf member of thoughts of self-harm. The nurse should instruct the client to notify staff if he has suicidal thoughts so that the client’s needs are immediately addressed, and actions are taken to prevent self-injury or suicide. The client will engage in an independent diversional activity. The nurse should encourage the client to participate in activities with others to decrease the client’s sense of isolation. The client will not verbalize thoughts or feelings related to suicide. The nurse should encourage the client to verbalize thoughts and feelings related to suicide rather than suppress them. 20 33. A nurse in a mental health clinic is caring for a client who has bipolar disorder (d/o) and states, I no longer take my medication because I like the feeling of being manic.” Which of the following response by the nurse is an example of therapeutic communication? A. "You might feel good now, but what about when you get depressed?" B. "Why do you think you like feeling manic?" C. "You feel better when you don't take your medication?" D. "What do you think your provider will say about you going off your medication?” Rationale "You might feel good now, but what about when you get depressed?" The nurse should avoid nontherapeutic communication that minimizes the client’s current feelings. "Why do you think you like feeling manic?" The nurse should avoid nontherapeutic communication that promotes a defensive client response. "You feel better when you don't take your medication?" The nurse should use the therapeutic communication tool of validating or clarifying the client’s feelings. The client has stated a preference for not taking the medication. This open-ended paraphrasing acknowledges the client’s statement and allows for further exploration of the subject. "What do you think your provider will say about you going off your medication?” The nurse should avoid nontherapeutic communication that takes the focus from the client and puts it on the provider. 34. A nurse is completing an admission assessment for an adolescent client who has depression. The nurse should identify which of the following findings as priority? A) The client is confrontational with his parents. B) The client is getting Ds in his classes because he frequently skips school. C) The client states he smokes half a pack of cigarettes per day. D) The client gave his favorite possessions to friends. Rationale The client is confrontational with his parents. The nurse should identify that a confrontational attitude and anger with parents is an expected finding for an adolescent, as well as an indication of depression. The nurse should promote positive interactions between the client and his parents and assist the client to address feelings of anger; however, there is another finding that is the priority. The client is getting Ds in his classes because he frequently skips school. The nurse should identify that withdrawal from social activities, including school, is an expected finding for an adolescent who has depression. The nurse should promote social interaction and school attendance; however, there is another finding that is the priority. The client states he smokes half a pack of cigarettes per day. The nurse should identify that substance use is an expected finding for an adolescent who has depression. The nurse should plan interventions to assist the client in smoking cessation; however, there is another finding that is the priority. The client gave his favorite possessions to friends. The nurse should apply the safety and risk reduction priority-setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow’s hierarchy of needs, the ABC prioritysetting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. Therefore, the nurse should identify this finding as the priority. Giving away 21 valued and prized possessions is an indication of suicidal ideation, which is the greatest risk for clients who have depression. 35. A nurse is caring for a client who has borderline personality disorder (d/o). The client previous ID another nurse as his favorite stating, “He’s the best nurse ever.” When that nurse calls in sick, which of the following indicates that the client is using splitting as a method of coping. A) “He's the worst nurse that's ever-taken care of me.” B) You're just lying to me. He's not really sick. C) He's my favorite nurse and I'm really worried about him. D) If anyone else tries to take care of me, I'm going to get really upset. Rationale "He's the worst nurse that's ever-taken care of me." The nurse should identify that the client is using splitting when he relates to others as if they are all good or all bad, rather than as integrated individuals who have both positive and negative attributes. Clients who have borderline personality disorder might use this coping style as a defense mechanism. "You're just lying to me. He's not really sick." The nurse should identify this client statement as an expression of paranoia and denial. "He's my favorite nurse and I'm really worried about him." The nurse should identify this client statement as an expression of concern. "If anyone else tries to take care of me, I'm going to get really upset." The nurse should identify this client statement as an expression of anger, which is expected for a client who has borderline personality disorder. 36. A nurse in a mental health clinic is caring for a client who states, "I think i might have a problem with alcohol." Nurse's priority action? A) Provide the client with information about a 12-step recovery program. B) Encourage the client to accept responsibility for his alcohol use. C) Teach the client alternate coping mechanisms to use in place of alcohol. D) Ask the client to complete a CAGE Questionnaire. Rationale Provide the client with information about a 12-step recovery program. The nurse should provide the client with information about a 12-step recovery program, such as Alcoholics Anonymous; however, there is another action that the nurse should take first. Encourage the client to accept responsibility for his alcohol use. The nurse should encourage the client to accept responsibility for his alcohol use, which encourages acceptance of the alcohol use problem and promotes recovery; however, there is another action that the nurse should take first. Teach the client alternate coping mechanisms to use in place of alcohol. The nurse should teach the client coping mechanisms to use in response to stress other than alcohol; however, there is another action that the nurse should take first. Ask the client to complete a CAGE Questionnaire. The nurse should apply the nursing process priority-setting framework. The nurse can use the nursing process to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify the provider of a change in the client's status, she must first 22 collect adequate data from the client. Assessing or collecting additional data will provide the nurse with knowledge to make an appropriate decision. Therefore, the first action the nurse should take is to assess the client’s alcohol use. Use of a CAGE Questionnaire is helpful to determine the impact of alcohol use on the client’s life. 37. A nurse receives a call on a crisis intervention hotline from a client.. Which of the following statements should the nurse ID as an overt statement indicating the clients risk for suicide? A) Everything will be better soon. B) Soon no one will have to worry about me. C) There's no point in living any longer. D) I want to donate my organs to help others. Rationale "Everything will be better soon." The nurse should identify this client comment as a covert statement. "Soon no one will have to worry about me." The nurse should identify this client comment as a covert statement. "There's no point in living any longer." The nurse should identify this client comment as an overt statement about the client’s risk for suicide. The nurse should assess the client’s suicidal ideation further and implement interventions to promote her safety. "I want to donate my organs to help others." The nurse should identify this client comment as a covert statement. 38. A nurse is caring for a client who has dementia. The client states to the nurse, "Everyone wants to kill me." Appropriate response? A) Tell me how everyone wants to hurt you. B) You must feel very frightened to think someone wants to hurt you. C) No one here wants to kill you. D) Who in particular do you think wants to kill you. Rationale "Tell me how everyone wants to hurt you." The nurse should reinforce reality rather than encourage the client to focus on the delusional belief. "You must feel very frightened to think someone wants to hurt you." The nurse should acknowledge the client’s feelings about the delusion. This acknowledgement helps the client to feel safe and accepted. "No one here wants to kill you." The nurse should avoid refuting the client’s delusion, which can actually promote the client’s delusional belief. "Who in particular do you think wants to kill you?" The nurse should reinforce reality rather than encourage the client to focus on the delusional belief. 23 39. A nurse enters a client room and observes 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? Appropriate response? A) I demand that you calm down now. Your behavior is unacceptable. B) I will close the door to provide privacy, and you can tell me what is bothering you. C) I will give you space if you calm down. Tell me what is causing you to feel so tense. D) I will leave you alone for a few minutes while you try to control yourself. Rationale "I demand that you calm down now. Your behavior is unacceptable." The nurse should avoid confrontational communication that will likely increase the client’s level of agitation. "I will close the door to provide privacy, and you can tell me what is bothering you." The nurse should consider staff safety when attempting to calm the client. By closing the door, the nurse does not have an escape route should the client become violent. "I will give you space if you calm down. Tell me what is causing you to feel so tense." The nurse should stay at a safe distance and remain calm while stressing the importance of maintaining control. The nurse should use verbal de-escalation techniques while determining the client’s needs and respecting the client’s personal space. Rationale: Stay at a safe distance and remain calm while stressing the importance of maintaining control. The nurse should use verbal de-escalation techniques while determining the client's needs and respecting the client's personal space. "I will leave you alone for a few minutes while you try to control yourself." The nurse should avoid leaving the client alone while he is in an agitated state and a potential danger to himself. If other de-escalation techniques are ineffective, then the nurse might implement seclusion in a safe and monitored environment. 40. A nurse is caring for a client who has alcohol use disorder (d/o) and receiving treatment (tx) for alcohol withdrawal (w/d). The client reports hand tremors, 12 hr after admission. Which of the following statements should the nurse make? A) The tremors are permanent due to nerve damage caused by chronic alcohol use. B) The tremors will persist for a few days as you are withdrawing from alcohol. C) Try not to worry about the tremors. Everyone has these during alcohol withdrawal. D) These tremors are an indication of seizures that are associated with alcohol withdrawal. Rationale "The tremors are permanent due to nerve damage caused by chronic alcohol use." The nurse should inform the client that manifestations of alcohol withdrawal are transient and are not a result of permanent nerve damage. "The tremors will persist for a few days as you are withdrawing from alcohol." The nurse should inform the client that tremors, as well as other manifestations of alcohol withdrawal, might persist for several days after the last intake of alcohol. "Try not to worry about the tremors. Everyone has these during alcohol withdrawal." The nurse should avoid nontherapeutic communication that generalizes the effects of alcohol withdrawal and minimizes the client’s concerns. "These tremors are an indication of seizures that are associated with alcohol withdrawal." 24 The nurse should inform the client that seizures can occur as a result of alcohol withdrawal; however, the fine tremors are a different manifestation and not an indication of seizure activity.