California State University, NorthridgeNURS 318Focus on Mental Health Exam

A nurse overhears a hospitalized client with mania telling another client, “I’m actually a journalist writing an article for a magazine — I’m just posing as a person with mental illness.” How should the nurse respond? A. Ignoring the delusion B. Taking the client to a quiet room C. Supporting the client’s denial of illness D. Presenting the client with the actual situation Correct Rationale: When dealing with a delusional client, it is important for the nurse to state clearly that the nurse does not share the client’s perceptions. All three of the other options — ignoring the delusion, taking the client to a quiet room, and supporting the client’s denial of illness — do not focus on reality, and they ignore the issue. Presenting the client with the actual situation helps orient the client to reality. Test-Taking Strategy: Reality orientation is the priority. Eliminate the comparable or alike options that ignore the client, or the client’s symptoms. The correct option illustrates a means of helping orient the client to reality. Review: care of the client experiencing delusions. Level of Cognitive Ability: Applying Client Needs: Psychosocial integrity Integrated Process: Nursing Process/Implementation Content Area: Mental Health Giddens Concepts: Communication, Psychosis HESI Concepts: Cognition, Communication Reference: Varcarolis, E. (2013). Essentials of Psychiatric Mental Health Nursing: A communication approach to evidence-based care. (revised reprint)) (2nd ed. pp. 305, 318-320). St. Louis: Saunders. Awarded 99.0 points out of 99.0 possible points. 2. A client who is hallucinating fearfully says to the nurse, “Please tell that demon to get out.” How should the nurse respond to the client? A. “If you tell the demon to go away, it will.” B. “I’ll stay here with you until the demon leaves your room.” C. “If you return to bed, you will find that the demon will leave.” D. “I know you must be very upset by this, but I don’t see a demon.” Correct Rationale: If the client hallucinates, it is best to provide reality-based perceptions and not negate the client’s experience, because this may lead to a regressive struggle with the client. Giving advice or false reassurance is incorrect because such techniques indicate that demons actually are present, which feeds into the client’s hallucination and reinforces the client’s behavior. Test-Taking Strategy: Use your knowledge of therapeutic communication techniques, noting . that the client is hallucinating. Remember that it is most important to maintain reality with the client. This will direct you to the correct option. Review: communication techniques for the client who is hallucinating Level of Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Giddens Concepts: Communication, Psychosis HESI Concepts: Cognition, Communication References: Stuart, G. (2013). Principles & practice of psychiatric nursing (10th ed., pp. 25-29). St. Louis: Mosby. Varcarolis, E. (2013). Essentials of Psychiatric Mental Health Nursing: A communication approach to evidence-based care. (revised reprint)) (2nd ed. p. 320). St. Louis: Saunders. Awarded 99.0 points out of 99.0 possible points. 3. The mother of a 3-year-old says, “My child hit his teddy bear after being scolded for picking the neighbors’ flowers.” The nurse should explain th