Foundations of Mental Health Nursing
On review of the client’s record, the nurse notes that the admission was voluntary. Based on this information, the nurse plans care anticipating which client behavior?
1. Fearfulness regarding treatment measures
2. Anger and aggressiveness directed toward others 3. An understanding of the pathology and symptoms of the diagnosis
4. A willingness to participate in the planning of the care and treatment plan
Correct answer: 4
Rationale:
In general, clients seek voluntary admission. If a client seeks voluntary admission, the most likely expectation is that the client will participate in the treatment program since he or she is actively seeking help. The remaining options are not characteristics of this type of admission. Fearfulness, anger, and aggressiveness are more characteristic of an involuntary admission. Voluntary admission does not guarantee that a client understands his or her illness, only the client’s desire for help.
A client is diagnosed with post-traumatic stress disorder following a rape by an unknown assailant. The nurse should give priority to:
A. Providing a supportive environment
B. Controlling the client’s feelings of anger
C. Discussing the details of the attack
D. Administering a hypnotic for sleep
Answer A is correct.
Rationale:
Providing a caring attitude and supportive environment will make the client feel safe.
Answer B is incorrect because the client needs to feel free to express anger.
Answer C is incorrect because it will increase the client’s anxiety.
Answer D is incorrect because it is not the most important aspect of care for the client with PTSD
A client is unwilling to go to his church because his ex-girlfriend goes there and he feels that she will laugh at him if she sees him. Because of this hypersensitivity to a reaction from her, the client remains homebound. The home care nurse develops a plan of care that addresses which personality disorder?
1. Avoidant. 2. Borderline
3. Schizotypal
4. Obsessive-compulsive
Answer: 1
Rationale: The avoidant personality disorder is characterized by social withdrawal and extreme sensitivity to potential rejection. The person retreats to social isolation.
A borderline personality disorder is characterized by unstable mood and self-image and impulsive and unpredictable behavior.
A Schizotypal personality disorder is characterized by the display of abnormal thoughts, perceptions, speech, and behaviors.
Obsessive-compulsive personality disorder is characterized by perfectionism, the need to control others, and a devotion to work.
The home health nurse visits a client at home and determines that the client is dependent on drugs. During the assessment, which action should the nurse take to plan appropriate nursing care?
1. Ask the client why he started taking illegal drugs.
2. Ask the client about the amount of drug use and its effect. 3. Ask the client how long he thought that he could take drugs without someone finding out.
4. Not ask any questions for fear that the client is in denial and will throw the nurse out of the home
Answer:2
Rationale: Whenever the nurse carries out an assessment for a client who is dependent on drugs, it is best for the nurse to attempt to elicit information by being nonjudgmental and direct. Option 1 is incorrect because it is judgmental and off- focus, and reflects the nurse’s bias. Option 3 is incorrect because it is judgmental, insensitive, and aggressive, which is nontherapeutic. Option 4 is incorrect because it indicates passivity on the nurse’s part and uses rationalization to avoid the therapeutic nursing intervention.
A client with a diagnosis of depression who has attempted suicide says to the nurse, “I should have died. I’ve always been a failure. Nothing ever goes right for me.” Which response by the nurse demonstrates therapeutic communication?
1. “You have everything to live for.”
2. “Why do you see yourself as a failure?”
3. “Feeling like this is all part of being depressed.”
4. “You’ve been feeling like a failure for a while?”
Correct answer: 4
Rationale:
Responding to the feelings expressed by a client is an effective therapeutic communication technique. The correct option is an example of the use of restating.
The remaining options block communication because they minimize the client’s experience and do not facilitate exploration of the client’s expressed feelings.
A client with obsessive-compulsive personality disorder annoys his co-workers with his rigid-perfectionistic attitude and his preoccupation with trivial details. An important nursing intervention for this client would be:
A. Helping the client develop a plan for changing his behavior
B. Contracting with him for the time he spends on a task
C. Avoiding a discussion of his annoying behavior because it will only make him worse
D. Encouraging him to set a time schedule and deadlines
Answer B is correct.
Rationale:
The nurse and the client should work together to form a contract that outlines the amount of time he spends on a task.
Answer A is incorrect because the client with a personality disorder will see no reason to change.
The nurse should discuss his behavior and its effects on others with him, so answer C is incorrect.
Answer D is incorrect because the client will not be able to set schedules and deadlines for himself.
An appropriate nursing intervention for the client with borderline personality disorder is:
A.Observing the client for signs of depression or suicidal thinking
B. Allowing the client to lead unit group sessions
C.Restricting the client's activity to the assigned unit of care throughout the hospitalization
D. Allowing the client to select a primary caregiver
Answer A is correct. Clients with borderline personality frequently suffer from depression and suicidal thinking and should be assessed for risk of self-injury. Answers B and D are incorrect choices because they allow the client too much control of the therapeutic environment. Answer C is incorrect because the client’s activities do not have to be restricted to the unit after the level of depression has been determined.
A client is admitted to the chemical dependency unit for poly-drug abuse. The client states, “I don’t know why you are all so worried; I am in control. I don’t have a problem.” Which defense mechanism is being utilized?
A. Rationalization B. Projection
C. Dissociation D. Denial
Answer D is correct. The statement in answer D reflects the use of denial as a means of coping with the illness. Answers A, B, and C are defense mechanisms not reflected by the statement, so they are incorrect.
A client admitted voluntarily for treatment of an anxiety disorder demands to be released from the hospital. Which action should the nurse take initially?
1. Contact the client’s health care provider (HCP). 2.Call the client’s family to arrange for transportation.
3. Attempt to persuade the client to stay“for only a few more days.”
4. Tell the client that leaving would likely result in an involuntary commitment.
Correct answer: 1
Rationale:
In general, clients seek voluntary admission. Voluntary clients have the right to demand and obtain release. The nurse needs to be familiar with the state and facility policies and procedures. The initial nursing action is to contact the HCP, who has the authority to discuss discharge with the client.
While arranging for safe transportation is appropriate, it is premature in this situation and should be done only with the client’s permission.
While it is appropriate to discuss why the client feels the need to leave and the possible outcomes of leaving against medical advice, attempting to get the client to agree to stay “for only a few more days” has little value and will not likely be successful.
Many states require that the client submit a written release notice to the facility psychiatrist, who reevaluates the client’s condition for possible conversion to involuntary status if necessary, according to criteria established by law. While this is a possibility, it should not be used as a threat with the client.
Which of the following is an expected finding in the assessment of a client with bulimia nervosa?
A. Extreme weight loss
B.Presence of lanugo over body
C. Erosion of tooth enamel
D. Muscle wasting
Answer C is correct. Erosion of tooth enamel caused by frequent self-induced vomiting is an expected finding in a client with bulimia nervosa.
Answers A, B, and D are expected findings in the client with anorexia nervosa; therefore, they are incorrect.
The nurse is caring for a client diagnosed with paranoid personality disorder who is experiencing disturbed thought processes. In formulating a nursing plan of care, which best intervention should the nurse include?
1. Increase the socialization of the client with peers.
2. Avoid using a whisper voice in front of the client.
3. Begin to educate the client about social supports in the community.
4. Have the client sign a release of information to appropriate parties for assessment purposes.
Answer: 2
Rationale: Disturbed thought process related to paranoid personality disorder is the client’s problem, and the plan of care must address this problem. The client is distrustful and suspicious of others. The members of the health care team need to establish a rapport and trust with the client. Laughing or whispering in front of the client would be counterproductive. The remaining options ask the client to trust on a multitude of levels. These options are actions that are too intrusive for a client with this disorder.
While interviewing a client who abuses alcohol, the nurse learns that the client has experienced “blackouts.” The wife asks what this means. What is the nurse’s best response at this time?
A. Your husband has experienced short-term memory amnesia.”
B. “Your husband has experienced the loss of remote memory.”
C. “Your husband has experienced a loss of consciousness.”
D. “Your husband has experienced a fainting spell"
Answer A is correct. The most appropriate response is to answer the request of the client’s spouse and define blackouts. Answers B, C, and D are not accurate definitions of blackouts, so they are incorrect.
A client is participating in a therapy group and focuses on viewing all team members as equally important in helping the clients to meet their goals. The nurse is implementing which therapeutic approach?
1. Milieu therapy
2. Interpersonal therapy 3. Behavior modification 4. Support group therapy
Correct Answer: 1
Rationale:
All treatment team members are viewed as significant and valuable to the client’s successful treatment outcomes in milieu therapy.
Interpersonal therapy is based on a one-to-one or group therapy approach in which the therapist-client relationship is often used as a way for the client to examine the relationships in his or her life.
Behavior modification is based on rewards and punishment.
Support groups are based on the premise that individuals who have experienced and are insightful concerning a problem are able to help others who have a similar problem.
The nurse is caring for a client with bulimia nervosa. The nurse recognizes that the major difference in the client with anorexia nervosa and the client with bulimia nervosa is the client with bulimia:
A. Is usually grossly overweight.
B. Has a distorted body image.
C. Recognizes that she has an eating disorder. D. Struggles with issues of dependence versus independence.
Answer C is correct. The client with bulimia nervosa recognizes that she has an eating disorder but feels helpless to correct it.
Answer A is incorrect because the client with bulimia nervosa is usually of normal weight.
Answers B and D are incorrect because they describe both the client with anorexia nervosa and the client with bulimia nervosa.
An adolescent is preparing to return home after psychiatric hospitalization for a suicide attempt. Which actions would be most effective to support family processes when the client returns home? SATA.
1. Make a video of the ride home in the car
2. Identify the family's strengths and weaknesses
3. Ask that the mother's boyfriend move out of the home
4.Provide and offer the family appropriate options and resources
5. Encourage communication and the sharing of feelings among the family members
Answer: 2, 4, 5
Rationale: After the crisis time of a family member's suicide attempt, safety for the recovering individual is a priority. Families can provide support and encouragement in a caring home environment. Options 2, 4, 5 offer helpful ways to enhance the family processes.
Options 1 and 3 are clearly the least effective options because there is no information in the question that indicates that these actions are relative to the suicide attempt.
A client taking the drug disulfiram (Antabuse) is admitted to the ER. Which clinical manifestations are most indicative of recent alcohol ingestion?
1. Vomiting, heart rate 120, chest pain
2. Nausea, mild headache, bradycardia
3. Respirations 16, heart rate 62, diarrhea
4. Temp 101°F, tachycardia, respirations 20
Answer A is correct. Vomiting, a heart rate of 120, and chest pain are symptoms of drinking alcohol while taking Antabuse. Additional symptoms include severe headache, nausea, cardiac collapse, respiratory collapse, convulsions, and death. Answers B, C, and D contain incomplete or inaccurate clinical signs of the combination of alcohol and Antabuse
The nurse in the mental health unit plans to use which therapeutic communication techniques when communicating with a client? Select all that apply.
1. Restating
2. Listening
3. Asking the client “Why?”
4. Maintaining neutral responses
5. Providing acknowledgment and feedback 6. Giving advice and approval or disapproval
Answer: 1, 2, 4, 5
Rationale:
Therapeutic communication techniques include: listening, maintaining silence, maintaining neutral responses, using broad openings and open-ended questions, focusing and refocusing, restating, clarifying and validating, sharing perceptions, reflecting, providing acknowledgment and feedback, giving information, presenting reality, encouraging formulation of a plan of action, providing nonverbal encouragement, and summarizing.
Asking “Why” is often interpreted as being accusatory by the client and should also be avoided.
Providing advice or giving approval or disapproval are barriers to communication
When planning the discharge of a client with chronic anxiety, the nurse directs the goals at promoting a safe environment at home. Which is the most appropriate maintenance goal?
1. Suppressing feelings of anxiety
2. Identifying anxiety-producing situations
3. Continuing contact with a crisis counselor 4. Eliminating all anxiety from daily situations
Answer: 2
Rationale:
Recognizing situations that produce anxiety allows the client to prepare to cope with anxiety or avoid a specific stimulus. Counselors will not be available for all anxiety-producing situations, and this option does not encourage the development of internal strengths. Suppressing feelings will not resolve anxiety. Elimination of all anxiety from life is impossible.
A client says to the nurse, “The federal guards were sent to kill me.” Which is the best response by the nurse to the client’s concern?
1. “I don’t believe this is true.”
2. “The guards are not out to kill you.”
3. “Do you feel afraid that people are trying to hurt you?”
4. “What makes you think the guards were sent to hurt you?”
Answer: 3
Rationale: It is most therapeutic for the nurse to empathize with the client’s experience. The remaining options lack this connection with the client. Disagreeing with delusions may make the client more defensive, and the client may cling to the delusions even more. Encouraging discussion regarding the delusion is inappropriate.
Which interventions are most appropriate for caring for a client in alcohol withdrawal? Select all that apply.
1. Monitor vital signs.
2. Provide a safe environment.
3. Address hallucinations therapeutically.
4. Provide stimulation in the environment.
5. Provide reality orientation as appropriate. 6. Maintain NPO (nothing by mouth) status.
Answer:
1, 2, 3, 5
Rationale: When the client is experiencing withdrawal from alcohol, the priority for care is to prevent the client from harming self or others. The nurse would monitor the vital signs closely and report abnormal findings. The nurse would provide a low-stimulation environment to maintain the client in as calm a state as possible. The nurse would reorient the client to reality frequently and would address hallucinations therapeutically. Adequate nutritional and fluid intake need to be maintained.