Unit 4: Foundations of Psychiatric Nursing
A 6-year-old client is diagnosed with attention deficit hyperactivity disorder (ADHD). When
asking this client to complete a task, what techniques should the nurse use to communicate
more effectively with him? - ANS-Obtain eye contact before speaking, use simple language, and
have him repeat what was said. Praise him if he completes the task.
Because the client with ADHD is easily distractible, it is important to obtain eye contact before
explaining the task. Simple language and having him repeat what he is told are necessary
because of his age. Praise encourages the client to repeat the task in the future as well as
building the client's self-esteem. A full explanation with verbal praise and a food reward is
inappropriate because a food reward increases the chance that he will expect a physical reward
for completing tasks. In addition, a full explanation might be too confusing for someone his age.
Explaining consequences focuses on punishment, rather than praise. Although demonstration
and imitation is an effective teaching method, rewarding with food fosters dependence on food
reward for task completion.
\A client becomes angry and belligerent toward the nurse after speaking on the phone with the
client's mother. The nurse recognizes this as what defense mechanism? - ANS-displacement
Displacement is a defense mechanism in which the client transfers feelings for one person to
another person who is less threatening. Rationalization is a defense mechanism in which the
client makes excuses to justify unacceptable feelings or behaviors. Repression is characterized
by an involuntary blocking of unpleasant experiences from one's consciousness. Suppression is
the conscious blocking of unpleasant experiences from one's awareness.
\A client changes topics quickly while relating past psychiatric history. This client's pattern of
thinking is called: - ANS-flight of ideas.
Flight of ideas describes a thought pattern in which a client moves rapidly from one topic to the
next with some connection. Looseness of association describes a pattern in which ideas lack an
apparent logical connection to one another. Tangential thoughts seem to be related but miss the
point. A client who talks around a subject and includes a lot of unnecessary information is
exhibiting circumstantial thinking.
\A client diagnosed with antisocial personality disorder asks the nurse for an additional smoke
break because of anxiety. Which response by the nurse is best? - ANS-"Clients are permitted to
smoke at designated times. You have to follow the rules."
Consistency is essential when dealing with antisocial clients. They disregard social norms and
don't believe the rules apply to them. Agreeing to give the client a smoke break would be
detrimental to the client because it reinforces the client's acting-out behaviors. Saying the nurse
is too busy avoids the client's attempt to manipulate. Telling the client that an extra smoke break
is not allowed because smoking is harmful is inappropriate because the nurse is lecturing the
client.
,\A client doesn't make eye contact with the nurse during an interview. The nurse suspects that
the client's behavior has a cultural basis. What should the nurse do first? - ANS-Observe how
the client and the client's family and friends interact with one another and with other staff
members.
Assessing the client's interactions with others helps the nurse determine whether the behavior is
part of a usual pattern. It also may help the nurse understand the meaning of the behavior for
this particular client. Reading about a different culture, consulting other staff members, and
talking with the client are helpful after the nurse has observed the client's interaction with others.
The nurse must be able to accept the client as an individual but need not accept unhealthy or
inappropriate behaviors. The nurse should work with the client to better understand the cultural
differences
\A client has been involuntarily committed to a hospital because he has been assessed as being
dangerous to self or others. The client has lost which right? - ANS-the right to leave the hospital
against medical advice
An involuntarily admitted client loses the right to leave the hospital until the condition is stable
enough that the client no longer poses a danger to self or others. While hospitalized, the client
retains all civil rights such as receiving mail, making phone calls, refusing treatment, and also
receiving the least restrictive treatment. Should the involuntarily admitted client refuse treatment
once admitted, he will be evaluated for the need to receive treatment against wishes in order to
decrease the risk for self-harm or harm to others.
\A client has chronic low self-esteem related to self-doubt as evidenced by self-deprecatory
statements. What goal should the nurse establish for the client? - ANS-Identify positive aspects
of self.
The expected outcome is that the client identify positive aspects of self-related to self-doubt as
evidenced by self-deprecatory comments. An expression of positive self-comments indicates a
realistic view of the client's self-concept.
Demonstrating reality-based thinking relates to altered thought processes.
Using relaxation exercises relates more to decreasing anxiety.
Setting attainable goals relates to hopelessness.
\A client in a group therapy setting is very demanding. The client repeatedly interrupts others
and monopolizes most of the group time. The nurse's best response would be: - ANS-"Will you
briefly summarize your point? Others also need time."
Asking the client to summarize directs the client to focus the comments and allows the client to
make a point. Saying the client's behavior is obnoxious is judgmental. Telling the client that the
behavior is frustrating doesn't facilitate communication. Ignoring the client's behavior focuses
more on the nurse's need than on the client's.
\A client in group therapy is restless. The client's face is flushed and the client makes sarcastic
remarks to group members. The nurse responds by saying, "You look angry." The nurse is using
which technique? - ANS-observation
, The nurse is using observation to give the client feedback about behavior and attitude. A broad
statement doesn't give feedback to the client. The nurse didn't ask the client to explain the
actions (the clarifying technique) and didn't reassure the client.
\A client is admitted for a surgical biopsy of a suspicious lump in the right breast. At the time the
nurse arrives to take the client to surgery, the client is finishing a letter to the client's children.
The client tearfully tells the nurse, "I just want to leave this for my children in case anything goes
wrong in the surgery." Which nursing response will be most therapeutic? - ANS-What are you
concerned about right now?"
The most therapeutic response is one in which the nurse reflects back to the client what the
client has said and asks the client to reflect further. Making light of the client's worries about the
biopsy does not help the client process their feelings or concerns. The client did not express
questions about the biopsy; therefore calling the doctor is not appropriate at this time.
Confronting the client about what the nurse feels is misplaced anxiety of the biopsy versus
cancer would not be beneficial to the client and not therapeutic in these circumstances.
\A client is admitted to a mental health unit with a diagnosis of depression and is participating in
group sessions. The client asks a nurse if they are married or in a romantic relationship. What is
the best response by the nurse to maintain a therapeutic relationship? - ANS-I'm curious about
your question but I want to know how you are feeling today."
Nurses must practice in a manner that is consistent with providing safe, competent, and ethical
care. If the nurse shared personal information with the client, the nurse would have crossed the
boundary of a therapeutic relationship and changed the focus of the discussion from a client
focus to a social focus. It is very important in all areas of care, but especially in the mental
health setting, that the relationship between the nurse and the client has very clear boundaries
and is client focused. The other options are incorrect because they do not follow the principles
of a therapeutic nurse-client relationship.
\A client is being discharged after 3 days of hospitalization for a suicide attempt that followed the
receipt of a divorce notice. Which client finding indicates to the nurse that the client is ready for
discharge? - ANS-has a list of support persons and community resources
The risk of suicide can persist for 2 to 3 months even after a crisis has abated. Therefore, it is
important for the client to be able to verbalize information about appropriate support persons
and community resources and to have this information readily available. Although the client may
state feeling ready to be discharged, this is not the most reliable indicator. A divorce lawyer may
not be appropriate at this point. At 3 days after a suicide attempt, emotional stability is not likely.
\A client is complaining to other clients about not being allowed by staff to keep food in the
client's room. What should the nurse do? - ANS-Set limits on the behavior.
The nurse needs to set limits on the client's manipulative behavior to help the client control
dysfunctional behavior. The manipulative client bends rules to have needs met without regard
for rules or the needs or rights of others. A consistent approach by the staff is necessary to
decrease manipulation. Ignoring the client's behavior reinforces or promotes the continuation of
the client's manipulative behavior. Reprimanding the client may be perceived as a threat,
A 6-year-old client is diagnosed with attention deficit hyperactivity disorder (ADHD). When
asking this client to complete a task, what techniques should the nurse use to communicate
more effectively with him? - ANS-Obtain eye contact before speaking, use simple language, and
have him repeat what was said. Praise him if he completes the task.
Because the client with ADHD is easily distractible, it is important to obtain eye contact before
explaining the task. Simple language and having him repeat what he is told are necessary
because of his age. Praise encourages the client to repeat the task in the future as well as
building the client's self-esteem. A full explanation with verbal praise and a food reward is
inappropriate because a food reward increases the chance that he will expect a physical reward
for completing tasks. In addition, a full explanation might be too confusing for someone his age.
Explaining consequences focuses on punishment, rather than praise. Although demonstration
and imitation is an effective teaching method, rewarding with food fosters dependence on food
reward for task completion.
\A client becomes angry and belligerent toward the nurse after speaking on the phone with the
client's mother. The nurse recognizes this as what defense mechanism? - ANS-displacement
Displacement is a defense mechanism in which the client transfers feelings for one person to
another person who is less threatening. Rationalization is a defense mechanism in which the
client makes excuses to justify unacceptable feelings or behaviors. Repression is characterized
by an involuntary blocking of unpleasant experiences from one's consciousness. Suppression is
the conscious blocking of unpleasant experiences from one's awareness.
\A client changes topics quickly while relating past psychiatric history. This client's pattern of
thinking is called: - ANS-flight of ideas.
Flight of ideas describes a thought pattern in which a client moves rapidly from one topic to the
next with some connection. Looseness of association describes a pattern in which ideas lack an
apparent logical connection to one another. Tangential thoughts seem to be related but miss the
point. A client who talks around a subject and includes a lot of unnecessary information is
exhibiting circumstantial thinking.
\A client diagnosed with antisocial personality disorder asks the nurse for an additional smoke
break because of anxiety. Which response by the nurse is best? - ANS-"Clients are permitted to
smoke at designated times. You have to follow the rules."
Consistency is essential when dealing with antisocial clients. They disregard social norms and
don't believe the rules apply to them. Agreeing to give the client a smoke break would be
detrimental to the client because it reinforces the client's acting-out behaviors. Saying the nurse
is too busy avoids the client's attempt to manipulate. Telling the client that an extra smoke break
is not allowed because smoking is harmful is inappropriate because the nurse is lecturing the
client.
,\A client doesn't make eye contact with the nurse during an interview. The nurse suspects that
the client's behavior has a cultural basis. What should the nurse do first? - ANS-Observe how
the client and the client's family and friends interact with one another and with other staff
members.
Assessing the client's interactions with others helps the nurse determine whether the behavior is
part of a usual pattern. It also may help the nurse understand the meaning of the behavior for
this particular client. Reading about a different culture, consulting other staff members, and
talking with the client are helpful after the nurse has observed the client's interaction with others.
The nurse must be able to accept the client as an individual but need not accept unhealthy or
inappropriate behaviors. The nurse should work with the client to better understand the cultural
differences
\A client has been involuntarily committed to a hospital because he has been assessed as being
dangerous to self or others. The client has lost which right? - ANS-the right to leave the hospital
against medical advice
An involuntarily admitted client loses the right to leave the hospital until the condition is stable
enough that the client no longer poses a danger to self or others. While hospitalized, the client
retains all civil rights such as receiving mail, making phone calls, refusing treatment, and also
receiving the least restrictive treatment. Should the involuntarily admitted client refuse treatment
once admitted, he will be evaluated for the need to receive treatment against wishes in order to
decrease the risk for self-harm or harm to others.
\A client has chronic low self-esteem related to self-doubt as evidenced by self-deprecatory
statements. What goal should the nurse establish for the client? - ANS-Identify positive aspects
of self.
The expected outcome is that the client identify positive aspects of self-related to self-doubt as
evidenced by self-deprecatory comments. An expression of positive self-comments indicates a
realistic view of the client's self-concept.
Demonstrating reality-based thinking relates to altered thought processes.
Using relaxation exercises relates more to decreasing anxiety.
Setting attainable goals relates to hopelessness.
\A client in a group therapy setting is very demanding. The client repeatedly interrupts others
and monopolizes most of the group time. The nurse's best response would be: - ANS-"Will you
briefly summarize your point? Others also need time."
Asking the client to summarize directs the client to focus the comments and allows the client to
make a point. Saying the client's behavior is obnoxious is judgmental. Telling the client that the
behavior is frustrating doesn't facilitate communication. Ignoring the client's behavior focuses
more on the nurse's need than on the client's.
\A client in group therapy is restless. The client's face is flushed and the client makes sarcastic
remarks to group members. The nurse responds by saying, "You look angry." The nurse is using
which technique? - ANS-observation
, The nurse is using observation to give the client feedback about behavior and attitude. A broad
statement doesn't give feedback to the client. The nurse didn't ask the client to explain the
actions (the clarifying technique) and didn't reassure the client.
\A client is admitted for a surgical biopsy of a suspicious lump in the right breast. At the time the
nurse arrives to take the client to surgery, the client is finishing a letter to the client's children.
The client tearfully tells the nurse, "I just want to leave this for my children in case anything goes
wrong in the surgery." Which nursing response will be most therapeutic? - ANS-What are you
concerned about right now?"
The most therapeutic response is one in which the nurse reflects back to the client what the
client has said and asks the client to reflect further. Making light of the client's worries about the
biopsy does not help the client process their feelings or concerns. The client did not express
questions about the biopsy; therefore calling the doctor is not appropriate at this time.
Confronting the client about what the nurse feels is misplaced anxiety of the biopsy versus
cancer would not be beneficial to the client and not therapeutic in these circumstances.
\A client is admitted to a mental health unit with a diagnosis of depression and is participating in
group sessions. The client asks a nurse if they are married or in a romantic relationship. What is
the best response by the nurse to maintain a therapeutic relationship? - ANS-I'm curious about
your question but I want to know how you are feeling today."
Nurses must practice in a manner that is consistent with providing safe, competent, and ethical
care. If the nurse shared personal information with the client, the nurse would have crossed the
boundary of a therapeutic relationship and changed the focus of the discussion from a client
focus to a social focus. It is very important in all areas of care, but especially in the mental
health setting, that the relationship between the nurse and the client has very clear boundaries
and is client focused. The other options are incorrect because they do not follow the principles
of a therapeutic nurse-client relationship.
\A client is being discharged after 3 days of hospitalization for a suicide attempt that followed the
receipt of a divorce notice. Which client finding indicates to the nurse that the client is ready for
discharge? - ANS-has a list of support persons and community resources
The risk of suicide can persist for 2 to 3 months even after a crisis has abated. Therefore, it is
important for the client to be able to verbalize information about appropriate support persons
and community resources and to have this information readily available. Although the client may
state feeling ready to be discharged, this is not the most reliable indicator. A divorce lawyer may
not be appropriate at this point. At 3 days after a suicide attempt, emotional stability is not likely.
\A client is complaining to other clients about not being allowed by staff to keep food in the
client's room. What should the nurse do? - ANS-Set limits on the behavior.
The nurse needs to set limits on the client's manipulative behavior to help the client control
dysfunctional behavior. The manipulative client bends rules to have needs met without regard
for rules or the needs or rights of others. A consistent approach by the staff is necessary to
decrease manipulation. Ignoring the client's behavior reinforces or promotes the continuation of
the client's manipulative behavior. Reprimanding the client may be perceived as a threat,
