Unit 4: Foundations of Psychiatric Nursing
Questions with Answers 2025
DuringAtheAmentalAstatusAexamination,AaAclientAmayAbeAaskedAtoAexplainAsuchAproverbsA
asA"Don'tAcryAoverAspilledAmilk."ATheApurposeAofAthisAisAtoAevaluateAtheAclient'sAabilityAtoA
think:A-AcorrectAanswers-abstractly.
AbstractAthinkingAisAtheAabilityAtoAconceptualizeAandAinterpretAmeaning.AIt'sAaAhigherAlevelA
ofAintellectualAfunctioningAthanAconcreteAthinking,AinAwhichAtheAclientAexplainsAtheAproverb
AbyAitsAliteralAmeaning.ARationalAthinkingAinvolvesAtheAabilityAtoAthinkAlogically,AmakeAjudg
ments,AandAbeAgoal-directed.ATangentialAthinkingAisAscattered,Anon-goal-
directed,AandAhardAtoAfollow.AClientsAwithAsuchAconditionsAasAorganicAbrainAdiseaseAandAs
chizophreniaAtypicallyAcan'tAconceptualizeAandAcomprehendAabstractAmeaning.ATheyAinter
pretAsuchAstatementsAasA"Don'tAcryAoverAspilledAmilk"AinAaAliteralAsense,AsuchAasA"EvenAifAy
ouAspillAyourAmilk,AyouAshouldn'tAcryAaboutAit."
AAclientAisAcomplainingAtoAotherAclientsAaboutAnotAbeingAallowedAbyAstaffAtoAkeepAfoodAinAth
eAclient'sAroom.AWhatAshouldAtheAnurseAdo?A-AcorrectAanswers-SetAlimitsAonAtheAbehavior.
TheAnurseAneedsAtoAsetAlimitsAonAtheAclient'sAmanipulativeAbehaviorAtoAhelpAtheAclientAcont
rolAdysfunctionalAbehavior.ATheAmanipulativeAclientAbendsArulesAtoAhaveAneedsAmetAwitho
utAregardAforArulesAorAtheAneedsAorArightsAofAothers.AAAconsistentAapproachAbyAtheAstaffAisA
necessaryAtoAdecreaseAmanipulation.AIgnoringAtheAclient'sAbehaviorAreinforcesAorApromot
esAtheAcontinuationAofAtheAclient'sAmanipulativeAbehavior.AReprimandingAtheAclientAmayAb
eAperceivedAasAaAthreat,AresultingAinAaggressiveAbehavior.AAllowingAtheAclientAtoAkeepAaAs
nackAinAtheAclient'sAroomAreinforcesAtheAdysfunctionalAbehavior.
AAnurseAisAcounselingAaAmarriedAwomanAwhoAhasAtwoAchildrenAunderA4AyearsAofAageAandA
isAaAvictimAofAspousalAabuse.ABeforeAtheAclientAleavesAtheAclinic,AwhatAisAtheAmostAimporta
ntAthingAtheAnurseAshouldAdo?A-AcorrectAanswers-HelpAtheAclientAdevelopAaAsafetyAplan.
ItAisAmostAimportantAforAtheAnurseAtoAhelpAtheAclientAdevelopAaAsafetyAplanAbecauseAtheAab
useAwillAoccurAagain,AandAtheAclientAwillAneedAaAplanAtoAseekAaAsafeAenvironmentAforAherse
lfAandAherAchildren.TeachingAaboutAtheAcycleAofAviolenceAisAnotAasAimportantAasAtheAclient'
sAsafetyAandAtheAsafetyAofAherAchildren.DiscussingAtheAabuser'sAbehaviorsAisAnotAasAimpor
tantAasAtheAclient'sAsafetyAandAtheAsafetyAofAherAchildren.GivingAtheAclientAtheAnameAofAaAd
omesticAviolenceAshelterAcanAbeApartAofAtheAsafetyAplan,AbutAtheAnurseAneedsAtoAassureAot
herAsafetyAmeasuresAareAinAplaceAuntilAtheAwomanAisAreadyAtoAleaveAtheAabusiveApartner.
WhichAintervention(s)AshouldAtheAnurseAincludeAinAtheAplanAofAcareAforAaAschool-
ageAchildAwithAanAautismAspectrumAdisorderAwhoAhasAbeenAadmittedAtoAtheAhospital?ASele
ctAallAthatAapply.A-AcorrectAanswers-AllowAaAfamilyAmemberAinAtheAroomA24AhoursAperAday.
LimitAtheAnumberAofAhealthAcareAprovidersAandAnursesAinteractingAwithAtheAchild.
DimAlightsAandAkeepAnoiseAlevelsAlow.
ShowAmedicalAequipmentAtoAtheAchildAbeforeAprocedures.
HaveAfamilyAmemberAbringApossessionsAfromAhome.
,ChildrenAwithAanAautismAspectrumApreferAroutineAandAfamiliarity.AHavingAaAfamilyAmember
AinAtheAroomA24AhoursAaAdayAmayAdecreaseAtheAchild'sAanxiety.ALimitingAtheAnumberAofAdiff
erentAhealthAcareAprovidersAandAnursesAthatAinteractAwithAtheAchildAmayAalsoAhelpAreduceA
anxiety.ADimmingAlightsAandAkeepingAnoiseAlevelsAlowAwillAreduceAsensoryAstimulation.AInt
roducingAaAchildAwithAanAautismAspectrumAdisorderAtoAequipmentApriorAtoAaAprocedureAma
yAhelpAreduceAanxiety.ABringingAinApossessionsAfromAhomeAwillAhelpAwithAroutineAandAfami
liarity.APeopleAwithAanAautismAspectrumAdisorderAoftenAhaveAaAlimitedAabilityAtoAcommunic
ate.AHealthAcareAprovidersAneedAtoAapproachAaAchildAwithAanAautismAspectrumAdisorderAca
refullyAwithAminimalAtouchAandAclearAandAconciseAinstructions;AtheirAinteractionsAshouldAb
eAbrief.
AAnurseAisAassessingAmilitaryApersonnelAwhoAhaveAexperiencedAcombatAandAareAdiagnos
edAwithAposttraumaticAstressAdisorder.AWhichAclientAstatementArequiresAimmediateAinterve
ntion?A-AcorrectAanswers-
IAcannotAstopAtheAnightmares,AevenAtheAextraAoxycodoneApillsAIAtakeAdoAnotAwork.AItAisAnotA
worthAit."
ClientAsafetyAisAtheApriority.AIncreasedAuseAofAopioidsAandAstatingA"itAisAnotAworthAit"AcanAbe
AconsideredAsuicidal.AAAclientAwhoAincreasedAlorazepam AintakeArequiresAfollowAup,AbutAthi
sAclientAisAnotAtheApriority.AIncreasingAbenzodiazepineAwillAcauseAfatigue,AsoAafternoonAna
psAareAexpected.AIncreasingAtheAfrequencyAofAvisitsAtoAaAtherapistAareAencouraged;AthereA
areAnoAimmediateAconcernsAwithAseeingAaAtherapistAmoreAoften.AAvoidingAalcoholAwithApo
sttraumaticAstressAdisorderAisAencouraged;Ahowever,Athere'sAnothingAimmediatelyAconcer
ningAwithAanAadultAhavingAoneAglassAofAwineAwithAsupper.
TheAchargeAnurseAinAanAacuteAcareAsettingAassignsAaAclientAwhoAisAonAone-on-
oneAsuicideAprecautionsAtoAaApsychiatricAaide.AThisAassignmentAisAconsidered:A-
AcorrectAanswers-reasonableAnursingApracticeAbecauseAone-on-
oneArequiresAtheAtotalAattentionAofAaAstaffAmember
AApsychiatricAaideAmayAsitAwithAaAclientAtoAensureAsafety.ATheAnurseAisAstillAresponsibleAfor
AassessingAtheAclientAandAensuringAthatAone-on-
oneAsupervisionAoccurs.AAidesAareAcapableAofAprovidingAone-to-
oneAobservation.AItAisn'tAillegalAtoAdelegateAobservationAtoAanAaide.
DuringAanAassessmentAinterview,AaAdepressedA15-year-
oldAclientAreportsA"IAcan'tAsleepAatAnight."ATheAnurseAbeginsAtoAexploreAfactorsAthatAmightAc
ontributeAtoAthisAsituationAbyAaskingAifAtheAclientAisAsexuallyAactive.ATheAclientAchangesAthe
Asubject.AWhatAshouldAtheAnurseAsuspectAbasedAonAtheAclient'sAresponseAtoAtheAassessm
entAquestion?A-AcorrectAanswers-sexualAabuse
VictimsAofAsexualAabuseAcommonlyArefuseAtoAtalkAaboutAtheAabuseAorAchangeAtheAsubjectA
becauseAtheyAhaveAbeenAthreatenedAbyAtheirAabuser.AAlthoughAthereAmayAbeAotherAexpla
nationsAforAtheAadolescent'sAinabilityAtoAsleepAatAnight,AsuchAasAnoise,Aanxiety,AspiritualAdi
stress,Apain,AorAotherAdisturbances,AadolescentsAareAtypicallyAwillingAtoAdiscussAtheseAfact
orsAasAcontributorsAtoAtheirAinabilityAtoAsleep.AAnAadolescentAwithAnarcolepsyAwouldAexperi
enceAbriefAperiodsAofAdeepAsleepAfollowedAbyAperiodsAofAfeelingArefreshedAandAwouldn'tAc
omplainAofAbeingAunableAtoAsleepAatAnight.
, AAclientAlivesAinAaAgroupAhomeAandAvisitsAtheAcommunityAmentalAhealthAcenterAregularly.A
DuringAoneAvisitAwithAtheAnurse,AtheAclientAstates,A"TheAvoicesAareAtellingAmeAtoAhurtAmysel
fAagain."AWhichAquestionAbyAtheAnurseAisAmostAimportantAtoAask?A-AcorrectAanswers-
AreAyouAgoingAtoAhurtAyourself?"
TheAnurseAneedsAtoAaskAtheAclientAwhetherAheAisAgoingAtoAhurtAhimselfAtoAdetermineAtheAcli
ent'sAabilityAtoAcopeAwithAtheAvoicesAandAtoAassessAtheAclient'sAimpulseAcontrol.ATheAnurse'
sAassessmentAwillAthenAdetermineAtheAcourseAofAactionAtoAtakeAregardingAtheAclient'sAsafet
y.AAskingAwhenAtheAclientAhearsAtheAvoicesAandAhowAlongAtheAclientAhasAheardAthemAisAim
portantAbutAnotAasAimportantAasAdeterminingAwhetherAtheAclientAwillAactAonAwhatAtheAvoice
sAareAsaying.AAsking,A"WhyAareAtheAvoicesAstartingAagain?"AwouldAbeAinappropriateAbecau
seAtheAclientAmayAnotAknowAwhyAandAmayAnotAbeAableAtoAanswerAtheAnurse.
AnAolderAadultAexperiencesAshort-
termAmemoryAproblemsAandAoccasionalAdisorientationAaAfewAweeksAafterAherAhusband'sAd
eath.ASheAalsoAisAnotAsleeping,AhasAurinaryAfrequencyAandAburning,AandAseesAratsAinAtheAk
itchen.ATheAhomeAcareAnurseAcallsAtheAwoman'sAhealthAcareAproviderAtoAdiscussAtheAclient
'sAsituationAandAbackground,Aassess,AandAgiveArecommendations.ATheAnurseAconcludesAt
hatAtheAclientAmostAlikelyAhasAwhichAproblem?A-AcorrectAanswers-
deliriumAandAaAurinaryAtractAinfectionA(UTI)
DeliriumAisAcommonlyAdueAtoAaAmedicalAconditionAsuchAasAaAUTIAinAtheAolderAadult.ADeliriu
mAoftenAinvolvesAmemoryAproblems,Adisorientation,AandAhallucinations.AItAdevelopsArather
Aquickly.AThereAareAnotAenoughAdataAtoAsuggestAAlzheimer'sAdiseaseAespeciallyAgivenAthe
AquickAonsetAofAsymptoms.ADelayedAgrievingAandAadjustingAtoAbeingAaloneAareAunlikelyAtoA
causeAhallucinations.
AAclientAhasAbeenAinvoluntarilyAcommittedAtoAaAhospitalAbecauseAheAhasAbeenAassessedAa
sAbeingAdangerousAtoAselfAorAothers.ATheAclientAhasAlostAwhichAright?A-AcorrectAanswers-
theArightAtoAleaveAtheAhospitalAagainstAmedicalAadvice
AnAinvoluntarilyAadmittedAclientAlosesAtheArightAtoAleaveAtheAhospitalAuntilAtheAconditionAisA
stableAenoughAthatAtheAclientAnoAlongerAposesAaAdangerAtoAselfAorAothers.AWhileAhospitaliz
ed,AtheAclientAretainsAallAcivilArightsAsuchAasAreceivingAmail,AmakingAphoneAcalls,ArefusingAt
reatment,AandAalsoAreceivingAtheAleastArestrictiveAtreatment.AShouldAtheAinvoluntarilyAadm
ittedAclientArefuseAtreatmentAonceAadmitted,AheAwillAbeAevaluatedAforAtheAneedAtoAreceiveAt
reatmentAagainstAwishesAinAorderAtoAdecreaseAtheAriskAforAself-harmAorAharmAtoAothers.
AAclientAwhoAisAsuspiciousAofAothers,AincludingAstaff,AisAbroughtAtoAtheAhospitalAwearingAaA
wrinkledAdressAwithAstainsAonAtheAfront.AAssessmentAalsoArevealsAaAflatAaffect,Aconfusion,A
andAslowAmovements.AWhichAgoalAshouldAtheAnurseAidentifyAasAtheAinitialApriorityAwhenApl
anningAthisAclient'sAcare?A-AcorrectAanswers-helpingAtheAclientAfeelAsafeAandAaccepted
TheAinitialApriorityAforAthisAclientAisAtoAhelpAherAovercomeAsuspiciousnessAofAothers,Aincludi
ngAstaff,AandAtherebyAfeelAsafeAandAaccepted.AIntroducingAtheAclientAtoAothers,AgivingAtheA
clientAinformationAaboutAtheAprogram,AandAprovidingAcleanAclothesAareAimportant,AbutAthes
eAareAofAlowerApriorityAthanAhelpingAtheAclientAfeelAsafeAandAaccepted.
AfterAtalkingAwithAtheAnurse,AaAclientAadmitsAtoAbeingAphysicallyAabusedAbyAherAhusband.A
SheAsaysAthatAsheAhasAneverAcalledAtheApoliceAbecauseAherAhusbandAhasAthreatenedAtoAk
Questions with Answers 2025
DuringAtheAmentalAstatusAexamination,AaAclientAmayAbeAaskedAtoAexplainAsuchAproverbsA
asA"Don'tAcryAoverAspilledAmilk."ATheApurposeAofAthisAisAtoAevaluateAtheAclient'sAabilityAtoA
think:A-AcorrectAanswers-abstractly.
AbstractAthinkingAisAtheAabilityAtoAconceptualizeAandAinterpretAmeaning.AIt'sAaAhigherAlevelA
ofAintellectualAfunctioningAthanAconcreteAthinking,AinAwhichAtheAclientAexplainsAtheAproverb
AbyAitsAliteralAmeaning.ARationalAthinkingAinvolvesAtheAabilityAtoAthinkAlogically,AmakeAjudg
ments,AandAbeAgoal-directed.ATangentialAthinkingAisAscattered,Anon-goal-
directed,AandAhardAtoAfollow.AClientsAwithAsuchAconditionsAasAorganicAbrainAdiseaseAandAs
chizophreniaAtypicallyAcan'tAconceptualizeAandAcomprehendAabstractAmeaning.ATheyAinter
pretAsuchAstatementsAasA"Don'tAcryAoverAspilledAmilk"AinAaAliteralAsense,AsuchAasA"EvenAifAy
ouAspillAyourAmilk,AyouAshouldn'tAcryAaboutAit."
AAclientAisAcomplainingAtoAotherAclientsAaboutAnotAbeingAallowedAbyAstaffAtoAkeepAfoodAinAth
eAclient'sAroom.AWhatAshouldAtheAnurseAdo?A-AcorrectAanswers-SetAlimitsAonAtheAbehavior.
TheAnurseAneedsAtoAsetAlimitsAonAtheAclient'sAmanipulativeAbehaviorAtoAhelpAtheAclientAcont
rolAdysfunctionalAbehavior.ATheAmanipulativeAclientAbendsArulesAtoAhaveAneedsAmetAwitho
utAregardAforArulesAorAtheAneedsAorArightsAofAothers.AAAconsistentAapproachAbyAtheAstaffAisA
necessaryAtoAdecreaseAmanipulation.AIgnoringAtheAclient'sAbehaviorAreinforcesAorApromot
esAtheAcontinuationAofAtheAclient'sAmanipulativeAbehavior.AReprimandingAtheAclientAmayAb
eAperceivedAasAaAthreat,AresultingAinAaggressiveAbehavior.AAllowingAtheAclientAtoAkeepAaAs
nackAinAtheAclient'sAroomAreinforcesAtheAdysfunctionalAbehavior.
AAnurseAisAcounselingAaAmarriedAwomanAwhoAhasAtwoAchildrenAunderA4AyearsAofAageAandA
isAaAvictimAofAspousalAabuse.ABeforeAtheAclientAleavesAtheAclinic,AwhatAisAtheAmostAimporta
ntAthingAtheAnurseAshouldAdo?A-AcorrectAanswers-HelpAtheAclientAdevelopAaAsafetyAplan.
ItAisAmostAimportantAforAtheAnurseAtoAhelpAtheAclientAdevelopAaAsafetyAplanAbecauseAtheAab
useAwillAoccurAagain,AandAtheAclientAwillAneedAaAplanAtoAseekAaAsafeAenvironmentAforAherse
lfAandAherAchildren.TeachingAaboutAtheAcycleAofAviolenceAisAnotAasAimportantAasAtheAclient'
sAsafetyAandAtheAsafetyAofAherAchildren.DiscussingAtheAabuser'sAbehaviorsAisAnotAasAimpor
tantAasAtheAclient'sAsafetyAandAtheAsafetyAofAherAchildren.GivingAtheAclientAtheAnameAofAaAd
omesticAviolenceAshelterAcanAbeApartAofAtheAsafetyAplan,AbutAtheAnurseAneedsAtoAassureAot
herAsafetyAmeasuresAareAinAplaceAuntilAtheAwomanAisAreadyAtoAleaveAtheAabusiveApartner.
WhichAintervention(s)AshouldAtheAnurseAincludeAinAtheAplanAofAcareAforAaAschool-
ageAchildAwithAanAautismAspectrumAdisorderAwhoAhasAbeenAadmittedAtoAtheAhospital?ASele
ctAallAthatAapply.A-AcorrectAanswers-AllowAaAfamilyAmemberAinAtheAroomA24AhoursAperAday.
LimitAtheAnumberAofAhealthAcareAprovidersAandAnursesAinteractingAwithAtheAchild.
DimAlightsAandAkeepAnoiseAlevelsAlow.
ShowAmedicalAequipmentAtoAtheAchildAbeforeAprocedures.
HaveAfamilyAmemberAbringApossessionsAfromAhome.
,ChildrenAwithAanAautismAspectrumApreferAroutineAandAfamiliarity.AHavingAaAfamilyAmember
AinAtheAroomA24AhoursAaAdayAmayAdecreaseAtheAchild'sAanxiety.ALimitingAtheAnumberAofAdiff
erentAhealthAcareAprovidersAandAnursesAthatAinteractAwithAtheAchildAmayAalsoAhelpAreduceA
anxiety.ADimmingAlightsAandAkeepingAnoiseAlevelsAlowAwillAreduceAsensoryAstimulation.AInt
roducingAaAchildAwithAanAautismAspectrumAdisorderAtoAequipmentApriorAtoAaAprocedureAma
yAhelpAreduceAanxiety.ABringingAinApossessionsAfromAhomeAwillAhelpAwithAroutineAandAfami
liarity.APeopleAwithAanAautismAspectrumAdisorderAoftenAhaveAaAlimitedAabilityAtoAcommunic
ate.AHealthAcareAprovidersAneedAtoAapproachAaAchildAwithAanAautismAspectrumAdisorderAca
refullyAwithAminimalAtouchAandAclearAandAconciseAinstructions;AtheirAinteractionsAshouldAb
eAbrief.
AAnurseAisAassessingAmilitaryApersonnelAwhoAhaveAexperiencedAcombatAandAareAdiagnos
edAwithAposttraumaticAstressAdisorder.AWhichAclientAstatementArequiresAimmediateAinterve
ntion?A-AcorrectAanswers-
IAcannotAstopAtheAnightmares,AevenAtheAextraAoxycodoneApillsAIAtakeAdoAnotAwork.AItAisAnotA
worthAit."
ClientAsafetyAisAtheApriority.AIncreasedAuseAofAopioidsAandAstatingA"itAisAnotAworthAit"AcanAbe
AconsideredAsuicidal.AAAclientAwhoAincreasedAlorazepam AintakeArequiresAfollowAup,AbutAthi
sAclientAisAnotAtheApriority.AIncreasingAbenzodiazepineAwillAcauseAfatigue,AsoAafternoonAna
psAareAexpected.AIncreasingAtheAfrequencyAofAvisitsAtoAaAtherapistAareAencouraged;AthereA
areAnoAimmediateAconcernsAwithAseeingAaAtherapistAmoreAoften.AAvoidingAalcoholAwithApo
sttraumaticAstressAdisorderAisAencouraged;Ahowever,Athere'sAnothingAimmediatelyAconcer
ningAwithAanAadultAhavingAoneAglassAofAwineAwithAsupper.
TheAchargeAnurseAinAanAacuteAcareAsettingAassignsAaAclientAwhoAisAonAone-on-
oneAsuicideAprecautionsAtoAaApsychiatricAaide.AThisAassignmentAisAconsidered:A-
AcorrectAanswers-reasonableAnursingApracticeAbecauseAone-on-
oneArequiresAtheAtotalAattentionAofAaAstaffAmember
AApsychiatricAaideAmayAsitAwithAaAclientAtoAensureAsafety.ATheAnurseAisAstillAresponsibleAfor
AassessingAtheAclientAandAensuringAthatAone-on-
oneAsupervisionAoccurs.AAidesAareAcapableAofAprovidingAone-to-
oneAobservation.AItAisn'tAillegalAtoAdelegateAobservationAtoAanAaide.
DuringAanAassessmentAinterview,AaAdepressedA15-year-
oldAclientAreportsA"IAcan'tAsleepAatAnight."ATheAnurseAbeginsAtoAexploreAfactorsAthatAmightAc
ontributeAtoAthisAsituationAbyAaskingAifAtheAclientAisAsexuallyAactive.ATheAclientAchangesAthe
Asubject.AWhatAshouldAtheAnurseAsuspectAbasedAonAtheAclient'sAresponseAtoAtheAassessm
entAquestion?A-AcorrectAanswers-sexualAabuse
VictimsAofAsexualAabuseAcommonlyArefuseAtoAtalkAaboutAtheAabuseAorAchangeAtheAsubjectA
becauseAtheyAhaveAbeenAthreatenedAbyAtheirAabuser.AAlthoughAthereAmayAbeAotherAexpla
nationsAforAtheAadolescent'sAinabilityAtoAsleepAatAnight,AsuchAasAnoise,Aanxiety,AspiritualAdi
stress,Apain,AorAotherAdisturbances,AadolescentsAareAtypicallyAwillingAtoAdiscussAtheseAfact
orsAasAcontributorsAtoAtheirAinabilityAtoAsleep.AAnAadolescentAwithAnarcolepsyAwouldAexperi
enceAbriefAperiodsAofAdeepAsleepAfollowedAbyAperiodsAofAfeelingArefreshedAandAwouldn'tAc
omplainAofAbeingAunableAtoAsleepAatAnight.
, AAclientAlivesAinAaAgroupAhomeAandAvisitsAtheAcommunityAmentalAhealthAcenterAregularly.A
DuringAoneAvisitAwithAtheAnurse,AtheAclientAstates,A"TheAvoicesAareAtellingAmeAtoAhurtAmysel
fAagain."AWhichAquestionAbyAtheAnurseAisAmostAimportantAtoAask?A-AcorrectAanswers-
AreAyouAgoingAtoAhurtAyourself?"
TheAnurseAneedsAtoAaskAtheAclientAwhetherAheAisAgoingAtoAhurtAhimselfAtoAdetermineAtheAcli
ent'sAabilityAtoAcopeAwithAtheAvoicesAandAtoAassessAtheAclient'sAimpulseAcontrol.ATheAnurse'
sAassessmentAwillAthenAdetermineAtheAcourseAofAactionAtoAtakeAregardingAtheAclient'sAsafet
y.AAskingAwhenAtheAclientAhearsAtheAvoicesAandAhowAlongAtheAclientAhasAheardAthemAisAim
portantAbutAnotAasAimportantAasAdeterminingAwhetherAtheAclientAwillAactAonAwhatAtheAvoice
sAareAsaying.AAsking,A"WhyAareAtheAvoicesAstartingAagain?"AwouldAbeAinappropriateAbecau
seAtheAclientAmayAnotAknowAwhyAandAmayAnotAbeAableAtoAanswerAtheAnurse.
AnAolderAadultAexperiencesAshort-
termAmemoryAproblemsAandAoccasionalAdisorientationAaAfewAweeksAafterAherAhusband'sAd
eath.ASheAalsoAisAnotAsleeping,AhasAurinaryAfrequencyAandAburning,AandAseesAratsAinAtheAk
itchen.ATheAhomeAcareAnurseAcallsAtheAwoman'sAhealthAcareAproviderAtoAdiscussAtheAclient
'sAsituationAandAbackground,Aassess,AandAgiveArecommendations.ATheAnurseAconcludesAt
hatAtheAclientAmostAlikelyAhasAwhichAproblem?A-AcorrectAanswers-
deliriumAandAaAurinaryAtractAinfectionA(UTI)
DeliriumAisAcommonlyAdueAtoAaAmedicalAconditionAsuchAasAaAUTIAinAtheAolderAadult.ADeliriu
mAoftenAinvolvesAmemoryAproblems,Adisorientation,AandAhallucinations.AItAdevelopsArather
Aquickly.AThereAareAnotAenoughAdataAtoAsuggestAAlzheimer'sAdiseaseAespeciallyAgivenAthe
AquickAonsetAofAsymptoms.ADelayedAgrievingAandAadjustingAtoAbeingAaloneAareAunlikelyAtoA
causeAhallucinations.
AAclientAhasAbeenAinvoluntarilyAcommittedAtoAaAhospitalAbecauseAheAhasAbeenAassessedAa
sAbeingAdangerousAtoAselfAorAothers.ATheAclientAhasAlostAwhichAright?A-AcorrectAanswers-
theArightAtoAleaveAtheAhospitalAagainstAmedicalAadvice
AnAinvoluntarilyAadmittedAclientAlosesAtheArightAtoAleaveAtheAhospitalAuntilAtheAconditionAisA
stableAenoughAthatAtheAclientAnoAlongerAposesAaAdangerAtoAselfAorAothers.AWhileAhospitaliz
ed,AtheAclientAretainsAallAcivilArightsAsuchAasAreceivingAmail,AmakingAphoneAcalls,ArefusingAt
reatment,AandAalsoAreceivingAtheAleastArestrictiveAtreatment.AShouldAtheAinvoluntarilyAadm
ittedAclientArefuseAtreatmentAonceAadmitted,AheAwillAbeAevaluatedAforAtheAneedAtoAreceiveAt
reatmentAagainstAwishesAinAorderAtoAdecreaseAtheAriskAforAself-harmAorAharmAtoAothers.
AAclientAwhoAisAsuspiciousAofAothers,AincludingAstaff,AisAbroughtAtoAtheAhospitalAwearingAaA
wrinkledAdressAwithAstainsAonAtheAfront.AAssessmentAalsoArevealsAaAflatAaffect,Aconfusion,A
andAslowAmovements.AWhichAgoalAshouldAtheAnurseAidentifyAasAtheAinitialApriorityAwhenApl
anningAthisAclient'sAcare?A-AcorrectAanswers-helpingAtheAclientAfeelAsafeAandAaccepted
TheAinitialApriorityAforAthisAclientAisAtoAhelpAherAovercomeAsuspiciousnessAofAothers,Aincludi
ngAstaff,AandAtherebyAfeelAsafeAandAaccepted.AIntroducingAtheAclientAtoAothers,AgivingAtheA
clientAinformationAaboutAtheAprogram,AandAprovidingAcleanAclothesAareAimportant,AbutAthes
eAareAofAlowerApriorityAthanAhelpingAtheAclientAfeelAsafeAandAaccepted.
AfterAtalkingAwithAtheAnurse,AaAclientAadmitsAtoAbeingAphysicallyAabusedAbyAherAhusband.A
SheAsaysAthatAsheAhasAneverAcalledAtheApoliceAbecauseAherAhusbandAhasAthreatenedAtoAk