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28 Cards in this Set
- Front
- Back
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Unresolved feelings related to loss may be most likely recognized during which phase of the therapeutic nurse-client relationship
1.Orientation 2. Working 3. Termination 3. Trusting |
3
In the termination phase, the relationship comes to a close. Ending the treatment can sometimes be traumatic for clients who have come to value the relationship and the help. Since loss is an issue, any unresolved feelings related to loss may resurface during this phase. |
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A client with a diagnosis of major depressiion who attempted suicide says to the nurse, "I should have died. I've always been a failure. Nothing ever goes right for me." The most therapeutic response to the client is:
1. I don't see you as a failure 2. Feeling like this is all part of being ill 3. You've been feeling like a failure for a while? 4. You have everything to live for. |
3
Responding to the feelings expressed by a client is an effective therapeutic communication technique. The correct option is an example of restating. Options 1, 2, and 4 block communication because they minimize the client's experience and do not facilitate exploration of the client's expressed feelings |
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A community health nurse visits a client at home. The client states, "I haven't slept at all the last couple of nights." Which response by the nurse illustrates the most therapeutic communication technique for this client?
1. "Go on ... ' 2. "Sleeping?" 3. "The last couple of nights?" 4. "You're having difficulty sleeping?" |
4
The most therapeutic nursing communication technique is a restatement. Although it 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 |
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A nurse is performing an admission assessment on a client and is attempting to obtain subjective data about the client's sexual and reproductive status. The client states .", "I don't want to discuss this; it's private and personal." Which statement if made by the nurse, indicates that the nurse is therapeutic?
1. "I hate being asked these sorts of questions too." 2. "I am a professionalnurse and as such I'll have you know that all information is kept confidential." 3." I know that some of these questions are difficult for you but, as a professional nurse, I must legally respect your confidentiality." 4. "This is difficult for you to speak about, but I am trying to perform a complete assessment and I need this information |
3
is the only option that identifies a therapeutic response |
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a nurse is caring for a native american client who says, "I don't want you to touch me. I'll take care of myself!" Which nursing response is most therapeutic?
1. Okay. If that's what you want. I'll just leave this cup for you to collect your urine in. After breakfast, I willtake more blood from you." 2."If you didn't want our care, why did you come here?" 3."Why are you being so difficult? I only want to help you." 4."It sounds as though you want to take care of yourself. Let's work together so you can do things for yourself." |
4
Native Americans view touch very differently from other Americans. The most therapeutic response is the one that reflects the client's feelings and empowers the client by offering self control over one's own care. |
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A client admitted to the mental health unit is experiencing altered thought processes. The client believes that the food is being poisened. Which communication technique does the nurse plan to use to encourage the client to express feelings?
1. Using open ended questions and silence. 2. Offering opinions about the necessity of adequate nutrition 3. Identifying the reasons that the client may not want to eat. 4. Focusing on self-disclosure about food preferences. |
1
Open-ended questions and silence are strategies used to encourage clients to discuss their problems |
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A nurse is working with a client who has sought counseling after trying to rescue a neighbor involved in a house fire. In spite of the client's efforts, the neighbor died. Which action does the nurse engage in with the client during the working phase of the nurse-client relationship?
1. Exploring the client's potential for self harm 2. Exploring the client's ability to function. 3. Inquiring about the client's perception or appraisel of the neighbor's death. 4. Inquiring about and examining the client's feelings that may block adaptive coping. |
4
The client must first deal with feelings and negative responses before being able to work through the meaning of the crisis. This pertains directly to the client's feelings. |
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A client who has just been sexually assaulted is very quiet and calm. The nurse analyzes this behavior as indicative of which defense mechanism?
1. Denial 2. Projection 3. Rationalization 4. Intellectualization |
1
Denial is an adaptive and protective reaction and may be a response by a victim of sexual abuse. |
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A nurse completes the initial assessment of a client admitted to the mental health unit. The nurse analyzes the data obtained on assessment and determines that which of the following presents a priority concern?
1The presence of bruises on the client's body 2. The client's report of not eating or sleeping 3. The client's report of suicidal thoughts 4. The significant other's disapproving of the treatment |
3
The client's thoughts are extremely important when verbalized. A client's report of suicidal thoughts is of highest priority |
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Laboratory work is prescribed for a client who has been experiencing delusions. When the nurse approaches the client to obtain a specimen of the client's blood, the client begins to shout, "You're all vampires. Let me out of here." The most appropriate nursing response is which of the following?
1. I am not going to hurt you, I am going to help you 2. What makes you think that I am a vampire? 3. I'll leave and come back later for your blood. 4. It must be fearful to think others want to hurt you. |
4
Helps the client to focus on the emotion underlying the delusion but does not argue with it |
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An inebriated client is brought to the emergency department by the local police. The client is told that the physician will be in to see the client in about 30 minutes. The client becomes very loud and offensive and wants to be seen by the physician immediately. The most appropriate nursing intervention is
1. Attempt to talk with the client to deescalte behavior 2. Watch the behavior excalate before intervening 3. Inform the client that he or she will be asked to leave if the behavior continues 4. Offer to take the client to an examination room until he or she can be treated |
4
Safety of the client, other clients,and staff is of prime concern |
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A client is admitted to a mental health unit for treatment of psychotic behavior. The client is at the locked exit door and is shouting, "Let me out. There's nothing wrong with me. I don't belong here." The nurse analyzes this behavior as
1. Projection 2. Denial 3. Regression 4. Rationalization |
2
Denial is refusal to admit to a painful reality, which is treated as if it does not exist. |
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A home health nurse is talking to the spouse of a client taking an antidepressant. The spouse says, "Now that my husband is responding to the antidepressant, the suicidal risk is over and you can stop making these home visits." After analyzing this statement, which of the following is the most appropriate nursing response?
1. I agree with you. Clients who want to kill themselves are only suicidal for a limited time. No one can feel self-destructive forever 2. I need to continue with my visits. Your comment reflects a lack of knowledge that this disease runs in families 3. I agree with yu. The suicidal threats were really attention seeking. Continuing to visit would reinforce your husband's use of manipulation 4. I need to continue with my visits. Most suicides occur within 3 months after improvement begins because the client now has the energy to carry out the suicidal intentions |
4
Most suicides occur within 3 months after the beginning of the improvement, when the client has the energy to carry out the suicidal intentions. |
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A supervisor reprimands the nurse in charge of a nursing unit because the charge nurse has not adhered to the unit budget. Later that afternoon, the charge nurse accuses the nursing staff of wasting supplies. This behavior is an example of
1 Denial 2. Repression 3. Suppression 4. Displacement |
4
Ego defense mechanisms are operations outside a person's awareness that the ego calls into play to protect against anxiety |
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a client says to the nurse, "I'm going to die, and I wish my family would stop hoping for a cure! I get so angry when they carry on like this! After all, I'm the one who's dying." The most therapeutic response is
1 You're feeling angry that your family continues to hope for you to be cured 2. I think we should talk more about your anger with your family 3. Well, it sounds like you're being pretty pessimistic. After all, years ago people died of pneumonia 4. Have you shared your feelings with your family |
1
Restating is the therapeutic communication technique in which the nurse repeats what the client says to show understanding and to review what was said. |
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A nurse employed in a mental health unit is assigned to care for a client admitted 2 days ago. On review of the client's record, the nurse notes that the admission was a voluntary admission. Based on this type of admission, the nurse anticipates which of the following
1. The client will be very resistant to treatment measures 2. The client will be angry and refuse care 3. The client's family will be very resistant to treatment measures 4. The client will participate in the planning of the care and treatment plan |
4
Generally, voluntary admission is sought by the client. Voluntary clients have the right to demand and obtain release. If the client is a minor, the release may be contingent on the consent of the parents or guardian. The nurse needs to be familiar with the state and facility policies and procedures. Many states require that the client submit a written release notice to the facility staff, who reevaluate the client's condition for possible conversion to involuntary status, according to criteria established by laws.. Contact the physician. |
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A nurse enters a client's room and the client is demanding release from the hospital. The nurse reviews the client's record and notes that the client was admitted 2 days ago for treatment of an anxiety disorder and that the admission was voluntary. which of the following actions will the nurse take?
1. Tell the client that discharge is not possible at this time 2. Call the client's family 3. Contact the physician 4. Persuade the client to stay for a few more days |
1
Involuntary admission is made without the client's consent. Involuntary admission is necessary when a person is a danger to self or others or is in need of psychiatric treatment or physical care |
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A client is admitted to the mental health unit. On admission assessment, the nurse notes that the client is admitted by involuntary status. Based on this type of admission, the nurse would most likely expect that the client:
1. Presents a harm to self 2. Requested the admission 3. Consented to the admission 4. Provided written application to the facility for admission |
3
Clients who are involuntarily admitted do not lose their right to informed consent. Clients must be considered legally competent until they have been declared incompetent through a legal proceding. The informed consent needs to be obtained through the client. |
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A nurse completes the initial assessment of a client admitted to the mental health unit. The nurse analyzes the data obtained on assessment and determines that which of the following presents a priority concern?
1The presence of bruises on the client's body 2. The client's report of not eating or sleeping 3. The client's report of suicidal thoughts 4. The significant other's disapproving of the treatment |
3
The client's thoughts are extremely important when verbalized. A client's report of suicidal thoughts is of highest priority |
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Laboratory work is prescribed for a client who has been experiencing delusions. When the nurse approaches the client to obtain a specimen of the client's blood, the client begins to shout, "You're all vampires. Let me out of here." The most appropriate nursing response is which of the following?
1. I am not going to hurt you, I am going to help you 2. What makes you think that I am a vampire? 3. I'll leave and come back later for your blood. 4. It must be fearful to think others want to hurt you. |
4
Helps the client to focus on the emotion underlying the delusion but does not argue with it |
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An inebriated client is brought to the emergency department by the local police. The client is told that the physician will be in to see the client in about 30 minutes. The client becomes very loud and offensive and wants to be seen by the physician immediately. The most appropriate nursing intervention is
1. Attempt to talk with the client to deescalte behavior 2. Watch the behavior excalate before intervening 3. Inform the client that he or she will be asked to leave if the behavior continues 4. Offer to take the client to an examination room until he or she can be treated |
4
Safety of the client, other clients,and staff is of prime concern |
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A client is admitted to a mental health unit for treatment of psychotic behavior. The client is at the locked exit door and is shouting, "Let me out. There's nothing wrong with me. I don't belong here." The nurse analyzes this behavior as
1. Projection 2. Denial 3. Regression 4. Rationalization |
2
Denial is refusal to admit to a painful reality, which is treated as if it does not exist. |
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A home health nurse is talking to the spouse of a client taking an antidepressant. The spouse says, "Now that my husband is responding to the antidepressant, the suicidal risk is over and you can stop making these home visits." After analyzing this statement, which of the following is the most appropriate nursing response?
1. I agree with you. Clients who want to kill themselves are only suicidal for a limited time. No one can feel self-destructive forever 2. I need to continue with my visits. Your comment reflects a lack of knowledge that this disease runs in families 3. I agree with yu. The suicidal threats were really attention seeking. Continuing to visit would reinforce your husband's use of manipulation 4. I need to continue with my visits. Most suicides occur within 3 months after improvement begins because the client now has the energy to carry out the suicidal intentions |
4
Most suicides occur within 3 months after the beginning of the improvement, when the client has the energy to carry out the suicidal intentions. |
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A supervisor reprimands the nurse in charge of a nursing unit because the charge nurse has not adhered to the unit budget. Later that afternoon, the charge nurse accuses the nursing staff of wasting supplies. This behavior is an example of
1 Denial 2. Repression 3. Suppression 4. Displacement |
4
Ego defense mechanisms are operations outside a person's awareness that the ego calls into play to protect against anxiety |
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a client says to the nurse, "I'm going to die, and I wish my family would stop hoping for a cure! I get so angry when they carry on like this! After all, I'm the one who's dying." The most therapeutic response is
1 You're feeling angry that your family continues to hope for you to be cured 2. I think we should talk more about your anger with your family 3. Well, it sounds like you're being pretty pessimistic. After all, years ago people died of pneumonia 4. Have you shared your feelings with your family |
1
Restating is the therapeutic communication technique in which the nurse repeats what the client says to show understanding and to review what was said. |
|
|
A nurse employed in a mental health unit is assigned to care for a client admitted 2 days ago. On review of the client's record, the nurse notes that the admission was a voluntary admission. Based on this type of admission, the nurse anticipates which of the following
1. The client will be very resistant to treatment measures 2. The client will be angry and refuse care 3. The client's family will be very resistant to treatment measures 4. The client will participate in the planning of the care and treatment plan |
4
Generally, voluntary admission is sought by the client. Voluntary clients have the right to demand and obtain release. If the client is a minor, the release may be contingent on the consent of the parents or guardian. The nurse needs to be familiar with the state and facility policies and procedures. Many states require that the client submit a written release notice to the facility staff, who reevaluate the client's condition for possible conversion to involuntary status, according to criteria established by laws.. Contact the physician. |
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|
A nurse enters a client's room and the client is demanding release from the hospital. The nurse reviews the client's record and notes that the client was admitted 2 days ago for treatment of an anxiety disorder and that the admission was voluntary. which of the following actions will the nurse take?
1. Tell the client that discharge is not possible at this time 2. Call the client's family 3. Contact the physician 4. Persuade the client to stay for a few more days |
1
Involuntary admission is made without the client's consent. Involuntary admission is necessary when a person is a danger to self or others or is in need of psychiatric treatment or physical care |
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A client is admitted to the mental health unit. On admission assessment, the nurse notes that the client is admitted by involuntary status. Based on this type of admission, the nurse would most likely expect that the client:
1. Presents a harm to self 2. Requested the admission 3. Consented to the admission 4. Provided written application to the facility for admission |
3
Clients who are involuntarily admitted do not lose their right to informed consent. Clients must be considered legally competent until they have been declared incompetent through a legal proceding. The informed consent needs to be obtained through the client. |
