A 22-year-old client is admitted to the psychiatric unit from the
medical unit following a suicide attempt with an overdose of
diazepam. When developing the nursing care plan for this client,
which action would be most important for the nurse to include?
A. Assist client to focus on personal strengths.
B. Set limits on self-defacing comments.
C. Remind the client of daily activities in the milieu.
D. Assist the client to identify why he or she was self-
destructive. Correct Answers A. Assist client to focus on
personal strengths.
Encouraging the client to focus on his or her strengths helps the
client become aware of positive qualities, assists in improving
self-image, and aids in coping with past and present situations.
Although nursing actions should assist the client in decreasing
self-defacing comments and informing the client of daily
activities in the milieu, these interventions are not priorities at
this time. Option D is not as important as assisting the client to
overcome the depression, which resulted in the overdose, and
asking "why" is not therapeutic.
A 24-year-old female presents to the emergency department
with her best friend. She states to the intake nurse, "My husband
forces me to have sex with him 2 to 3 times every day.
Sometimes I tell him I don't want to, but then he gets mean with
me, forces me on my stomach and has anal sex with me." What
are the nurse's next actions? (Select all that apply.)
, A. Tell the client, "Having sex is a marital duty whether you
want to or not."
B. Ask the client, "Why don't you want to have sex that
frequently?"
C. Contact a S.A.N.E. nurse.
D. Assist the client into a private exam room.
E. Insist the best friend not accompany the client. Correct
Answers C. Contact a S.A.N.E. nurse.
D. Assist the client into a private exam room.
Marital sexual abuse occurs when the spouse does not consent to
a sexual act. Asking about the client's intentions toward
nonconsensual sex is nontherapeutic and does not support the
client's chief complaint. SANE nurses are trained in conducting
an examination for sexual abuse victims. The client needs a
quiet, private space. The best friend is the client's support
system and can initially accompany the client to help ease the
transition to the medical environment.
A 25-year-old client has been particularly restless, and the nurse
finds the client trying to leave the psychiatric unit. The client
tells the nurse, "Please let me go! I must leave because the secret
police are after me." What is the nurse's best response?
A. "No one is after you. You're safe here."
B. "You'll feel better after you have rested."
C. "I know you must feel lonely and frightened."
D. "Come with me to your room, and I will sit with you."
Correct Answers D. "Come with me to your room, and I will sit
with you."
,Option D is the best response because it offers support without
judgment or demands. Option A is challenging the client's
delusion. Option B is offering false reassurance. Option C is a
violation of therapeutic communication because the nurse is
telling the client how she or he feels (frightened and lonely),
rather than allowing the client to describe his or her own
feelings. Hallucinating and delusional clients are not capable of
discussing their feelings, particularly when they perceive a
crisis.
A 25-year-old client has suffered extensive burns and is crying
during dressing change treatment. The client tells the nurse,
"Please let me die. Why are you all torturing me like this? I just
want to die." Which response by the nurse is best?
A. "We aren't torturing you. These treatments are necessary to
prevent a terrible infection."
B. "I know these treatments must seem like torture to you, but
we want to help you recover."
C. "You have so much to live for, and all of your family
members want you to live."
D. "Would you like me to call the chaplain so that you can
discuss your feelings privately?" Correct Answers B. "I know
these treatments must seem like torture to you, but we want to
help you recover."
Options B offers an empathetic response without sounding
patronizing. Options A is not empathetic and is actually
somewhat argumentative. The client is not asking for
information as much as pleading for understanding. Option C
appears as scolding and places blame on the client for wanting
to die and possibly hurting the client's family members as a
, result. Option D might be appropriate if the nurse simply asks
the client if a chaplain's visit is desired, but the nurse is
dismissing the client's needs by not addressing them at the
moment.
A 27-year-old client is admitted to the psychiatric hospital with
a diagnosis of bipolar disorder, manic phase. The client is
demanding and active. Which action should the nurse include in
this client's plan of care?
A. Schedule the client to attend various group activities.
B. Reinforce the client's ability to make decisions.
C. Encourage the client to identify feelings of anger.
D. Provide a structured environment with little stimuli. Correct
Answers D. Provide a structured environment with little stimuli.
Clients in the manic phase of a bipolar disorder require
decreased stimuli and a structured environment. Noncompetitive
activities that can be carried out alone should be planned for
these clients. Option A is contraindicated because stimuli should
be reduced as much as possible. Impulsive decision-making is
characteristic of clients with bipolar disorder. To prevent future
complications, the nurse should monitor these clients' decisions
and assist them in the decision-making process. Option C is
more often associated with depression than with bipolar
disorder.
A 33-year-old client is admitted to a psychiatric facility with a
medical diagnosis of major depression. When the nurse is
assigning the client to a room, which roommate is best for this
client?
A. A 35-year-old client who recently attempted suicide
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