assessment
The nurse observes a client repeatedly tapping their fingers on the table and blinking rapidly without apparent awareness of their actions. The client denies being aware of these movements. How should the nurse document this finding?
Client displays automatisms
This type of life event, especially when combined with feelings of hopelessness, is considered the most immediate risk factor for suicide.
What is a recent major loss or stressor
A client with acute myocardial infarction wants to leave despite life-threatening risks. What should the nurse do?
What is explain the risks and document the AMA decision?
This type of grief is prolonged, intense, and interferes with daily functioning, often requiring professional intervention.
What is complicated grief?
A nurse is assessing a patient with a history of aggressive outbursts. According to neurobiological theories, which brain-related factor is most likely to contribute to aggressive behavior?
Decreased serotonin levels in the brain
During a mental health assessment, the nurse aims to understand factors that influence the patient’s current condition. Which component of the patient’s background should the nurse prioritize?
Coping skills
When a client says, “No one cares if I live or die,” this is the most therapeutic response by the nurse.
What is “You feel like no one cares. Can you tell me more about that?”
A patient wants to leave the hospital, but the nurse says they cannot until they have been seen by a doctor. This is an example of?
False imprisonment
A nurse is caring for a client who recently immigrated to the United States. The client reports feeling stressed while trying to adopt new cultural practices, while also maintaining their own traditions. The nurse recognizes this process as:
Acculturation
A patient becomes verbally hostile during a routine nursing procedure. Verbal de-escalation attempts have not fully resolved the situation. What should the nurse do?
What is set firm, clear limits on behavior while remaining calm?
During a mental health assessment, the nurse notes that the client’s affect appears constricted. Which behavior best supports this documentation?
The client shows minimal facial expression and rarely changes tone of voice.
A client says, “I don’t think I’m good at anything, and everyone would be better off without me.” This statement reflects this aspect of self-concept.
What is self-esteem?
A patient becomes extremely agitated and poses a threat to others on the psychiatric unit. The nurse places the patient alone in a locked room to prevent harm. Which of the following statements about this intervention is correct?
Seclusion is a form of restraint and must follow legal and institutional guidelines.
This type of grief occurs when a person’s loss is not socially recognized or openly acknowledged, making it difficult for them to receive support.
What is disenfranchised grief?
This pattern involves tension building, an abusive incident, and a subsequent reconciliation or “honeymoon” phase.
What is the cycle of abuse?
During an assessment, the nurse observes that the client’s responses jump from one topic to another, with answers that are often unrelated to the questions asked. This behavior is an example of:
Tangential Association
This type of question encourages a client to express feelings without judgment and avoids “why” or leading questions.
What is an open-ended, reflective question
This ethical framework focuses on duty, rules, and obligations, emphasizing that actions are morally right or wrong regardless of their consequences.
What is deontology?
During intense grief, patients may experience physical symptoms such as sleep disturbances, loss of appetite, fatigue, and chest tightness.
What are physiological responses to grief?
A nurse notices a female patient with an injury appears fearful, avoids eye contact, and seems hesitant while explaining how it occurred.
What is ask the patient privately about the possibility of intimate partner violence?
During a mental status examination, the client begins to answer the nurse’s question but suddenly stops speaking mid-sentence and appears unable to continue. This behavior is an example of:
Thought Blocking
A client recognizes that their distorted thinking affects their life and expresses a desire to learn strategies to manage it.
What is good insight
A patient is agitated and aggressive on the psychiatric unit. The nurse considers using a locked room, but first tries verbal de-escalation and a quiet sitting area with staff supervision.
What is applying the least restrictive alternative?
A patient from a culture that values emotional restraint refuses to cry or speak about their loss in a group therapy session, but shows signs of tension such as fidgeting and pacing.
What is recognize the cultural norms and offer a private space for grieving?
A nurse feels frustration while caring for a patient who stays in an abusive relationship. To maintain professional, empathetic care, the nurse takes action to process their own emotions appropriately.
What is seek supervision or peer support to process feelings while maintaining empathy?