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N450 Mental Health Assessment (1)
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N450 Mental Health Assessment (1)
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N450 Mental Health AssessmentWhy is knowing a patient's history vital in promoting the least restrictive environment? - ANS-To
avoid them becoming combative; could push them into illusions from past seclusion experiences
What is the difference between hospitalized and non-hospitalized mental health patients? -
ANS--ability to cope with stressors
-ability to draw upon available resources and weather life's daily stressors
What do you always need in order to place a patient in restraints? - ANS-Doctor's order
Explain the 4 S's
1. Safety
2. Support
3. Structure
4. Symptom management - ANS-1. move others away from patient and position yourself
between patient's and the door
2. therapeutic communication, normal eye contact, remain calm
3. following policies and protocols, routines, set limits on phone time and dress code
4. medications, therapies, calming techniques
Explain the Tarasoff Decision and who does it affect? - ANS-It means that the nurse has a duty
to warn a person if a threat is made against them; effects the intended victim
Countertransference - ANS--redirected feelings and behaviors of a psychotherapist toward a
client
-transference: client directing feeling/attitudes towards psychotherapist
Displacement - ANS-Feelings about one person are directed to another who is less threatening,
thereby satisfying an impulse with a substitute object
ex: coming home and kicking the dog
Conversion - ANS-Putting forth extra effort to achieve in areas where one has real or imagined
deficiency.
Denial - ANS--unconscious failure to recognize an event, thought or feeling
-too painful to recognize
-ex. alcoholic pt
Disassociation - ANS-The blocking off of an anxiety-provoking event or period of time from the
conscious mind
-usually a result from traumatic/stressful events
,Fantasy - ANS-Fixation: Never advancing to the next level of emotional development and
organization; the persistence in later life of interests and behavior patterns appropriate to an
earlier age
Identification - ANS-The unconscious attempt to change oneself to resemble an admired person
ex: a teenage girl dresses and acts like her favorite celebrity
Compensation - ANS-Putting forth extra effort to achieve in areas where one has a real or
imagined deficiency.
Insulation - ANS-Withdrawing into passivity and becoming inaccessible to avoid further
threatening situations
Intellectualization - ANS-Excessive reasoning to avoid feelings
ex: understands in a very informative way the process of alcoholism but still calls in as being ill
Introjection - ANS-A type of identification in which the individual incorporates the traits or values
of another into himself or herself
ex: son talks to people the same way as his dad
Isolation - ANS--completely block out feelings, ideas, or impulse from thought process
ex: oncology nurse completely isolating and separating emotions related to dying client
Passive-aggression - ANS--indirectly expressing aggression towards others
ex: a nurse is reminded 15 times of the staff meeting and to be on time, but intentionally comes
in late
Projection - ANS-Transferring one's internal feelings, thoughts, and unacceptable ideas and
traits to someone else
ex: a patient finds a nurse very attractive, but in turn tells their family that the nurse is extremely
into them
Rationalization - ANS--having an acceptable explanation for unacceptable feelings and
behaviors
ex: a student who did poor on a test blames the instructor for not teaching well
Reaction Formation - ANS-laughing at a funeral; opposite of what you would expect
Regression - ANS-Returning to an earlier developmental stage to express an impulse to deal
with anxiety
Repression - ANS-An unconscious process in which the client blocks undesirable and
unacceptable thoughts from conscious expression
,Sublimation - ANS-Replacement of an unacceptable need, attitude, or emotion with one more
socially acceptable
ex: an extremely self-conscious woman becomes a model
Substitution - ANS-The replacement of a valued unacceptable object with an object that is more
acceptable to the ego
Suppression - ANS-The conscious, deliberate forgetting of unacceptable or painful thoughts,
ideas, and feelings
Symbolization - ANS-The conscious use of an idea or object to represent another actual event
or object; many times the meaning is not clear because the symbol may be representative of
something unconscious
Undoing - ANS-Engaging in behavior that is considered to be opposite of a previous
unacceptable behavior, thought, or feeling
ex: someone thinks about being violent towards someone, but in turn is overly nice to them
The nurse is assigned to care for a client experiencing disturbed thought processes. The nurse
is told that the client believes that the food is being poisoned. Which communication technique
should the nurse plan to use to encourage the client to eat?
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 - ANS-1. Open-ended questions
and silence
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.
The nurse is assigned to care for a client admitted to the hospital after sustaining an injury from
a house fire. The client attempted to save a neighbor involved in the fire, but despite the client's
efforts, the neighbor died. Which action should the nurse take to enable the client to work
through the meaning of the crisis?
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 - ANS-3. Inquiring
about the client's feelings that may affect coping
, 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.
The nurse is assisting with the data collection on a client admitted to the psychiatric unit. After
review of the data obtained, the nurse should identify which as a priority concern?
1. The client's report of not eating or sleeping
2. The presence of bruises on the client's body
3. The client's report of self-destructive thoughts
4. The family member is disapproving of the treatment - ANS-3. The client's report of
self-destructive thoughts
The client's thoughts are extremely important when verbalized. Self-destructive thoughts are the
highest priority. Options 1, 2, and 4 will all affect the treatment of the client but are not of
greatest importance at this time.
Laboratory work is prescribed for a client who has been experiencing delusions. When the
laboratory technician approaches the client to obtain a specimen of the client's blood, the client
begins to shout, "You're all vampires. Let me out of here!" The nurse present at the time should
respond by stating which?
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." - ANS-3. "Are you fearful and
think that others may want to hurt you?"
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.
An intoxicated client is brought to the emergency department by local police. The client is told
that the health care provider (HCP) will be in to see the client in about 30 minutes. The client
becomes very loud and offensive and wants to be seen by the HCP immediately. The nurse
assisting to care for the client should plan for which appropriate nursing intervention?
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. - ANS-3. Offer
to take the client to an examination room until he or she can be treated.
Rationale: Safety of the client, other clients, and staff is of prime concern. 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. When dealing with an impaired individual,
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