NURSING 2230 Mental Health Exam 3

NURSING 2230 Mental Health Exam 3 Chapters 12, 13, 14, 15, 16, 17, 18, 19, 26 Chapter 12 Milieu Therapy - The Therapeutic Community 1. An angry client on an inpatient unit approaches a nurse, stating, Someone took my lunch! People need to respect others, and you need to do something about this now! The nurses response should be guided by which basic assumption of milieu therapy? A. Conflict should be avoided at all costs on inpatient psychiatric units. B. Conflict should be resolved by the nursing staff. C. Every interaction is an opportunity for therapeutic intervention. D. Conflict resolution should be addressed only during group therapy. The nurses response should be guided by the basic assumption that every interaction is an opportunity for therapeutic intervention. The nurse can utilize milieu therapy to effect behavioral change and improve psychological health and functioning. 2. A client on an inpatient unit angrily states to a nurse, Peter is not cleaning up after himself in the community bathroom. You need to address this problem. Which is the appropriate nursing response? A. Ill talk to Peter and present your concerns. B. Why are you overreacting to this issue? C. You should bring this to the attention of your treatment team. D. I can see that you are angry. Lets discuss ways to approach Peter with your concerns. The most appropriate nursing response involves restating the clients feeling and developing a plan with the client to solve the problem. According to Skinner, every interaction in the therapeutic milieu is an opportunity for therapeutic intervention to improve communication and relationship-development skills. 3. A newly admitted client asks, Why do we need a unit schedule? Im not going to these groups. Im here to get some rest. Which is the most appropriate nursing reply? A. Group therapy provides the opportunity to learn and practice new coping skills. B. Group therapy is mandatory. All clients must attend. C. Group therapy is optional. You can go if you find the topic helpful and interesting. D. Group therapy is an economical way of providing therapy to many clients concurrently. The nurse should explain to the client that the purpose of group therapy is to learn and practice new coping skills. A basic assumption of milieu therapy is that every interaction, including group therapy, is an opportunity for therapeutic intervention. 4. A client diagnosed with schizophrenia functions well and is bright, spontaneous, and interactive during hospitalization but then decompensates after discharge. What does the milieu provide that may be missing in the home environment? A. Peer pressure B. Structured programming C. Visitor restrictions D. Mandated activities The milieu, or therapeutic community, provides the client with structured programming that may be missing in the home environment. The therapeutic community provides a structured schedule of activities in which interpersonal interaction and communication with others are emphasized. In the milieu, time is also devoted to personal problems and focus groups. 5. To promote self-reliance, how should a psychiatric nurse best conduct medication administration? A. Encourage clients to request their medications at the appropriate times. B. Refuse to administer medications unless clients request them at the appropriate times. C. Allow the clients to determine appropriate medication times. D. Take medications to the clients bedside at the appropriate times. The psychiatric nurse promoting self-reliance would encourage clients to request their medications at the appropriate times. Nurses are responsible for the management of medication administration on inpatient psychiatric units; however, nurses must work with clients to foster independence and provide experiences that would foster increased self-esteem. 6. A nurse working on an inpatient psychiatric unit is assigned to conduct a 45-minute education group. What should the nurse identify as an appropriate group topic? A. Dream analysis B. Creative cooking C. Paint by number D. Stress management The nurse should identify that teaching clients about stress management is an appropriate education group topic. Nurses should be able to perform the role of client teacher in the psychiatric area. Nurses need to be able to assess a clients learning readiness. Other topics for education groups include medical diagnoses, side effects of medications, and the importance of medication compliance. 7. What is the best rationale for including the clients family in therapy within the inpatient milieu? A. To structure a program of social and work-related activities B. To facilitate discharge from the hospital C. To provide a concrete demonstration of caring D. To encourage the family to model positive behaviors The nurse should include the clients family in therapy within the inpatient milieu to facilitate discharge from the hospital. Family members are invited to participate in some therapy groups and to share meals with the client in the communal dining room. Family involvement may also serve to prevent the client from becoming too dependent on the therapeutic environment. 8. How does a democratic form of self-government in the milieu contribute to client therapy? A. By setting punishments for clients who violate the community rules B. By dealing with inappropriate behaviors as they occur C. By setting community expectations wherein all clients are treated on an equal basis D. By interacting with professional staff members to learn about therapeutic interventions A democratic form of self-government in the milieu contributes to client therapy by setting the expectation that all clients should be treated on an equal basis. Clients participate in the decision-making and problem-solving aspects that affect treatment setting. The norms, rules, and behavioral limits are established by the staff and clients. All individuals have input. 9. A client has undergone psychological testing. With which member of the interdisciplinary team should a nurse collaborate to review these results? A. The psychiatrist B. The psychiatric social worker C. The clinical psychologist D. The clinical nurse specialist The nurse should consult with the clinical psychologist to review psychological testing results for the client. Clinical psychologists can administer, interpret, and evaluate psychological tests to assist in the diagnostic process. 10. In the role of milieu manager, which activity should the nurse prioritize? A. Setting the schedule for the daily unit activities B. Evaluating clients for medication effectiveness C. Conducting therapeutic group sessions D. Searching newly admitted clients for hazardous objects The milieu manager should search newly admitted clients for hazardous objects. Safety of the client and others is the priority. Nurses are responsible for ensuring that the clients safety and physiological needs are met within the milieu. 11. A nurse attends an interdisciplinary team meeting on an inpatient unit. Which of the following individuals are typically included as members of the interdisciplinary treatment team in psychiatry? Select all that apply. A. Respiratory therapist B. Occupational therapist C. Recreational therapist D. Social worker E. Mental health technician The typical interdisciplinary treatment team in a psychiatric inpatient setting consists of a psychiatrist, psychiatric nurse, psychiatric social worker, music therapist, dietician, psychologist, occupational therapist, recreational therapist, art therapist, mental health technician, and chaplain. Other disciplines may be included on the basis of resources available in a particular hospital setting and individual patient needs. 12. Which of the following are accurate descriptors of a therapeutic community? Select all that apply. A. The unit schedule includes unlimited free time for personal reflection. B. Unit responsibilities are assigned according to client capabilities. C. A flexible schedule is determined by client needs. D. The individual is the sole focus of therapy. E. A democratic form of government exists. In a therapeutic community the unit responsibilities are assigned according to client capability, and a democratic form of government exists. Therapeutic communities are structured and provide therapeutic interventions that focus on communication and relationship-development skills. Chapter 13 Crisis Intervention 1. A mother is concerned about her ability to perform in her new role. She is quite anxious and refuses to leave the postpartum unit. To offer effective client care, a nurse should recognize which information about this type of crisis? A. This type of crisis is precipitated by unexpected external stressors. B. This type of crisis is precipitated by preexisting psychopathology. C. This type of crisis is precipitated by an acute response to an external situational stressor. D. This type of crisis is precipitated by normal life-cycle transitions that overwhelm the client. The nurse should understand that this type of crisis is precipitated by normal life-cycle transitions that overwhelm the client. Reassurance and guidance should be provided as needed, and the client should be referred to services that can provide assistance. 2. A wife brings her husband to an emergency department after an attempt to hang himself. He is a full-time student and works 8 hours at night to support his family. He states, I cant function any longer under all this stress. Which type of crisis is the client experiencing? A. Maturational/developmental crisis B. Psychiatric emergency crisis C. Anticipated life transition crisis D. Traumatic stress crisis The nurse should determine that the client is experiencing a psychiatric emergency crisis. Psychiatric emergencies occur when crisis situations result in severe impairment, incompetence, or inability to assume personal responsibility. 3. A client comes to a psychiatric clinic, experiencing sudden extreme fatigue and decreased sleep and appetite. The client works 12 hours a day and rates anxiety as 8/10 on a numeric scale. What correctly written long-term outcome is realistic in addressing this clients crisis? A. The client will change his or her type A personality traits to more adaptive ones by week 1. B. The client will list five positive self-attributes. C. The client will examine how childhood events led to an overachieving orientation. D. The client will return to previous adaptive levels of functioning by week 6. The nurse should identify that a realistic long-term outcome for this client would be to return to previous adaptive levels of functioning. The nurse should work with the client to develop attainable outcomes that reflect the immediacy of the situation. To be correctly written, an outcome must be client-centered, specific, measurable, realistic, and contain a time frame. 4. A high school student has learned that she cannot graduate. Her boyfriend will be attending a college out of state that she planned to also attend. She is admitted to a psychiatric unit after overdosing on Tylenol. Which is the correctly written priority nursing diagnosis for this client? A. Ineffective coping R/T situational crisis AEB powerlessness B. Anxiety R/T fear of failure C. Risk for self-directed violence R/T hopelessness D. Risk for low self-esteem R/T loss events AEB suicidal ideations The priority nursing diagnosis for this client is Risk for self-directed violence R/T hopelessness. Nurses should prioritize diagnoses and outcomes on the basis of potential safety risk to the client and/or others. Nursing diagnoses should be correctly written to include evidence if actual and no evidence if the diagnosis is determined to be potential. 5. After threatening to jump off a bridge, a client is brought to an emergency department by police. To assess for suicide potential, which question should a nurse ask first? A. Are you currently thinking about harming yourself? B. Why do you want to harm yourself? C. Have you thought about the consequences of your actions? D. Who is your emergency contact person? The nurse should first assess the client for current suicidal thoughts to minimize risk of harm and provide appropriate interventions. A suicidal client is experiencing a psychiatric emergency. The crisis team should prioritize safety by assessing the client for thoughts of self-harm. 6. An involuntarily committed client, when offered a dinner tray, pushes it off the bedside table onto the floor. Which intervention should a nurse prioritize to address this behavior? A. Initiate forced medication protocol. B. Help the client to explore the source of anger. C. Ignore the act to avoid reinforcing the behavior. D. With staff support and a show of solidarity, set firm limits on the behavior. The most appropriate nursing intervention is to set firm limits on the behavior. Pushing food onto the floor does not warrant forced medication because the behavior is not a direct safety concern. Exploring the source of anger may be appropriate after the client has gained emotional control. Ignoring the act may further upset the client and does not reinforce appropriate behavior. 7. A college student who was nearly raped while jogging completes a series of appointments with a rape crisis nurse. At the final session, which client statement most clearly suggests that the goals of crisis intervention have been met? A. Youve really been helpful. Can I count on you for continued support? B. I dont work out anymore. C. Im really glad I didnt go home. It would have been hard to come back. D. I carry mace when I jog. It makes me feel safe and secure. The nurse should evaluate that the client who has developed adaptive coping strategies has achieved the goals of crisis intervention. 8. A despondent client, who has recently lost her husband of 30 years, tearfully states, Ill feel a lot better if I sell my house and move away. Which nursing reply is most appropriate? A. Im confident you know whats best for you. B. This may not be the best time for you to make such an important decision. C. Your children will be terribly disappointed. D. Tell me why you want to make this change. During crisis intervention, the nurse should guide the client through a problem-solving process. The nurse should help the individual confront the source of the problem, encourage the individual to discuss changes he or she would like to make, and encourage exploration of feelings about aspects of the crisis that cannot be changed. The nurse should also assist the client in determining whether any changes are realistic and if timing of change is appropriate. This response encourages the client to think through what may be an impulsive decision. 9. An inpatient client with a known history of violence suddenly begins to pace. Which client behavior should alert a nurse to escalating anger and aggression? A. The client requests prn medications. B. The client has a tense facial expression and body language. C. The client refuses to eat lunch. D. The client sits in group therapy with back to peers. The nurse should assess that tense facial expressions and body language may indicate that a clients anger is escalating. The nurse should conduct a thorough assessment of the clients past and current violent behaviors and develop interventions for de-escalation. 10. What is the best nursing rationale for holding a debriefing session with clients and staff after clients have witnessed a peer being taken down after a violent outburst? A. To reinforce unit rules with the client population B. To create protocols for the future release of tensions associated with anger C. To process feelings and concerns related to the witnessed intervention D. To discuss the client problems that led to inappropriate expressions of anger The nurse should determine that the purpose for holding a debriefing session with clients and staff after clients have witnessed a peer being taken down after a violent outburst is to process feelings and concerns related to the witnessed intervention. 11. Which of the following nursing statements and/or questions represent appropriate communication to assess an individual in crisis? Select all that apply. A. Tell me what happened. B. What coping methods have you used, and did they work? C. Describe to me what your life was like before this happened. D. Lets focus on the current problem. E. Ill assist you in selecting functional coping strategies. In the assessment phase, the nurse should gather information regarding the precipitating stressor and the resulting crisis. Focusing on the current problem and selecting functional coping strategies are nursing interventions rather than assessments. 12. Which of the following are effective interventions that a nurse should utilize when caring for an inpatient client who expresses anger inappropriately? Select all that apply. A. Maintain a calm demeanor. B. Clearly delineate the consequences of the behavior. C. Use therapeutic touch to convey empathy. D. Set limits on the behavior. E. Teach the client to avoid I statements related to expression of feelings. The nurse should determine that when working with an inpatient client who expresses anger inappropriately, it is important to maintain a calm demeanor, clearly define the consequences, and set limits on the behavior. The use of therapeutic touch may not be appropriate and could escalate the clients anger. Chapter 14 Assertiveness Training 1. During a psychoeducational group on assertiveness training, a client asks, Why do we need to learn about this stuff? Which is the most appropriate nursing reply? A. Because your doctor requires you to attend this group. B. Being assertive is the ability to stand up for yourself while respecting the rights of others. C. Assertiveness training teaches you how to ask for what you want, when you want it. D. Assertive people place the needs and rights of others before their own. Assertiveness training assists people to maintain their own self-respect and meet their needs while respecting the rights of others. 2. Two clients are roommates on an inpatient psychiatric unit. At breakfast, client A, who had been missing her gold locket, notices client B wearing it. Which should a nurse recognize as a nonassertive or passive behavioral response from client A? A. Client A ignores the situation. B. Client A discusses the situation with her nurse and develops a plan of action. C. Client A immediately approaches client B and pulls the necklace off her neck. D. Client A offers to wash client Bs clothes and accidentally spills bleach in the water. By ignoring the situation, client A avoids conflict, denies her feelings, and does not assertively resolve the problem. This is an example of nonassertive behavior. 3. A client on an inpatient unit is angry with a peer. During lunch, when the peer is not looking, the client spits into his soup. How would the nurse document this interaction? A. Client is displaying assertive behaviors. B. Client is displaying aggressive behaviors. C. Client is displaying passive behaviors. D. Client is displaying passiveaggressive behaviors. This response is passiveaggressive. The clients anger is expressed indirectly by spitting in the soup when the peer is not looking. 4. A client continually waits more than an hour before being seen at the mental health clinic. The client approaches the nurse and states, When I have to wait for more than an hour to be seen, I feel like my time is not important. The nurse recognizes this as what type of behavior? A. Aggressive behavior B. Assertive behavior C. Passiveaggressive behavior D. Passive behavior This response is assertive. The client is openly expressing feelings and attempting to correct a stressful situation. 5. During an assertiveness training group, a client admits to aggressive behaviors. The client asks for suggestions for how to become more assertive and less aggressive. Which is the most appropriate nursing reply? A. Several techniques, including meditation and progressive muscle relaxation, appear helpful. B. Theres not much that can be done about aggressive behavior because of biological responses. C. Certain types of medications have been proven effective in promoting assertive communication. D. There are several techniques, including I statements, role playing, and thought stopping, that can help promote assertive behaviors and decrease aggressive behaviors. These techniques promote assertive behaviors and would help diminish aggressive responses. 6. During an assertiveness training group, a nurse suggests using I statements. The group questions the usefulness of this communication technique. Which explanation by the nurse is most appropriate? A. When I statements are used, opinions are communicated without blaming others. B. When I statements are used, anger is displaced by using indirect means. C. When I statements are used, responsibility for ones behavior is attributed to another. D. When I statements are used, eye contact is promoted. I statements clearly state ones feelings and needs without blaming or demeaning others. 7. While trying to control aggressive behavior, a client asks an assertiveness training nurse to give an example of an I statement. Which of the following statements is the best example of this assertive communication technique? A. I would like to know why you came home late without calling me. B. I hate it when you think you can just come home late without calling anyone to let them know where you are. C. I feel angry when you come home late without calling. D. I think you dont care about me, because if you did, youd call me if you were planning on coming home late. This response clearly states feelings about a situation without blaming another. 8. After vying for a nurse management position, nurse A is chosen over nurse B. When nurse manager A calls for staff meetings, nurse B is chronically late or absent. Nurse B is exhibiting which type of behavior? A. Passive B. Assertive C. Aggressive D. Passiveaggressive This response is passiveaggressive. The colleague is expressing anger indirectly by being late or absent from the meetings. 9. A nurse should assign which nursing diagnosis to a client needing assistance with assertiveness? A. Disturbed personal identity B. Disturbed thought processes C. Defensive coping D. Impaired verbal communication Defensive coping reflects a self-protective pattern that defends against underlying perceived threats to positive self-regard. Clients who are utilizing defensive coping lack assertiveness skills. 10. Two clients get into a heated argument regarding TV program selections. The nurse turns off the TV and asks the clients to go to their rooms to cool off, after which they will discuss and attempt to resolve the problem. The nurses action is promoting which assertive technique? A. Defusing B. Clouding or fogging C. Responding as a broken record D. Shifting from content to process Defusing is a technique that delays further discussion with an angry individual until a calm demeanor has been achieved. In the situation presented, the nurse is allowing the clients to calm down prior to addressing their issues. 11. An emergency department nurse, who has worked 10 straight days, is pulled to the psychiatric unit. Which represents a passiveaggressive statement by the emergency department nurse? A. Get someone else to work 3 to 11! Ive been working 10 days straight, and I need a break! B. Okay. Ill do it, then purposefully leaves paperwork undone when leaving the unit at 11 p.m. C. I have worked 10 days straight, and I cannot work tonight. I will work for you tomorrow if you need me. D. Yes, Ill do it. Anything to keep peace with the hospital administration is a good thing. This response is passiveaggressive. The staff nurses anger is expressed indirectly. 12. Which best describes a nurses use of assertive behavior? A. When a nurse attempts to please others and apologizes for awkwardness in a new role B. When a nurse becomes defensive and angry when peers offer suggestions for improvement C. When a nurse has problems making decisions and has a tendency to procrastinate D. When a nurse is open and direct when asked by the nurse manager to complete assignments This is an assertive response. There is clear expression of needs and feelings. 13. Which is the most appropriate nursing reply when a client asks what the goal and benefit are of assertive skills training? A. It protects the client from others who express aggressive feelings. B. It gives reliable, expert information so that clients may correct faulty behaviors. C. It clarifies misperceptions that have caused clients to distort reality. D. It improves communication skills in order to improve interpersonal relationships. Assertiveness training helps to develop satisfying interpersonal relationships by teaching people how to communicate in a manner to meet their own needs while respecting the rights and needs of others. 14. An instructor is teaching about assertive rights. Which student statement indicates a need for further instruction? A. The right to be treated with respect is an assertive right. B. The right to say no without feeling guilty is an assertive right. C. The right to change your mind is an assertive right. D. The right to always put oneself first is an assertive right. This is not an assertive right. An assertive right is to consider others as well as yourself. This student statement indicates a need for further instruction. 15. One nurse confronts another and says, You are always so talkative in the meetings. I dont know why you cant stay quiet sometimes. Which reply by the other nurse reflects the technique of clouding/fogging? A. Youre right. I do speak up a lot. B. Sounds to me like youre agitated and we need to talk. What are you truly angry about? C. Are you offended that I speak up, or because my thoughts are in opposition to yours? D. I have the right to express my opinion. This response reflects the use of clouding/fogging. When clouding/fogging is used it concurs with the critics argument without becoming defensive and without agreeing to change. 16. A teenager gets a C in algebra. The mother angrily states, All you ever do is listen to music and text your friends. The teenager replies, What is it that youre really upset about, mom? Which response pattern is the teenager expressing? A. Clouding and fogging B. Shifting from content to process C. Delaying assertively D. Assuming responsibility for ones own statements This response reflects the use of shifting from content to process. The teenager is changing the focus of the communication from discussing the topic at hand to analyzing what is actually going on in the interaction. 17. The dean of nursing criticizes a faculty member about views on academic freedom. The faculty member states, Are you upset because I believe in academic freedom or because you dont? The faculty member is using which technique to promote assertive behavior? A. Standing up for ones basic human rights B. Delaying assertively C. Inquiring assertively D. Responding assertively with irony This response reflects the use of inquiring assertively. Inquiring assertively is an attempt to seek additional information about critical statements. 18. An aggressive nurse manager tells a staff nurse she has no business rallying staff to change the schedule. What would be an example of a technique that the staff nurse could use to stand up for her basic human rights? A. What is the real reason that you dont want the schedule changed? B. Sounds to me like youre threatened by this change. C. Are you upset because you dont want to redo the schedule? D. I have the right to express my opinion about the schedule. This response reflects the use of standing up for ones basic human rights. 19. A nursing supervisor is scheduling holiday hours. When the supervisor tells the staff nurse that she needs to work Christmas day, the staff nurse calmly states, I worked last Christmas and will not work this Christmas. When the supervisor says But I need you to work, the nurse repeats I worked last Christmas and will not work this Christmas. This is an example of which assertive behavior technique? A. Shifting from content to process B. Standing up for ones basic rights C. Responding as a broken record D. Defusing Responding as a broken record is an assertive behavior technique that consists of persistently repeating in a calm voice what is wanted. 20. A nurse has identified the following nursing diagnosis: ineffective communication R/T lack of assertiveness skills AEB inability to state needs. Which statement encourages the client to acknowledge the priority of this problem? A. Are you having thoughts of harming yourself or others? B. With whom are you least assertive? C. On a scale of 1 to 10, rank the importance of being assertive. D. When are you available to attend the assertiveness training class? This nursing statement encourages the client to objectively evaluate the priority of being assertive. It is important in patient-centered care for the client to prioritize his or her goals for treatment. 21. Which of the following are behavioral components of assertive communication? A. Listening B. You statements C. Closed posture D. Continuous direct eye contact One part of assertiveness communication and behavior is to listen and take time to understand what is being said before giving a response. 22. A client is experiencing high stress. The client states, My boss treats me like a doormat and thinks nothing of demanding frequent overtime. Which nursing intervention would be appropriate? A. To incorporate the family support system into the clients plan of care B. To teach thought-reframing techniques C. To encourage the client to seek other employment D. To teach the client how to use I statements The ability to use I statements is essential in assertive communication. The situation presented indicates that the client needs assertiveness training. 23. A nurse is caring for four clients. Which of the following clients should the nurse identify as likely to experience difficulty in being assertive? Select all that apply. A. A 20-year-old woman who is completing college homework assignments for several peers. B. A 69-year-old widow who is socially isolated C. A 17-year-old boy with conduct disorder D. A 45-year-old successful executive E. A 50-year-old diagnosed with narcissistic personality disorder The woman who is taking on the work of others in addition to her own may be having difficulty assertively saying no; the widow who is socially isolated may lack the necessary skills to communicate her needs; and the boy with a conduct disorder is likely to demonstrate aggressive behaviors. The business executive and an individual diagnosed with narcissistic personality disorder are the least likely to have difficulty being assertive. Chapter 15 Promoting Self-Esteem 1. A nurse is working in a nursing home. How best can this nurse foster self-esteem in the residents of this facility? A. Allowing them to remain in their rooms as much as they desire to maintain privacy B. Administering anti-anxiety medications as ordered C. Providing a sense of mastery over their environment by giving choices when appropriate D. Teaching assertiveness skills and self-esteem principles A sense of having some power and control over ones life enhances self-esteem. 2. A client shows a nurse a piece of artwork that took 3 days to create. How will this achievement improve the clients self-esteem? A. By providing a framework for assertive behavior B. By providing an expression of feelings and a sense of competence and pride C. By providing a positive perception of body image D. By providing appropriate boundaries for relationship establishment Creating the artwork provides expression of feelings and a sense of competence and pride. This will most likely have a positive effect on the clients self-esteem. 3. A nurse is running a group on self-esteem. A client asks, Where does self-esteem come from? Which is the most appropriate nursing reply? A. Many factors, over the life span, influence development and maintenance of self-esteem. B. Self-esteem is determined by factors outside of an individuals control. C. Self-esteem is established in childhood and remains relatively fixed throughout life. D. Genetics are the single largest contributor to an individuals self-esteem. Self-esteem refers to the degree of regard or respect that individuals have for themselves and is a measure of worth that they place on their abilities and judgments. Many factors influence the development of self-esteem over a persons life span. 4. In what way should a nurse expect a school-aged child to gain positive self-esteem, according to Eriksons psychosocial developmental stages? A. Through basic need fulfillment and environmental predictability B. Through exploration and experimentation, resulting in self-confidence in ability to perform C. Through positive reinforcement of creativity and recognition of performance D. Through receiving recognition when learning, competing, and performing successfully The school-aged child develops self-confidence by learning, competing, and performing successfully and receiving recognition from significant others, peers, and acquaintances. 5. The nurse is working with a 15-year-old client suffering from low self-esteem. According to Eriksons psychosocial developmental theory, which factor has most probably influenced this clients self-esteem? A. Regret over life choices B. Lack of personal concern for others C. Inconsistent, overly harsh, or absent parental discipline D. Parental labeling of the child as good regardless of their behavior. When there is inconsistent, overly harsh, or absent discipline in the home, it is difficult for a teenager to develop the independent sense of self needed to achieve a positive self-esteem. 6. On the basis of Eriksons theory, how should a nurse encourage a 40-year-old client to improve his or her self- esteem? A. Encourage the client to review life goals and accomplishments. B. Encourage the client to volunteer at a school, reading to underprivileged children. C. Encourage the client to form lasting intimate relationships. D. Encourage the client to seek recognition for task achievement. Making meaningful contributions to others is a way to meet the developmental task of the generativity versus stagnation (30 to 65 years) stage of Eriksons developmental theory. This action would promote a 40-year-old clients self-esteem. 7. Which is an appropriate initial nursing intervention for a client with chronic low self-esteem? A. Assessing the content of negative self-talk B. Administering anxiolytic medications C. Using reassurance and physical touch D. Using distraction techniques Self-negating verbalizations and internal self-talk undermine self-esteem. Assessing and then intervening to limit or eliminate these negative communications will help improve self-esteem. 8. A 30-year-old client diagnosed with depression has been exclusively cared for and financially subsidized by his mother since age 17. According to Eriksons theory, the nurse recognizes that the client has been unsuccessful in meeting which developmental task? A. Trust B. Initiative C. Intimacy D. Ego integrity The clients relationship with his mother has contributed to failing completion of the developmental task of intimacy in Eriksons stage of intimacy versus isolation (20 to 30 years). This has resulted in behaviors such as withdrawal, social isolation, aloneness, and the inability to form lasting relationships, leading to his diagnosis of depression. 9. A 40-year-old female client has never experienced an intimate relationship. A nursing student tells an instructor that this client remains in Eriksons developmental stage of intimacy versus isolation. What is the instructors most appropriate reply? A. Eriksons stages of development are assessed by chronological age, not task achievement. This client is in the generativity versus stagnation stage, which occurs from 30 to 65 years of age. B. Eriksons stages of development are assessed by task achievement, not chronological age. This client is in the intimacy versus isolation stage, which occurs from 20 to 30 years of age. C. Eriksons stages of development are assessed by task achievement, not chronological age. This client is in the generativity versus stagnation stage, which occurs from 30 to 65 years of age. D. Eriksons stages of development are assessed by chronological age, not task achievement. This client is in the intimacy versus isolation stage, which occurs from 20 to 30 years of age. Eriksons stages of development are assessed by chronological age, not task achievement. This client is in Eriksons stage of generativity versus stagnation because she is 40 years old. The student has failed to recognize that even though the client did not successfully achieve the intimacy task of the intimacy versus isolation stage, the client must now be assessed at the age-appropriate developmental stage of generativity versus stagnation. 10. A home health nurse visits an 18-year-old client who lives with his mother. The client has been assessed as having low self-esteem. The nurse refers the client for individual counseling. During the next home visit, which assessed client behavior clearly indicates treatment success? A. The client wants to buy a dog but has not yet asked his mothers permission. B. The client asks his mother for permission to buy a dog. C. The client tells his mother he plans to buy a dog. D. The client buys a dog and hides it in the garage. When the client tells his mother he plans to buy a dog, he is making decisions and taking on responsibilities. This indicates an increase in self-confidence and therefore self-esteem. 11. A 40-year-old client lives with her parents. She has a high school diploma and works at a low-paying job. Her parents give her a weekly allowance to supplement her income. How should the nurse classify their client- parent boundaries? A. As loose B. As rigid C. As flexible D. As enmeshed The client and her parents are overly dependent. The parents control too many aspects of the clients life. Their boundaries are blurred so that it is hard for the client to differentiate her wants and needs from those of her parents. The clientparent boundaries are enmeshed. 12. A father tells his 5-year-old, Son, today instead of picking flowers in the outfield, lets try to catch a ball. The child subsequently pays attention and catches a ball. Which principle of building self-esteem has the father implemented? A. A sense of competence B. Unconditional love C. Realistic goals D. Reality orientation Low self-esteem can be the result of not being able to achieve established goals. The father has set for the child a realistic goal that the child accomplished. This should promote self-esteem. 13. A nursing instructor is teaching about self-concept. Which student statement indicates a need for further instruction? A. Self-concept is the thinking component of the self. B. Self-concept is a system of learned beliefs about self. C. Self-concept is the degree of regard that individuals have for themselves. D. Self-concept is the attitudes and opinions held true about personal existence. Self-esteem, not self-concept, is the degree of regard that individuals have for themselves. This student statement indicates a need for further teaching. 14. A client has continual problematic relationships and rejects others before possibly being rejected. The client states, I am afraid of failing in my job responsibilities. Which correctly written nursing diagnosis should be prioritized for this client? A. Poor self-esteem R/T negative self-image AEB fear of failure B. Altered thought processes R/T anxiety AEB delusions C. Role confusion R/T rejection and poor job productivity D. High risk for violence: self-directed R/T rejection of others Individuals with low self-esteem perceive themselves to be incompetent, unlovable, insecure, and unworthy. A correctly written actual nursing diagnosis must have a related to (R/T) and an evidenced by (AEB) statement. A risk for nursing diagnosis does not contain an AEB statement because the problem has not yet occurred. 15. A nurse is caring for a client who has recently undergone a radical prostatectomy. Which of the following should the nurse recognize as objective symptoms of low self-esteem? Select all that apply. A. Withdrawal from activities B. A decrease in self-care behaviors C. Poor eye contact D. Reports of pain E. Poor posture Withdrawal from activities, a decrease in self-care behaviors, eye contact, and poor posture are all common objective manifestations of low self-esteem. A report of pain should be evaluated as a physical issue before being attributed solely to low self esteem. 16. A 47-year-old mother of two has recently undergone a radical mastectomy. She refuses to see anyone and remains isolated and withdrawn. Which of the following may be relevant nursing diagnoses for this client? Select all that apply. A. Disturbed body image B. Situational low self-esteem C. Ineffective coping D. Altered thought processes E. Altered sensory perception The mastectomy is likely to disturb the clients body image. She is ineffectively coping by withdrawing. She may be experiencing negative feelings about herself related to her altered body image, which would result in low self-esteem. None of the symptoms presented indicate a problem with either altered thought or altered sensory perception. Chapter 16 Anger/Aggression Management 1. A student nurse has just entered a psychiatric rotation. The student asks a nursing instructor, How will we know if someone may get violent? Which is the most appropriate reply by the nursing instructor? A. You cant really say for sure. There are limited indicators of potential violence. B. Certain behaviors indicate a potential for violence. They are labeled as a prodromal syndrome and include rigid posture, clenched fists, and raised voice. C. Any client can become violent, so it is best to be aware of your surroundings at all times. D. When a client suddenly becomes quiet, is withdrawn, and maintains a flat affect, this is an indicator of potential violence. These behaviors have been identified as predictors of violent behavior. 2. A nursing instructor is teaching about the concept of anger. Which student statement indicates the need for further instruction? A. Anger is physiological arousal. B. Anger and aggression are essentially the same. C. Anger expression is a learned response. D. Anger is not a primary emotion. Further teaching is necessary when the student states that anger and aggression are essentially the same. Anger and aggression are significantly different. 3. Which client statement demonstrates improvement in anger/aggression management? A. I realize I have a problem expressing my anger appropriately. B. I know I cant use physical force anymore, but I can intimidate someone with my words. C. Its bad to feel as angry as I feel. Im working on eliminating this poisonous emotion entirely. D. Because my wife seems to be the one to set me off, Ive decided to remain separated from her. The client is recognizing and taking responsibility for personal anger. 4. A client is served divorce papers while on the inpatient psychiatric unit. When a nurse tells the client the unit telephone cannot be used after hours, the client raises his fists, swears, and spits at the nurse. Which negative coping mechanism has the client exhibited? A. The defense mechanism of projection B. The defense mechanism of reaction formation C. The defense mechanism of sublimation D. The defense mechanism of displacement Anger can lead to aggression when the coping response is displacement. This client has discharged anger against a person (the nurse) unrelated to the true target of the anger (the spouse). 5. A nurse is caring for four clients. Which client should the nurse identify as least prone to developing problems with anger and aggression? A. A child raised by a physically abusive parent B. An adult with a history of epilepsy C. A young adult living in the ghetto of an inner city D. An adolescent raised by Scandinavian immigrant parents An adolescent raised by Scandinavian immigrant parents would be least prone to developing problems with anger and aggression as compared with the other clients presented. A history of abuse, epilepsy, overcrowding, and poverty all contribute as predisposing factors to anger and aggression. 6. After less restrictive means have been attempted, an order for client restraints has been obtained for a hostile, aggressive 30- year-old client. If client aggression continues, how long will the nurse expect the client to remain in restraints without a physician order renewal? A. 1 hour B. 2 hours C. 3 hours D. 4 hours The Joint Commission (JCAHO) requires that a physician or licensed independent provider (LIP) must reissue a new order for restraints every 4 hours for adults, every 1 hour for clients younger than 9, and every 2 hours for clients 9 to 17 years. 7. An adult client assaults another client and is placed in restraints. Which statement from the client while in restraints should alert a nurse that further assessment is necessary? A. I hate all of you! B. My fingers are tingly. C. You wait until I tell my lawyer. D. I have a sinus headache. This statement may mean that the restraints are excessively tight and impeding circulation. 8. After restraints are removed from a client, the staff discusses the incident and establishes guidelines for the clients return to the therapeutic milieu. Which unit procedure is the staff implementing? A. Milieu reenactment B. Treatment planning C. Crisis intervention D. Debriefing Debriefing is an important part of restraint/seclusion. It allows the staff an opportunity to review and learn from the experience and to express feelings generated by the incident. 9. Once the nurse initiates restraint for an out-of-control 45-year-old patient, what must occur within 1 hour, according to JCAHO standards? A. The patient must be let out of restraint. B. A physician or other licensed independent practitioner must conduct an in-person evaluation. C. The patient must be bathed and fed. D. The patient must be included in debriefing. Joint Commission (JCAHO) standards require that a physician or other licensed independent practitioner conduct an in-person evaluation of the client within 1 hour of the initiation of restraint. 10. For select clients, physical restraint is considered to be a beneficial intervention. This is based on which premise? A. Clients with poor boundaries do not respond to verbal redirection, and they need firm and consistent limit setting. B. Clients with limited internal control over their behavior need external controls to prevent harm to themselves and others. C. Clients with antisocial tendencies need to submit to authority. D. Clients with behavioral dysfunction need behavioral interventions. Restraints are used for clients who are unable to control their behavior in order to prevent harming themselves or others. 11. A client diagnosed with paranoid schizophrenia has a history of aggravated assault. A nurse assigns Risk for other-directed violence as the clients priority nursing diagnosis. Based on this diagnosis, which would be an appropriate, correctly written outcome for this client? A. The client will not verbalize anger or hit anyone. B. The client will verbalize anger rather than hit others. C. The client will not inflict harm on others during this shift. D. The client will be restrained if verbal or physical abuse is observed during this shift. Preventing injury to others is the appropriate outcome. Outcomes must be client centered, specific, realistic, and measureable and contain a time frame. Answer A does not contain a time frame. 12. At 3 a.m., when less restrictive methods fail, a physician orders restraints for an angry, aggressive client. To meet Joint Commission standards, at what time and by whom should a nurse expect an in-person client evaluation? A. No later than 8 a.m., by a licensed independent practitioner or a clinical nurse specialist B. No later than 4 a.m., by a physician or a licensed independent practitioner (LIP) C. No later than 3:30 a.m., by a physician or the clients case manager D. No later than 6 a.m., by the psychiatrist or a clinical nurse specialist To meet Joint Commission standards, an in-person evaluation by a physician or LIP should be conducted within 1 hour of the initiation of restraints. 13. Which risk factor should a nurse recognize as the most reliable indicator of potential client violence? A. A diagnosis of schizotypal personality disorder B. History of assaultive behavior C. Family history of violence D. Recent eviction from a homeless shelter A prior history of assault is the most widely recognized risk factor for client violence. 14. A nursing instructor is teaching about violence-intervention protocols. Which student statement would indicate the need for further instruction? A. Administering psychotropic medications can be a part of violence-intervention protocols. B. Soothing the client by stroking an arm or shoulder can be a part of violence-intervention protocols. C. Applying leather restraints can be a part of violence-intervention protocols. D. Calling for assistance is a part of violence-intervention protocols. Touching the client could be seen by him or her as threatening and provoke further violence. 15. A client begins to smash furniture, cannot be talked down, and refuses medications. Which is the most appropriate nursing intervention? A. Call a violence code. B. Ask the ward clerk to put in a call for the physician. C. Place the client in seclusion. D. Place the client in four-point restraints. In this situation the nurse must have adequate, trained help to prevent injury to the client or staff. Calling a violence code will access this help. 16. On an inpatient psychiatric unit, a restrained 16-year-old client continues to verbally lash out and threatens to abuse staff and kill self when released. To meet Joint Commission standards, at what time should a nurse expect the physician to renew the clients restraint order? A. Within 1 hour of the original restraint order B. Within 2 hours of the original restraint order C. Within 3 hours of the original restraint order D. Within 4 hours of the original restraint order The Joint Commission (JCAHO) requires that a physician or a licensed independent practitioner reissue a new order for restraints every 4 hours for adults, every 2 hours for adolescents, and every 1 hour for children. 17. A client diagnosed with brief psychotic disorder is pacing the milieu and occasionally punches the wall. Which should be the initial nursing action? A. Assertively instruct the client to stop punching the wall. B. Encourage the client to write down feelings in a journal. C. With the help of staff, initiate seclusion protocol. D. Ensure adequate physical space between the nurse and the client. To maintain a safe environment, it is important to initially assure that there is adequate physical space between the nurse and the client. Violence can be related to increased contact and decreased defensible space. 18. The nurse observes a clients escalating anger. The client begins to pace the hall and shouts, You all better watch out. Im going to hurt anyone who gets in my way. Which should be the priority nursing intervention? A. Calmly tell the client, Staff will help you to control your impulse to hurt others. B. Remove other clients from the area and maintain milieu safety. C. Gather a show of force by contacting security for assistance. D. Calmly tell the client, You will need to be medicated and secluded. During an emergent situation on an inpatient unit, the nurses priority action should be to keep all clients safe by removing them from the area of conflict. 19. The client states, I get into trouble because I respond violently without thinking. That usually gets me into a mess. Which nursing reply would be most therapeutic to address this clients problem? A. Everybody loses their temper. Its good that you know that about yourself. B. Ill bet you have some interesting stories to share about overreacting. C. Lets explore methods to help you stop and think before taking action. D. Its good that you are showing readiness for behavioral change. Helping the client to find alternative ways to release tension by more appropriate problem-solving behaviors is a therapeutic nursing intervention. 20. Which initial nursing approach makes limit-setting better accepted by clients who are aggressively acting out? A. Confronting clients with their needs for secondary gains B. Teaching relaxation techniques C. Reflecting back to the client empathy about the clients distress D. Presenting appropriate values that need to be modified Reflecting back to the client empathy about the clients distress promotes a trusting relationship and may prevent the clients anxiety from escalating when limits are set. 21. Which nursing approach is likely to be most therapeutic when dealing with a newly admitted, hostile, suspicious client? A. Place a hand on the clients shoulder and state, I will help you to your room. B. Slowly and matter-of-factly state, I am your nurse and I will show you to your room. C. Firmly set limits by stating, If your behavior does not improve you will be secluded. D. Smile and state, I am your nurse. When do you want to go to your room? It is important to maintain an unemotional tone of voice when dealing with a hostile client. The client might misinterpret touch and become violent. 22. A nurse notices a client clenching fists periodically and pacing the hallway. Which of the following nursing interventions would best assist the client at this time? Select all that apply. A. Acknowledge the clients behavior. B. Initiate forced medication protocol. C. Assist the client to a quiet area. D. Initiate confinement measures. E. Speak with a soft and calming voice. The nurse should remain calm when dealing with an angry client. It is important to acknowledge the clients behavior and assist the client to a less stimulating environment. Chapter 17 The Suicidal Client 1. A nurse discovers a clients suicide note that details the time, place, and means to commit suicide. What should be the priority nursing intervention and the rationale for this action? A. Administering lorazepam (Ativan) prn, because the client is angry about the discovery of the note B. Establishing room restrictions, because the clients threat is an attempt to manipulate the staff C. Placing this client on one-to-one suicide precautions, because the more specific the plan, the more likely the client will attempt suicide D. Calling an emergency treatment team meeting, because the clients threat must be addressed The priority nursing action should be to place this client on one-to-one suicide precautions, because the more specific the plan, the more likely the client will attempt suicide. The appropriate nursing diagnosis for this client would be risk for suicide. 2. During the planning of care for a suicidal client, which correctly written outcome should be a nurses first priority? A. The client will not physically harm self. B. The client will express hope for the future by day 3. C. The client will establish a trusting relationship with the nurse. D. The client will remain safe during the hospital stay. The nurses priority should be that the client will remain safe during the hospital stay. Client safety should always be the nurses priority. The A answer choice is incorrectly written. Correctly written outcomes must be client focused, measurable, and realistic and contain a time frame. Without a time frame, an outcome cannot be correctly evaluated. 3. A client diagnosed with major depressive disorder with psychotic features hears voices commanding self- harm. The client refuses to commit to developing a plan for safety. What should be the nurses priority intervention at this time? A. Obtaining an order for locked seclusion until client is no longer suicidal B. Conducting 15-minute checks to ensure safety C. Placing the client on one-to-one observation while monitoring suicidal ideations D. Encouraging client to express feelings related to suicide The nurses priority intervention when a client hears voices commanding self-harm is to place the client on one- to-one observation while continuing to monitor suicidal ideation. 4. A client with a history of three suicide attempts has been taking fluoxetine (Prozac) for 1 month. The client suddenly presents with a bright affect, rates mood at 9/10, and is much more communicative. Which action should be the nurses priority at this time? A. Give the client off-unit privileges as positive reinforcement. B. Encourage the client to share mood improvement in group. C. Increase frequency of client observation. D. Request that the psychiatrist reevaluate the current medication protocol. The nurse should be aware that a sudden increase in mood rating and change in affect could indicate that the client is at risk for suicide and client observation should be more frequent. Suicide risk may occur early during treatment with antidepressants. The return of energy may bring about an increased ability to act out self- destructive behaviors prior to attaining the full therapeutic effect of the antidepressant medication. 5. A nurse recently admitted a client to an inpatient unit after a suicide attempt. A health-care provider orders amitriptyline (Elavil) for the client. Which intervention related to this medication should be initiated to maintain this clients safety upon discharge? A. Provide a 6-month supply of Elavil to ensure long-term compliance. B. Provide a 1-week supply of Elavil with refills contingent on follow-up appointments. C. Provide a pill dispenser as a memory aid. D. Provide education regarding the avoidance of foods containing tyramine. The health-care provider should provide a 1-week supply of Elavil with refills contingent on follow-up appointments as an appropriate intervention to maintain the clients safety. Tricyclic antidepressants have a narrow therapeutic range and can be used in overdose to commit suicide. Distributing limited amounts of the medication decreases this potential. 6. During a one-to-one session with a client, the client states, Nothing will ever get better, and Nobody can help me. Which nursing diagnosis is most appropriate for a nurse to assign to this client at this time? A. Powerlessness R/T altered mood AEB client statements B. Risk for injury R/T altered mood AEB client statements C. Risk for suicide R/T altered mood AEB client statements D. Hopelessness R/T altered mood AEB client statements The clients statements indicate the problem of hopelessness. Prior to assigning either risk for injury or risk for suicide, a further evaluation of the clients suicidal ideations and intent would be necessary. 7. The treatment team is making a discharge decision regarding a previously suicidal client. Which client assessment information should a nurse recognize as contributing to the teams decision? A. No previous admissions for major depressive disorder B. Vital signs stable; no psychosis noted C. Able to comply with medication regimen; able to problem-solve life issues D. Able to participate in a plan for safety; family agrees to constant observation Participation in a plan of safety and constant family observation will decrease the risk for self-harm. All other answer choices are not directly focused on suicide prevention and safety. 8. The family of a suicidal client is very supportive and requests more facts related to caring for their family member after discharge. Which information should the nurse provide? A. Address only serious suicide threats to avoid the possibility of secondary gain. B. Promote trust by verbalizing a promise to keep suicide attempt information within the family. C. Offer a private environment to provide needed time alone at least once a day. D. Be available to actively listen, support, and accept feelings. Being available to actively listen, support, and accept feelings increases the potential that a client would confide suicidal ideations to family members. 9. A stockbroker commits suicide after being convicted of insider trading. In speaking with the family, which statement by the nurse demonstrates accurate and appropriate sharing of information? A. Your grieving will subside within 1 year; until then I recommend antidepressants. B. Support groups are available specifically for survivors of suicide, and I would be glad to help you locate one in this area. C. The only way to deal effectively with this kind of grief is to write a letter to the brokerage firm to express your anger with them. D. Since stigmatization often occurs in these situations, it would be best if you avoid discussing the suicide with anyone. Bereavement following suicide is complicated by the complex psychological impact of the act on those close to the victim. Support groups for survivors can provide a meaningful resource for grief work. 10. After years of dialysis, an 84-year-old states, Im exhausted, depressed, and done with these attempts to keep me alive. Which question should the nurse ask the spouse when preparing a discharge plan of care? A. Have there been any changes in appetite or sleep? B. How often is your spouse left alone? C. Has your spouse been following a diet and exercise program consistently? D. How would you characterize your relationship with your spouse? This client has many risk factors for suicide. The client should have increased supervision to decrease likelihood of self-harm. 11. A nursing instructor is teaching about suicide in the elderly population. Which information should the instructor include? A. Elderly people use less lethal means to commit suicide. B. Although the elderly make up less than 13% of the population, they account for 16% of all suicides. C. Suicide is the second leading cause of death among the elderly. D. It is normal for elderly individuals to express a desire to die, because they have come to terms with their mortality. This factual information should be included in the nursing instructors teaching plan. An expressed desire to die is not normal in any age group. 12. A nurse is caring for a client who has threatened to commit suicide by hanging. The client states, Im going to use a knotted shower curtain when no one is around. Which information would determine the nurses plan of care for this client? A. The more specific the plan is, the more likely the client will attempt suicide. B. Clients who talk about suicide never actually commit it. C. Clients who threaten suicide should be observed every 15 minutes. D. After a brief assessment, the nurse should avoid the topic of suicide. Clients who have specific plans are at greater risk for suicide. 13. A suicidal client says to a nurse, Theres nothing to live for anymore. Which is the most appropriate nursing reply? A. Why dont you consider doing volunteer work in a homeless shelter? B. Lets discuss the negative aspects of your life. C. Things will look better in the morning. D. It sounds like you are feeling pretty hopeless. This statement verbalizes the clients implied feelings and allows him or her to validate and explore them. 14. A new nursing graduate asks the psychiatric nurse manager how to best classify suicide. Which is the nurse managers best reply? A. Suicide is a DSM-5 diagnosis. B. Suicide is a mental disorder. C. Suicide is a behavior. D. Suicide is an antisocial affliction. Suicide is not a diagnosis, disorder, or affliction. It is a behavior. 15. A nursing student is developing a plan of care for a suicidal client. Which documented intervention should the student implement first? A. Communicate therapeutically. B. Observe the client. C. Provide a hazard-free environment. D. Assess suicide risk. Assessment is the first step of the nursing process to gain needed information to determine further appropriate interventions. 16. Which is a correctly written, appropriate outcome for a client with a history of suicide attempts who is currently exhibiting symptoms of low self-esteem by isolating self? A. The client will not physically harm self. B. The client will express three positive self-attributes by day 4. C. The cli