VN 101: MENTAL HEALTH GUIDE

VN 101: MENTAL HEALTH GUIDE .....Rationale: Provide the client with small meals frequently is correct. Clients who have anorexia generally will not consume large meals. Monitor the client’s weight daily is correct. Daily weighing makes it difficult for the client to hide weight loss. Allow the client to choose the meals she will eat is incorrect. The BMI in the underweight category is the result of the client choosing her own meals. Stay with the client during meals and for 1 hr afterward is correct. The nurse should offer support and encouragement at mealtimes but also monitor the client’s behavior to prevent purging following food ingestion. Offer specific privileges for sustained weight gain is correct. Positive reinforcement includes rewards for improvements in eating behaviors and is an appropriate strategy for clients who have eating disorders. 1. A client who is depressed and has attempted suicide tells the nurse, "I should have died because I am totally worthless." Which of the following responses by the nurse is appropriate? A. "You've been feeling that your life has no meaning." Rationale: This open-ended statement uses the communication tool of empathy and addresses the client's feeling of worthlessness. This therapeutic response communicates to the client that the nurse was listening, and it will encourage the client to talk further about personal feelings. B. "It's not unusual for persons with depression to feel this way." Rationale: This nontherapeutic response is a generalization and does not address the client's feelings or the client as an individual. C. "Why do you feel you are worthless?" Rationale: This nontherapeutic response requires the client to answer a "why" question that the client may be unable to answer. D. "You have a great deal to live for." Rationale: In this nontherapeutic response the nurse is using a cliché. 2. After a cesarean delivery due to dysfunctional labor, a client and her partner express their disappointment to the nurse that they did not have natural childbirth. Which of the following is an appropriate nursing response? A. “It sounds like you are feeling sad that things didn’t go as planned.” Rationale: With this response, the nurse is using the therapeutic communication technique of restating to encourage the couple to continue to communicate their feelings. B. “At least you know you have a healthy baby.” Rationale: With this response, the nurse is using the nontherapeutic communication technique of making stereotyped comments. This encourages the client to make similar trite comments and repress concerns and feelings. C. “Maybe next time you can have a vaginal delivery.” Rationale: With this response, the nurse is using the nontherapeutic communication technique of giving reassurance. D. “You will be able to resume sex sooner than if you had delivered vaginally.” Rationale: With this response, the nurse is using the nontherapeutic communication technique of introducing an unrelated topic. 3. A nurse is discussing the possible physical effects of alcohol withdrawal with a newly licensed nurse. Which of the following should the nurse include in the discussion? (Select all that apply.) A. Seizures B. Illusions C. Tremors D. Polyphagia E. Nystagmus Rationale: Seizures is correct. Seizures are an expected finding of alcohol withdrawal. Illusions is correct. Illusions are an expected finding of alcohol withdrawal. Tremors is correct. Tremors are an expected finding of alcohol withdrawal. Polyphagia is incorrect. Nausea and vomiting, rather than polyphagia, are expected findings of alcohol withdrawal. ...