1. Neglecting personal grooming
2. Looking at old snapshots of family
3. Participating in a senior citizens’ program
4. Visiting their spouse’s grave once a month
Coping mechanisms are behaviors used to decrease stress and anxiety. In response to a death, ineffective coping is manifested by an extreme behavior that in some cases may be harmful to the individual physically or psychologically. The correct option is indicative of a behavior that identifies an ineffective coping behavior in the grieving process.
1. “You have everything to live for.”
2. “Why do you see yourself as a failure?”
3. “Feeling like this is all part of being depressed.”
4. “You’ve been feeling like a failure for a while?”
Responding to the feelings expressed by a client is an effective therapeutic communication technique. The correct option is an example of the use of restating. The remaining options block communication because they minimize the client’s experience and do not facilitate exploration of the client’s expressed feelings. In addition, use of the word “why” is nontherapeutic.
1. “I see.”
3. “You’re having difficulty sleeping?”
4. “Sometimes, I have trouble sleeping too.”
The correct option uses the therapeutic communication technique of restatement. Although restatement is a technique that has a prompting component to it, it repeats the client’s major theme, which assists the nurse to obtain a more specific perception of the problem from the client. The remaining options are not therapeutic responses since none encourage the client to expand on the problem. Offering personal experiences moves the focus away from the client and onto the nurse.
1. Using open-ended questions and silence
2. Sharing personal preference regarding food choices
3. Documenting reasons why the client does not want to eat
4. Offering opinions about the necessity of adequate nutrition
Open-ended questions and silence are strategies used to encourage clients to discuss their problems. Sharing personal food preferences is not a client-centered intervention. The remaining options are not helpful to the client because they do not encourage the client to express feelings. The nurse should not offer opinions and should encourage the client to identify the reasons for the behavior.
Denial is refusal to admit to a painful reality, which is treated as if it does not exist. In projection, a person unconsciously rejects emotionally unacceptable features and attributes them to other persons, objects, or situations. Regression allows the client to return to an earlier, more comforting, although less mature, way of behaving. Rationalization is justifying illogical or unreasonable ideas, actions, or feelings by developing acceptable explanations that satisfy the teller and the listener.
1. “Have you shared your feelings with your family?”
2. “I think we should talk more about your anger with your family.”
3. “You’re feeling angry that your family continues to hope for you to be cured?”
4. “You are probably very depressed, which is understandable with such a diagnosis.”
Restating is a therapeutic communication technique in which the nurse repeats what the client says to show understanding and to review what was said. While it is appropriate for the nurse to attempt to assess the client’s ability to discuss feelings openly with family members, it does not help the client discuss the feelings causing the anger. The nurse’s attempt to focus on the central issue of anger is premature. The nurse would never make a judgment regarding the reason for the client’s feeling; this is nontherapeutic in the one-to-one relationship.
1. Fearfulness regarding treatment measures.
2. Anger and aggressiveness directed toward others.
3. An understanding of the pathology and symptoms of the diagnosis.
4. A willingness to participate in the planning of the care and treatment plan.
In general, clients seek voluntary admission. If a client seeks voluntary admission, the most likely expectation is that the client will participate in the treatment program since they are actively seeking help. The remaining options are not characteristics of this type of admission. Fearfulness, anger, and aggressiveness are more characteristic of an involuntary admission. Voluntary admission does not guarantee a client’s understanding of their illness, only of their desire for help.
1. Monitor closely for harm to self or others.
2. Assist in completing an application for admission.
3. Supply the client with written information about their mental illness.
4. Provide an opportunity for the family to discuss why they felt the admission was needed.
Involuntary admission is necessary when a person is a danger to self or others or is in need of psychiatric treatment regardless of the client’s willingness to consent to the hospitalization. A written request is a component of a voluntary admission. Providing written information regarding the illness is likely premature initially. The family may have had no role to play in the client’s admission.
1. Planning short-term goals
2. Making appointment referrals
3. Developing realistic solutions
4. Identifying expected outcomes
Tasks of the termination phase include evaluating client performance, evaluating achievement of expected outcomes, evaluating future needs, making appropriate referrals, and dealing with the common behaviors associated with termination. The remaining options identify tasks appropriate for the working phase of the relationship.
3. Asking the client, “Why?”
4. Maintaining neutral responses
5. Providing acknowledgment and feedback
6. Giving advice and approval or disapproval
Therapeutic communication techniques include listening, maintaining silence, maintaining neutral responses, using broad openings and open-ended questions, focusing and refocusing, restating, clarifying and validating, sharing perceptions, reflecting, providing acknowledgment and feedback, giving information, presenting reality, encouraging formulation of a plan of action, providing nonverbal encouragement, and summarizing. Asking why is often interpreted as being accusatory by the client and should also be avoided. Providing advice or giving approval or disapproval are barriers to communication.
Denial is refusal to admit to a painful reality and may be a response by a victim of sexual abuse. In this case the client is not acknowledging the trauma of the assault either verbally or nonverbally. Projection is transferring one’s internal feelings, thoughts, and unacceptable ideas and traits to someone else. Rationalization is justifying the unacceptable attributes about oneself. Intellectualization is the excessive use of abstract thinking or generalizations to decrease painful thinking.
In the termination phase, the relationship comes to a close. Ending treatment sometimes may be traumatic for clients who have come to value the relationship and the help. Because loss is an issue, any unresolved feelings related to loss may resurface during this phase. The remaining options are not specifically associated with this issue of unresolved feelings.
1. Exploring the client’s ability to function
2. Exploring the client’s potential for self-harm
3. Inquiring about the client’s perception or appraisal of why the rescue was unsuccessful
4. Inquiring about and examining the client’s feelings for any that may block adaptive coping
The client must first deal with feelings and negative responses before the client can work through the meaning of the crisis. The correct option pertains directly to the client’s feelings and is client-focused. The remaining options do not directly focus on or address the client’s feelings.
1. Acknowledging that the group has identified goals
2. Encouraging the accomplishment of the group’s work
3. Acknowledging the contributions of each group member
4. Encouraging members to become acquainted with one another
In the termination stage, the group leader’s task is to acknowledge the contributions of each member and the experience of the group as a whole. In this stage, the group members prepare for separation and assist each other to prepare for the future. Acknowledging that the group has identified goals and encouraging group bonding both occur during the initial stage. Encouraging accomplishment of the group’s work is appropriate during the working stage.
1. The group evaluates the experience.
2. The real work of the group is accomplished.
3. Group interaction involves superficial conversation.
4. Group members become acquainted with each other.
5. Some structuring of group norms, roles, and responsibilities takes place.
6. The group explores members’ feelings about the group and the impending separation.
The stages of group development include the initial stage, the working stage, and the termination stage. During the initial stage, the group members become acquainted with each other, and some structuring of group norms, roles, and responsibilities takes place. During the initial stage, group interaction involves superficial conversation. During the working stage, the real work of the group is accomplished. During the termination stage, the group evaluates the experience and explores members’ feelings about the group and the impending separation.
1. Providing a supportive environment
2. Examining intrapsychic conflicts and past issues
3. Emphasizing social interaction with clients who withdraw
4. Helping the client to examine dysfunctional thoughts and beliefs
Cognitive behavioral therapy is used to help the client identify and examine dysfunctional thoughts and to identify and examine values and beliefs that maintain these thoughts. The remaining options, while therapeutic in certain situations, are not the focus of cognitive behavioral therapy.
1. It emphasizes self-expression, self-exploration, and self-awareness in the present.
2. It promotes the individual’s comfort in the group, which then transfers to other relationships.
3. The therapist focuses on how irrational beliefs and thoughts contribute to psychological distress.
4. The therapist’s goal is to help others express their feelings toward one another during group sessions.
Gestalt therapy emphasizes self-expression, self-exploration, and self-awareness in the present. The client and therapist focus on everyday problems and try to solve them. Interpersonal group therapy promotes the individual’s comfort in the group, which then transfers to other relationships. In rational emotive therapy, the therapist focuses on how irrational beliefs and thoughts contribute to psychological distress. In Rogerian therapy, the therapist’s goal is to help others express their feelings toward one another during group sessions.
1. Admitting to having a problem
2. Substituting other activities for gambling
3. Stating that the gambling will be stopped
4. Discontinuing relationships with people who gamble
The first step in the 12-step program is to admit that a problem exists. Substituting other activities for gambling may be a strategy but it is not the first step. The remaining options are not realistic strategies for the initial step in a 12-step program.
1. A form of behavior modification therapy
2. A cognitive approach to changing behavior
3. A living, learning, or working environment
4. A behavioral approach to changing behavior
Milieu therapy, or “therapeutic community,” has as its focus a living, learning, or working environment. Such therapy may be based on numerous therapeutic modalities ranging from structured behavioral therapy to spontaneous, humanistically oriented approaches. Although milieu therapy may include behavioral approaches, the correct option describes its primary focus.
1. Milieu therapy
2. Aversion therapy
3. Self-control therapy
4. Systematic desensitization
Systematic desensitization is a form of therapy used when the client is introduced to short periods of exposure to the phobic object while in a relaxed state. Exposure is gradually increased until the anxiety about or fear of the object or situation has ceased. Milieu management refers to providing a safe, therapeutic environment and is applicable to not just this scenario. The remaining options are incorrect since they do not involve the intervention described.
1. “The leader is a nurse or psychiatrist.”
2. “The members provide support to each other.”
3. “People who have a similar problem are able to help others.”
4. “It is designed to serve people who have a common problem.”
The sponsor of a self-help group is an experienced member of the group. The nurse or psychiatrist may be asked by the group to serve as a resource, but would not be the leader of the group. The remaining options are characteristics of a self-help group.
1. Ask the client to leave the group for this session only.
2. Refer the client to another group that includes other manic clients.
3. Tell the client to stop monopolizing in a firm but compassionate manner.
4. Thank the client for the input, but inform the client that now others need a chance to contribute.
If a client is monopolizing the group, the nurse must be direct and decisive. The best action is to thank the client and suggest that the client stop talking and try listening to others. Although telling the client to stop monopolizing in a firm but compassionate manner may be a direct response, the correct option is more specific and provides direction for the client. The remaining options are inappropriate since they are not directed towards helping the client in a therapeutic manner.
1. Milieu therapy
2. Interpersonal therapy
3. Behavior modification
4. Rational emotive therapy
All treatment team members are viewed as significant and valuable to the client’s successful treatment outcomes in milieu therapy. Interpersonal therapy is based on a one-to-one or group therapy approach in which the therapist-client relationship is often used as a way for the client to examine other relationships in his or her life. Behavior modification is based on rewards and punishment. Rational emotive therapy deals with the correction of distorted thinking.
1. “I don’t believe this is true.”
2. “The guards are not out to kill you.”
3. “Do you feel afraid that people are trying to hurt you?”
4. “What makes you think the guards were sent to hurt you?”
It is most therapeutic for the nurse to empathize with the client’s experience. The remaining options lack this connection with the client. Disagreeing with delusions may make the client more defensive, and the client may cling to the delusions even more. Encouraging discussion regarding the delusion is inappropriate.
1. Move the client next to the nurse’s station.
2. Use an indirect light source and turn off the television.
3. Keep the television and a soft light on during the night.
4. Play soft music during the night, and maintain a well-lit room.
Provision of a consistent daily routine and a low stimulating environment is important when a client is disoriented. Noise, including radio and television, may add to the confusion and disorientation. Moving the client next to the nurses’ station may become necessary but is not the initial action.
1. Encouraging quiet reading and writing for the first few days
2. Identification of physical activities that will provide exercise
3. No socializing activities, until the client asks to participate in milieu
4. A structured program of activities in which the client can participate
A client with depression often is withdrawn while experiencing difficulty concentrating, loss of interest or pleasure, low energy, fatigue, and feelings of worthlessness and poor self-esteem. The plan of care needs to provide successful experiences in a stimulating yet structured environment. The remaining options are either too “restrictive” or offer little or no structure and stimulation.
1. Suppressing feelings of anxiety
2. Identifying anxiety-producing situations
3. Continued contact with a crisis counselor
4. Eliminating all anxiety from daily situations
Recognizing situations that produce anxiety allows the client to prepare to cope with anxiety or avoid a specific stimulus. Counselors will not be available for all anxiety-producing situations, and this option does not encourage the development of internal strengths. Suppressing feelings will not resolve anxiety. Elimination of all anxiety from life is impossible.
2. Social phobia
Social phobia is a fear of situations in which one might be embarrassed or criticized, such as the fear of speaking, performing, or eating in public. The person fears making a fool of oneself. Agoraphobia is a fear of open spaces and the fear of being trapped in a situation from which there may not be an escape. Claustrophobia is a fear of closed places. Clients with hypochondriacal symptoms focus their anxiety on physical complaints and are preoccupied with their health.
1. Setting limits on the client’s behavior
2. Asking the client to leave the group session
3. Asking another nurse to escort the client out of the group session
4. Telling the client that they will not be able to attend any future group sessions
Manic clients may be talkative and can dominate group meetings or therapy sessions by their excessive talking. If this occurs, the nurse initially would set limits on the client’s behavior. Initially, asking the client to leave the session or asking another person to escort the client out of the session is inappropriate. This may agitate the client and escalate the client’s behavior further. Barring the client from group sessions is also an inappropriate action because it violates the client’s right to receive treatment and is a threatening action.
3. Conversion disorder
4. Dissociative disorder
A conversion disorder is the alteration or loss of a physical function that cannot be explained by any known pathophysiological mechanism. A conversion disorder is thought to be an expression of a psychological need or conflict. In this situation, the client witnessed an accident that was so psychologically painful that the client became blind. Psychosis is a state in which a person’s mental capacity to recognize reality, communicate, and relate to others is impaired, interfering with the person’s ability to deal with life’s demands. Repression is a coping mechanism in which unacceptable feelings are kept out of awareness. A dissociative disorder is a disturbance or alteration in the normally integrative functions of identity, memory, or consciousness.
1. Place the client in seclusion for 30 minutes.
2. Tell the client that the behavior is inappropriate.
3. Escort the client to their room, with the assistance of other staff.
4. Tell the client that their telephone privileges are revoked for 24 hours.
The client is at risk for injury to self and others and should be escorted out of the dayroom. Seclusion is premature in this situation. Telling the client that the behavior is inappropriate has already been attempted by the nurse. Denying privileges may increase the agitation that already exists in this client.
1. Communicate expected behaviors to the client.
2. Ensure that the client knows that they are not in charge of the nursing unit.
3. Assist the client in identifying ways of setting limits on personal behaviors.
4. Follow through about the consequences of behavior in a nonpunitive manner.
5. Enforce rules by informing the client that they will not be allowed to attend therapy groups.
6. Have the client state the consequences for behaving in ways that are viewed as unacceptable.
Interventions for dealing with the client exhibiting manipulative behavior include setting clear, consistent, and enforceable limits on manipulative behaviors; being clear with the client regarding the consequences of exceeding limits set; following through with the consequences in a nonpunitive manner; and assisting the client in identifying means of setting limits on personal behaviors. Ensuring that the client knows that he or she is not in charge of the nursing unit is inappropriate; power struggles need to be avoided. Enforcing rules and informing the client that he or she will not be allowed to attend therapy groups is a violation of a client’s rights.
1. Provide safety for the client and other clients on the unit.
2. Provide the clients on the unit with a sense of comfort and safety.
3. Assist the staff in caring for the client in a controlled environment.
4. Offer the client a less stimulating area to calm down in and gain control.
Safety of the client and other clients is the priority. The correct option is the only one that addresses the safety needs of the client as well as those of the other clients.
1. “My medications aren’t likely to make me anxious.”
2. “I’ll go to support group and talk so that I don’t hurt anyone.”
3. “It’s not likely that I’ll get anxious or hear things if I get enough sleep and eat well.”
4. “When I begin to hallucinate, I’ll call my therapist and talk about what I should do.”
The risk for impulsive and aggressive behavior may increase if a client is receiving command hallucinations to harm self or others. If the client is experiencing a hallucination, the nurse should ask the client whether he or she has intentions to hurt him- or herself or others. Talking about auditory hallucinations can interfere with subvocal muscular activity associated with a hallucination. The client statements in the remaining options will aid in wellness, but are not specific interventions for hallucinations, if they occur.
1. Ask direct questions to encourage talking.
2. Leave the client alone so as to minimize external stimuli.
3. Sit beside the client in silence with occasional open-ended questions.
4. Take the client into the dayroom with other clients so that they can help watch him.
Clients who are withdrawn may be immobile and mute and may require consistent, repeated approaches. Communication with withdrawn clients requires much patience from the nurse. Interventions include the establishment of interpersonal contact. The nurse facilitates communication with the client by sitting in silence, asking open-ended questions rather than direct questions, and pausing to provide opportunities for the client to respond. While overstimulation is not appropriate, there is no therapeutic value in ignoring the client. The client’s safety is not the responsibility of other clients.
1. Increase socialization of the client with peers.
2. Avoid laughing or whispering in front of the client.
3. Begin to educate the client about social supports in the community.
4. Have the client sign a release of information to appropriate parties for assessment purposes.
Disturbed thought process related to paranoia is the client’s problem, and the plan of care must address this problem. The client is experiencing paranoia and is distrustful and suspicious of others. The members of the health care team need to establish a rapport and trust with the client. Laughing or whispering in front of the client would be counterproductive. The remaining options ask the client to trust on a multitude of levels. These options are actions that are too intrusive for a client who is paranoid.
3. Ping Pong
Solitary activities that require a short attention span with mild physical exertion are the most appropriate activities for a client who is exhibiting aggressive behavior. Writing (journaling), walks with staff, and finger painting are activities that minimize stimuli and provide a constructive release for tension. The remaining options have a competitive element to them and should be avoided because they can stimulate aggression and increase psychomotor activity.
1. Ask the client why he started taking illegal drugs.
2. Ask the client about the amount of drug use and its effect.
3. Ask the client how long he thought that he could take drugs without someone finding out.
4. Not ask any questions for fear that the client is in denial and will throw the nurse out of the home.
Whenever the nurse carries out an assessment for a client who is dependent on drugs, it is best for the nurse to attempt to elicit information by being nonjudgmental and direct. Option 1 is incorrect because it is judgmental and off-focus, and reflects the nurse’s bias. Option 3 is incorrect because it is judgmental, insensitive, and aggressive, which is nontherapeutic. Option 4 is incorrect because it indicates passivity on the nurse’s part and uses rationalization to avoid the therapeutic nursing intervention.
1. Monitor vital signs.
2. Maintain NPO status.
3. Provide a safe environment.
4. Address hallucinations therapeutically.
5. Provide stimulation in the environment.
6. Provide reality orientation as appropriate.
When the client is experiencing withdrawal from alcohol, the priority for care is to prevent the client from harming self or others. The nurse would provide a low-stimulation environment to maintain the client in as calm a state as possible. The nurse would monitor the vital signs closely and report abnormal findings. The nurse would reorient the client to reality frequently and would address hallucinations therapeutically. Adequate nutritional and fluid intake need to be maintained.
1. “I no longer feel that I deserve the beatings my husband inflicts on me.”
2. “My attendance at the meetings has helped me to see that I provoke my husband’s violence.”
3. “I enjoy attending the meetings because they get me out of the house and away from my husband.”
4. “I can tolerate my husband’s destructive behaviors now that I know they are common with alcoholics.”
Al-Anon support groups are a protected, supportive opportunity for spouses and significant others to learn what to expect and to obtain excellent pointers about successful behavioral changes. The correct option is the healthiest response because it exemplifies an understanding that the alcoholic partner is responsible for his behavior and cannot be allowed to blame family members for loss of control. Option 2 is incorrect because the nonalcoholic partner should not feel responsible when the spouse loses control. Option 3 indicates that the group is viewed as an escape, not as a place to work on issues. Option 4 indicates that the wife remains codependent.
1. Call the nursing supervisor.
2. Call security to block all exit areas.
3. Restrain the client until the health care provider (HCP) can be reached.
4. Tell the client that the client cannot return to this hospital again if the client leaves now.
Most health care facilities have documents that the client is asked to sign relating to the client’s responsibilities when the client leaves against medical advice. The client should be asked to wait to speak to the HCP before leaving and to sign the “against medical advice” document before leaving. If the client refuses to do so, the nurse cannot hold the client against the client’s will. Therefore, in this situation, the nurse should call the nursing supervisor. The nurse can be charged with false imprisonment if a client is made to believe wrongfully that he or she cannot leave the hospital. Restraining the client and calling security to block exits constitutes false imprisonment. All clients have a right to health care and cannot be told otherwise.
1. Dental decay
2. Moist oily skin
3. Loss of tooth enamel
4. Electrolyte imbalances
5. Body weight well below ideal range
Clients with bulimia nervosa initially may not appear to be physically or emotionally ill. They are often at or slightly below ideal body weight. On further inspection, a client exhibits dental decay and loss of tooth enamel if the client has been inducing vomiting. Electrolyte imbalances are present. Dry, scaly skin (rather than moist, oily skin) is present.
1. Interrupt the client and weigh her immediately.
2. Interrupt the client and offer to take her for a walk.
3. Allow the client to complete her exercise program.
4. Tell the client that she is not allowed to exercise rigorously.
Clients with anorexia nervosa frequently are preoccupied with rigorous exercise and push themselves beyond normal limits to work off caloric intake. The nurse must provide for appropriate exercise and place limits on rigorous activities. The correct option stops the harmful behavior yet provides the client with an activity to decrease anxiety that is not harmful. Weighing the client immediately reinforces the client’s preoccupation with weight. Allowing the client to complete the exercise program can be harmful to the client. Telling the client that she is not allowed to complete the exercise program will increase the client’s anxiety.
1. A client with pneumonia
2. A client undergoing diagnostic tests
3. A client who thrives on managing others
4. A client who could benefit from the client’s assistance at mealtime
The client undergoing diagnostic tests is an acceptable roommate. The client with anorexia nervosa is most likely experiencing hematological complications, such as leukopenia. Having a roommate with pneumonia would place the client with anorexia nervosa at risk for infection. The client with anorexia nervosa should not be put in a situation in which the client can focus on the nutritional needs of others or be managed by others because this may contribute to sublimation and suppression of personal hunger.
1. Hypotension, ataxia, hunger
2. Stupor, lethargy, muscular rigidity
3. Hypotension, coarse hand tremors, lethargy
4. Hypertension, changes in level of consciousness, hallucinations
Symptoms associated with alcohol withdrawal delirium typically include anxiety, insomnia, anorexia, hypertension, disorientation, hallucinations, changes in level of consciousness, agitation, fever, and delusions.
1. “Why don’t you tell your wife about this?”
2. “What do you find difficult about this situation?”
3. “This is not the best time to make that decision.”
4. “I agree with you. You should get out of this situation.”
The most helpful response is one that encourages the client to solve problems. Giving advice implies that the nurse knows what is best and can foster dependency. The nurse should not agree with the client, and the nurse should not request that the client provide explanations.
1. Normal behavior
2. Evidence of the client’s disturbed body image
3. Regression as the client is moving toward the community
4. Indicative of the client’s ambivalence about hospital discharge
Disturbed body image is a concern with clients with anorexia nervosa. Although the client may struggle with ambivalence and show regressed behavior, the client’s coping pattern relates to the basic issue of disturbed body image. The nurse should address this need in the support group.
1. Signs of depression
2. Normal reactions to a devastating event
3. Evidence that the client is a high suicide risk
4. Indicative of the need for hospital admission
During the acute phase of the rape crisis, the client can display a wide range of emotional and somatic responses. The symptoms noted indicate a normal reaction. Options 1, 3, and 4 are incorrect interpretations.
1. Witnessing a murder
2. The death of a loved one
3. A fire that destroyed the client’s home
4. A recent rape episode experienced by the client
A situational crisis arises from external rather than internal sources. External situations that could precipitate a crisis include loss of or change of a job, the death of a loved one, abortion, change in financial status, divorce, addition of new family members, pregnancy, and severe illness. Options 1, 3, and 4 identify adventitious crises. An adventitious crisis refers to a crisis of disaster; it is unplanned or accidental.
1. “With whom do you live?”
2. “Who is available to help you?”
3. “What leads you to seek help now?”
4. “What do you usually do to feel better?”
The nurse’s initial task when assessing a client in crisis is to assess the individual or family and the problem. The more clearly the problem can be defined, the better the chance a solution can be found. The correct option would assist in determining data related to the precipitating event that led to the crisis. Options 1 and 2 assess situational supports. Option 4 assesses personal coping skills.
1. A crisis state indicates that the client has a mental illness.
2. A crisis state indicates that the client has an emotional illness.
3. Presenting symptoms in a crisis situation are similar for all clients experiencing a crisis.
4. A client’s response to a crisis is individualized and what constitutes a crisis for one client may not constitute a crisis for another client.
Although each crisis response can be described in similar terms as far as presenting symptoms are concerned, what constitutes a crisis for one client may not constitute a crisis for another client because each is a unique individual. Being in the crisis state does not mean that the client has a mental or emotional illness.
1. “You need to stop that behavior now.”
2. “You will need to be placed in seclusion.”
3. “You seem restless; tell me what is happening.”
4. “You will need to be restrained if you do not change your behavior.”
The best statement is to ask the client what is causing the agitation. This will assist the client to become aware of the behavior and may assist the nurse in planning appropriate interventions for the client. Option 1 is demanding behavior that could cause increased agitation in the client. Options 2 and 4 are threats to the client and are inappropriate.
1. “Have you talked to your family about this?”
2. “Everyone feels this way when they are depressed.”
3. “You will feel better once your medication begins to work.”
4. “You sound very upset. Are you thinking of hurting yourself?”
Clients who are depressed may be at risk for suicide. It is critical for the nurse to assess suicidal ideation and plan. The nurse should ask the client directly whether a plan for self-harm exists. Options 1, 2, and 3 do not deal directly with the client’s feelings.
1. Initiate confinement measures.
2. Acknowledge the client’s behavior.
3. Assist the client to an area that is quiet.
4. Maintain a safe distance from the client.
During the escalation period, the client’s behavior is moving toward loss of control. Nursing actions include taking control, maintaining a safe distance, acknowledging behavior, moving the client to a quiet area, and medicating the client if appropriate. To initiate confinement measures during this period is inappropriate. Initiation of confinement measures, if needed, is most appropriate during the crisis period.
1. The adolescent gives away a DVD and a cherished autographed picture of a performer.
2. The adolescent runs out of the therapy group, swearing at the group leader, and runs to her room.
3. The adolescent becomes angry while speaking on the telephone and slams down the receiver.
4. The adolescent gets angry with her roommate when the roommate borrows the client’s clothes without asking.
A depressed suicidal client often gives away that which is of value as a way of saying goodbye and wanting to be remembered. Options 2, 3, and 4 deal with anger and acting-out behaviors that are often typical of any adolescent.
1. Administer an antianxiety agent.
2. Examine and treat the wound sites.
3. Secure and record a detailed history.
4. Encourage and assist the client to ventilate feelings.
The initial nursing action is to assess and treat the self-inflicted injuries. Injuries from lacerated wrists can lead to a life-threatening situation. Other interventions, such as options 1, 3, and 4, may follow after the client has been treated medically.
1. Suggesting a reduction of medication
2. Allowing increased “in-room” activities
3. Increasing the level of suicide precautions
4. Allowing the client off-unit privileges as needed
A client who is moderately depressed and has only been in the hospital 2 days is unlikely to have such a dramatic cure. When a depression suddenly lifts, it is likely that the client may have made the decision to harm himself or herself. Suicide precautions are necessary to keep the client safe. The remaining options are therefore incorrect interpretations.
1. One-to-one suicide precautions
2. Suicide precautions with 30-minute checks
3. Checking the whereabouts of the client every 15 minutes
4. Asking the client to report suicidal thoughts immediately
One-to-one suicide precautions are required for a client who has attempted suicide. Options 2 and 3 may be appropriate, but not at the present time, considering the situation. Option 4 also may be an appropriate nursing intervention, but the priority is identified in the correct option. The best intervention is constant supervision so that the nurse may intervene as needed if the client attempts to harm himself or herself.
1. Information regarding shelters
2. Instructions regarding calling the police
3. Instructions regarding self-defense classes
4. Explaining the importance of leaving the violent situation
Tertiary prevention of family violence includes assisting the victim after the abuse has already occurred. The nurse should provide the client with information regarding where to obtain help, including a specific plan for removing the self from the abuser and information regarding escape, hotlines, and the location of shelters. An abused person is usually reluctant to call the police. Teaching the victim to fight back is not the appropriate action for the victim when dealing with a violent person. Explaining the importance of leaving the violent situation is important, but a specific plan is necessary.
1. “You need to try to be realistic. The rape did not just occur.”
2. “It will take some time to get over these feelings about your rape.”
3. “Tell me more about the incident that causes you to feel like the rape just occurred.”
4. “What do you think that you can do to alleviate some of your fears about being raped again?”
The correct option allows the client to express her ideas and feelings more fully and portrays a nonhurried, nonjudgmental, supportive attitude on the part of the nurse. Clients need to be reassured that their feelings are normal and that they may express their concerns freely in a safe, caring environment. Option 1 immediately blocks communication. Option 2 places the client’s feelings on hold. Option 4 places the problem-solving totally on the client.
1. Requesting that a peer remain with the client at all times
2. Removing the client’s clothing and placing the client in a hospital gown
3. Assigning a staff member to the client who will remain with the client at all times
4. Admitting the client to a seclusion room where all potentially dangerous articles are removed
Hanging is a serious suicide attempt. The plan of care must reflect action that ensures the client’s safety. Constant observation status (one-to-one) with a staff member is the best choice. Placing the client in a hospital gown and requesting that a peer remain with the client would not ensure a safe environment. Seclusion should not be the initial intervention, and the least restrictive measure should be used.
1. “I’m afraid of spiders.”
2. “I keep reliving the robbery.”
3. “I see his face everywhere I go.”
4. “I don’t want anything to eat now.”
5. “I might have died over a few dollars in my pocket.”
6. “I have to wash my hands over and over again many times.”
Reliving an event, experiencing emotional numbness (facing possible death), and having flashbacks of the event (seeing the same face everywhere) are all common occurrences with posttraumatic stress disorder. The statement. “I’m afraid of spiders,” is more relative to having a phobia. The statement “I have to wash my hands over and over again many times” describes ritual compulsive behaviors to decrease anxiety for someone with obsessive compulsive disorder. Stating “I don’t want anything to eat now” is vague and could relate to numerous conditions.
1. Adhering to the mandatory abuse-reporting laws
2. Notifying the case worker of the family situation
3. Removing the client from any immediate danger
4. Obtaining treatment for the abusing family member
Whenever an abused client remains in the abusive environment, priority must be placed on ascertaining whether the client is in any immediate danger. If so, emergency action must be taken to remove the client from the abusing situation. Options 1, 2, and 4 may be appropriate interventions, but are not the priority.
1. Incessant talking and sexual innuendoes
2. Grandiose delusions and poor concentration
3. Outlandish behaviors and inappropriate dress
4. Nonstop physical activity and poor nutritional intake
Mania is a mood characterized by excitement, euphoria, hyperactivity, excessive energy, decreased need for sleep, and impaired ability to concentrate or complete a single train of thought. The client’s mood is predominantly elevated, expansive, or irritable. All of the options reflect a client’s possible symptoms. The correct option clearly presents a problem, however, that compromises physiological integrity and needs to be addressed immediately.
1. Uses confabulation
2. Improvement in sleeping
3. Absence of sundown syndrome
4. Presence of personal hygienic care
The clinical picture of dementia ranges from mild cognitive deficits to severe, life-threatening alterations in neurological functioning. For the client to use confabulation or the fabrication of events or experiences to fill in memory gaps is not unusual. Often, lack of inhibitions on the part of the client may constitute the first indication of something being “wrong” to the client’s significant others (e.g., the client may undress in front of others, or the formerly well-mannered client may exhibit slovenly table manners). As the dementia progresses, the client will have difficulty sleeping and episodes of wandering or sundowning.
1. Engaging in immoral acts
2. Always reinforcing self-approval
3. Observing rigid rules and regulations
4. Having the need always to make the right decision
Clients with anorexia nervosa have the desire to please others. Their need to be correct or perfect interferes with rational decision-making processes. These clients are moralistic. Rules and rituals help these clients manage their anxiety.
1. Reassure the client that things will get better.
2. Tell the client that this is not true and that we all have a purpose in life.
3. Identify recent behaviors or accomplishments that demonstrate the client’s skills.
4. Remain with the client and sit in silence; this will encourage the client to verbalize feelings.
Feelings of low self-esteem and worthlessness are common symptoms of a depressed client. An effective plan of care to enhance the client’s personal self-esteem is to provide experiences for the client that are challenging, but that will not be met with failure. Reminders of the client’s past accomplishments or personal successes are ways to interrupt the client’s negative self-talk and distorted cognitive view of self. Options 1 and 2 give advice and devalue the client’s feelings. Silence may be interpreted as agreement.
1. An expected coping mechanism
2. An ineffective coping mechanism
3. A need to notify the hospital lawyer
4. An expression of guilt on the part of the client
The nurse needs to be aware of the effective and ineffective coping mechanisms that can occur in a client when loss is anticipated. The expression of anger is known to be a normal response to impending loss, and the anger may be directed toward the self, God or other spiritual being, or caregivers. Notifying the hospital lawyer is inappropriate. Guilt may or may not be a component of the client’s feelings, and the data in the question do not indicate that guilt is present.
1. “This form of therapy can be applied to new situations.”
2. “An advantage of this technique is that change is likely to last.”
3. “Talking to oneself is a basic component of this form of therapy.”
4. “This form of therapy provides a negative reinforcement when the stimulus is produced.”
Negative reinforcement when the stimulus is produced is descriptive of aversion therapy. Options 1, 2, and 3 are characteristics of self-control therapy.
1. Provide authority, action, and participation.
2. Display an attitude of detachment, confrontation, and efficiency.
3. Demonstrate confidence in the client’s ability to deal with stressors.
4. Provide hope and reassurance that the problems will resolve themselves.
A crisis is an acute, time-limited state of disequilibrium resulting from situational, developmental, or societal sources of stress. A person in this state is temporarily unable to cope with or adapt to the stressor by using previous coping mechanisms. The person who intervenes in this situation (the nurse) “takes over” for the client (authority) who is not in control and devises a plan (action) to secure and maintain the client’s safety. When this has occurred, the nurse works collaboratively with the client (participates) in developing new coping and problem-solving strategies.
1. Begin to teach relaxation techniques.
2. Encourage the client to discuss the assault.
3. Remain with the client until the anxiety decreases.
4. Place the client in a quiet room alone to decrease stimulation.
This client is in a severe state of anxiety. When a client is in a severe or panic state of anxiety, it is crucial for the nurse to remain with the client. The client in a severe state of anxiety would be unable to learn relaxation techniques. Discussing the assault at this point would increase the client’s level of anxiety further. Placing the client in a quiet room alone may also increase the anxiety level.
2. Unrealistic outlook
3. Lack of ability to cope effectively
4. Disturbances in thoughts and ideas
Lack of ability to cope effectively may be evidenced by a client’s inability to meet basic needs, inability to meet role expectations, alteration in social participation, use of inappropriate defense mechanisms, or impairment of usual patterns of communication. Anxiety is a broad description and can occur as a result of many triggers and although the client was experiencing anxiety, the client’s concern now is the ability to meet role expectations and financial obligations. There is no information in the question that indicates an unrealistic outlook or disturbances in thoughts and ideas.
1. Disrupted appearance because of weight
2. Inability to feed self because of weakness
3. Pain because of an inflamed gastric mucosa
4. Nutritional imbalance because of lack of intake
The priority client problem for the client with anorexia nervosa is lack of intake and nutritional imbalance. Although the problems identified in options 1, 2, and 3 may be considerations in the plan of care for the client with anorexia nervosa, nutritional imbalance is the priority.
1. “Discussing suicide with a client is not harmful.”
2. “Those clients who talk about suicide never do it.”
3. “Depressed clients are the only persons who commit suicide.”
4. “When a person talks about making suicide threats, the only thing the person wants is attention from family and friends.”
An open discussion of suicide will not encourage a client to make a decision to commit suicide and in fact often will help to prevent it. Such a discussion offers the health care professional the opportunity to assess the reality of suicide for the client and take necessary precautions to keep the client safe. Options 2, 3, and 4 are inaccurate statements regarding suicide.
1. A 75-year-old client with metastatic cancer
2. A 71-year-old client with a cardiac disorder
3. A 24-year-old client who just had an argument with her roommate
4. A 30-year-old newly divorced client who states she has custody of the children
The person most at risk for suicide is the client with terminal illness. Other high-risk groups include adolescents, drug abusers, persons who have experienced recent losses, those who have few or no social supports, and those with a history of suicide attempts and a suicide plan.
1. “Abusers use fear and intimidation.”
2. “Abusers usually have poor self-esteem.”
3. “Abusers often are jealous or self-centered.”
4. “Abuse occurs more often in low-income families.”
Personal characteristics of abusers include low self-esteem, immaturity, dependence, insecurity, and jealousy. Abusers often use fear and intimidation to the point at which their victims will do anything just to avoid further abuse. The statement that abuse occurs more often in lower socioeconomic groups is incorrect.
1. Does not smoke at all
2. Receives no visitors and participates in limited unit activities
3. Reports to the clinic for blood draws and an electrocardiogram (ECG)
4. Is placed on nothing by mouth (NPO) status for 16 to 24 hours before the ECT
Before ECT, blood tests are performed and an ECG is done to determine a baseline status of the client. The nurse needs to explain the need for these preprocedures to the client. Maintaining *NPO status for 6 to 8 hours before treatment* is adequate; NPO status for 16 to 24 hours is not necessary. Some hospitals place clients on NPO status at midnight before ECT in the morning. Some clients who are on cardiovascular medication may be instructed to take their medicine with sips of water several hours before ECT. Options 1 and 2 are incorrect.
1. “It uses positive reinforcement.”
2. “It uses negative reinforcement.”
3. “It increases social behaviors in the client.”
4. “It increases the level of self-care in the client.”
Operant conditioning entails rewarding a client for desired behaviors and is the basis for behavior modification. It uses a positive reinforcement approach. Options 1, 3, and 4 are accurate characteristics of this form of therapy.
1. “What are you feeling right now?”
2. “Do you have a plan to commit suicide?”
3. “How many times have you attempted suicide in the past?”
4. “Why were your attempts at suicide unsuccessful in the past?”
When assessing for suicide risk, the nurse must determine if the client has a suicide plan. Clients who have a definitive plan pose a greater risk for suicide. Although options 1, 3, and 4 are questions that may provide information that will be helpful in planning care for the client, these questions will not provide information regarding the risk of suicide.
3. Somatization disorder
4. Obsessive-compulsive disorder
Somatization disorder is characterized by a long history of multiple physical problems with no satisfactory organic explanation. The clinical findings associated with schizophrenia, depression, and obsessive-compulsive disorder are unrelated to somatic complaints.
1. “You have said this many times before!”
2. “Tell me what makes you feel that you are ready.”
3. “I have not seen any changes in you to believe that you are ready to go straight.”
4. “I’m so glad to hear you talking this way. I will let your health care provider know.”
Clients with a long history of acting out and violent behavior and those who have used drugs need to demonstrate motivation to change the behavior, not just verbalization of the behavior. The therapeutic response by the nurse would be directed at assisting the client to look at the behaviors that indicate the change. The correct option is the only one that will provide this direction to the client.
1. “Why did you lose your job?”
2. “There are homeless shelters available, and we will get you into one if you are evicted from your apartment.”
3. “If you get evicted from your apartment, we will commit you to the hospital, so you will have a place to eat and sleep.”
4. “Let’s talk about contacting your daughter. Wouldn’t you want to know if your daughter was having difficulty and try to help her if you could?”
The therapeutic communication technique is clarification that attempts to put vague ideas into words. It helps the client to view the explicit correlation between the client’s feelings and actions. Asking why a client lost a job is not directly related to the client’s feelings and concerns. Offering to provide a homeless shelter or to commit the client to the hospital does not address the issue at hand and places the client’s concerns and feelings on hold.
1. “Your comment is inappropriate.”
2. “Thank you for noticing. I just bought this new perfume.”
3. “My hair has been a mess. I really needed to have it done.”
4. “We are not here to discuss how I look or smell. We are here to talk about you.”
The therapeutic response by the nurse is the one that clarifies the content of the client’s statements and directs the client to the purpose of the session. The nurse should confront the client verbally regarding the inappropriate statements and refocus the client back to the issue of the session. Option 1 may be judgmental and may provide an opening for a verbal struggle. Options 2 and 3 are social responses and could be misinterpreted by the client.
1. “You look lovely today.”
2. “You’re wearing a new blouse.”
3. “Don’t worry-everyone gets depressed once in a while.”
4. “You will feel better when your medication starts to work.”
A client who is depressed sees the negative side of everything. Telling the client that she looks lovely today can be interpreted as “didn’t look lovely last time we met.” Neutral comments such as that identified in the correct option will avoid negative interpretations. The client should not be told not to worry, that everyone gets depressed once in a while, or that he or she will feel better, because such statements are inappropriate.
1. Reading letters and books in a quiet environment
2. Providing an activity such as checkers for the client
3. Involving the client in a card game with other clients on the unit
4. Including the client in a clay-molding class that is scheduled for today
When a client is experiencing psychomotor agitation, it is best to provide activities that involve the use of hands and gross motor movements. Such activities can include volleyball, finger-painting, drawing, and working with clay. These activities provide an appropriate way for the client to discharge motor tension. Reading and simple card games are sedentary activities. Playing checkers requires concentration and more intensive use of thought processes.
1. Assist the client in selecting foods from the food menu.
2. Offer high-calorie fluids throughout the day and evening.
3. Allow the client to eat alone in the room if the client requests to do so.
4. Offer small high-calorie, high-protein snacks during the day and evening.
5. Select the foods for the client to be sure that the client eats a balanced diet.
In caring for a client with depression whose nutritional intake is poor, the nurse should remain with the client during the meal. The nurse also should assist the client in selecting foods from the menu because the client is more likely to eat the foods that he or she likes. Offering small high-calorie, high-protein snacks and high-calorie fluids throughout the day and evening are appropriate interventions for the client to maintain nutrition.
1. Flat affect
2. Bizarre affect
3. Blunted affect
4. Inappropriate affect
An inappropriate affect refers to an emotional response to a situation that is incongruent with the tone of the situation. A flat affect is manifested as an immobile facial expression or blank look. A bizarre affect such as grimacing, laughing, and self-directed mumbling is marked when the client is unable to relate logically to the environment. A blunted affect is a minimal emotional response or outward affect that typically does not coincide with the client’s inner emotions.
1. The client has a flat affect.
2. The client has an inappropriate affect.
3. The client is exhibiting bizarre behavior.
4. The client’s emotional responses exhibit a blunted affect.
A flat affect is manifested as an immobile facial expression or blank look. An inappropriate affect refers to an emotional response to a situation that is incongruent with the tone of the situation. A bizarre affect such as grimacing, laughing, and self-directed mumbling is marked when the client is unable to relate logically to the environment. A blunted affect is a minimal emotional response or outward affect that typically does not coincide with the client’s inner emotions.
1. Provide a warm approach to the client.
2. Ask permission before touching the client.
3. Eliminate physical contact with the client.
4. Defuse any anger or verbal attacks with a nondefensive stance.
5. Use simple and clear language when communicating with the client.
When caring for a client with paranoia, the nurse should ask permission if touch is necessary because touch may be interpreted as a sexual or physical assault. The nurse must eliminate any physical contact and not touch the client. The anger that a paranoid client expresses often is displaced, and when a staff member becomes defensive, both client and staff anger may escalate. Simple and clear language should be used in speaking to the client to prevent misinterpretation and to clarify the nurse’s intent and action. The nurse should avoid a warm approach because warmth can be frightening to a person who needs emotional distance.
1. Obtain an informed consent.
2. Have the client void before the procedure.
3. Remove dentures and contact lenses before the procedure.
4. Withhold food and fluids for 6 hours before the treatment.
5. Administer tap water enemas on the evening before the procedure.
Enemas are not a component of the pretreatment care for a client scheduled for ECT. Options 1, 2, 3, and 4 are a part of the pretreatment plan. Additionally, the nurse should teach the client and family what to expect with ECT and allow the client to discuss his or her feelings regarding the procedure.
1. Platelet count
2. Cholesterol level
3. Blood urea nitrogen
4. White blood cell (WBC) count
Clozapine is an antipsychotic medication. Clients taking clozapine can experience hematological adverse effects, including agranulocytosis and mild leukopenia. The WBC count should be assessed before initiation of treatment and should be monitored closely during the use of this medication. The client also should be monitored for signs indicating agranulocytosis, which may include sore throat, malaise, and fever. Options 1, 2, and 3 are incorrect and unrelated to this medication.
1. If there is a history of hyperthyroidism
2. When the last full meal was consumed
3. If there is a history of diabetes insipidus
4. When the last alcoholic drink was consumed
Disulfiram is an adjunctive treatment for some clients with chronic alcoholism to assist in maintaining enforced sobriety. Because clients must abstain from alcohol for at least 12 hours before the initial dose, the most important assessment is when the last alcoholic intake was consumed. The medication should be used cautiously in clients with hypothyroidism, diabetes mellitus, epilepsy, cerebral damage, nephritis, and hepatic disease. It is contraindicated in persons with severe heart disease, psychosis, or hypersensitivity to the medication.
3. Seizure disorder
4. Obsessive-compulsive disorder
Donepezil hydrochloride is a cholinergic agent that is used in the treatment of mild to moderate dementia of the Alzheimer’s type. It increases concentration of acetylcholine, which slows the progression of Alzheimer’s disease. The other options are incorrect and are not indications for use of this medication.
1. A fear of dirt and germs
2. A fear of leaving the house
3. A fear of speaking in public
4. A fear of riding in elevators
Agoraphobia is a fear of leaving the house and experiencing panic attacks when doing so. Option 1 describes an obsessive-compulsive behavior. Option 3 describes a social phobia. Option 4 describes claustrophobia.
1. Teach self-grooming skills.
2. Reward cleanliness with unit privileges.
3. Monitor the adequacy of the antipsychotic dosage.
4. Encourage frequent fluid intake and a high-fiber diet.
Constipation is a common elimination problem with clients in a manic phase of bipolar disorder. Constipation may occur as the result of a combination of factors, including taking antipsychotic medications, suppressing the urge to defecate, and a decreased fluid intake as a result of the manic activity level. The symptoms listed in the question, dehydrated, unkempt, and abdominal fullness and discomfort, in combination with antipsychotic medications, are indicators of constipation. A high-fiber diet and increased fluids can reduce constipation.
1. The nurse must have the client go to the local mental health center daily for counseling.
2. The nurse must ask the client not to reveal suicidal plans if the information needs to be kept confidential.
3. The nurse cannot tell anyone what the client said and must strictly adhere to the professional duty for confidentiality.
4. The nurse must override the duty to observe confidentiality and notify the client’s health care provider (HCP) about the suicidal ideation.
In this situation, the nurse must override the duty to observe confidentiality and notify the client’s HCP about the client’s suicidal ideation. Option 1 is incorrect because the client is homebound. Option 2 is incorrect because the nurse has a professional obligation to intervene when a client tells the nurse about ideas or plans to harm himself or herself or others. Option 3 is incorrect because the nurse has a moral obligation to protect the client.
1. The community’s opposition
2. The client’s noncompliance with medication therapy
3. The associated increased incidence of social problems
4. The family’s reaction to keeping the client in the community
Clients often forget to take their medications as scheduled, and this is the most prominent problem. Options 1, 3, and 4 may occur, but the problems described are not the most prominent and can be addressed and often controlled.
1. Refusing to eat and excessive exercising
2. Eating only vegetables and fruits and fasting
3. Hoarding of food and difficulty controlling food intake
4. Eating a lot of food in a short period of time and misuse of laxatives
Eating binges and purging are the characteristic that would be seen in bulimia. Eating only certain types of foods may reflect a preference but does not indicate bulimia. Bulimic persons usually do not refuse to eat; rather, they binge and purge. Hoarding of food may indicate another problem.
1. Allow the client to pace.
2. Escort the client to a quiet room.
3. Change the conversation to a less threatening subject.
4. Share the observation with the client and help the client to recognize his feelings.
Sharing observations with the client may help him recognize and acknowledge feelings. Allowing the client to pace may also allow him to get out of control. Moving to a quiet room or changing the subject will not help the client to recognize his behaviors and feelings.
4. Posttraumatic stress disorder (PTSD)
The major clinical manifestation associated with PTSD is client experience of flashbacks. Flashbacks are not specifically associated with anxiety, agoraphobia, or schizophrenia.
1. Explain the unit rules.
2. Orient the client to the unit.
3. Stabilize the client’s psychiatric needs.
4. Accept the client and make the client feel safe.
It is important to make a confused client feel safe. Explaining the unit rules and orientation to the unit are part of any admission process. Stabilizing psychiatric needs is a long-term goal.
1. “Don’t worry so much.”
2. “I can see that you are upset.”
3. “Everything is going to be all right.”
4. “Why are you having so much trouble controlling your anxiety?”
The correct option is the only one that addresses the client’s feelings and concerns. Options 1 and 3 provide false reassurance and place the client’s feelings on hold. Option 4 is a nontherapeutic communication technique and will increase the client’s anxiety.
1. 1 week
2. 3 weeks
3. 4 weeks
4. 8 weeks
Health care providers generally administer ECT treatments three times a week, with an average series including 8 to 12 treatments. After three sessions of ECT, the client should start to demonstrate improvement in 1 week. Options 2, 3, and 4 are incorrect.
1. Force foods and fluids.
2. Provide small, frequent meals.
3. Provide snacks and meals as requested.
4. Tell the client that social activities will be restricted unless food intake is increased.
A depressed client may eat small amounts of food because large amounts may seem overwhelming. If the client becomes overwhelmed, he or she may respond by withdrawing further. Providing snacks and meals when the client requests them will not ensure adequate nutritional intake. Forcing foods and fluids and telling the client that social activities will be restricted will cause further withdrawal by the client. Telling the client that social activities will be restricted also is a demeaning action.
1. Clonidine (Catapres)
2. Disulfiram (Antabuse)
3. Pyridoxine hydrochloride (vitamin B6)
4. Chlordiazepoxide hydrochloride (Librium)
Disulfiram is a medication used for alcoholism, and it aids in the maintenance of sobriety. Clonidine is an antihypertensive medication. Pyridoxine hydrochloride is used in the treatment of vitamin B6 deficiency. Chlordiazepoxide hydrochloride is an antianxiety medication (a benzodiazepine) that is used in the management of acute alcohol withdrawal symptoms.
1. “You must go. You have no choice.”
2. “Why don’t you want to attend? What is the real reason?”
3. “The health care provider has prescribed this therapy for you.”
4. “You don’t have to sing at the session. You can listen and enjoy the music.”
The correct option encourages the client to socialize and indicates that it is not necessary to sing. Option 2 asks why, and use of this word should be avoided. Options 1 and 3 imply a demand and do not address the client’s concern. The correct option is the only one that addresses the client’s concern.
1. Administered medication has taken effect.
2. The client verbalizes the reasons for the violent behavior.
3. The client apologizes and tells the nurse that it will never happen again.
4. No acts of aggression have been observed within 1 hour after the release of two of the extremity restraints.
The best indicator that the behavior is controlled is the fact that the client exhibits no signs of aggression after partial release of restraints. Options 1, 2, and 3 do not ensure that the client has controlled the behavior.
3. Attention seeking
4. Desire to be accepted
The behaviors identified in the question indicate improvement in the client’s condition. The question presents no information indicating that the client is being manipulative. Acting out is attention-seeking behavior. All clients have a desire to be accepted.
1. The average series involves 6 to 12 treatments.
2. Some confusion may be noted after the procedure.
3. Memory loss will occur but will resolve with time.
4. This treatment is a permanent cure to the condition.
5. This treatment is tried before the use of medications.
ECT as a form of treatment is considered when medication therapy has failed, the client is at high risk for suicide, or depression is judged to be overwhelmingly severe. Treatments are administered three times a week, with an average series involving 8 to 12 treatments over a duration of 2 to 4 weeks. The most common side effect is amnesia for events occurring near the period of treatment. Memory deficits may occur and tend to resolve with time. This treatment is not a permanent cure to the client’s condition.
1. Biofeedback has the advantage of using no equipment at all.
2. Guided imagery is a helpful technique but requires video equipment for its use.
3. Confrontation is a useful method for solving potentially stressful conflicts with others.
4. Progressive muscle relaxation techniques are useful for easing tension from many causes.
Biofeedback, guided imagery, progressive muscle relaxation, and meditation are techniques that the nurse can teach the client to reduce the physical impact of stress on the body and promote a feeling of self-control. Biofeedback uses electronic equipment, whereas each of the other techniques requires no equipment after it is learned. Confrontation is not a stress management technique; it is a communication technique.