17 notecards = 5 pages (4 cards per page)
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:
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.
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- 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.
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?
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- 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?
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?
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?
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?
4- A depressed, suicidal client often gives away that which is of value as a way of saying "goodbye" & wanting to be remembered.
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- 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- The initial nursing actions is to examine and treat the self-inflicted injuries.
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:
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?
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.
A client experiencing a severe major depressive episode is unable to address activities of daily living. The appropriate nursing intervention is to:
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.
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?
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?
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-
1,3,4- Be honest & truthful & let the client & family know that you will not abandon them
A crisis that relates to a crisis, disaster, or event that is not a part of everyday life, is unplanned, and is accidental.