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1) client sitting in corner of day room during admission assessment, what nursing action – ask 2

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1) client sitting in corner of day room during admission assessment, what nursing action – ask

2.An older man with a hx of falls at home tells the clinic nurse that his son, who was incarcerated last year for assault and battery, has become abusive since his release from prison. Which intervention is most important for the nurse to implement?

A. Tell the client to call Adult Protective Services if his son's abuse continues.

2. Refer the client to a program for victims of domestic violence
3. Verify the client's report by determining if there is physical evidence of abuse
4. Assist the client in developing an emergency safety plan

 

3.A client with schizophrenia explains that she has 20 children and then very seriously points to the RN and explains that she is one of them. What is the most therapeutic response for the RN to provide/

1. “Let’s go ask another RN is this is true.”
2. “My name tag shows that I am a RN here.”
3. “I can’t possibly be one if your children.”
4. “I know that you don’t have 20 children.”

4.male client admitted depression and self mutilation –

5.male employee says i'm gonna shoot a coworker - find out if he has a weapon Assessing male client with paranoia, which behavior can this client be expected to exhibit –

 

6.A young female client is admitted to the emergency room because she was raped that evening by her date. How should the nurse record the client’s chief complaint in the medical record?

a.) Client reported that she had sexual relations against her will.

b.) Client claims that she was forced to participate in sexual intercourse.

c.) Client has been sexually assaulted.

d.) Client states, “my date raped me tonight.”

7. A client is discussing feelings related to a recent loss with the nurse. The nurse remains silent….. …..

8. A female client with obsessive compulsive disorder complains that she is feels “driven” to check the locks on her front door at…Which response is best for the nurse to provide? a. have you had a bad experience related to unlocked doors?

2. What are your thoughts when you are checking the locks?
3. feelings of being drive to do something are related to anxiety
4. repeating the same behavior helps you to diminish your anxiety

 9. The nurse on the day shift receives report about a client with depression who was in bed most of the weekend. The nurse...the morning and finds the client in bed. What intervention is best for the nurse to implement?

1. explain that staff will check on the client every 30 mins
2. assist the client to get out of bed and involved in an activity
3. monitor the client’s appetite and pattern of sleep
4. assess the client’s feelings about the hospital stay

10.a client is admitted to the mental health unit and reports taking extra antianxiety medication because, “I’m so stressed out. I just…” The nurse should plan one-on-one observation of the client based on which statement?

1. I really think that I don’t need to be here
2. I don’t want to talk. Nothing matters anymore
3. I have been so tired lately and needed to sleep
4. What should I do? Nothing seems to help

11. What is the most important goal for a client with major depression who has been receiving an antidepressant medication for two weeks?

a. ventilate feelings of sadness

2. eats three meals a day
3. participates in group meetings
4. does not attempt to commit suicide

12. A mental health worker is caring for a client with escalating aggressive behavior. Which action by the mental health worker...intervention by the nurse?

a. remains at a distance of 4 feet from the client

2. is attempting to physically restrains the client
3. tells the client to go to the quiet area of the unit
4. is using a loud voice to talk to the client

13. An older male client with schizophrenia is found smearing feces on the bathroom walls of the chronic mental health unit where he resides. What should the nurse implement?

 a. assist the client to clean the walls

2. show the client how to clean the walls
3. escort the client out of the bathroom
4. explain that feces belong in the toilet

14. A young adult female visits the mental health clinic complaining of diarrhea, headache, and muscle aches. She is...laboratory findings are within normal limits. During the physical assessment, the client tells the nurse that her sister...hypochondriac. Which response is best for the nurse to provide?

1. I can hear your sister’s comments are overwhelming you
2. Do you think it is possible that you might be a hypochondriac?
3. unless your sister has a medical education, ignore her comments
4. Besides your sister’s comments, what in your life is troubling you?

15. After meeting with a healthcare provider, a client who is diagnosed with bipolar disorder is screaming and stomping. Which action should the nurse take?

1. instruct the client to reduce the volume of his voice
2. administer a PRN sedative by injection
3. accompany the client to a quiet area of the unit
4. encourage the client to attend a support group

16. A client with depression is not attentive to personal hygiene, uses television watching as a means of escape from...inability to enjoy the things that once gave them pleasure. Which coping strategy should the nurse include in the plan of care?

 A. Relax and reduce the amount of effort to solve the problem

2. Recall methods that were most successful in the past
3. reach out to family and friends about feelings of abandonment
4. turn to other activities to take one’s mind off of the issues