Therapeutic Communication
The nurse states to the client, "You say that you are sad, but you are smiling and laughing." Which describes the purpose of this therapeutic communication technique?
1. To provide suggestions for coping strategies.
2. To redirect the client to an idea of importance.
3. To bring into incongruence or inconsistencies into awareness.
4. To provide feedback to the client.
3. The nurse uses the therapeutic technique of confronting to bring incongruences or inconsistencies into awareness.
On which client would a nurse on an in-patient psychiatric unit appropriately use four point restraints?
1. A client who is hostile and threatening the staff and other clients.
2. A client who is intrusive and demanding and requires added attention.
3. A client who is noncompliant with medications and treatments.
4. A client who splits staff and manipulates other clients.
1. When a patient is hostile and threatening the staff and other clients, that client is a danger to others and after attempts at deescalation have failed, should be secluded and restrained
A client on an inpatient unit is exhibiting extreme aviation. Using a biliolgical approach, which nursing intervention should be implemented?
1. The nurse should discuss emotional triggers that predicate angry outbursts
2. The nurse should encourage the client to use exercise to deal with increased agitation
3. The nurse should be give ordered PRN medications to decrease anxiety and agitation
4. The nurse should develop a plan to address tension during family therapy
3. Administering ordered PRN mediations when the patient is experiencing extreme anxiety and tension would be a biological approach to dealing with the clients agitation.
A newly admitted client diagnosed with bipolar I disorder is experiencing a manic episode. Which nursing diagnosis is a priority at this time?
1. Risk for violence: other directed R/T poor impulse control
2. Altered Thought Process R/Th hallucinations
3. Social isolation R/T manic excitement
4. Low Self-Esteem R/T guilt about promiscuity
1. Risk for violence: other directed is defined as behaviors in which an indicials demonstrates that he or she can psychically, emotional, or sexually harmful to others. Because of poor impulse control, irritability, and hyperactive psychomotor behaviors experienced during a manic episode this client is at risk offer violence directed froward other. keeping everyone in the milieu safe is always a nursing priority
A client who has recently relapsed from alcohol abstinence is seen int he outpatient mental health clinic. The client states, "I don't know what all the fuss is about. Can't I have a few drinks now and then?" Which nursing diagnosis applies to this patient?
1. Risk for Injury
2. Risk for violence-self direct5ed
3. Ineffective denial
4. Powerlessness
3. Ineffective denies is defines as the conscious or unconscious attempt to disavow knowledge or meaning of an event to reduce anxiety or fear, leading to the the detriment of health. The client in the question is denying the need to continue abstinence from alcohol.
A client on a psychiatric unit says, "Its a waste f time to be here. I can't talk to you or anyone," Which would be an appropriate therapeutic nursing response?
1. I find that hard to believe.
2. Are you feeling that no-one understands?
3. I think you should calk down and look at the positive side.
4. Our staff here is excellent, and you are in good hands.
2. putting into words what the client has only implied or said indirectly is he therapeutic communication tecnique of verbalizing the impaired. This clarifies that which is implicit rather than explicit by giving the client the opportunity to agree or disagree with the implication
A client has been placed in seclusion because the client has been deemed a danger to others. Which is the priority nursing intervention for this client?
1. have little contact with the client to decrease stimulation
2. Provide the client with privacy to maintain confidentiality
3. Maintain contact and assure the client that seclusion will maintain the client's safety
4. Teach the client relaxation techniques and effective coping strategies to deal with anger
3. It is important to maintain contact with eh client and assure the client that seclusion is a way to maintain the client's safety. Seclusion, when appropriate, should be implemented in a matter of fact manner, focusing on the client's behavior and the consequences of the behavior
Which situation reflects the defense mechanism of projection?
1. A husband has an affair, then busy his wife a diamond anniversary bracelet.
2. A promiscuous wife accuses her husband of having an affair
3. A wife, fault to be come pregnant, works hard at becoming teacher of the year
4. A man who was sexually assaulted as a child remembers nothing of the event
2. This is an example of the defense mechanism of projection, in which a person attributes unacceptable impulses and feelings to another
A client experiencing mania states, "Everything I do is great" Using a cognitive approach, which nursing response would be most appropriate?
1. is there a time in your life when things didn't go as planned?
2. Everything you do is great.
3. What are some other things you do well?
4. Lets talk about the feelings you have about your childhood.
1. By asking, is there a time in you your life things didn't go as planned, is used to challenge the thought process of the client
A newly admitted client with a a long history of alcohol use disorder complains of burring and tingling sensations of the feet. The nurse would recognize these symptoms as indicative of which condition?
1. Peripheral neuropathy
2. Alcoholic myopathy
3. Wernickes' encephalopathy
4. Korsakoff's psychosis
1.peripheral neuropathy, characterized by peripheral nerve damage, results in pain, nuriongkn, tingling, orprickley senstionations of the extremities. Researchers believes it is the direct result of deficiency in the B vitamins, particularly thiamine
A depressed client discussing marital problems with the nurse says "what will I do if my husband asks me for a divorce?" Which response by the nurse would be an example of therapeutic communication.
1. Why do you think that your husband will ask you for a divorce
2. You seem to be worrying over nothing. Im sure everything will be fine.
3. What has happened to you make you think that your husband will ask for a divorce?
4. Talking about this will only make your more anxious and increase your depression.
3. The therapeutic technique of exploring along with reflective listening, draws out the client and can help the client feel valued, understood, and supported. Exploring also gives the nurse the necessary assessment information to interventions appropriately
1. The client may retain none, some, or all civil rights depending on state law.
2. The client cannot make discharge decisions. These are initiated by the hospital or court or both.
3. The client has been determined to be a danger to self or others.
4. The client makes decisions about discharge, unless he or she is determined to be a danger to self or others.
4. A voluntarily admitted client can make decisions about discharge, unless the client has been determined to be a danger to self or others. If the treatment team determines that voluntary admitted client is a danger to self or others, the client is held for a court hearing, and the client's admission status is changed to involuntary .
A client with rigid posture and raised voice uses profanity while demanding to use the phone. Which correctly written nursing diagnosis is a priority?
1. Risk for injury toward others R/T anxiety AEB rigid posture and profanity
2. Ineffective coping R/T inability to express feelings AEB aggressive demeanor
3. Disturbed thought process R/T altered perception AEB demanding behaviors.
4. SOcial isolation R/T anger AEB inability to get along with staff
2. Ineffective coping R/T inability to express feelings AEB aggressive demeanor is a correctly worded diagnostic statement. This diagnosis takes priority because altered or ineffective coping can lead to aggressive behaviors that may result in injury .
A nurse working with a client diagnosed with bipolar I disorder attempts to recognize the motivation behind the clients use of grandiosity. Which is the rationale for this nurses action?
1. Understanding the reason behind a behavior would assist the nurse in accepting and relating to the client, not the behavior
2. Change in behavior cannot occur until the client can accept responsibility for his or her own actions
3. as self esteem is incased, the client will meet individual needs without the use of manipulation
4.
1 grandiosity which is defined as an exaggerated sense of self importance power or status, is exhibited by client diagnosed with bipolar affective disorder. When the nurse understands the characteristics of this behavior, the nurse edna Bette work with, and relate to the client
Which is the priority nursing diagnosis for a client experiencing alcohol induced intoxication?
1. Pain
2. Ineffective denial
3. Ineffective coping
4. Risk for aspiration
4. Alcohol depresses the central nervous system and with significant intake, can render an individual unconscious. The effects of alcohol on the stomach include inflammation of the stomach lining characterisixed by epigatic distress, nausea, vomiting, and distention. These effects of alcohol could lead to aspiration, making this the most life threatening priority client problem
On a substance abuse unit, a client diagnosed with cirrhosis of the liver tells the nurse, " I really don't believe that drinking a couple of cocktails every night has anything to do with my liver problems." Which is the best nursing response?
1. You find it hard to believe that drinking alcohol can damage the liver?
2. How long have you been drinking a couple of cocktails every night?
3. If not by alcohol, explain how your liver became damaged.
4. Everyone knows that increased alcohol consumption can damage your liver
1. paraphrasing is briefly restating another message using ones own words. Through paraphrasing, the nurse sends feedback that lets the client know that the nurse is actively involved in the search for an answer
The nurse is having a therepuatiuc conversation with a client in a locked inpatient unity. The client states "Please don't tell anyone about my sexual abuse" Which is the appropriate nursing response.
1. Yes, I will keep this information confidential.
2. All of the health care team is focused on helping you. I will bring information to the team that can assist them in planning your treatment.
3. Why don't you want the team to know about your sexual abuse? It is significant information.
4. Lets talk about your feelings about history of sexual abuse.
2. The nurse is being honest and open with the client and giving information about the client focus of the treatment team. This builds trust and sets limits on potentially manipulative behavior by the client.
The nurse is assessing clients on an inpatient unit. Which client would require immediate interventions?
1. A client experiencing rapid, pressured speech and poor personal boundaries.
2. A client expressing homicidal ideation toward the neighborhood butcher
3. A client who has slept only 1-2 hours per night for the past 2 nights
4. A client secluding self from others and refusing to attend groups in the milieu
1. Clients experiencing rapid, pressured speech and poor personal boundaries are at increased risk for violence. The nurse needs to monitor clients exhibiting these behaviors closely to ensure that the individual and the milieu remain safe.
A client is newly prescribed Lithium (lithium carbonate). Which teaching point by the nurse take priority?
1. Make sure your salt intake is consistent
2. Limit your fluid intake to 2000 ml/day
3. monitor your caloric intake because of potential weight gain
1. Lithium is similar in chemical strucur to sodium, behaving in the body in much the sam manner and commuting with sodium at various sites in the body. IF sodium intake is reduced, or the body is depleted of its normal sodium, lithium is reabsorbed by the kidney and this increases a potential for toxicity
When the nurse is planning relapse precautions strategies for clients diagnose with substance use disorders, which should be the initial nursing approach?
1. Address previously successful coping skills
2. Encourage rehearsing stressful situations that may lead to relapse
3. Present information simply, using easily understood terminology
4. Provide numerous choices of community resources
3. because 40-50% of clients who abuse substances have mild to moderate cognitive problems while actively using, relapse preventions rattegesi initially would be approached simply. All interventions should be in the context of simple planning to be fully comprehended by the client
The nursing making self available and presenting emotional support is:
1. focusing
2. offering self
3. restating
4. giving recognition
2. offering self by the nurse offers the client availability and emotional support Example: Ill stay with you a while
The phone rings at the nurse's station of an inpatient psychiatric facility. The caller asks to speak with Mr. Hawkins, a client om app, 200. Which nursing response protects this client's right to autonomy and confidentiality?
1. I am sorry, you cannot talk to Mr. Hawkins
2. I cannot confirm or deny that Mr. Hawkins is a client admitted here.
3. I'll see if Mr. Hawkins wants to talk to you.
4. I'm sorry. Mr. Hawkins is not taking any calls.
2. This statement gives no information related to the presence of the client at the facility. This statement maintains the clients right to confidentiality.
The nurse is evaluation labs results for a client presrcribed lithium. the client's lithium levels is 1.9 mEq/l. Which nursing intervention takes priority?
1. Give next does because the lithium level is normal for acute mania
2. Hold the next dose and continue the medication as prescribed the following day
3. Give the next dose after assessing for signs and symptoms of lithium toxicity
4. Immediately notify the provider and hold the dose until instructed further
4. the nurse needs to notify the provider immediately of the serum lithium level, which is outside the therapeutic range, to avoid any risk for further toxicity
What classification of drugs shares similar features with alcohol induced intoxication with alcohol induced withdrawal?
1. anxiolytics
2. amphetamines
3. cocaine
4. phencylindine (PCP)
1. alcohol is a CNS depressant. Alcohol induced intoxication symptoms are related to this depression, and withdrawal symptoms are related to a rebound of the CNS. Because anxiolytics also depress the CNS, they share similar features of alcohol induced intoxication and withdrawal