NCLEX Practice Exam for Psychiatric Nursing 3

EXPLANATION

✔Correct answer:

He learns to express his feelings and concerns verbally. The best indicator of successful treatment for a client with a psychosomatic disorder is that he learns to express his feelings and concerns verbally. Psychosomatic disorders, also known as somatic symptom disorders, often involve the expression of psychological distress through physical symptoms. Learning to verbalize emotions and concerns is a crucial step in addressing the underlying psychological issues and reducing the need to express distress through physical symptoms.

When a client can effectively communicate their feelings and concerns, it indicates progress in understanding and managing their emotional health. This skill helps reduce the reliance on somatic complaints as a form of emotional expression, leading to better overall mental and physical well-being.

Imagine a pressure cooker with a faulty release valve. If the valve is fixed, the cooker can release steam safely instead of building up pressure until it causes a problem. Similarly, learning to express emotions verbally allows the client to release emotional "steam" safely, reducing the buildup of psychological distress that manifests as physical symptoms.

In the long-term management of psychosomatic disorders, nurses should focus on teaching clients effective communication and emotional expression skills. This involves providing a supportive environment, offering therapy or counseling, and encouraging the client to explore and verbalize their emotions. Developing these skills can lead to a significant reduction in physical symptoms and improve the client’s quality of life.

✘Incorrect answer options:

His symptoms are substituted with indifference to his emotions. Indifference to emotions is not a healthy outcome and does not indicate successful treatment. It suggests emotional suppression rather than healthy emotional expression and management.

He engages in various recreational activities. While participating in recreational activities can be beneficial for overall well-being, it does not specifically address the core issue of expressing and managing emotions, which is central to psychosomatic disorders.

He acknowledges that his behavior is irrational. Acknowledging that behavior is irrational may be a step toward insight, but it does not necessarily translate into improved emotional expression or management. Effective treatment involves more than just recognizing irrational behavior; it includes developing healthy coping mechanisms and communication skills.

EXPLANATION

✔Correct answer:

Comfort and confidence in her own sexuality. The most fundamental factor Nurse Adams should possess when discussing sensitive topics such as sexuality is comfort and confidence in her own sexuality. This foundational aspect allows her to approach the topic without embarrassment, judgment, or discomfort, creating a safe and open environment for patients to express their concerns. Comfort in one's own sexuality enables the nurse to maintain professionalism and empathy, essential for effective communication and therapeutic intervention.

Imagine trying to help someone swim if you’re uncomfortable in the water yourself. You need to be confident and at ease in the water to provide the best support. Similarly, being comfortable with your own sexuality allows you to better assist patients with their concerns.

When addressing sensitive topics like sexuality, nurses must create a trusting and non-judgmental space. Being comfortable with their own sexuality helps nurses to communicate effectively, ask appropriate questions, and provide relevant information or interventions without bias. This confidence also ensures patients feel respected and understood, which is crucial for effective care.

✘Incorrect answer options:

A thorough understanding of sexuality. While knowledge is important, it is secondary to the nurse’s own comfort and confidence in discussing the topic.

Practical experience in addressing sexual issues with clients. Experience is valuable but cannot substitute for the fundamental comfort and confidence needed to address sensitive topics effectively.

Proficiency in clear and effective communication. Clear communication is crucial, but it is built upon the foundation of the nurse’s comfort and confidence in her own sexuality.

EXPLANATION

✔Correct answer:

Sexual Arousal Disorder. Sexual Arousal Disorder refers to the inability to maintain the physiological responses necessary for sexual intercourse, such as sufficient lubrication in women or an erection in men. This disorder affects the sexual arousal stage of the sexual response cycle, where the body should exhibit physical readiness for sexual activity. Inability to maintain these physiological responses can significantly impact sexual satisfaction and overall well-being.

Think of starting a car engine that runs but then suddenly stalls before you can drive. Sexual Arousal Disorder is like this situation, where the initial response occurs but maintaining the necessary conditions for the activity fails.

Addressing sexual arousal disorders involves a comprehensive assessment to identify underlying causes, which may include physical health issues, psychological factors, or medication side effects. Nurses should provide a non-judgmental space for patients to discuss their concerns and offer appropriate referrals to specialists such as urologists, gynecologists, or sex therapists for further evaluation and treatment.

✘Incorrect answer options:

Sexual Desire Disorder. This disorder involves a lack of interest in or desire for sexual activity, not the inability to maintain physiological responses.

Orgasm Disorder. Orgasm disorders are related to difficulty achieving orgasm despite adequate stimulation and arousal, not maintaining arousal.

Sexual Pain Disorder. Sexual pain disorders, such as dyspareunia or vaginismus, involve pain during intercourse and are not related to maintaining physiological arousal.

EXPLANATION

✔Correct answer:

Place in the semi-Fowler's position and administer O2 inhalation as ordered. The priority of care for a client admitted with bronchial asthma is to ensure adequate oxygenation and respiratory function. Placing the client in a semi-Fowler's position helps improve lung expansion and breathing. Administering oxygen inhalation as ordered is essential to address any hypoxia and support the client’s respiratory needs. Ensuring the client’s immediate physical stability takes precedence over other interventions.

Think of a house fire. The first priority is to put out the fire and ensure everyone's safety before investigating the cause or addressing other concerns. Similarly, ensuring the client's breathing is stabilized is the immediate priority before addressing emotional and psychological aspects.

Once the client’s respiratory status is stable, other interventions can be introduced, such as encouraging verbalization of concerns, engaging in ward activities, and helping the client recognize the emotional component of their physical condition. Providing holistic care that addresses both physical and emotional needs is important, but immediate physical stability is always the first priority.

✘Incorrect answer options:

Encourage verbalization of concerns instead of demonstrating them through the body. While important for long-term management, this is not the immediate priority in an acute asthma situation.

Divert attention to ward activities. Diversion techniques can be helpful for emotional support, but addressing the acute respiratory needs is more critical initially.

Help him recognize that his physical condition has an emotional component. This is an important aspect of comprehensive care but should be addressed after stabilizing the client's respiratory condition.

EXPLANATION

✔Correct answer:

Low self-esteem related to failure in role performance. The statement, "I can't even take care of my baby. I'm good for nothing," indicates feelings of worthlessness and inadequacy, which are key indicators of low self-esteem. This nursing diagnosis is appropriate because the client is expressing a negative self-assessment and attributing this to perceived failures in her role as a mother.

Low self-esteem can significantly impact a person's mental health and ability to function, especially after a traumatic event such as losing a child. The feelings of failure and worthlessness suggest that the client is struggling with her self-worth and may need interventions aimed at rebuilding her self-esteem and addressing her negative self-perceptions.

Think of self-esteem like a mirror reflecting one's self-worth. If the mirror is cracked by trauma or loss, the reflection is distorted, making the person see themselves as broken or worthless. Rebuilding self-esteem involves repairing the mirror to see a true reflection of one's worth and abilities.

Interventions should focus on providing emotional support, validating the client’s feelings, and helping her recognize her strengths and positive qualities. Encouraging participation in support groups, therapy, and activities that promote self-worth can also be beneficial. Developing a therapeutic relationship where the client feels heard and understood is crucial for addressing low self-esteem.

✘Incorrect answer options:

Ineffective individual coping related to loss. While the client may be experiencing ineffective coping due to the loss of her child, the specific statement provided focuses more on her feelings of worthlessness and inadequacy, which align more closely with low self-esteem.

Impaired verbal communication related to inadequate social skills. The client’s statement does not indicate issues with verbal communication or social skills. The primary issue is her negative self-assessment and feelings of worthlessness.

Impaired social interaction related to repressed anger. There is no indication in the client’s statement that she is experiencing impaired social interaction or repressed anger. The focus is on her self-perceived failure and worthlessness.

EXPLANATION

✔Correct answer:

It involves the desire to live as or engage in activities of the opposite sex. Gender identity disorder, now more commonly referred to as gender dysphoria, involves a strong and persistent identification with a gender different from one’s assigned sex at birth. Individuals with gender dysphoria experience significant distress and discomfort due to a mismatch between their gender identity and their physical or assigned gender. This condition is characterized by the desire to live as or engage in activities typically associated with the opposite sex.

Think of it like wearing shoes that are the wrong size every day. The discomfort and distress from the mismatch would be constant, and you would long for shoes that fit correctly. Similarly, individuals with gender dysphoria feel a constant mismatch between their physical gender and their true gender identity.

When working with clients with gender dysphoria, it is important for nurses to provide a supportive and non-judgmental environment. This includes using the client's preferred pronouns, respecting their gender identity, and offering resources for counseling and support groups. Education about gender dysphoria and its treatment options, including hormone therapy and surgical interventions, can also be beneficial.

✘Incorrect answer options:

It involves deriving sexual pleasure from inanimate objects. This describes fetishistic disorder, which involves a sexual focus on non-living objects or specific non-genital body parts.

It involves finding pleasure in being humiliated and suffering. This describes masochistic disorder, which involves deriving sexual pleasure from experiencing pain or humiliation.

It involves the thrill of shocking others by exposing one's genitalia. This describes exhibitionistic disorder, which involves exposing one’s genitals to an unsuspecting person for sexual arousal.

EXPLANATION

✔Correct answer:

Hold the next dose and obtain an order for a stat serum lithium level. Diarrhea and vomiting are potential signs of lithium toxicity. Lithium has a narrow therapeutic range, and symptoms of toxicity can develop if the blood levels become too high. Holding the next dose and obtaining a stat serum lithium level is essential to determine the client's current lithium levels and prevent further complications. Early detection and management of lithium toxicity are crucial to prevent serious adverse effects, including renal damage, neurological impairments, and cardiovascular issues.

Think of lithium levels like the fuel gauge in a car. If the gauge shows the tank is too full, you need to stop adding fuel to avoid spilling and causing damage. Similarly, stopping the lithium dose and checking the blood level prevents "spillage" of toxicity.

Nurses should be vigilant for signs of lithium toxicity, especially gastrointestinal symptoms like diarrhea and vomiting. Immediate action, including holding the medication and obtaining a serum lithium level, is crucial. Nurses should educate clients on the importance of reporting any new or worsening symptoms and the need for regular monitoring of lithium levels.

✘Incorrect answer options:

Recognize this as a drug interaction. While drug interactions can occur, the primary concern with diarrhea and vomiting in a client on lithium is potential toxicity. Recognizing this as a drug interaction without further assessment could delay appropriate intervention.

Administer Cogentin to the client. Cogentin (benztropine) is used to treat extrapyramidal symptoms caused by antipsychotics, not lithium toxicity. Administering this medication would not address the underlying issue and could lead to further complications.

Reassure the client that these are common side effects of lithium therapy. Although gastrointestinal side effects can occur with lithium, persistent or severe symptoms like diarrhea and vomiting warrant immediate evaluation for toxicity. Reassuring the client without further investigation could result in serious harm.

EXPLANATION

✔Correct answer:

Establishing relationships with the opposite sex and career planning. The relevant developmental focus for a 15-year-old male is establishing relationships with the opposite sex and career planning. According to Erikson's stages of psychosocial development, adolescents (ages 12-18) are in the stage of "Identity vs. Role Confusion." During this period, they explore different roles, relationships, and career options to develop a sense of identity. The significant changes in their lives, such as a parent leaving for work abroad, can impact their emotional and social development.

Think of adolescence like planting seeds in a garden. This stage is about exploring different "seeds" (interests, relationships, career options) to see what grows best. Major changes, like a parent leaving, can affect how these seeds grow and develop.

Nurses should provide support by encouraging healthy peer relationships and discussing future aspirations and goals. Addressing the emotional impact of the mother's departure is also crucial to help the adolescent process their feelings and maintain their developmental trajectory.

✘Incorrect answer options:

Parental and societal responsibilities. This developmental focus is more relevant for middle adulthood, where individuals are concerned with generativity vs. stagnation (ages 40-65), focusing on contributing to society and helping the next generation.

Establishing one's sense of competence in school. This focus is relevant for school-aged children (ages 6-12), in the stage of "Industry vs. Inferiority," where children work on developing competence through school and social interactions.

Developing initial commitments and collaboration in work. This focus pertains to young adulthood (ages 18-40), in the stage of "Intimacy vs. Isolation," where individuals form intimate relationships and commit to work and personal goals.

EXPLANATION

✔Correct answer:

"You seem to have concerns about going home." This response is the most therapeutic because it acknowledges Mr. Johnson's feelings and opens the door for him to express his concerns. It shows empathy and invites him to share more about what is troubling him. This approach helps in understanding his worries and provides an opportunity to address them effectively, ensuring a smoother transition from hospital to home.

Imagine a friend looks upset, and you say, "You seem upset. Do you want to talk about it?" This shows you care and are ready to listen, which can help them feel supported and open up about their feelings.

Active listening and empathetic communication are crucial when addressing a patient's emotional needs. By recognizing and validating Mr. Johnson's concerns, Nurse Patel can better support him through his discharge process. This may involve discussing his worries, providing resources, or coordinating follow-up care to ensure he feels supported after leaving the hospital.

✘Incorrect answer options:

"You are much better than when you were admitted, so there’s no reason to worry." This response dismisses Mr. Johnson's feelings and does not encourage him to express his concerns. It may make him feel misunderstood or unsupported.

"What would you like to do now that you’re about to go home?" This question shifts the focus away from his current feelings of sadness and concern, potentially missing the opportunity to address his immediate emotional needs.

"Aren’t you glad that you’re going home soon?" This response assumes a positive feeling about discharge and may invalidate his current emotional state, making him feel pressured to agree rather than expressing his true concerns.

EXPLANATION

✔Correct answer:

“It must really be frustrating for you. How can I best help you?”  This response acknowledges Pamela's feelings of frustration and offers support, showing empathy and a willingness to assist her in coping with her emotions. Validating her feelings and asking how the nurse can help opens the door for Pamela to express her needs and preferences, fostering a therapeutic nurse-client relationship. This approach aligns with patient-centered care, emphasizing respect, empathy, and active listening.

Imagine if someone is overwhelmed with a heavy workload. Telling them, "It must be really overwhelming for you. How can I help?" acknowledges their struggle and offers practical support, making them feel understood and less alone.

Nurses should employ active listening, validate clients' feelings, and provide emotional support. Asking open-ended questions like “How can I best help you?” encourages clients to express their needs and participate in their care, which can empower them and enhance their coping mechanisms.

✘Incorrect answer options:

“I will refer you to a clergy who can help you understand what is happening to you.” While involving a clergy may be helpful, it is not the most immediate or therapeutic response. Pamela needs emotional validation and support from the nurse at this moment.

“It isn’t fair that an innocent like you will suffer from AIDS.” This response, although sympathetic, reinforces a sense of injustice and victimization, which may not be helpful in coping with her diagnosis.

“That is a negative attitude.” This response invalidates Pamela's feelings and may make her feel judged or misunderstood, which is counterproductive to building a therapeutic relationship.

EXPLANATION

✔Correct answer:

Anger. Pamela's reaction, expressing frustration and questioning "Why me?" and "How could God do this to me?", is indicative of the anger stage of grief. In this stage, individuals often feel intense emotions and may direct their anger at themselves, others, or even a higher power. This reaction is a normal part of the grieving process and represents an individual's struggle to understand and make sense of their loss or diagnosis.

Imagine you are stuck in a traffic jam that makes you late for an important event. You might find yourself angrily questioning why this is happening to you and feeling frustrated at the situation, even though it's beyond your control. Similarly, in the anger stage of grief, individuals express frustration and anger about their situation.

When dealing with clients in the anger stage of grief, nurses should provide a supportive presence, actively listen, and acknowledge the client's feelings. It is important to offer empathy and validate their emotions without judgment. Encouraging clients to express their anger in healthy ways, such as through talking, journaling, or engaging in physical activities, can be beneficial.

✘Incorrect answer options:

Depression. Depression in grief is characterized by feelings of deep sadness, hopelessness, and withdrawal. While Pamela may experience depression later, her current expressions of frustration and questioning suggest she is in the anger stage.

Denial. Denial involves refusing to accept the reality of the situation. Statements like "This can't be happening to me" or acting as if the loss or diagnosis did not occur are common in denial. Pamela's acknowledgment of her diagnosis and questioning why it happened to her indicates she has moved beyond denial.

Bargaining. Bargaining often involves making deals or promises in an attempt to change the outcome. Phrases like "If only I had..." or "I will do anything to change this" are typical of the bargaining stage. Pamela's expressions do not reflect attempts to bargain but rather show her anger and frustration.

EXPLANATION

✔Correct answer:

Zyprexa. Zyprexa (olanzapine) is an atypical antipsychotic medication primarily used to treat conditions like schizophrenia and bipolar disorder. It is less likely to be prescribed for a client experiencing depression following the loss of a child, as it is not a first-line treatment for depression or grief-related issues unless there are co-occurring symptoms of psychosis or severe mood instability that require an antipsychotic.

For a client presenting with depressive symptoms, medications more commonly prescribed include selective serotonin reuptake inhibitors (SSRIs) like Prozac (fluoxetine), tricyclic antidepressants (TCAs) like Tofranil (imipramine), and monoamine oxidase inhibitors (MAOIs) like Parnate (tranylcypromine). These medications target the symptoms of depression more directly and are standard treatments for major depressive disorder.

Imagine needing a specific tool to fix a problem—using an antipsychotic like Zyprexa for depression is like using a wrench when you really need a screwdriver. It might be useful in some situations, but it’s not the right tool for this particular job.

When caring for a patient with depression, it is important for nurses to understand the rationale behind medication choices and to monitor the patient for effectiveness and side effects. Education about the medications, their intended effects, and potential side effects is crucial for supporting the patient in their treatment plan.

✘Incorrect answer options:

Prozac. Prozac (fluoxetine) is an SSRI commonly prescribed for depression. It is likely to be considered for a client with depressive symptoms following a significant loss.

Tofranil. Tofranil (imipramine) is a tricyclic antidepressant that can be prescribed for depression. Although it is not as commonly used as SSRIs due to its side effect profile, it is still a relevant option for treating depression.

Parnate. Parnate (tranylcypromine) is an MAOI used to treat depression, particularly in cases where other treatments have not been effective. It is a less common choice due to dietary restrictions and potential interactions but is still a recognized treatment for depression.

EXPLANATION

✔Correct answer:

Sexual Arousal. The sexual response cycle comprises several stages, and during the sexual arousal stage, sexual interest and physiological responses continue to build. This phase is characterized by increased blood flow to the genitalia, elevated heart rate, and heightened sensitivity. It prepares the body for potential sexual activity and is marked by sustained sexual excitement and anticipation.

Imagine climbing a hill where each step you take increases your excitement and anticipation of reaching the top. The arousal stage is like this climb, with each moment building more interest and physiological readiness.

When educating patients about the sexual response cycle, it's important for nurses to explain each stage clearly and address any concerns or misconceptions. Providing a safe space for patients to discuss their sexual health promotes understanding and helps them feel more comfortable with their own sexual experiences and responses.

✘Incorrect answer options:

Sexual Desire. The sexual desire stage involves the initial feelings of interest and attraction, but the buildup of sexual interest and physiological changes become more pronounced during the arousal stage.

Climax. The climax, or orgasm stage, is the peak of sexual pleasure and involves the release of sexual tension built up during the arousal stage. It is not characterized by a continued buildup of interest but rather the culmination of it.

Resolution. The resolution stage follows climax and is when the body returns to its normal physiological state. Sexual interest typically diminishes during this stage as the body relaxes and recovers from the sexual response.

EXPLANATION

✔Correct answer:

"I only need your arm exposed to take your blood pressure. Just the sleeve is fine." This response is the most appropriate and therapeutic because it sets a clear boundary while maintaining professionalism. It addresses the client's flirtatious comment by redirecting the focus back to the medical procedure in a calm and assertive manner. This approach helps to de-escalate the situation, reinforces the nurse's professional role, and minimizes the risk of further inappropriate behavior.

Imagine a teacher asking a student to take out their book for a lesson, and the student responds with a joke about skipping class. The teacher calmly responds, "Just take out your book, please," redirecting the student's focus to the task at hand and maintaining authority in a respectful way.

When handling inappropriate behavior, it is crucial for nurses to maintain clear boundaries, demonstrate professionalism, and avoid engaging in any way that could be misconstrued. Providing clear instructions and staying focused on the medical task helps to uphold the therapeutic relationship and ensures a respectful and safe environment for both the nurse and the client.

✘Incorrect answer options:

“You’re attractive but I’m not interested.” This response is inappropriate and unprofessional. It could be misinterpreted and does not effectively set boundaries.

“You wouldn’t be the first that I will see naked.” This response is unprofessional and could escalate the situation or be taken as encouragement.

“I will report you to the guard if you don’t control yourself.” This response is confrontational and may escalate the situation rather than de-escalate it. It also does not provide a professional and therapeutic approach to handling inappropriate behavior.

EXPLANATION

✔Correct answer:

Dependent. The personality type most relevant to this scenario is "Dependent." The client’s asthma exacerbation following the news of his mother's departure suggests a reaction tied to feelings of insecurity and reliance on his mother. Dependent personality traits often manifest as difficulty in making decisions without reassurance, needing others to take care of them, and experiencing discomfort when alone. The significant change in his life—his mother leaving—could trigger stress and exacerbate his physical condition, reflecting his dependency on her for emotional and possibly practical support.

Think of a young tree that has always grown in the shelter of a larger tree, relying on it for protection and support. When the larger tree is suddenly removed, the young tree struggles to stand on its own and withstand the elements, showing signs of stress and vulnerability. Similarly, the 15-year-old boy relies heavily on his mother for emotional support and stability. Her departure to the U.K. leaves him feeling exposed and stressed, leading to an exacerbation of his asthma, much like the young tree struggling without its protective counterpart.

In managing a client with dependent traits, it's important to provide support and reassurance while also encouraging independence. Nurses can help the client develop coping strategies and build confidence in handling situations on their own. Engaging the client in activities that promote self-reliance and offering consistent emotional support can be beneficial.

✘Incorrect answer options:

Conforming. A conforming personality is characterized by a strong desire to fit in and adhere to social norms and expectations. While this could contribute to stress, it is not as directly related to the client's situation as dependency is.

Perfectionist. Perfectionist traits involve a constant striving for flawlessness and setting high standards, often leading to stress and anxiety. However, this does not directly relate to the client’s reaction to his mother leaving.

Masochistic. Masochistic personality traits involve deriving satisfaction from self-sacrifice or enduring hardship. This does not align with the client's reaction to his mother's departure and the resulting stress exacerbating his asthma.

EXPLANATION

✔Correct answer:

Cleaning. For a manic client exhibiting demanding, arrogant, fast-talking, and hyperactive behavior, an activity that involves physical movement and can be done without requiring significant concentration or fine motor skills is most appropriate. Cleaning is an ideal activity because it allows the client to expend excess energy in a structured way. It provides an outlet for physical activity and can help in channeling hyperactivity productively.

Manic clients often have high energy levels and difficulty focusing on complex tasks. Activities like cleaning are repetitive, simple, and do not require sustained attention or fine motor coordination, making them suitable for individuals in a manic state. Additionally, cleaning can provide a sense of accomplishment and order, which can be calming.

Think of a hyperactive dog needing to burn off energy. A long walk or play session is more suitable than a training session that requires focus and obedience. Similarly, cleaning allows the manic client to use their energy without requiring intense concentration.

When planning activities for a manic client, it is important to choose those that are safe, do not require intricate skills, and help manage hyperactivity. Providing a calm and structured environment, offering consistent limits, and using positive reinforcement can also help in managing manic behavior.

✘Incorrect answer options:

Table tennis. While table tennis involves physical activity, it also requires quick reflexes, coordination, and focus. This might be too stimulating and challenging for a manic client, potentially leading to frustration or escalation of symptoms.

Painting. Painting requires fine motor skills and concentration, which may be difficult for a manic client to maintain. It is better suited for clients who are in a more stable state.

Chess. Chess is a highly cognitive game requiring strategy, focus, and concentration. It is not suitable for a manic client who is experiencing hyperactivity and difficulty focusing.

EXPLANATION

✔Correct answer:

“I haven’t been able to open the door and go into my baby’s room.” The statement, “I haven’t been able to open the door and go into my baby’s room,” supports the diagnosis of dysfunctional grieving. This indicates that the woman is avoiding reminders of her loss, which is a common symptom of dysfunctional or complicated grief. Avoidance behaviors suggest that she is struggling to process her grief and move forward, which is interfering with her ability to function in daily life.

Dysfunctional grieving involves a prolonged and intense response to loss that impairs the individual’s ability to return to normal functioning. This can include avoiding places, people, or activities associated with the deceased, experiencing severe emotional distress, and being unable to engage in normal life activities. The inability to enter the baby's room signifies that the woman is stuck in her grieving process and unable to confront her loss.

Think of grief as a river that one needs to cross. In normal grieving, a person gradually finds ways to navigate the river, even if it's difficult. In dysfunctional grieving, the person is unable to take the first step into the water, stuck on the shore, avoiding the crossing entirely.

For patients experiencing dysfunctional grieving, nurses should provide empathetic support, encourage the expression of feelings, and facilitate connections with grief counseling or support groups. Creating a safe space for the patient to discuss their emotions and providing resources for professional mental health support can help them process their grief more effectively.

✘Incorrect answer options:

“I feel envious of mothers who have toddlers.” Envy of other mothers is a common emotion in the grieving process and does not necessarily indicate dysfunctional grieving. It reflects normal feelings of loss and longing.

“I watch other toddlers and think about their play activities and I cry.” Crying when thinking about other toddlers and their activities is a typical response in the grieving process. It indicates that the woman is still processing her emotions but does not by itself indicate dysfunctional grieving.

“I often find myself thinking of how I could have prevented the death.” Thinking about ways to have prevented the death is a common part of grief, involving feelings of guilt and regret. While this can be distressing, it is a normal part of the grieving process and not necessarily indicative of dysfunctional grieving.

EXPLANATION

✔Correct answer:

Suicidal ideation. When a client asks a nurse to pray for them and entrusts their wedding ring, it may signal suicidal ideation. These actions can be indicative of the client preparing for the end of their life, as entrusting a valuable and sentimental item like a wedding ring can be a sign of saying goodbye or settling affairs. Additionally, the request for prayer often reflects a sense of finality and seeking solace in what they perceive as their last moments.

Imagine if a person suddenly starts giving away their prized possessions and saying farewell to friends and family. These actions might suggest that they are planning to go on a long journey, one they might not return from. Similarly, a client giving away a cherished item and asking for prayer can indicate thoughts of suicide.

Nurses should take any indication of suicidal ideation seriously. Immediate actions include conducting a thorough risk assessment, ensuring the client is in a safe environment, and communicating with the healthcare team to provide appropriate interventions. Establishing a therapeutic rapport, actively listening, and offering support are crucial steps in addressing the client's emotional needs and preventing self-harm.

✘Incorrect answer options:

Anxiety. Anxiety might lead to behaviors such as seeking reassurance or expressing worry, but it typically does not involve giving away valuable personal items or making final requests.

Severe depression. While severe depression can be linked to suicidal thoughts, the specific behaviors of entrusting a wedding ring and asking for prayer are more directly indicative of suicidal ideation.

Hopelessness. Hopelessness is often a component of suicidal ideation, but on its own, it does not explain the specific actions of giving away a wedding ring and asking for prayer, which are more directly associated with preparing for suicide.

EXPLANATION

✔Correct answer:

Take a directive role in helping the client verbalize feelings. Taking a directive role in helping the client verbalize their feelings is a proactive and therapeutic approach to managing escalating anger. This technique involves the nurse guiding the client to express their emotions verbally, which can help de-escalate the situation and prevent violent behavior. It demonstrates respect for the client's rights by acknowledging their feelings and providing them with a safe way to express themselves. This approach also promotes the development of healthy communication skills and emotional regulation.

Imagine a pot of boiling water. If you leave the lid on, the pressure builds up until it spills over. But if you lift the lid and let the steam escape, the water stays contained and calm. Similarly, helping a client verbalize their feelings allows the "steam" of anger to escape, preventing an explosive outburst.

When dealing with escalating anger, nurses should employ techniques such as active listening, providing a calm and non-threatening presence, and encouraging the client to talk about their feelings. These interventions help in de-escalating anger while ensuring the client's rights are respected. It's essential to create an environment where clients feel heard and supported, reducing the likelihood of aggression.

✘Incorrect answer options:

Use a strict, confrontational approach. A confrontational approach can exacerbate the client's anger and lead to increased aggression. It does not respect the client's rights or promote a therapeutic environment.

Place the client in a seclusion room. Seclusion should be a last resort used only when the client poses an immediate danger to themselves or others. Using seclusion without attempting less restrictive interventions first violates the client's rights and can escalate the situation.

Apply mechanical restraints. Mechanical restraints are also a last-resort measure and should only be used when all other de-escalation techniques have failed. Immediate use of restraints without trying less restrictive measures first does not respect the client's rights and can be traumatic.

EXPLANATION

✔Correct answer:

Agree on a consistent approach among the staff assigned to the client. Consistency in the approach among staff members is crucial when managing clients who display manipulative or arrogant behaviors. Such clients often attempt to create divisions among the staff to gain control or get their needs met inappropriately. By ensuring that all staff members use a consistent approach, the team can prevent manipulation and maintain a therapeutic environment. Consistent responses and boundaries help the client understand acceptable behaviors and the consequences of their actions, promoting a sense of stability and security.

Imagine a classroom where every teacher enforces different rules. This inconsistency would confuse students, and they might try to exploit the differences to avoid doing their work. However, if all teachers follow the same rules and enforce them consistently, students know what to expect and are less likely to try manipulative behaviors.

When dealing with manipulative clients, nurses should collaborate to establish and maintain consistent limits and rules. Regular team meetings can help ensure everyone is on the same page. This consistency not only prevents manipulation but also helps the client feel more secure and understood, which is essential for their therapeutic progress. Clear communication among staff and with the client about expectations and consequences is key to managing such behaviors effectively.

✘Incorrect answer options:

Suggest that the client take a leading role in the social activities. While involving clients in social activities can be beneficial, suggesting a leading role to a manipulative client may reinforce their controlling behaviors and could lead to further manipulation of peers and staff.

Provide the client with extra time for one-on-one sessions. Extra one-on-one sessions could be interpreted by the client as special treatment, potentially reinforcing their manipulative behavior rather than addressing it.

Allow the client to negotiate the plan of care. Allowing a manipulative client to negotiate their care plan can lead to inappropriate demands and undermine the therapeutic structure needed to manage their behavior effectively.

EXPLANATION

✔Correct answer:

Remove all items that could be used for self-harm from the client’s room. The immediate priority when caring for a suicidal client is ensuring their safety. Removing all items that could be used for self-harm from the client’s room minimizes the risk of the client attempting suicide or inflicting harm on themselves. This is a crucial first step in creating a safe environment for the client, which allows other therapeutic interventions to be implemented effectively.

Imagine trying to keep a toddler safe in a room full of sharp objects and dangerous items. The first step would be to remove those hazards to ensure the child cannot hurt themselves. Similarly, removing potential self-harm items is essential to protect a suicidal client.

After ensuring the client's environment is safe, other therapeutic interventions can be introduced, such as encouraging the client to express their feelings, acknowledging their strengths, and establishing a therapeutic rapport. Continuous monitoring and assessment of the client's mental state are also critical to provide ongoing support and adjust the care plan as needed.

✘Incorrect answer options:

Encourage the client to express feelings of hopelessness. While important, this should follow the immediate safety measures. Encouraging expression of feelings is valuable but secondary to ensuring the client's physical safety.

Acknowledge the client’s strengths to boost self-esteem. This is a beneficial intervention for long-term support but not the immediate priority in an acute suicidal crisis.

Establish a “no suicide” contract with the client. While a "no suicide" contract can be part of the care plan, its effectiveness is debated, and it should not be relied upon as the primary safety measure. Physical safety measures take precedence.

EXPLANATION

✔Correct answer:

A living, learning, or working environment. A therapeutic milieu refers to a structured environment that promotes healing, personal growth, and development. It encompasses the physical, social, and emotional aspects of the environment where clients live, learn, and work. The goal of a therapeutic milieu is to create a safe, supportive space where clients can practice new skills, engage in meaningful activities, and receive feedback from peers and staff. This holistic approach helps clients develop adaptive behaviors and enhances their overall well-being.

Think of a therapeutic milieu like a well-maintained garden where different plants (clients) receive the right amount of sunlight, water, and care (supportive environment) to grow and thrive. The gardener (nurse) ensures that the garden provides the necessary conditions for each plant to reach its full potential.

In a therapeutic milieu, nurses play a crucial role in fostering a positive environment by encouraging participation in group activities, facilitating open communication, and providing consistent, structured care. This approach helps clients feel valued and understood, promoting recovery and personal growth.

✘Incorrect answer options:

A therapy that rewards adaptive behavior. This describes behavior modification techniques, such as token economies, but does not encompass the full concept of a therapeutic milieu.

A cognitive approach to change behavior. This refers to cognitive-behavioral therapy (CBT), which focuses on changing thought patterns to influence behavior, but it is not the same as a therapeutic milieu.

A permissive and congenial environment. While a therapeutic milieu should be supportive and nurturing, it also requires structure and clear boundaries, not just permissiveness.

EXPLANATION

✔Correct answer:

Establish realistic limits on the client's behavior. The initial plan for managing a manic client should include establishing realistic limits on the client's behavior. This approach helps to create a structured and safe environment, which is crucial for a patient exhibiting manic behaviors such as being demanding, arrogant, fast-talking, and hyperactive. Setting clear and consistent boundaries can help manage the client’s behavior and prevent potential harm to themselves or others.

Manic patients often exhibit impulsivity, poor judgment, and a lack of awareness of the consequences of their actions. Establishing limits helps to contain their behavior within safe and acceptable boundaries, providing a sense of stability and control. This intervention also aids in minimizing the disruption to other patients and staff in the unit.

Think of managing a manic patient like setting boundaries for a child who is highly energetic and impulsive. Clear and consistent rules help the child understand what is acceptable behavior and create a sense of security and order.

Along with setting limits, it is important for Nurse Kelly to ensure the safety of the patient by monitoring for signs of escalating behavior, providing a low-stimulation environment, and administering medications as prescribed to manage symptoms of mania. Engaging the patient in structured activities and providing opportunities for physical activity can also help in channeling their excess energy constructively.

✘Incorrect answer options:

Repeat verbal instructions as frequently as needed. While repeating instructions can be helpful, it is not as critical as setting limits. Manic patients may have difficulty focusing, and frequent repetition alone may not be effective without clear behavioral boundaries.

Encourage the client to express feelings to relieve tension. Encouraging expression of feelings is important, but for a manic patient, it is more crucial initially to establish limits to manage disruptive behaviors. Emotional expression can be facilitated once the patient is more stable.

Assign a staff member to stay with the client at all times for maintaining control. Continuous one-on-one supervision may be necessary in some cases, but it is not the first line of intervention. Establishing limits and boundaries is a more foundational step to manage the behavior of a manic client effectively.

EXPLANATION

✔Correct answer:

Giving broad opening .The communication technique Nurse Taylor uses is giving a broad opening. By asking, “What are you thinking about?” she is inviting the client to share their thoughts and feelings without directing the conversation in a specific direction. This technique encourages the client to take the lead in discussing their concerns, which can help them feel more in control and open up about their emotions. It is particularly useful in building rapport and trust in the nurse-client relationship.

Imagine you walk into a room and someone says, “Tell me about your day.” This open-ended question allows you to start the conversation wherever you feel most comfortable, making it easier to share your experiences and feelings.

Using broad openings helps create a supportive environment where clients feel heard and understood. It is essential for nurses to employ this technique to encourage clients to express their thoughts and feelings, facilitating better understanding and effective intervention.

✘Incorrect answer options:

Focusing. Focusing involves directing the conversation to a specific topic or issue. Nurse Taylor’s question is open-ended and does not narrow down the subject, so it does not fit this technique.

Validating. Validating involves affirming the client’s feelings or experiences, showing acceptance and understanding. Nurse Taylor's question does not provide affirmation but rather invites the client to share more.

Reflecting. Reflecting involves mirroring the client's feelings or statements to show understanding and encourage further discussion. Nurse Taylor's question is not a reflection of the client’s words or feelings but an invitation to elaborate.

EXPLANATION

✔Correct answer:

Monitor respiratory status. The highest priority in the post-ECT (electroconvulsive therapy) care phase is to monitor the patient's respiratory status. ECT involves the use of anesthesia and muscle relaxants, which can affect respiratory function. Ensuring that the patient's airway is clear and that they are breathing adequately is crucial immediately following the procedure. Compromised respiratory function can lead to life-threatening complications, making it the top priority.

While other aspects of post-ECT care, such as observing for confusion, reorienting the patient, and documenting their response to treatment, are important, maintaining a patent airway and monitoring respiratory status take precedence to ensure the patient's safety.

Think of monitoring respiratory status like ensuring a lifeline is secure for a diver emerging from deep waters. Before checking their orientation or condition, you must first ensure they are breathing properly, as it is vital for their survival.

After ECT, nurses should continuously assess the patient's airway, breathing, and oxygen saturation levels. They should be prepared to provide interventions such as oxygen therapy or airway management if needed. Once the patient's respiratory status is stable, the nurse can then focus on reorientation, monitoring for confusion, and documenting the patient's response to the treatment.

✘Incorrect answer options:

Observe for confusion. While important, confusion is a common side effect of ECT and typically resolves with time. It is not as immediately life-threatening as respiratory issues.

Reorient to time, place, and person. Reorientation is an essential part of post-ECT care but is secondary to ensuring the patient's respiratory status is stable.

Document the client’s response to the treatment. Documentation is crucial for ongoing care and assessment but is not the highest immediate priority compared to monitoring and ensuring adequate respiratory function.