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LS2 Nclex comprehensive review- mental health Essay

question

A client with a diagnosis of major depression who has attempted suicide says to the nurse I should have died I’ve always been a failure nothing ever goes right for me which response demonstrates therapeutic communication?
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You been feeling like a failure for a while
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When the community health nurse visits a client at home the client states I haven’t slept at all the last couple of nights which response by the nurse illustrates a therapeutic communication response to this client?
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You’re having difficulty sleeping?
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A client experiencing disturbed thought processes believes that his food is being poisoned. Which communication technique should the nurse use to encourage the client to eat?
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Using open ended questions and silence
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A client admitted to a mental health unit for treatment of psychotic behavior spends hours at the locked exit door shouting. let me out there’s nothing wrong with me I don’t belong here. What defense mechanism is the client implementing?
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Denial
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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?
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You’re feeling angry that your family continues to hope for you to be cured
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On review the clients record the nurse notes that the new admission was voluntary based on this information the nurse anticipates which client behavior?
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A willingness to participate in planning of the care and treatment plan
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The client admitted voluntarily for treatment of an anxiety disorder demands to be released from the hospital. Which action should the nurse take initially?
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Contact the clients health care provider.
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When reviewing the admission assessment the nurse knows 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?
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Monitor closely for harm to self or others.
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The nurse is preparing a client for the termination phase of the nurse client relationship. The nurse prepares to implement which nursing task that is most appropriate for this phase?
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Making appropriate referrals
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The nurse is providing care to a client admitted to the hospital with diagnosis of acute anxiety disorder The client says to the nurse I have a secret that I want to tell you. You won’t tell anyone about it will you? What is most appropriate nursing response?
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I cannot promise to keep a secret
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The nurse employed in a mental health clinic is greeted by a neighbor in a local grocery store. The neighbor says to the nurse how is Carol doing she is my best friend and is seen at your clinic every week. What is the most appropriate nursing response?
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I cannot discuss any client situation with you.
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The nurse call security and has physicals restraint applied when a client who was admitted voluntarily becomes both physically and verbally abusive while demanding to be discharged from the hospital. Which represents the possible legal ramifications for the nurse associated with these interventions?
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battery assault and false imprisonment
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The nurse in the mental health unit recognizes which as being therapeutic communication techniques?
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Restating listening maintaining neutral responses and providing acknowledgment and feedback
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A client being seen in the emergency department immediately after being sexually assaulted appears calm and controlled the nurse analyzes this behavior as indicating which defense mechanism?
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Denial
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A client unresolved feelings related to Loss would be most likely observed during which phase of the therapeutic nursing client relationship?
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Termination
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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?
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Inquiring about and examining the clients feelings for any that may block adaptive coping
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Which statement demonstrates best understanding of the nurses role regarding ensuring that each client rights are respected?
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Being respectful and concerned will ensure that I’m attentive to my clients rights.
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The nurse employed in the mental health unit of the hospital as a leader of a group psychotherapy session what is the nurses role during the termination stage of group development?
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Acknowledging the contributions of each group member
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Which are characteristics of the termination stage of development?
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The group evaluated experience. The group explores members feelings about the group and the impending separation.
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When a client is admitted to an inpatient mental health unit with the diagnosis of anorexia nervosa a cognitive behavioral approach is used as part of the treatment plan the nurse understands that which is the purpose of this approach?
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Helping the client to examine dysfunctional thoughts and beliefs.
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The nurse understands that which best describes to Gestalt therapy?
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It emphasizes self-expression self exploration and self-awareness in the present.
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The client is preparing to attend a gamblers anonymous meeting for the first time the nurse should tell the client that which is the first step in this 12 step program?
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Admitting to having a problem
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What describes the primary focus of milieu therapy?
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A living learning or working environment
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The client is planning to attend overeaters anonymous which statement by the client indicates the need for additional information regarding the self-help group?
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The leader is a nurse or psychiatrist
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What is the most appropriate nursing action to help manage a manic client who is monopolizing a group therapy session?
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Thank the client for the input But inform the client that now others need a chance to contribute
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Which type of THERAPUETIC approach has the characteristics that all team members are seen as equally important in helping clients meet their goals?
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Milieu therapy
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The client says to the nurse the federal guards were sent to kill me what is the best nursing response to the clients concern?
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Do you feel afraid that people are trying to hurt you?
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The client diagnosed with delirium becomes disoriented and confused at night which intervention should the nurse implement initially?
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Use an indirect light source and turn off the television
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The client is admitted to the mental health unit with the diagnosis of depression the nurse should develop plan of care for the client that includes which intervention?
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A structured program of activities in which the client can participate
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When planning to discharge client was chronic anxiety the nurse directs the goals at promoting a safe environment at home which is most appropriate maintenance goal?
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identifying anxiety producing situations
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The client is unwilling to go out of the house for fear of making a fool of myself in public because of this fear the client remains homebound based on this data which mental health disorder is the client experiencing?
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Social phobia
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The nurse is conducting a group therapy session during session client diagnosed w/ mania consistently disrupts the group interactions which intervention should the nurse initially implement?
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Setting limits on the clients behavior
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Client was admitted to medical nursing unit with the diagnosis of acute blindness after being involved in hit-and-run accident and diagnostic testing cannot identify any organic reason why this client cannot see a mental health consult is prescribed. Which condition will be the focus of this consult?
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Conversion disorder
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A manic client begins to make sexual advances towards visitors in the day room. when the nurse finally states that this is inappropriate and will not be allowed the client becomes verbally abusive and threatens physical violence to the nurse based on the analysis of the situation which intervention should the nurse implement?
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Escort the client to their room with the assistance of other staff.
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Which nursing interventions are appropriate for a hospitalized client with mania who is exhibiting manipulative behavior?
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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 non-punitive manner, have the client state the consequences for behaving in ways that are viewed as unacceptable
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The nurse observes that a client is pacing agitated and presenting aggressive gestures the clients speech pattern is rapid and affect is belligerent based on these observations what is the nurses immediate priority care?
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Provide safety for the client and other clients on the unit
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The nurses preparing a client with a history of command hallucinations for discharge by providing instructions on the interventions for managing hallucinations and anxiety which statement in response to these instructions suggest to the nurse that the client understands instructions?
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When I began to hallucinate ill call my therapist and talk about what I should do
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The nurses caring for a client diagnosed with catatonic stupor who is lying in bed in the fetal position what is most appropriate nursing intervention?
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Sit beside the client in silence w/ occasionally open ended questions
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Nurses caring for client who is experiencing disturbed thought processes as a result of paranoia in formulating nursing interventions with the members of the healthcare team what Best instruction should the nurse provide to the staff?
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Avoid laughing or whispering in front of a client
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The nurse is planning activities for client diagnosed w/ bipolar disorder with aggressive social behavior which activity would be most appropriate for this client?
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Writing
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The home Health nurse visit to client home and determined that the client is dependent on drugs during assessment which action should the nurse take to plan appropriate nursing care?
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Ask the client about the amount of drug use and it’s effect
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Which interventions are most appropriate for caring for a client in alcohol withdrawal?
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Monitor vs, Provide safe environment, Address hallucinations therapeutically, provide reality orientation as appropriate
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The nurse determines the wife of an alcoholic is benefiting from attending an AL anon group if the nurse hears the wife making which statement?
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I no longer feel that I deserve the beatings my husband inflicts on me
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Hospitalize client with a history of alcohol abuse tells the nurse I am leaving now have to go I don’t want anymore treatment I have things I have to do right away the client Has not been discharged and is scheduled for an important diagnostic tests to be performed in one hour after the nurse discusses the clients concerns with the client the client dresses begins to walk out of the hospital room what action should the nurse take?
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Call the nursing supervisor
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The nurse is preparing to perform an admission assessment on the client with bulimia nervosa which assessment finding does the nurse expecting to note?
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Dental decay loss of tooth enamel electrolyte imbalances
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The nurses caring for a client who has admitted to mental health unit recently for anorexia Nervosa the nurse enters the clients room and notes that the client is engaged in rigorous push-ups which nursing action is most appropriate?
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Interrupt the client and offer to take her for a walk
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It was diagnosed of anorexia nervosa who Is in a state of starvation is in a two bedroom A newly admitted client will be assigned to the clients room which client should be the best choice as a roommate for the client with anorexia nervosa?
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The client undergoing diagnostic tests
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The nurses monitoring a hospitalize client abuses alcohol which finding should alert the nurse to the potential for alcohol withdrawal delirium?
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Hypertension changes in level of consciousness and hallucinations
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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 what is the most helpful response by the nurse?
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What to do you find difficult about the situation?
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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 finances are limited group members have bought some used clothes to the client to replace the clients old clothes. I believe that the new clothes were much too tight and has reduced her calorie intake to 800 cal daily how’s the nurse evaluate this behavior?
answer

Evidence of the clients disturbed body image