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112 Cards in this Set
- Front
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An adult female client becomes combative with the nurse during routine medication administration. What is the nurses primary responsibility in this situation? |
To ensure that the client is kept safe while trying to protect staff safety and to reason with the client to try to de-escalate the combative behavior |
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A nurse is trying to develop trust with a client on an inpatient mental health unit. Which action by the nurse is going to best promote development of a mutually trusting relationship? |
At the beginning of the shift, the nurse promises to play a game of cards with the client at some point during that day and does so before the end of the shift. |
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An adult female client is exhibiting behavior that the nurse interprets as anger toward another client. What is the nurses best action? |
Talk with the client about the observations made, and ask whether she was displaying anger toward the other client. |
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A nurse and an adolescent female client develop a plan of care together that addresses the clients difficult relationship with her parents. The client says that her parents just dont understand her, and she is always getting privileges taken away for not doing things that she is supposed to do. What is the nurses best action? |
Identify two priority responsibilities that are agreed upon between the client and her parents, and monitor her ability to comply with the plan for 1 week. |
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coping mechanisms are means of successfully solving a problem or reducing ones stress level. |
Constructive, or adaptive, coping mechanisms are effective because they deal with the problem to attempt to solve it and in turn reduce stress. Defensive and maladaptive mechanisms do not deal with the problem effectively. Individual coping mechanisms may or may not be effective. |
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A married woman, who is the mother of two children, has been in an abusive relationship for 4 years. She decides to leave her husband after suffering an episode of severe physical abuse. She and her children, ages 7 and 9, arrive at a crisis intervention center. What is the nurses priority intervention? |
Offer immediate emotional support |
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A male client with the diagnosis of depression has not attended his last two group meetings. The nurse provides a printed schedule of meeting dates and times to the client the next time she sees him. The nurses actions can be described as: |
Client advocacy Advocacy is when the nurse works on behalf of the client by providing him with the tools needed to make decisions. It is especially important to be an advocate for clients with mental health disorders because it often is difficult for them to make informed decisions. Insight refers to the ability to see intuitively, self-awareness is looking into and analyzing oneself, and empathy encompasses the ability to understand and enter into another persons emotions. |
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An adolescent female client continually displays a negative attitude toward everyone she comes into contact with and toward life in general. Which action should the nurse implement first that will be helpful in assisting this client to develop a more positive attitude? |
Helping the client recognize negative thoughts, emotions, and attitudes |
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A caregiver is said to be practicing __________ care not only when she takes into consideration the clients actual or potential problems but also when she considers the clients family, work responsibilities, and social aspects of life. |
Holistic care encompasses all aspects of an individual. |
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A client is believed to have adapted to a situation when he or she exhibits which characteristic? |
The client has shown improvement in behavior as evidenced by the ability to carry out activities normal to his or her life. |
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One of the goals of therapy established with a client on a mental health unit who has been given a diagnosis of obsessive-compulsive disorder (OCD) is to improve his feelings of stability in his environment. Much of his OCD behavior manifests as cleanliness and control of germs. Which nursing intervention most likely would help this client to feel more stable in his environment? |
Allowing him to wash his hands only for an agreed upon number of times daily |
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Which is the best way that a nursing unit manager can assist his or her staff in maintaining a professional commitment to their job and profession? |
Frequently offering and requiring a specific number of hours of in-service training on new care modalities within the facility |
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The nurse is working with a male client to instill a feeling of self-commitment to improve his self-esteem. From which of the following interventions would the client most benefit? |
Having the client promise himself that he will do the best he can in a particular situation, knowing that failure is a possibility |
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The nurse is working with a health care team with that believes in the philosophy of reality therapy. The nurse is aware that the teams belief is centered around: |
Describing clients as irresponsible rather than mentally ill |
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A busy community mental health center treats a client who is in crisis. The client is provided with instruction on relaxation exercises, but throws them away. Two weeks later the staff is dismayed when the client returns with her condition worsened. This lack of success after the previous visit is due to which of the following factors? |
Pseudoresolution |
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A client is monopolizing a group session, not allowing other members to participate. What is the most appropriate way to address the client? |
You need to stop this behavior. Lets see what others have to say. |
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The night before her final exam, the nursing student cannot sleep, and is convinced she will fail. Which of the following actions will help to promote a more positive outlook? |
Visualize staying relaxed during the exam and successfully passing. |
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A client with frequent re-admissions to the inpatient unit refuses to eat or participate in activities. The nurse functions as the client advocate by which of the following actions? |
Providing consistent encouragement to attend activities and having food available |
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Identify the stages experienced by a person in a crisis. (Select all that apply.) |
Recovery, Disorganization, Crisis, denial, reorganization, perception |
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Which of the following are signs that indicate that the mental health nurse is becoming overly involved with a clients care? (Select all that apply.) |
Showing greater levels of concern for one client over all other clients Feeling that the nurse is the only caregiver who understands the client |
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An important component of providing good care is for health caregivers to take care of, or nurture, themselves. Which of the following are ways that effectively assist health caregivers to nurture themselves? (Select all that apply.) |
-Be supportive of colleagues. -Recognize and accept ones own limitations, and strive to improve. -Take pride in oneself. -Be responsible and accountable for ones own actions. |
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A recently widowed 74-year-old male is seen in the mental health clinic for sleep disorders and depression. Which of the following nursing actions demonstrate caring? (Select all that apply.) |
Providing a private place to interview the client b. Delegating other tasks to a colleague while speaking to the client Asking about his daily activities and hobbies during the interview |
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The nurse asks the client a series of questions upon entry into a mental health care system. This action is an example of which phase of the nursing process? |
Assessment |
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A nurse administers antidepressant medication to a client in an assisted-living facility. This is an example of which phase of the nursing process? |
intervention |
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Following completion of a male clients series of group therapy sessions, the nurse periodically talks with the client to determine whether he has any signs of relapse of his previous problems. This action by the nurse is an example of: |
assessment |
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During a session with a female client with a diagnosis of social phobia, she talks about how proud she is of herself because she was finally able to shop at the grocery store. The nurse documents the events and knows that this would be considered which phase of the nursing process? |
evaluation |
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The treatment team meets with a client for the first time and determines, with the clients input, a nursing diagnosis, goal, and steps to reach this goal. In addition to a nursing diagnosis, the treatment team has completed which phase of the nursing process? |
planning |
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Without assessment of six specific aspects of an individuals being, the mental health nurses scope of care is narrow and limited in effectiveness. These aspects include social, physical, cultural, intellectual, emotional, and spiritual areas of a persons life, known as a(n) __________ assessment. |
holistic |
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The nurse is reviewing information regarding a female client that was obtained with the psychiatric assessment tool. The clients ability to provide food and shelter for herself is included in which area of the assessment? |
Coping responses, discharge planning needs |
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During an interview with a 15-year-old female client admitted for depression, the nurse expresses her disappointment when she to learns that the client recently became pregnant and then had an abortion. The nurse is contradicting the effective interview guideline of: |
Avoiding ones personal values that may cloud professional judgment |
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A male client with a history of schizophrenia was admitted to the mental health facility after he was found on the street in a confused state and was uncooperative when approached by the police. One of the first assessments that should be performed on this client upon admission is a _____ assessment. |
physical |
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During the mental status examination, the nurse observes that the client rapidly changes from one idea to another related thought. Which disordered thinking process is the client displaying? |
flight of ideas |
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When reviewing the nursing notes from the previous shift, the nurse notices notations indicating that the client was experiencing a somnolent level of consciousness. The clients behavior would be described as: |
Falling asleep easily and only awakening with strong verbal stimuli |
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During the mental status assessment, the nurse hands the client a piece of paper that reads Please raise your left hand. If the client follows the command, the nurse has just assessed which ability of the client? |
reading |
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According to the DSM-IV-TR Axis guidelines, clinical disorders are described as: |
Mood disorder, substance abuse, and schizophrenic disorders |
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A score of 1 to 10 on the global assessment functioning (GAF) scale would indicate that a client was at risk for: |
hurting himself or others |
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A client with a history of delusions demonstrates which of the following behaviors? |
Insists the government is out to harm them |
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A client complains to the nurse that he has been fired from his fourth job in 10 months because his bosses and co-workers didnt understand him. While he once had a few close friends, he no longer associates with them for the same reason. His level of functioning on the global assessment of functioning (GAF) scale would be: |
41-50; serious symptoms |
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The nurse suspects the client is experiencing a manic episode based on which of the following observations? |
a. Clothing is very colorful and mismatched, and client cannot sit in chair during interview. |
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A client seen in the emergency department is noted to be stuporous. Which of the following assessment findings would be of most concern? |
Painting furniture in a windowless room |
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Upon entrance into a mental health care system, clients are thoroughly assessed, and this is followed by the development of a mental health treatment plan. Which of the following are purposes of the treatment plan? (Select all that apply.) |
A means of monitoring the clients progress c. An instrument for communication and coordination of care d. A guide for planning and implementation of care e. Evaluating the effectiveness of interventions |
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The assessment phase of the nursing process refers to the phase when data collection occurs. Which methods does the nurse use to collect data? (Select all that apply.) |
Interviewing the client and significant others c. Observing client behavior d. Performing physical assessment e. Reviewing diagnostic testing results |
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During the sociocultural assessment of a client who is entering a mental health program, the nurse focuses on which information related to the client? (Select all that apply.) |
a. Education b. Income c. Ethnicity d. Age e. Gender belief system |
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Short-term memory loss is seen in which of the following disorders? (Select all that apply.) |
depression , alzheimer’s , anxiety |
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is how the client displays his or her emotions through facial, vocal, or gestural behavior. |
affect |
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A male client with a diagnosis of schizophrenia begins to have hallucinations during a conversation with the nurse; this prevents him from receiving the message that the nurse is trying to communicate to him. According to Rueschs theory of communication, this unsuccessful interaction is called _____ communication. |
disturbed |
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The theorist Eric Berne theorized that an individuals three ego states of parent, child, and adult make up ones: |
personality |
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The nursing student is assigned a client to interview and is asked to practice the therapeutic communication technique of sharing perceptions. Which statement made by the student nurse best describes this technique? |
I noticed that you pace the halls, and you have a tense look on your face. I sense that you are anxious about something. |
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The nurse is talking with a male client regarding his recent relapse of alcohol addiction. The client alludes to the fact that he started to drink again after a fight with his wife. The nurse uses clarification to ensure an accurate understanding of the client. Which statement is the best example of clarification? |
Could you tell me again when and what happened that you feel caused you to start drinking again? |
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A female client discusses her feelings of jealousy regarding the relationship between her mother and her daughter. The nurse responds in a nontherapeutic way by making a statement that is defensive and challenging. Which statement is the best example of a defensive and challenging nontherapeutic response? |
Dont you think that you should be thankful that your daughter has a good relationship with her grandmother? |
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A female client has been attending group therapy for support regarding an abusive relationship with her husband. The client voices concern about her 10-year-old daughter growing up in this environment but states that she just cant find the strength to leave her husband. The nurse responds by using the nontherapeutic technique of reassuring. Which statement is the best example of this nontherapeutic technique? |
Im sure it wont be that bad to be out on your own. I know you can do it. |
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Therapeutic communication techniques support effective communication between the client and the nurse. Which group of therapeutic techniques is most likely to be effective when one is conversing with a client? |
Listening, silence, and reflection |
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While the nurse is talking with a female client, the client becomes silent for several seconds. Which is the nurses best response? |
To remain silent and be attentive to the clients nonverbal communication |
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A client who usually is very active in her therapy group tells the nurse that she really does not feel well today and would rather not attend the group therapy session. Which is the nurses most appropriate response? |
You dont feel like attending the group therapy today? |
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The nurse is talking with a male client with a diagnosis of schizophrenia who often experiences auditory hallucinations. For this communication to be most effective, the nurse should: |
Use simple, concrete language. |
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The nurses ability to interpret communication effectively in the mental health setting depends mostly on: |
The nurses ability to listen to and observe the clients verbal and nonverbal messages |
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Which nurse response is the best example of the therapeutic principle of respect? |
I hear how worried you are about your future and can imagine how you feel. |
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A female client is being discharged from an inpatient mental health unit after receiving treatment for bipolar disorder. She has responded well to treatment but voices concern about going home and maintaining balance in her life. The client would benefit most by a response from the nurse that conveyed the therapeutic communication principle of: |
protection |
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A nurse has just graduated from nursing school and has been hired on a mental health unit. The nurse wants to practice good communication skills with clients but knows that a mistake made by many new nurses in trying to communicate effectively involves: |
parroting |
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A client has difficulty in communicating as a result of his illness. He displays a rapid, confusing delivery of speech patterns. Which term best describes this difficulty in communicating? |
speech cluttering |
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When practicing therapeutic communication with a client, the nurse demonstrates which of the following listening skills? |
Changing the environment to decrease distractions |
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The nurse asks a client how she is feeling, and the client provides a detailed description of everything she is experiencing. This is an example of: |
Circumstantiality |
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The client tells the nurse that she believes there is no improvement in her manic episodes. Her clothing matches, and her makeup is more subdued. She sits quietly in the chair during the session. What does this indicate? |
Verbal communication is not congruent with nonverbal communication. |
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When the adolescent client is asked about the magazine she is reading, she responds, Its an article about my favorite movie star. Did you see all the stars out last night? I used to be afraid of the dark at night. Which speech pattern is this an example of? |
Loose association |
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Which elements must be present for communication to occur? (Select all that apply.) |
a. Feedback b. Transmission c. Sender e. Receiver g. Context |
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Which interventions assist the nurse to effectively communicate with clients from other cultures? (Select all that apply.) |
a. The nurse adapts his or her behavior to accommodate the difference in communication styles. b. The nurse identifies and clarifies confusion during the interaction. |
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Which nurse responses could block effective communication with a client? |
This is what I think you should say b. Dont stress over it. Everything will turn out fine. c. Why did you do that? d. Most people in your circumstance |
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In order to be therapeutic when communicating with a client living in a homeless shelter, it is important to apply which techniques? (Select all that apply.) |
a. Show acceptance and respect. d. Consider the clients environment. e. Assess clients pattern of verbal and nonverbal communication. |
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The nurse is attempting to develop trust with a newly admitted female client for the purpose of establishing a therapeutic relationship. The nurse is currently administering medications to all clients on the unit. The newly admitted client asks the nurse to sit and talk with her for a while. What is the nurses best response? |
I have to finish giving all the clients their medications, but I will then come back so we can talk. |
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A nurse is working with a male client in a mental health outpatient clinic. The client voices a desire to become more autonomous. Which goal will assist the client in becoming more autonomous? |
The client will check his calendar each night to plan for commitments scheduled on the following day. |
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An important aspect of developing a therapeutic relationship with a mental health client is for the nurse to show that she cares about the client. The nurse who is working on an inpatient unit can show signs of caring by: |
Asking a client what his or her favorite movie is, then showing that movie during a movie night on the unit |
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The nurse is caring for a female client with a diagnosis of severe bipolar disorder. Out of many treatment methods, the one treatment that the client and the team have found to be most effective is the medication lithium. The client voices concern about her future with this diagnosis. Which nurse response best represents the concept of hope? |
You are doing very well since we found that lithium helps. You should do well as long as you continue your therapy and medication. |
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A male client with schizophrenia has lost his job and home and has been living in a homeless shelter. He voluntarily admits himself into a mental health treatment facility. The clients current living situation and lack of a job at this time likely will contribute to his having difficulty with which dimension of hope? |
contextual |
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A female client with obsessive-compulsive disorder is undergoing treatment in an outpatient setting and is attending group therapy sessions. She is working on controlling the compulsion of touching her head three times every time she talks. To maintain the therapeutic relationship established with the client, by which action can the nurse show acceptance? |
Ignoring the compulsion during the group therapy session and talking with the client privately about the behavior |
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The characteristic of genuineness helps in establishing a therapeutic relationship with a client. Which nurse response is the best example of a display of genuineness to a client who is going through a difficult divorce? |
I have friends who have gone through a divorce. It must be difficult for you. |
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During the preparation phase of a therapeutic relationship with a client, what is the main task to be completed by the nurse? |
To gather and review all possible information regarding the client |
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When should the nurse begin preparations for the termination phase of a therapeutic relationship? |
prior to the last meeting |
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The nurse is preparing an adult male client, who has been successfully treated for a social phobia, for the termination phase of the therapeutic relationship. During their last meeting, the client told the nurse that he noticed he has developed a nervous habit that started a few days ago of checking his door at home several times a day to be sure it is locked. This client is exhibiting the client response to termination known as: |
continuation |
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When a caregiver becomes a role model for a client during a therapeutic relationship, the caregiver is functioning in the role of: |
change agent |
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A male client is being discharged from a mental health facility and is worried about what to tell his friends and co-workers regarding his time away. The nurse helps the client plan what to say to others about his disease. The nurse is functioning in the role of: |
teacher |
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A female client is admitted with suicidal tendencies. The client is placed in suicide precautions for the first 24 hours of her stay. Ensuring client safety is included in the therapeutic role of: |
technition |
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The nurse who is caring for a client begins to have very protective feelings toward the client that are interfering with the therapeutic relationship between the nurse, the client, and the clients family. This is an example of a problem that is encountered in some therapeutic relationships and is known as: |
countertransferance |
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A 19-year-old male client is being treated for a drug addiction. He continually voices his dread of being discharged because he knows he will have to live with his parents and follow their rules until he can earn enough money to live on his own. He is showing increasing resistance to treatment measures, such as attending group sessions, but is refusing to acknowledge that he has an addiction or that he needs treatment. Which behavior is the client demonstrating? |
secondary resistance |
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A client response to the termination phase of the therapeutic relationship is withdrawal. This response most often is manifested by client behaviors such as: |
being absent from appointments |
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A 22-year-old woman with depression misses her scheduled meeting with the nurse. Although they have established a contract to meet on an agreed upon schedule, the nurse understands that the client is still testing the relationship and working on trusting her care provider. This behavior usually manifests itself during which phase of the therapeutic relationship? |
orientation |
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The new nurse confides to his supervisor, I am feeling frustrated. Mr. J has been doing so well in dealing with his issues over the last month, and today he refused to discuss anything productive in our session. What is the most appropriate response? |
During the working phase the client may have growth and resistance. |
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Which of the following actions indicates that the nurse has gone beyond the boundaries of the clientcaregiver relationship? |
The nurse defends the client to her family and the staff. |
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As the nurse begins to discuss discharge plans for a 45-year-old female client hospitalized for anxiety, the client states, You never really cared whether I get better! Why not stop this charade? The nurse recognizes this to be: |
transference |
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For which roles is the caregiver responsible in a therapeutic relationship? (Select all that apply.) |
a. Teacher b. Therapist c. Technician change agent |
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Which of the following are characteristics of a therapeutic relationship? (Select all that apply.) |
a. Acceptance b. Rapport d. Genuineness e. Therapeutic use of self |
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Crisis stabilization provides care to clients in treatment settings with the purpose of reestablishing homeostasis; it usually lasts for _____ days. |
1-2 days |
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Which is an accepted criterion for inpatient admission to a mental health facility? |
The client feels that he is no longer able to cope with life stressors or maintain control of his behavior. |
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A male client with a diagnosis of schizophrenia refuses to take his medication because of his paranoia that the medication may be poisoned. Frequent inpatient readmissions to the facility occur as a result. Which term is given to repeated inpatient admissions? |
recidivism |
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An adult female inpatient client with a diagnosis of paranoid schizophrenia will not take her medications from the nurse. She states, I know you are poisoning that medicine. Which nursing action is most appropriate? |
Administer medications to her in unit dose packages so that she can open the packages herself. |
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A male inpatient client who is experiencing depression has no interest in eating. He skips meals frequently and has been losing weight. What is the best nursing action in this situation? |
Leave food with him at mealtime and offer snacks frequently. |
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Encouragement for clients to practice good hygiene habits not only meets basic physiological needs, it also meets the hierarchal need of: |
love and belonging |
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With regard to the environment, it is important for the nurse to be aware of lighting for some clients. Clients with a diagnosis of schizophrenia may be bothered by lights that are flickering because this may trigger: |
hallucinations |
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A female client on the mental health unit experiences periods of psychosis at intervals. She often asks what day she came to the facility and what day it is now, and she seems never to be aware of the time. Which nursing intervention would help this client the most? |
Assist her to keep a written schedule, including her day of admission, on a calendar posted in her room and a clock beside the calendar. |
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A 15-year-old female client is noted to often sit alone in the activity room of the facility while watching television. She often begins to join in activities on the unit but then retreats back to her room. Which intervention is most appropriate in this situation? |
Encourage her to join in on a group activity and actively participate in the activity with her until she feels more comfortable on her own. |
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The nurse can assist a client best in meeting his or her needs for self-esteem and/or self-actualization by: |
Allowing the client to make choices involving his or her care when appropriate |
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The nurse is aware that during the admission process to a mental health facility, the anxious client: |
Often forgets some of what is said in the unfamiliar surroundings |
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Bright colors in the environment of the client are often: |
stimulating |
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The nurse should monitor the temperature of the environment of a client who becomes easily agitated, with awareness that increased temperatures sometimes may cause the client to become: |
more distressed |
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A male client is in the process of being admitted to a mental health facility. He is sure that the nurse is the administrator of the hospital, despite the nurses insistence that he is a staff nurse on the unit. This client is experiencing: |
delusions |
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When establishing a clients level of consciousness, the nurse is aware that this is determined by assessing the clients: |
level of awareness. |
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A 16-year-old client is in the lounge with other clients on the inpatient unit when he suddenly becomes agitated. Which action by the nurse would be most appropriate in this situation |
Accompany him to a room where soft music is playing. |
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The goal in treating a client with a chronic mental illness is to prevent recidivism. Which factor is crucial in this effort? |
Group residential homes with vocational training |
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The use of therapeutic touch as a relaxation technique in the mental health setting is beneficial for clients displaying which symptoms? |
depression |
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A 22-year-old woman is brought to the inpatient unit for attempting suicide. Her clothes are clean, and her general appearance is neat and well groomed. She appears to be well nourished. In considering Maslows hierarchy of needs, which is a priority for this client? |
safety and security |
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Inpatient services provide care mainly for mental health clients who are experiencing which conditions? (Select all that apply.) |
a. Acute mental or emotional problems b. Chronic mental or emotional problems c. crisis |
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Which are common causes for client noncompliance in the plan of care? (Select all that apply.) |
a. Financial concerns b. Lack of support by family d. Inability to understand the treatment plan e. Lack of access to treatment services |
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Admission to an inpatient mental health unit is often a stressful event. Which actions on the part of the health care provider will help to decrease the anxiety of the client? (Select all that apply.) |
b. Answer any questions the client may have. c. Support the client in being oriented to the unit. d. Provide simple, clear instructions and repeat if needed. e. Communicate concern for the client. |
