Foundations of psychiatric Mental Health Nursing
A nurse is reviewing the health care record of a client admitted to the psychiatric unit. The nurse notes that the admission nurse has documented that the client is experiencing anxiety as a result of a situational crisis. The nurse would determine that this type of crisis could be caused by:
1. A fire that destroyed the client's home.
2. A recent rape episode experienced by the client
3. The death of a loved one
4. Witnessing a murder
3- A situational crisis is associated w/a life event. External situations that could precipitate a situational crisis include- loss or change of a job, the death of a loved one, abortion, change in financial status, divorce, addition of new family members, pregnancy, severe illness.
* Options 1,2,4 identify adventitious crisis.
A nurse is gathering data from a client in crisis. When determining the client's perception of the precipitating event that led to the crisis, the most appropriate question to ask is:
1. "What leads you to seek help now?"
2. "Who is available to help you?"
3. "What do you usually do to feel better?"
4. "With whom do you live?"
1- A nurse's initial task when gathering data from a client in crisis is to assess the individual or family & the problem. The more clearly the problem can be defined, the better the chance a solution can be found.
* Option 1 will assist in getting the data related to the precipitating event that led to the crisis. Options 2 & 4 identify situational supports. Option 3 identifies personal coping skills
A nurse is assisting in developing a plan of care for the client in a crisis state. When developing the plan, the nurse will consider which of the following?
1. Presenting symptoms in a crisis situation are similar for all individuals experience a crisis.
2. A crisis state indicates that the individual is suffering from an emotional illness.
3. A crisis state indicates that the individual is suffering from a mental illness.
4. A client's response to a crisis is individualized, and what constitutes a crisis for one person may not constitute a crisis for another person.
4- * Eliminate option 1 because of the absolute word "all." Next, eliminate options 2 & 3 because a crisis does not indicate "illness."
A nurse observes that a client with a potential for violence is agitated, pacing up & down in the hallway, and making aggressive & belligerent gestures at other clients. Which statement would be appropriate to make to this client?
1. "What is causing you to become agitated?"
2. "You need to stop that behavior now!"
3. "You will need to be restrained if you do not change your behavior."
4. "You will need to be placed in seclusion!"
1- This will assist the client to become aware of his/her behavior & will assist the nurse in planning appropriate interventions for the client.
During a conversation with a depressed client on a psychiatric unit, the client says to the nurse, "My family would be better off without me." The nurse should make which therapeutic response to the client?
1. "Everyone feels this way when they are depressed."
2. "Have you talked to your family about this?"
3. "You sound very upset. Are you thinking of hurting yourself?"
4. "You will feel better once your medication begins to work."
3- The client should be directly asked if a plan for self-harm exists
A nurse caring for an older adult client who has recently lost her husband. The client says, "No one cares about me anymore. All the people I loved are dead." Which response by the nurse is therapeutic?
1. "That seems rather unlikely to me."
2. "You must be feeling all alone at this point."
3. "I don't believe that, and neither do you."
4. "Right! Why not just 'pack it in'?"
2- The therapeutic response from the nurse is one that translates words & feelings.
A nurse is planning care of a client who is being hospitalized because the client has been displaying violent behavior & is at risk for potential harm to others. The nurse avoids which intervention in the plan of care?
1. Keeping the door to the client's room open when with the client.
2. Assigning the client to a room at the end of the hall to avoid disturbing the other clients
3. Facing the client when providing care
4. Ensuring that a security officer is within the immediate area.
2- The client should be placed in a room near the nurses' station & not at the end of a long, relatively unprotected corridor.
Which behaviors observed by the nurse might lead to the suspicion that a depressed adolescent client could be suicidal?
1. The client becomes angry while speaking on the telephone and slams the receiver down on the hook.
2. The client runs out of the therapy group swearing at the group leader, and runs to her room.
3. The client gets angry w/her roommate when the roommate borrows her clothes without asking.
4. The client gives away a prized CD & a cherished autographed picture of the performer.
4- A depressed, suicidal client often gives away that which is of value as a way of saying "goodbye" & wanting to be remembered.
* The remaining options identify acting-out behaviors.
A client is admitted to the psychiatric unit following a serious suicidal attempt by hanging. The nurse's most important aspect of care is to maintain client safety and plans to:
1. Assign a staff member to the client who will remain w/the client at all times.
2. Admit the client to a seclusion room where all potentially dangerous articles are removed
3. Remove the client's clothing & place the client in a hospital gown
4. Request that a peer remain with the client at all times.
1- Hanging is a serious suicide attempt. Constant observation status (one on one) w/a staff member who is never less than an arm's length away is the safest intervention.
The police arrive at the emergency room w/a client who has seriously lacerated both wrists. The initial nursing action is to:
1. Examine & treat the wound site
2. Secure & record a detailed history
3. Encourage & assist the client to ventilate feelings.
4. Administer an antianxiety agent
1- The initial nursing actions is to examine and treat the self-inflicted injuries.
* Use Maslow's Hierarchy of needs theory to prioritize.
A nurse receives a telephone call from a male client who states that he wants to kill himself & has a bottle of sleeping pills in front of him. The best nursing action is to:
1. Insist that the client give you his name & address so that you can get the police there immediately
2. Keep the client talking & allow the client to ventilate feelings
3. Use therapeutic communications, especially the reflection of feelings
4. Keep the client talking and signal to another staff member to send help to the client
4- In a crisis, the nurse must take an authoritative, active role to promote the client's safety.
A nurse is caring for a client w/severe depression. Which of the following activities would be most appropriate for this client?
1. Paint by number
2. A puzzle
3- Concentration & memory are poor in a client w/severe depression. When a client has a diagnosis of severe depression, the nurse needs to provide activities that require little concentration. Activities that have NO RIGHT OR WRONG choices or decisions minimized opportunities for the client to put him/herself down.
* Use process of elimination. Notice 1,2,4 are alike*
A client experiencing a severe major depressive episode is unable to address activities of daily living. The appropriate nursing intervention is to:
1. Feed, bathe, & dress the client as needed until the client can perform these activities independently
2. Structure the client's day so that adequate time can be devoted to the client's assuming responsibility for the activities of daily living
3. Offer the client choices & consequences to the failure to comply w/the expectation of maintaining activities of daily living
4. Have the client's peers confront the client about how the noncompliance in addressing activities of daily living affects the milieu
1- The client w/depression may not have the energy or interest to complete ADLs. Often, severely depressed clients are unable to perform even the simplest activities of daily living. The nurse assumes this role & completes these tasks with the client.
*Options 2 & 3 are incorrect because the client lacks the energy & motivation to perform these tasks independently. Option 4 will increase the client's feelings of poor self-esteem & unworthiness.
An older male client who is a victim of elder abuse & the client's family have been attending weekly counseling sessions. Which statement by the abusive family member would indicate that he or she has learned positive coping skills?
1. "I will be more careful to make sure that my father's needs are met."
2. "I am so sorry & embarrassed that the abusive event occurred. It won't happen again."
3. "I feel better able to care for my father now that I know where to obtain assistance."
4. Now that my father is moving into my home, I will need to change my ways."
3- Elder abuse sometimes occurs with family members who are being expected to care for their aging parents. This can cause family members to become overextended, frustrated, or finically depleted. knowing where to go for help within the community for assistance can bring much needed relief.
A nurse is assisting in planning for a client being admitted to the nursing unit who has attempted suicide. Which priority nursing intervention will the nurse include in the plan of care?
1. Check the whereabouts of the client every 15mins
2. Suicide precautions, with 30min checks
3. One-to-one suicide precautions
4. Ask that the client report suicidal thoughts immediately
3- One-to-one suicide precautions are required for the client who has attempted suicide.
A nurse is preparing to care for a dying client & several family members are at the client's bedside. Select the therapeutic techniques that the nurse will use when communicating with the family. -select all that apply-
__ Be honest & truthful & let the client & family know that you will not abandon them
__ Explain everything that is happening to all family members
__ Encourage expression of feelings, concerns, and fears member's hand if appropriate
__ Extend touch & hold the client's or family member's hand if appropriate
__ Make the decisions for the family
__ Discourage reminiscing
1,3,4- Be honest & truthful & let the client & family know that you will not abandon them
Encourage expression of feelings, concerns, and fears
Extend touch & hold the client's or family member's hand if appropriate.
* It's important for the nurse to determine if there is a spokesperson for the family & how much the client & family want to know.
A crisis that relates to a crisis, disaster, or event that is not a part of everyday life, is unplanned, and is accidental.