Therapeutic Communication
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." Give an example of how the nurse should respond.
Therapeutic communication:
Open Ended Questions
Restating
Silence
Listening
A client is unwilling to go to church because he feels that his ex girlfriend goes there and will laugh if she sees him. Because of this he has become homebound. What type of personality disorder does this describe?
Avoidant
A hospitalized patient is started on phenelzine for the treatment of depression. The nurse should instruct the client to avoid which foods?
This is an MAOI. Foods with tyramine including yogurt aged cheeses, smoked or processed meats, red wines, avocados, raisins, and figs
Characterized by episodes of mania and depression with periods of normal mood and activity in between.
The nurse visits a client at home. The client states, "I haven't slept at all the past couple of nights." The nurse responds "You're having difficulty sleeping?" What technique did the nurse use?
Restating
A client diagnosed with delirium becomes disoriented and confused at night. What is the first intervention the nurse should implement?
Consistent daily routine and low stimulus in the evening.
The nurse is caring for the client with paranoid personality disorder who is experiencing impaired thought processes. What intervention should be included in the plan of care?
Establish and maintain rapport with patient.
The nurse is caring for a client with command hallucinations. The nurse is providing discharge instructions concerning the need for medication continuation. What type of statement would indicate understanding?
Restatement of instructions and of understanding of need for medication continuation. Understanding that symptoms will return if medications are not taken.
What is the medication of choice for bipolar disorder?
Lithium
A client is experiencing disturbed thought processes and believes that his food is being poisoned. Which communication technique should the nurse use to encourage the client to eat?
Open-Ended Questions
Describe the CAGE questionnaire. What is this used for?
Has anyone every suggested you cut down on your drinking? Do family and friends become annoyed with the amount you drink? Do you ever feel guilty about your alcohol use? Do you need to have an eye opener in the morning?
A charge nurse is developing teaching for staff regarding personality disorders. What do you expect to be included?
1. Difficulty with social and professional relationships.
2. Maladaptive response to stress.
3. Difficulty understanding personal boundaries.
The nurse is caring for a patient admitted with catatonic stupor. The client is lying on the bed in fetal position. What intervention should the nurse take?
Establish interpersonal contact.
Describe mild depression
Triggered by an external event and follow the normal grief reaction. Feeling sad, let down, or disappointed. Feeling less alert, irritability
What type of response from the patient would the nurse expect when they review the client's chart and note a voluntary admission?
The client will participate in treatment.
A nurse is planning care to promote a safe and therapeutic environment for a client who has a severe cognitive decline due to Alzheimer's disease. Identify five nursing actions.
1. Assign a room near nursing station.
2. Provide a room with low stimuli.
3. Provide well lit environment.
4. Have client wear identification.
5. Monitor level of comfort.
6. Assisting devices as needed.
7. Keep consistent daily routine.
8. Ensure adequate nutrition.
A client's medication sheet contains a prescription for sertraline. To ensure safe administration of the medication how should the nurse administer the dose?
At the same time each day. Preferably in the evening.
Name general interventions for a patient with personality disorder.
Maintain safety against self destructive behaviors.
Allow the client to make choices and be as independent as possible.
Encourage the client to discuss feelings rather than act on them.
Provide consistency
Discuss consequences of negative behaviors.
Major Depressive Disorder is characterized by:
Moderate depression that persists over time. The person experiences a sense of change and often seeks help. Despondent and gloomy. Low self-esteem. Helplessness and powerlessness.
How should a nurse respond to a manic group member who is monopolizing group time on the unit?
Re-orient and set boundaries.
Urine Sample for possible UTI.
A client taking lithium reports vomiting, abdominal pain, diarrhea, blurred vision, tinnitus, and tremors. Lithium level is 2.5 mEq/L. The nurse know the client is experiencing:
Lithium toxicity
What characteristics are seen in borderline personality disorder?
Unclear identity.
Unstable and intense
Extreme shifts in mood
Easily angered
Easily bored
argumentative
depression
manipulation
self destructive behavior
inability to tolerate anxiety.
What is the most important intervention for a patient admitted with a mood disorder?
Safety, suicide risk.