psych NCLEX – Flashcards

*1. Constantly neglects personal grooming* 2. Visits her husband's grave once a month 3. Visits the senior citizens' center once a month 4. Frequently looks at snapshots of her husband and family *rationale* Coping mechanisms are behaviors that are used to decreased stress and anxiety. In response to a death, ineffective coping is manifested by an extreme behavior that in some instances may be harmful to the individual, physically, psychologically, or both. Option 1 is indicative of a behavior that identifies an ineffective coping behavior as part of the grieving process. The remaining options identify effective coping behaviors.

1. A 75-year-old man with moderate hypertension 2. A 68-year-old man with newly diagnosed cataracts *3. A 90-year-old woman with advanced Parkinson's disease* 4. A 70-year-old woman with early diagnosed Lyme disease *rationale* Elder abuse is widespread and occurs among all subgroups of the population. It includes physical and psychological abuse, the misuse of property, and the violation of rights. The typical abuse victim is a woman of advanced age with few social contacts and at least one physical or mental impairment that limits her ability to perform activities of daily living. In addition, the client usually lives alone or with the abuser and depends on the abuser for care.

1. Poor hygiene 2. Consistent hunger 3. Bald spots on the scalp *4. Swelling of the genitals* *rationale* The most likely findings among children who have been sexually abused include difficulty walking or sitting; torn, stained, or bloody underclothing; pain, swelling, or itching of the genitals; and bruises, bleeding, or lacerations in the genital or anal area. Poor hygiene and consistent hunger may be indicative of physical neglect. Bald spots on the scalp are most likely associated with physical abuse.

*1. Open-ended questions and silence* 2. Focusing on self-disclosure regarding food preferences 3. Stating the reasons that the client may not want to eat 4. Offering opinions about the necessity of adequate nutrition *rationale* Open-ended questions and silence are strategies used to encourage clients to discuss their problem. Options 3 and 4 do not encourage the client to express feelings. The nurse should not offer opinions and should not state the reasons, but should encourage the client to identify the reasons for the behavior. Option 2 is not a client-centered intervention.

1. Identifying the client's ability to function 2. Identifying the client's potential for self-harm *3. Inquiring about the client's feelings that may affect coping* 4. Inquiring about the client's perception of the cause of the neighbor's death *rationale* The client must first deal with feelings and negative responses before the client is able to work through the meaning of the crisis. Option 3 pertains directly to the client's feelings. Options 1, 2, and 4 do not directly address the client's feelings.

*1. The client's report of suicidal thoughts* 2. The client's report of not eating or sleeping 3. The presence of bruises on the client's body 4. The family member is disapproving of the treatment *rationale* The client's thoughts are extremely important when verbalized. Suicidal thoughts are the highest priority. Options 2, 3, and 4 will all affect the treatment of the client but are not of greatest importance at this time.

1. "The technician will leave and come back later for your blood." 2. "What makes you think that the technician wants to hurt you?" *3. "Are you fearful and think that others may want to hurt you?"* 4. "The technician is not going to hurt you, but is going to help you!" *rationale* Option 3 is the only option that recognizes the client's need. This response helps the client focus on the emotion underlying the delusion but does not argue with it. If the nurse attempts to change the client's mind, the delusion may, in fact, be even more strongly held. Options 1, 2, and 4 do not focus on the client's feelings.

1. Watch the behavior escalate before intervening. 2. Attempt to talk with the client to de-escalate the behavior. *3. Offer to take the client to an examination room until he or she can be treated.* 4. Inform the client that he or she will be asked to leave if the behavior continues. *rationale* Safety of the client, other clients, and staff is of prime concern. When dealing with an impaired individual, trying to talk may be out of the question. Waiting to intervene could cause the client to become even more agitated and a threat to others. Option 4 would only further aggravate an already agitated individual. Option 3 is in effect an isolation technique that allows for separation from others and provides a less stimulating environment, where the client can maintain dignity.

*1. Denial* 2. Projection 3. Regression 4. Rationalization *rationale* Denial is refusal to admit to a painful reality and is treated as if it does not exist. In projection, a person unconsciously rejects emotionally unacceptable features and attributes them to other people, objects, or situations. In regression, the client returns to an earlier, more comforting, although less mature way of behaving. Rationalization is justifying the unacceptable attributes about oneself.

1. "Have you shared your feelings with your family?" 2. "I think we should talk more about your anger with your family." *3. "You're feeling angry that your family continues to hope for you to be 'cured'?"* 4. "Well, it sounds like you're being pretty pessimistic. After all, years ago people died of pneumonia." *rationale* Reflection is the therapeutic communication technique that redirects the client's feelings back to validate what the client is saying. In option 2, the nurse attempts to use focusing, but the attempt to discuss central issues is premature. In option 4, the nurse makes a judgment and is nontherapeutic in the one-on-one relationship. In option 1, the nurse is attempting to assess the client's ability to openly discuss feelings with family members. Although this may be appropriate, the timing is somewhat premature and closes off facilitation of the client's feelings.

1. The client will be angry and will refuse care. *2. The client will participate in the treatment plan.* 3. The client will be very resistant to treatment measures. 4. The client's family will be very resistant to treatment measures. *rationale* Generally, voluntary admission is sought by the client or client's guardian. If the client seeks voluntary admission, the most likely expectation is that the client will participate in the treatment program.

*1. Contact the health care provider (HCP).* 2. Call the client's family. 3. Persuade the client to stay a few more days. 4. Tell the client that discharge is not possible at this time. *rationale* Generally, voluntary admission is sought by the client or client's guardian. Voluntary clients have the right to demand and obtain release. The best nursing action is to contact the HCP.

*1. Presents a harm to self* 2. Requested the admission 3. Consented to the admission 4. Provided written application to the facility for admission *rationale* Involuntary admission is made without the client's consent. Involuntary admission is necessary when a person is a danger to self or others or is in need of psychiatric treatment or physical care. Options 2, 3, and 4 describe the process of voluntary admission.

1. Call the client's family. 2. Place the client in seclusion immediately. 3. Inform the client that seclusion has not been prescribed. *4. Get a written prescription from the health care provider (HCP) and obtain an informed consent.* *rationale* A client may request to be secluded or restrained. Federal laws require the consent of the client, unless an emergency situation exists in which an immediate risk to the client or others can be documented. The use of seclusion and restraint is permitted only on the written prescription of the health care provider (HCP), which must be reviewed and renewed every 24 hours. It must also specify the type of restraint to be used.

1. "No, I won't tell anyone." *2. "I cannot promise to keep a secret."* 3. "If you tell me the secret, I will tell it to your doctor." 4. "If you tell me the secret, I will need to document it in your record." *rationale* The nurse should never promise to keep a secret. Secrets are appropriate in a social relationship, but not in a therapeutic one. The nurse needs to be honest with the client and tell the client that a promise cannot be made to keep the secret.

*1. "I cannot discuss any client situation with you."* 2. "I'm not supposed to discuss this, but since you are my neighbor, I can tell you that she is doing great!" 3. "You may want to know about Carol, so you need to ask her yourself so you can get the story firsthand." 4. "I'm not supposed to discuss this, but since you are my neighbor, I can tell you that she really has some problems!" *rationale* A nurse is required to maintain confidentiality regarding clients and their care. Confidentiality is basic to the therapeutic relationship and is a client's right. Option 3 is correct in a sense; however, it is a rather blunt statement. Both options 2 and 4 identify statements that do not maintain client confidentiality.

1. Plan short-term goals. 2. Identify expected outcomes. *3. Assist in making appropriate referrals.* 4. Assist in developing realistic solutions. *rationale* Tasks of the termination phase include evaluating client performance, evaluating achievement of expected outcomes, evaluating future needs, making appropriate referrals, and dealing with the common behaviors associated with termination. Options 1, 2, and 4 identify the tasks of the working phase of the relationship.

*1. Restating* *2. Listening* 3. Asking the client, "Why?" *4. Maintaining neutral responses* 5. Giving advice or approval or disapproval *6. Providing acknowledgment and feedback* *rationale* Some of the therapeutic communication techniques include listening, maintaining silence, maintaining neutral responses, using broad openings and open-ended questions, focusing and refocusing, restating, clarifying and validating, sharing perceptions, reflecting, providing acknowledgment and feedback, giving information and presenting reality, encouraging formulation of a plan of action, providing nonverbal encouragement, and summarizing.

1. Move the client next to the nurse's station. *2. Use a night light and turn off the television.* 3. Keep the television and a soft light on during the night. 4. Play soft music during the night and maintain a well-lit room. *rationale* It is important to provide a consistent daily routine and a low-stimulation environment when the client is agitated and confused. Noise levels including a radio and television may add to the confusion and disorientation. Moving the client next to the nurses' station is not the initial intervention.

1. "I know you feel 'they are out to get you,' but it's not true." 2. "I can hear the voice and she wants you to come to dinner." *3. "Sometimes people hear things or voices others can't hear."* 4. "I talked to the voices you're hearing and they won't hurt you now." *rationale* It is important for the nurse to reinforce reality with the client. Options 1, 2, and 4 do not reinforce reality but reinforce the hallucination that the voices are real.

1. Poor dietary choices 2. Lack of exercise and poor diet 3. Inadequate dietary intake and dehydration *4. Psychomotor retardation and side effects of medication* *rationale* Constipation can be related to inadequate food intake, lack of exercise, and poor diet. In this situation, urinary retention is most likely caused by medications. Option 4 is the only option that addresses both constipation and urinary retention.

1. "It sounds as though you need to speak to the psychiatrist." 2. "Perhaps you'd like to see the ECT room and speak to the staff." 3. "Your child has decided to have this treatment. You should be supportive of the decision." *4. "It sounds as though you have some concerns about the ECT procedure. Why don't we sit down together and discuss any concerns you may have?"* *rationale* The nurse needs to encourage the family and client to verbalize their fears and concerns. Option 4 is the only option that encourages verbalization. Options 1, 2, and 3 avoid dealing with the client or family concerns.

1. "When children are hurt as you hurt them, people want you isolated." 2. "You're lucky it doesn't escalate into something pretty scary after your crime." *3. "You understand that people fear for their children, but you're feeling unfairly treated?"* 4. "You seem angry, but you have committed serious crimes against several children, so your neighbors are frightened." *rationale* Focusing and verbalizing the implied concern is the therapeutic response because it assists the client to clarify thinking and re-examine what the client is really saying. Option 3 is the only option that reflects the use of this therapeutic communication technique. Option 1 is insensitive and anxiety-provoking. Option 4 does not facilitate the client's expression of feelings. Option 2 gives advice and does not facilitate the client's expression of feelings.

1. "My medications won't make me anxious." 2. "I'll go to a support group and talk so that I won't hurt anyone." 3. "I won't get anxious or hear things if I get enough sleep and eat well." *4. "I can call my therapist when I'm hallucinating so that I can talk about my feelings and plans and not hurt anyone."* *rationale* There may be an increased risk for impulsive and/or aggressive behavior if a client is receiving command hallucinations to harm self or others. Talking about the auditory hallucinations can interfere with the subvocal muscular activity associated with a hallucination. Option 4 is a specific agreement to seek help and evidences self-responsible commitment and control over his or her own behavior.

*1. Provide safety for the client and other clients on the unit.* 2. Provide the clients on the unit with a sense of comfort and safety. 3. Assist the staff in caring for the client in a controlled environment. 4. Offer the client a less-stimulating area to calm down and gain control. *rationale* Safety of the client and other clients is the priority. Option 1 is the only option that addresses the client and other clients' safety needs. Option 4 addresses the client's needs. Option 2 addresses other clients' needs. Option 3 is not client centered.

1. Ask direct questions to encourage talking. 2. Leave the client alone and intermittently check on him. *3. Sit beside the client in silence and verbalize occasional open-ended questions.* 4. Take the client into the dayroom with other clients so they can help watch him. *rationale* Clients with catatonic stupor may be immobile and mute and may require consistent, repeated approaches. The nurse facilitates communication with the client by sitting in silence, asking open-ended questions, and pausing to provide opportunities for the client to respond. The nurse would not leave the client alone. Fortunately, with pharmacotherapy and improved individual management, severe catatonic symptoms rarely occur. Option 4 relies on other clients to care for this one, which is an inappropriate expectation. Asking direct questions of this client is not therapeutic. Option 3 is the best action because it provides for client supervision and communication as appropriate.

1. Restrict the daughter's socializing time with her friends. *2. Restrict the amount of chocolate and caffeine products in the home.* 3. Keep her daughter out of school until she can adjust to the school environment. 4. Consider taking time from work to help her daughter readjust to the home environment. *rationale* Clients with anxiety disorder should abstain from or limit their intake of caffeine, chocolate, and alcohol. These products have the potential of increasing anxiety. Options 1 and 3 are unreasonable and are an unhealthy approach. It may not be realistic for a family member to take time away from work.

*1. Agoraphobia* 2. Hematophobia 3. Claustrophobia 4. Hypochondriasis *rationale* Agoraphobia is a fear of being alone in open or public places where escape might be difficult. Agoraphobia includes experiencing fear or a sense of helplessness or embarrassment if a phobic attack occurs. Avoidance of such situations usually results in the reduction of social and professional interactions. Hematophobia is the fear of blood. Claustrophobia is a fear of closed-in places. Clients with hypochondriacal symptoms focus their anxiety on physical complaints and are preoccupied with their health.

*1. Weight loss* 2. Sleep patterns 3. Medication compliance 4. Onset of the crying spells *rationale* All the options are possible issues to address; however, the weight loss is the first item that needs further data collection because ill-fitting clothing could indicate a problem with nutrition. The client has already told the nurse that the crying spells have been a problem. Medication or sleep patterns are not mentioned or addressed in the question.

1. Psychosis 2. Repression *3. Conversion disorder* 4. Dissociative disorder *rationale* A conversion disorder is the alteration or loss of a physical function that cannot be explained by any known pathophysiological mechanism. It is thought to be an expression of a psychological need or conflict. In this situation, the client witnessed an accident that was so psychologically painful that the client became blind. A dissociative disorder is a disturbance or alteration in the normally integrative functions of identity, memory, or consciousness. Psychosis is a state in which a person's mental capacity to recognize reality, communicate, and relate to others is impaired, thus interfering with the person's capacity to deal with life's demands. Repression is a coping mechanism in which unacceptable feelings are kept out of awareness.

*1. Escort the manic client to his or her room.* 2. Orient the client to time, person, and place. 3. Tell the client that the behavior is not appropriate. 4. Tell the client that smoking privileges are revoked for 24 hours. *rationale* The client is at risk for injury to self and others and therefore should be escorted out of the dayroom. Option 4 may increase the agitation that already exists in this client. Orientation will not halt the behavior. Telling the client that the behavior is not appropriate has already been attempted by the psychiatric nurse's aide.

1. The false belief that one is a very powerful person 2. The false belief that one is a very important person *3. The false belief that one is being singled out for harm by others* 4. The false belief that one's partner is going out with other people *rationale* A delusion is a false belief held to be true even when there is evidence to the contrary. A delusion of persecution is the thought that one is being singled out for harm by others. A delusion of grandeur is the false belief that he or she is a very powerful and important person. A delusion of jealousy is the false belief that one's partner is going out with other people.

*1. Communicate expected behaviors to the client. 2. Ensure that the client knows that he or she is not in charge of the nursing unit.* *3. Assist the client in developing means of setting limits on personal behavior.* *4. Follow through about the consequences of behavior in a nonpunitive manner.* 5. Enforce rules and inform the client that he or she will not be allowed to attend therapy groups. *6. Be clear with the client regarding the consequences of exceeding limits set regarding behavior.* *rationale* Interventions for dealing with the client exhibiting manipulative behavior include setting clear, consistent, and enforceable limits on manipulative behaviors; being clear with the client regarding the consequences of exceeding limits set; following through with the consequences in a nonpunitive manner; and assisting the client in developing means of setting limits on personal behaviors. Enforcing rules and informing the client that he or she will not be allowed to attend therapy groups is a violation of a client's rights. Ensuring that the client knows that he or she is not in charge of the nursing unit is inappropriate; power struggles need to be avoided.

1. Interrupt the client and weigh her immediately. *2. Interrupt the client and offer to take her for a walk.* 3. Allow the client to complete her exercise program. 4. Tell the client that she is not allowed to exercise vigorously. *rationale* Clients with anorexia nervosa are frequently preoccupied with vigorous exercise and push themselves beyond normal limits to work off caloric intake. The nurse must provide for appropriate exercise as well as place limits on vigorous activities. Options 1, 3, and 4 are inappropriate nursing actions.

1. Engaging in immoral acts 2. Always reinforcing self-approval *3. Observing rigid rules and regulations* 4. Having the need to always make the right decision *rationale* Clients with anorexia nervosa have the desire to please others. Their need to be correct or perfect interferes with rational decision-making processes. These clients are moralistic. Rules and rituals help the clients manage their anxiety. Options 1, 2, and 4 are incorrect.

1. Monitor intake and output. 2. Monitor electrolyte levels. *3. Observe for excessive exercise.* 4. Monitor for the use of laxatives and diuretics. *rationale* Excessive exercise is a characteristic of anorexia nervosa, not bulimia nervosa. Frequent vomiting, in addition to laxative and diuretic abuse, may lead to dehydration and electrolyte imbalance. Monitoring for dehydration and electrolyte imbalance are important nursing actions. Option 3 is the only option that is not associated with care of the client with bulimia.

1. Hypotension, ataxia, vomiting 2. Stupor, agitation, muscular rigidity 3. Hypotension, bradycardia, agitation *4. Hypertension, disorientation, hallucinations* *rationale* The symptoms associated with alcohol withdrawal delirium typically are anxiety, insomnia, anorexia, hypertension, disorientation, visual or tactile hallucinations, agitation, fever, and delusions.

1. "Why don't you tell your husband about this?" 2. "This is not the best time to make that decision." *3. "What do you find difficult about this situation?"* 4. "I agree with you. You should get out of this situation." *rationale* The most helpful response is the one that encourages the client to problem solve. Giving advice implies that the nurse knows what is best and can also foster dependency. The nurse should not agree with the client nor should the nurse request that the client provide explanations.

1. "Why did you get started on these drugs?" *2. "How much do you use and what effect does it have on you?"* 3. "How long did you think you could take these drugs without someone finding out?" 4. The nurse does not ask any questions because of fear that the client is in denial and will throw the nurse out of the room. *rationale* Whenever the nurse collects data from a client who is dependent on drugs, it is best for the nurse to attempt to elicit information by being nonjudgmental and direct. Option 1 is incorrect because it is judgmental, off focus, and reflects the nurse's bias. Option 3 is incorrect because it is judgmental, insensitive, and aggressive, which is nontherapeutic. Option 4 is incorrect because it indicates passivity on the nurse's part and uses rationalization to avoid the therapeutic nursing intervention.

1. Al-Anon 2. Fresh Start 3. Families Anonymous *4. Alcoholics Anonymous* *rationale* Alcoholics Anonymous is a major self-help organization for the treatment of alcoholism. Option 1 is a group for families of alcoholics. Option 3 is for parents of children who abuse substances. Option 2 is for nicotine addicts.

1. A client with pneumonia *2. A client receiving diagnostic tests* 3. A client who thrives on managing others 4. A client who could benefit from the client's assistance at mealtime *rationale* The client receiving diagnostic tests is an appropriate roommate. The client with anorexia is most likely experiencing hematological complications, such as leukopenia. Having a roommate with pneumonia would place the client with anorexia nervosa at risk for infection. The client with anorexia nervosa should not be put in a situation in which he or she can focus on the nutritional needs of others or be managed by others, because this may contribute to sublimation and suppression of his or her own hunger.

1. In 7 days 2. In 14 days 3. In 21 days *4. Within a few hours* *rationale* Early signs of alcohol withdrawal develop within a few hours after cessation or reduction of alcohol and peak after 24 to 48 hours.

*1. "I no longer feel that I deserve the beatings my husband inflicts on me."* 2. "My attendance at the meetings has helped me to see that I provoke my husband's violence." 3. "I enjoy attending the meetings because they get me out of the house and away from my husband." 4. "I can tolerate my husband's destructive behaviors now that I know they are common in alcoholics." *rationale* Al-Anon support groups are a protected, supportive opportunity for spouses and significant others to learn what to expect and to obtain suggestions about successful behavioral changes. Option 1 is the healthiest response, because it exemplifies an understanding that the alcoholic partner is responsible for his behavior and cannot be allowed to blame family members for loss of control. The nonalcoholic partner should not feel responsible when the spouse loses control (option 2). Option 4 indicates that the wife remains codependent. Option 3 indicates that the group is being seen as an escape, not a place to work on issues.

1. Normal 2. Regression 3. Indicative of the client's ambivalence *4. Evidence of the client's altered and distorted body image* *rationale* Altered or distorted body image is a concern with clients with anorexia nervosa. Although the client may struggle with ambivalence and present with regressed behavior, the client's coping pattern relates to the basic issue of distorted body image. The client's behavior is not normal.

*1. Call the nursing supervisor.* 2. Call security to block all exit areas. 3. Restrain the client until the health care provider (HCP) can be reached. 4. Tell the client that she cannot return to this hospital again if she leaves now. *rationale* A nurse can be charged with false imprisonment if a client is made to wrongfully believe that he or she cannot leave the hospital. Most health care facilities have documents that the client is asked to sign, which relate to the client's responsibilities when he or she leaves against medical advice (AMA). The client should be asked to sign this document before leaving. The nurse should request that the client wait to speak to the HCP before leaving, but, if the client refuses to do so, the nurse cannot hold the client against his or her will. Restraining the client and calling security to block exits constitutes false imprisonment. Any client has a right to health care (option 4) and cannot be told otherwise.

1. Dental erosion 2. Electrolyte imbalances 3. Enlarged parotid glands *4. Body weight well below ideal range* *rationale* Clients with bulimia nervosa may not initially appear to be physically or emotionally ill. They are often at or slightly below ideal body weight. On further inspection, the client demonstrates enlargement of the parotid glands with dental erosion and caries if he or she has been inducing vomiting. Electrolyte imbalances are present.

1. Dilated pupils, tachycardia, and diaphoresis *2. Yawning, irritability, diaphoresis, cramps, and diarrhea* 3. Tachycardia, hypertension, sweating, and marked tremors 4. Depressed feelings, high drug craving, fatigue, and agitation *rationale* Opioids are central nervous system (CNS) depressants. Withdrawal effects include yawning, insomnia, irritability, rhinorrhea, diaphoresis, cramps, nausea and vomiting, muscle aches, chills, fever, lacrimation, and diarrhea. Withdrawal is treated by methadone tapering or medication detoxification. Option 2 identifies the clinical manifestations associated with withdrawal from opioids. Option 3 describes withdrawal from alcohol. Option 1 describes intoxication from hallucinogens. Option 4 describes withdrawal from cocaine.

*1. Monitor vital signs.* 2. Maintain an NPO status. *3. Provide a safe environment.* *4. Address hallucinations therapeutically.* 5. Provide stimulation in the environment. *6. Provide reality orientation as appropriate.* *rationale* When the client is experiencing withdrawal from alcohol, the priority for care is to prevent the client from harming himself or herself or others. The nurse would provide a low stimulating environment to maintain the client in as calm a state as possible. The nurse would monitor the vital signs closely and report abnormal findings. The nurse would frequently reorient the client to reality and would address hallucinations therapeutically. Adequate nutritional and fluid intake needs to be maintained.

1. "Right! Why not just 'pack it in'?" 2. "That seems rather unlikely to me." 3. "I don't believe that, and neither do you." *4. "You must be feeling all alone at this point."* *rationale* The client is experiencing loss and is feeling hopeless. The therapeutic response by the nurse is the one that attempts to translate words into feelings. In option 2, the nurse is voicing doubt, which is often used when a client verbalizes delusional ideas. In option 3, the nurse is disagreeing with the client, which implies that the nurse has passed judgment on the client's ideas or opinions. In option 1, the nurse uses sarcasm, which gives advice and is nontherapeutic as a nursing response.

1. Facing the client when providing care 2. Ensuring that a security officer is within the immediate area 3. Keeping the door to the client's room open when with the client *4. Assigning the client to a room at the end of the hall to prevent disturbing the other clients* *rationale* The client should be placed in a room near the nurses' station and not at the end of a long, relatively unprotected corridor. The nurse should not isolate himself or herself with a potentially violent client. The door to the client's room should be kept open, and the nurse should never turn away from the client. A security officer or male aide should be within immediate call in case the possibility of violence is suspected.

*1. The client gives away a prized CD and a cherished autographed picture of the performer.* 2. The client runs out of the therapy group swearing at the group leader and then runs to her room. 3. The client gets angry with her roommate when the roommate borrows her clothes without asking. 4. The client becomes angry while speaking on the telephone and slams the receiver down on the hook. *rationale* A depressed, suicidal client often gives away that which is of value as a way of saying "goodbye" and wanting to be remembered. Options 2, 3, and 4 identify acting-out behaviors.

1. Request that a peer remain with the client at all times. 2. Remove the client's clothing and place the client in a hospital gown. *3. Assign a staff member to the client who will remain with him or her at all times.* 4. Admit the client to a seclusion room where all potentially dangerous articles are removed. *rationale* Hanging is a serious suicide attempt. The plan of care must reflect action that will promote the client's safety. Constant observation status (one on one) with a staff member who is never less than an arm's length away is the safest intervention.

1. Administer an antianxiety agent. *2. Examine and treat the wound sites.* 3. Secure and record a detailed history. 4. Encourage and assist the client to vent feelings. *rationale* The initial nursing action is to examine and treat the self-inflicted injuries. Injuries from lacerated wrists can lead to a life-threatening situation. Other interventions may follow after the client has been treated medically.

1. A puzzle *2. Drawing* 3. Checkers 4. Paint by number *rationale* Concentration and memory are poor in a client with severe depression. When a client has a diagnosis of severe depression, the nurse needs to provide activities that require little concentration. Activities that have no right or wrong choices or decisions minimize opportunities for the client to put down himself or herself. The nurse can also process the client's feelings by sitting with the client and talking or encouraging the client to write in a journal.

*1. Feed, bathe, and dress the client as needed until the client can perform these activities independently.* 2. Offer the client choices and consequences to the failure to comply with the expectation of maintaining activities of daily living. 3. Structure the client's day so that adequate time can be devoted to the client's assuming responsibility for the activities of daily living. 4. Have the client's peers confront the client about how the noncompliance in addressing activities of daily living affects the milieu. *rationale* The client with depression may not have the energy or interest to complete activities of daily living. Often, severely depressed clients are unable to perform even the simplest activities of daily living. The nurse assumes this role and completes these tasks with the client. Options 2 and 3 are incorrect because the client lacks the energy and motivation to perform these tasks independently. Option 4 will increase the client's feelings of poor self-esteem and unworthiness.

1. "I will be more careful to make sure that my father's needs are met." 2. "Now that my father is moving into my home, I will need to change my ways." *3. "I feel better able to care for my father now that I know where to obtain assistance."* 4. "I am so sorry and embarrassed that the abusive event occurred. It won't happen again." *rationale* Elder abuse sometimes occurs with family members who are being expected to care for their aging parents. This can cause family members to become overextended, frustrated, or financially depleted. Knowing where in the community to turn for assistance in caring for aging family members can bring much-needed relief. Using these alternatives is a positive alternative coping strategy, which many families use.

*1. One-to-one suicide precautions* 2. Suicide precautions, with 30-minute checks 3. Checking the whereabouts of the client every 15 minutes 4. Asking that the client report suicidal thoughts immediately *rationale* One-to-one suicide precautions are required for the client who has attempted suicide. Options 2 and 3 are not appropriate, considering the situation. Option 4 may be an appropriate nursing intervention, but the priority is stated in option 1. The best option is constant supervision so that the nurse may intervene as needed if the client attempts to cause harm to him or herself.

1. Witnessing a murder *2. The death of a loved one* 3. A fire that destroyed the client's home 4. A recent rape episode experienced by the client *rationale* A situational crisis is associated with a life event. External situations that could precipitate a situational crisis include loss or change of a job, the death of a loved one, abortion, change in financial status, divorce, and severe illness. Options 1, 3, and 4 identify adventitious crises. An adventitious crisis relates to a crisis, disaster, or event that is not a part of everyday life, is unplanned, and is accidental.

1. "With whom do you live?" 2. "Who is available to help you?" *3. "What leads you to seek help now?"* 4. "What do you usually do to feel better?" *rationale* A nurse's initial task when gathering data from a client in crisis is to assess the individual or family and the problem. The more clearly the problem can be defined, the better the chance a solution can be found. Option 3 will assist in determining data related to the precipitating event that led to the crisis. Options 1 and 2 identify situational supports. Option 4 identifies personal coping skills.

1. A crisis state indicates that the individual is suffering from a mental illness. 2. A crisis state indicates that the individual is suffering from an emotional illness. 3. Presenting symptoms in a crisis situation are similar for all individuals experiencing a crisis. *4. A client's response to a crisis is individualized, and what constitutes a crisis for one person may not constitute a crisis for another person.* *rationale* Although each crisis response can be described in similar terms as far as presenting symptoms are concerned, what constitutes a crisis for one person may not constitute a crisis for another person, because each is a unique individual. Being in a crisis state does not mean that the client is suffering from an emotional or mental illness.

1. "You need to stop that behavior now!" 2. "You will need to be placed in seclusion!" *3. "What is causing you to become agitated?"* 4. "You will need to be restrained if you do not change your behavior." *rationale* The best statement is to ask the client what is causing the agitation. This will assist the client to become aware of the behavior and will assist the nurse in planning appropriate interventions for the client. Option 1 is demanding behavior, which could cause increased agitation in the client. Options 2 and 4 are threats to the client and are inappropriate.

1. "Have you talked to your family about this?" 2. "Everyone feels this way when they are depressed." 3. "You will feel better once your medication begins to work." *4. "You sound very upset. Are you thinking of hurting yourself?"* *rationale* Clients who are depressed may be at risk for suicide. It is critical for the nurse to assess suicidal ideation and plan. The client should be directly asked if a plan for self-harm exists. Options 1, 2, and 3 are not therapeutic responses.