saunders mental health
The nurse should plan which goals of the termination stage of group development?
Select all that apply. - ANS - the group evaluates the experience.
- The group explores members' feelings about the group and the impending separation.
A client diagnosed with terminal cancer says to the nurse, "I'm going to die, and I wish
my family would stop hoping for a cure! I get so angry when they carry on like this. After
all, I'm the one who's dying." Which response by the nurse is therapeutic? - ANS
"You're feeling angry that your family continues to hope for you to be cured?"
When reviewing the admission assessment, the nurse notes that a client was admitted
to the mental health unit involuntarily. Based on this type of admission, the nurse should
provide which intervention for this client? - ANS Monitor closely for harm to self or
others.
The nurse in the mental health unit plans to use which therapeutic communication
techniques when communicating with a client? Select all that apply. - ANS -Restating
- Listening
- Maintaining neutral responses
- Providing acknowledgment and feedback
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? - ANS Milieu therapy
The nurse is working with a client who despite making a heroic effort was unable to
rescue a neighbor trapped in a house fire. Which client-focused action should the nurse
engage in during the working phase of the nurse-client relationship? - ANS Inquiring
about and examining the client's feelings for any that may block adaptive coping
A client diagnosed with delirium becomes disoriented and confused at night. Which
intervention should the nurse implement initially? - ANS Use an indirect light source
and turn off the television.
,The nurse is conducting a group therapy session. During the session, a client
diagnosed with mania consistently disrupts the group's interactions. Which intervention
should the nurse initially implement? - ANS Setting limits on the client's behavior
A client is admitted to a medical nursing unit with a diagnosis of acute blindness after
being involved in a hit-and-run accident. When diagnostic testing cannot identify any
organic reason why this client cannot see, a mental health consult is prescribed. The
nurse plans care based on which condition that should be the focus of this consult? -
ANS Conversion disorder
Which nursing interventions are appropriate for a hospitalized client with mania who is
exhibiting manipulative behavior? Select all that apply. - ANS - Communicate expected
behaviors to the client.
- Assist the client in identifying ways of setting limits on personal behaviors.
- Follow through about the consequences of behavior in a nonpunitive manner.
- Have the client state the consequences for behaving in ways that are viewed as
unacceptable.
The nurse is preparing a client with a history of command hallucinations for discharge
by providing instructions on interventions for managing hallucinations and anxiety.
Which statement in response to these instructions suggests to the nurse that the client
has a need for additional information? - ANS "When I have command hallucinations, I'll
call a friend and ask him what I should do."
The nurse is caring for a client just admitted to the mental health unit and diagnosed
with catatonic stupor. The client is lying on the bed in a fetal position. Which is the most
appropriatenursing intervention? - ANS Sit beside the client in silence with occasional
open-ended questions.
The nurse is planning activities for a client diagnosed with bipolar disorder with
aggressive social behavior. Which activity would be most appropriate for this client? -
ANS Writing
Which interventions are most appropriate for caring for a client in alcohol withdrawal?
Select all that apply. - ANS - Monitor vital signs.
- Provide a safe environment.
-Address hallucinations therapeutically.
- Provide reality orientation as appropriate.
, A hospitalized client with a history of alcohol abuse tells the nurse, "I am leaving now. I
have to go. I don't want any more treatment. I have things that I have to do right away."
The client has not been discharged and is scheduled for an important diagnostic test to
be performed in 1 hour. After the nurse discusses the client's concerns with the client,
the client dresses and begins to walk out of the hospital room. What action should the
nurse take? - ANS Call the nursing supervisor.
The nurse is preparing to perform an admission assessment on a client with a diagnosis
of bulimia nervosa. Which assessment findings should the nurse expect to note? Select
all that apply. - ANS - Loss of tooth enamel
-Electrolyte imbalances
- Dental decay
A client with a diagnosis of anorexia nervosa, who is in a state of starvation, is in a
2-bed room. A newly admitted client will be assigned to this client's room. Which client
would be the best choice as a roommate for the client with anorexia nervosa? - ANS A
client undergoing diagnostic tests
rationale: The client undergoing diagnostic tests is an acceptable roommate. The client
with anorexia nervosa is most likely experiencing hematological complications, such as
leukopenia.
The nurse is monitoring a hospitalized client who abuses alcohol. Which findings should
alert the nurse to the potential for alcohol withdrawal delirium? - ANS Hypertension,
changes in level of consciousness, hallucinations
alcohol withdrawal delirium symptoms - ANS delirium typically include anxiety,
insomnia, anorexia, hypertension, disorientation, hallucinations, changes in level of
consciousness, agitation, fever, and delusions.
The spouse of a client admitted to the mental health unit for alcohol withdrawal says to
the nurse, "I should get out of this bad situation." Which is the most helpful response by
the nurse? - ANS "What do you find difficult about this situation?"
A client with anorexia nervosa is a member of a predischarge support group. The client
verbalizes that she would like to buy some new clothes, but her finances are limited.
Group members have brought some used clothes to the client to replace the client's old
clothes. The client believes that the new clothes are much too tight and has reduced her
calorie intake to 800 calories daily. How should the nurse evaluate this behavior? - ANS
Evidence of the client's disturbed body image
The nurse should plan which goals of the termination stage of group development?
Select all that apply. - ANS - the group evaluates the experience.
- The group explores members' feelings about the group and the impending separation.
A client diagnosed with terminal cancer says to the nurse, "I'm going to die, and I wish
my family would stop hoping for a cure! I get so angry when they carry on like this. After
all, I'm the one who's dying." Which response by the nurse is therapeutic? - ANS
"You're feeling angry that your family continues to hope for you to be cured?"
When reviewing the admission assessment, the nurse notes that a client was admitted
to the mental health unit involuntarily. Based on this type of admission, the nurse should
provide which intervention for this client? - ANS Monitor closely for harm to self or
others.
The nurse in the mental health unit plans to use which therapeutic communication
techniques when communicating with a client? Select all that apply. - ANS -Restating
- Listening
- Maintaining neutral responses
- Providing acknowledgment and feedback
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? - ANS Milieu therapy
The nurse is working with a client who despite making a heroic effort was unable to
rescue a neighbor trapped in a house fire. Which client-focused action should the nurse
engage in during the working phase of the nurse-client relationship? - ANS Inquiring
about and examining the client's feelings for any that may block adaptive coping
A client diagnosed with delirium becomes disoriented and confused at night. Which
intervention should the nurse implement initially? - ANS Use an indirect light source
and turn off the television.
,The nurse is conducting a group therapy session. During the session, a client
diagnosed with mania consistently disrupts the group's interactions. Which intervention
should the nurse initially implement? - ANS Setting limits on the client's behavior
A client is admitted to a medical nursing unit with a diagnosis of acute blindness after
being involved in a hit-and-run accident. When diagnostic testing cannot identify any
organic reason why this client cannot see, a mental health consult is prescribed. The
nurse plans care based on which condition that should be the focus of this consult? -
ANS Conversion disorder
Which nursing interventions are appropriate for a hospitalized client with mania who is
exhibiting manipulative behavior? Select all that apply. - ANS - Communicate expected
behaviors to the client.
- Assist the client in identifying ways of setting limits on personal behaviors.
- Follow through about the consequences of behavior in a nonpunitive manner.
- Have the client state the consequences for behaving in ways that are viewed as
unacceptable.
The nurse is preparing a client with a history of command hallucinations for discharge
by providing instructions on interventions for managing hallucinations and anxiety.
Which statement in response to these instructions suggests to the nurse that the client
has a need for additional information? - ANS "When I have command hallucinations, I'll
call a friend and ask him what I should do."
The nurse is caring for a client just admitted to the mental health unit and diagnosed
with catatonic stupor. The client is lying on the bed in a fetal position. Which is the most
appropriatenursing intervention? - ANS Sit beside the client in silence with occasional
open-ended questions.
The nurse is planning activities for a client diagnosed with bipolar disorder with
aggressive social behavior. Which activity would be most appropriate for this client? -
ANS Writing
Which interventions are most appropriate for caring for a client in alcohol withdrawal?
Select all that apply. - ANS - Monitor vital signs.
- Provide a safe environment.
-Address hallucinations therapeutically.
- Provide reality orientation as appropriate.
, A hospitalized client with a history of alcohol abuse tells the nurse, "I am leaving now. I
have to go. I don't want any more treatment. I have things that I have to do right away."
The client has not been discharged and is scheduled for an important diagnostic test to
be performed in 1 hour. After the nurse discusses the client's concerns with the client,
the client dresses and begins to walk out of the hospital room. What action should the
nurse take? - ANS Call the nursing supervisor.
The nurse is preparing to perform an admission assessment on a client with a diagnosis
of bulimia nervosa. Which assessment findings should the nurse expect to note? Select
all that apply. - ANS - Loss of tooth enamel
-Electrolyte imbalances
- Dental decay
A client with a diagnosis of anorexia nervosa, who is in a state of starvation, is in a
2-bed room. A newly admitted client will be assigned to this client's room. Which client
would be the best choice as a roommate for the client with anorexia nervosa? - ANS A
client undergoing diagnostic tests
rationale: The client undergoing diagnostic tests is an acceptable roommate. The client
with anorexia nervosa is most likely experiencing hematological complications, such as
leukopenia.
The nurse is monitoring a hospitalized client who abuses alcohol. Which findings should
alert the nurse to the potential for alcohol withdrawal delirium? - ANS Hypertension,
changes in level of consciousness, hallucinations
alcohol withdrawal delirium symptoms - ANS delirium typically include anxiety,
insomnia, anorexia, hypertension, disorientation, hallucinations, changes in level of
consciousness, agitation, fever, and delusions.
The spouse of a client admitted to the mental health unit for alcohol withdrawal says to
the nurse, "I should get out of this bad situation." Which is the most helpful response by
the nurse? - ANS "What do you find difficult about this situation?"
A client with anorexia nervosa is a member of a predischarge support group. The client
verbalizes that she would like to buy some new clothes, but her finances are limited.
Group members have brought some used clothes to the client to replace the client's old
clothes. The client believes that the new clothes are much too tight and has reduced her
calorie intake to 800 calories daily. How should the nurse evaluate this behavior? - ANS
Evidence of the client's disturbed body image
