Focus on Mental Health Exam Review Solution Graded A+ Questions Passed.

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? - correct answer Presenting the client with the actual situation 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. 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? - correct answer "I know you must be very upset by this, but I don't see a demon." 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. The mother of a 3-year-old says, "My child hit his teddy bear after being scolded for picking the neighbors' flowers." Which defense mechanism was the child using? - correct answer Displacement Rationale: The defense mechanism of displacement involves the discharge of intense feelings for one person onto a less threatening substitute person or object to satisfy an impulse. Projection involves attributing an attitude, behavior, or impulse to someone else, such as that which occurs in blaming or scapegoating. Sublimation is rechanneling an impulse into a more socially acceptable object. Identification involves modeling behavior after someone else's. A client says to the nurse, "Even though my husband and I keep telling them we don't want to have children, our parents are pressuring us to 'start a family.' What should we say to them?" Which of the following responses by the nurse is therapeutic? - correct answer "This must be very difficult for both of you." Rationale: Childless families may elect not to have children or to postpone having them until they have established themselves occupationally or financially. Telling the client to tell the parents that the couple can't have children is incorrect because the client is being encouraged to lie about life decisions rather than helping the parents understand the couple's choices. Asking how they usually cope with such interference is incorrect because it indicates that the nurse is judgmental and has decided that the parents are interfering with the client and spouse. Saying, "Tell them to have more children if they want them so badly," is incorrect because it is sarcastic and ridicules the situation over which the client has expressed concerns. A young adult client says, "I just can't seem to stop snapping at my parents. I know they work hard to support me, but what do I do when they're so overbearing?" Which responses by the nurse is therapeutic? - correct answer "Have you talked to your parents about your frustrations?" Rationale: The correct response is focused on the client's concerns and encourages the therapeutic technique of formulating a plan of action. "It's important not to be rude to your parents" and "You need to be more patient with your parents" are both nontherapeutic, judgmental responses that do not encourage the client to further explore her feelings and problem-solve. "Snapping at your parents is childish. How could you?" is incorrect because it is sarcastic and condescending, which is nontherapeutic. A client says, "I have so much trouble caring for my husband's child from his first marriage. I resent the money we have to pay for child support because we have to deprive my own child of things. How can I stop feeling this way?" Which response by the nurse is therapeutic? - correct answer "Have you shared your feelings with your husband?" Rationale: Remarried individuals often encounter problems as a result of the stressors they bring into a marriage without prior discussion with the new partner. Bonding sometimes does always occur when a child is not one's biological offspring. The correct answer is focused on the client's feelings. "Your child benefits from having a sibling" is not facilitative. "I wonder why you married him, knowing that he wouldn't desert his biological child" is incorrect because it prejudges the client. "You need to take a second job to give your child what you think she deserves" is not open ended, does not facilitate feelings, and gives advice. A client says to the nurse, "My wife retired last year from a lucrative law practice, and I'm really discouraged. I'll be working until I die, even though I helped pay for her education." Which response by the nurse is supportive? - correct answer "You sound very troubled by this." Rationale: Saying that the situation is unfair is judgmental and does not encourage the client to express his feelings; nor does "That's such a tough break for you." Suggesting that the husband approach the spouse for help is incorrect because it prematurely gives advice, a nontherapeutic communication technique. The correct option is focused on the client's feelings. A gay man is brought to the emergency department by the police. The client tells the nurse, "I was beaten up. I guess I just have to expect this kind of treatment for the rest of my life." Which statement by the nurse is therapeutic? - correct answer "You feel that being beaten up goes along with being gay?" Rationale: Many lesbians and gays encounter harassment or violence in the course of their lives. "I think you should take some self-defense classes" is incorrect because it advises the client, and giving advice is not therapeutic. "Maybe you should be more discreet when you're in public" also gives advice and presumes that the client has been indiscreet. "Why not try counseling to change your sexual orientation?" is incorrect because it assumes that sexual orientation can or should be changed. The correct option indicates reflection and is focused on the client's feelings. A client whose spouse recently died is experiencing dysfunctional grieving. Which intervention has priority in the plan of care? - correct answer Assessing the client's risk for violence toward self and others Rationale: The priority intervention for a client with dysfunctional grieving is assessment of the client's risk for violence toward self and others. Although the nurse will assist the client in resolving the grief and monitor the client's sleep pattern, these are not the priority interventions of the options given. Obtaining a prescription for an antidepressant is not a priority. A nurse develops a plan of care for a client in whom AIDS was recently diagnosed. The client is experiencing difficulty adjusting to the illness. Which interventions are appropriate for this client? Select all that apply. - correct answer Assisting the client in verbalizing fears Helping the client identify sources of hope Monitoring the client for signs of self-harm Assisting the client with problem-solving and decision-making Rationale: Assisting the client with problem-solving and decision-making, helping the client verbalize fears, helping the client identify sources of hope, and monitoring the client for signs of self-harm are all appropriate interventions. In planning care for a client having difficulty adjusting to an illness, the nurse develops interventions to promote social networking that will provide needed support and information to the client. An emergency department nurse is caring for an older client who is a victim of physical abuse. List in order of priority the following nursing actions, with number 1 representing the first action and number 4 the last. - correct answer 1. Checking the client for physical injuries 2. Contacting the appropriate state officials to report the abuse 3. Contacting a social worker to assist in planning care for the client 4. Calling a member of the clergy to address the client's spiritual needs Rationale: The priority intervention in the event of physical abuse is to check the client for physical injuries. The nurse should then fulfill the legal obligation of reporting suspected elder abuse. The next action is to contact the social worker to obtain assistance in planning care for the client. The client may need the social worker's help with housing as well. Last, a referral to a member of the clergy is an appropriate intervention if the client desires it. The parents of an 18-month-old arrive at the emergency department with their unconscious child. Physical examination reveals bruises on the child's upper arms that resemble grip marks. Which nursing intervention is the priority? - correct answer Stabilizing the child's physical condition Rationale: In all child abuse cases, the primary concern is the physical condition of the child. Although contacting appropriate state officials to report suspected abuse and securing a safe environment for the child are both interventions that need to be performed, this child is unconscious, so the priority is to stabilize the child's physical condition. Confronting the parents about the abuse at this time may cause resentment and conflict in the parents, and the parents might attempt to leave the emergency department with their child. A nurse in a women's clinic develops a plan of care for abused women. Which tertiary prevention intervention should be included in the plan of care? - correct answer Assisting abused women in overcoming the physical and psychological effects of abuse Rationale: Primary prevention intervention (here, identifying families at risk for abuse and changing societal views toward domestic abuse) is focused on risk identification and health promotion and prevention of disorders. Secondary prevention interventions (early case-finding and decisive intervention) are focused on early identification and treatment of a problem. Tertiary prevention intervention (helping abused women overcome the physical and psychological effects of abuse) is focused on reducing the residual effects of a disorder and rehabilitation. A nurse assists in caring for victims of an explosion at a local industrial plant. The nurse plans to implement crisis interventions, knowing that this incident is characteristic of: - correct answer An adventitious crisis Rationale: Adventitious crises are unpredictable tragedies that occur without warning. An individual may experience crisis, but there is no formal type of crisis known as "individual crisis." A situational crisis occurs when a specific external event disturbs an individual's psychological equilibrium. A maturational crisis involves the normal life transitions that produce changes in individuals and how they perceive themselves, their roles, and their status. A nurse prepares equipment in the electroconvulsive therapy (ECT) suite for a client who will be arriving shortly for therapy. Which items are essential? Select all that apply. - correct answer Pulse oximeter Suction device Ventilation equipment Rationale: In the ECT suite, blood pressure, cardiac, and electroencephalographic monitors are placed on the client to assess vital functions. Whenever ECT is administered, emergency equipment, including oxygen, suction, and ventilation equipment, must also be available. Bath blankets and a thermometer are not essential equipment.