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DETAILED ANSWERS
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Terms in this set (83)
,1. A nurse assesses a client C
at a community mental
health facility using the A.INCORRECT: SAD PERSONS is not a tool to provide
SAD PERSONS tool. The data related to the client's current anxiety level.
nurse knows that this tool B.INCORRECT: SAD PERSONS is not a tool to provide
provides which of the data related to a client's ability to problem solve.
following data related to a C.CORRECT: SAD PERSONS is a tool that provides
client? data related to a client's suicide potential.
A.Current anxiety level D.INCORRECT: SAD PERSONS does not provide data
B.Problem-solving ability related to a client's mood disturbance.
C.Suicide potential NCLEX® Connection: Psychosocial Integrity, Crisis
D.Mood disturbance Intervention
1. A nurse is assisting the C, D, E
parents of a school-age
child who has A.IncOrrEct: The parents should set clear limits on
oppositional defiant unacceptable behavior.
disorder in identifying B.IncOrrEct: The parents should focus on acceptable
strategies to promote behavior and should demonstrate this through
positive behavior. Which modeling.
of the following is an C.CORRECT: The parents should have a method to
appropriate strategy for reward the child for acceptable behavior.
the nurse to recommend? D.CORRECT: The parents should encourage physical
(Select all that apply.) activity through which the child can use energy and
A.Allow the child to obtain success.
choose consequences for E.CORRECT: The parents should set clear limits on
negative behavior. unacceptable behavior and should be consistent.
B.Use role playing to act NCLEX® Connection: Psychosocial Integrity,
out unacceptable Behavioral Interventions
behavior.
C.Develop a reward
system for acceptable
behavior.
D.Encourage the child to
participate in school
sports.
E.Be consistent when a
,1. A nurse manager is A
discussing the care of a
client who has a 1. A. CoRRECT: Rather than establishing a schedule,
personality disorder with a the nurse should ask for the client's input and offer
newly licensed nurse. realistic choices to promote the client's sense of
Which of the following control.
statements by the newly B. inCorrECt: Caring for a client who has a personality
licensed nurse indicates a disorder can evoke an intense emotional response by
need for further teaching? the nurse. Self-assessment assists the nurse to cope
A."I can promote my with these reactions.
client's sense of control by C. inCorrECt: When caring for a client who has a
establishing a schedule." personality disorder, limit-setting is appropriate to
B."Self-assessment will help prevent client manipulation.
help me cope with D. inCorrECt: When caring for a client who has a
emotional reactions to personality disorder, the nurse should always maintain
client care." professional boundaries.
C."I should practice limit- NCLEX® Connection: Psychosocial Integrity,
setting to help prevent Behavioral Interventions
client manipulation."
D."Maintaining
professional boundaries is
a priority of cl
, B
2. A client says, "I plan to
commit suicide." Which of A.INCORRECT: This is an appropriate action by the
the following should be nurse. However, it is not the priority.
the nurse's priority B.CORRECT: The greatest risk to the client is self-harm
assessment? as a result of carrying out a suicide plan. Therefore,
A.Client's educational and the priority assessment is to determine how lethal the
economic background method is, how available the method is, and how
B.Lethality of the method detailed the plan is.
and availability of means C.INCORRECT: This is an appropriate action by the
C.Quality of the client's nurse. However, it is not the priority.
social support D.INCORRECT: This is an appropriate action by the
D.Client's insight into the nurse. However, it is not the priority.
reasons for the decision NCLEX® Connection: Psychosocial Integrity, Crisis
Intervention
2. A nurse is caring for a A
client who has avoidant
personality disorder. A. CoRRECT: Clients who have avoidant personality
Which of the following disorder often have a fear of abandonment. Therefore,
statements is expected this type of statement is expected.
from a client who has this B. inCorrECt: This statement indicates manipulation,
type of personality which is not expected from a client who has
disorder? borderline rather than avoidant personality disorder.
A."I'm scared that you're C. inCorrECt: This statement indicates a need for
going to leave me." admiration, which is expected from a client who has
B. "I'll go to group therapy narcissistic rather than avoidant personality disorder.
if you'll let me smoke." D. inCorrECt: This statement indicates a risk for self-
C."I need to feel that injury, which is expected from a client who has
everyone admires me." borderline rather than avoidant personality disorder.
D."I sometimes feel better NCLEX® Connection: Psychosocial Integrity, Mental
if I cut myself." Health Concepts