129 OBJ: 1 TOP: Crisis Stabilization KEY: Nursing Process Step: Intervention MSC: Client Needs: Psychosocial Integrity 2.. 129 OBJ: 1 TOP: Use of the Inpatient Setting KEY: Nursing Proce
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1 Crisis stabilization provides care to clients in treatment settings with the
purpose of reestablishing homeostasis; it usually lasts for _ days a
crisis This usually is accomplished within 1 to 2 days, and the client is
discharged with follow -up care
DIF: Cogn itive Level: Knowledge REF: p 129 OBJ: 1
TOP: Crisis Stabilization KEY: Nursing Process Step: Intervention
MSC: Client Needs: Psychosocial Integrity
2 Which is an accepted criterion for inpatient admission to a mental health
facility?
a The client likes the security and comfort of the mental health facility
b The client feels that he is no longer able to cope with life stressors or
maintain control of his behavior
c A client ’s behavior becomes unusual
d The client suffers from depression
ANS: B
This situation meets the criteria for an inpatient admission Other criteria
include being a threat to one’s safety or the safety of others and having people who are a part of the client ’s
Trang 2environment who that are not willing or able to support him The other options
do not meet
the criteria
DIF: Cognitive Level: Comprehension REF: p 129 OBJ: 1
TOP: Use of the Inpatient Setting KEY: Nursing Process Step: Planning
MSC: Client Needs: Psychosocial Integrity
3 A male client with a diagnosis of schizophrenia refuses to take his medication because of his
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paranoia that the medication may be poisoned Frequent inpatient readmissions
to the facility occur as a result Which term is given to repeated inpatient admissions? a Milieu
long duration, such as occurs with a chronic illness such as schizophrenia;
and noncompliance
describes a situation in which the client does not follow the prescribed plan of care, often r esulting in recidivism
DIF: Cognitive Level: Comprehension REF: p 130 OBJ: 2
TOP: The Chronically Mentally Ill Population
KEY: Nursing Process Step: Planning MSC: Client Needs: Psychosocial Integrity
4 An adult female inpatient client with a diagnosis of paranoid schizophrenia will not take her medications from the nurse She states, “I know you are
poisoning that medicine.” Which nursing action is most appropriate?
a Promise the client that the staff would not do anything to harm her
b Let the client watch the medication preparation process
c Administer medications to her in unit dose packages so that she can open
the packages herself
d Allow the client to retrieve the medications out of the medication cart with
supervision
ANS: C
Administering medications in unit dose packages would help to prevent the client from thinking that the nurse is poisoning the medications The client would be allowed to open the
packages herself Promising the client that the staff would not harm her will not alleviate her
paranoia Letting the client watch the medication preparation process may help, but
if she feels that the poisoning is happening when the nurse is placing the medication
in the cup, the
Trang 4client will remain paranoid Allowing the client to retrieve medications
from the medication cart would go against facility policy
Trang 5DIF: Cognitive Level: Application REF: p 131 OBJ: 3
TOP: Physiological Needs KEY: Nursing Process Step: Intervention
MSC: Client Needs: Psychosocial Int egrity
5 A male inpatient client who is experiencing depression has no interest in
eating He skips
meals frequently and has been losing weight What is the best nursing action in
this situation?
a Ask the client to “Please eat one meal for me.”
b Leave food with him at mealtime and offer snacks frequently c Give
the client information on the benefits of good nutrition d Remove
client privileges every time he doesn’t eat
ANS: B
Trying not to make an ordeal out of mealtime and food may allow the client to
choose to eat,
especially as his condition improves Asking the client to “please eat one meal”
for the nurse
is bargaining and trying to make the client feel that he owes the nurse Giving the
client information about nutrition is not important to this client; his refusal to eat
is not related to
good or bad nutrition Removing client privileges each time he doesn’t eat goes
against the client ’s rights
DIF: Cognitive Level: Application REF: p 131 OBJ: 3
TOP: Physiological Needs KEY: Nursing Process Step: Intervention
MSC: Client Needs: Psychosocial Integrity
6 Encouragement for clients to practice good hygiene habits not
only meets basic physiological needs, it also meets the hierarchal
need of: a Love and belonging b Safety and security c Infection
control d Self -care
environment and providing measures to keep clients safe; infection control and
self -care are
not actual needs, but the concepts fall into the category of physiological
needs DIF: Cognitive Level: Comprehension REF: p 131 OBJ: 3
TOP: Physiological Needs KEY: Nursing Process Step: Planning
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7 With regard to the environment, it is important for the nurse to be aware of lighting for some
clients Clients with a diagnosis of schizophrenia may be bothered by lights
that are flickering because this may trigger: a
Overstimulation
b Hallucinations
c Aggressive behaviors d Photophobia
ANS: B
The flickering of a light bulb can trigger hallucinations and delusions; therefore, it
is important for the nurse to monitor the physical environment Overstimulation, aggressive behaviors, and photophobia usually occur when light is too bright
DIF: Cognitive Level: Comprehension REF: p 132 OBJ: 3
TOP: Physiological Needs KEY: Nursing Process Step: Intervention
MSC: C lient Needs: Psychosocial Integrity
8 A female client on the mental health unit experiences periods of psychosis at intervals She
often asks what day she came to the facility and what day it is now, and she
seems never to be
aware of the time Which nursing intervention would help this client the most?
a Remind her of the time of day every time she asks
b Assist her to keep a written schedule, including her day of admission,
on a calendar posted in her room and a clock beside the calendar
c Tell her it doesn’t really matter what day she came to the facility; what matters is what day and time it is now
d Instruct the staff to not answer her repetitive questions because she has been told numerous times her day of admission, and there is a clock on the
wall
ANS: B
A written schedule in her room and a clock will assist her in learning to
monitor this information on her own, and this will help to keep her oriented
and will foster independence
Reminding her of the time will not help the client monitor the time on her own; it allows the
ineffective cycle to continue Telling the client that it doesn’t matter when she entered the facility and instructing the staff not to answer her questions are
belittling to the client DIF: Cognitive Level: Applica tion REF: p 133 OBJ:
3
Trang 7TOP: Safety and Security Needs KEY: Nursing Process Step: Intervention MSC: Client Needs: Psychosocial Integrity
9 A 15-year-old female client is noted to often sit alone in the activity room
of the facility while
Trang 8watching television She often begins to join in activities on the unit but then retreats back to her room Which intervention is most appropriate in this situation?
a Encourage her to join in on a group activity and actively participate in the activity with her until she feels more comfortable on her own b Keep
encouraging her to participate in the group activity
c Offer her rewards, such as extended television privileges, for joining in a group activity
d Offer her support as she tries to become more involved in activities ANS: A
Encouraging the client to join the activity and participating with her will offer her security and
will help her to meet others in the group and feel less alone Love and belonging needs are
met by socializing with others Offering encouragement to participate in the group activity
and supporting her as she tries to become more involved are helpful, but these actions do not
give her the same sense of security as she receives with encouragement and p articipation in
the group activity until she is comfortable Offering her rewards defeats the purpose of instilling motivation and the improvement in self-esteem that results from participating according to her own desire DIF: Cognitive Level: Application REF: p 134 OBJ: 6
TOP: Love and Belonging Needs KEY: Nursing Process Step: Intervention MSC: Client Needs: Psychosocial Integrity
10 The nurse can assist a client best in meeting his or her needs for self-esteem and/or self -actualization by:
a Setting rules and regulations
b Allowing the client to set rules and regulations for the inpatient unit
c Informing the client of what the treatment team has decided regarding the plan of care
d Allowing the client to make choices involving his or her care when
Trang 9assists in improving his or her self-esteem Rules and regulations are necessary for limit setting, but the nurse can include the client and improve his or her selfesteem by informing
the client of the rules and regulations, so the client is able to follow them Allowing the
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to set rules is difficult in that the ability for limit setting often is lacking in
clients with mental
health disorders Sharing with the client should reflect a combined effort
between the client and the treatment team
DIF: Cognitive Level: Application REF: p 135 OBJ: 3
TOP: Self -Esteem Needs KEY: Nursing Process Step: Intervention
MSC: Client Needs: Psychosocial Integrity
11 The nurse is aware that during the admission process to a mental
health facility, the anxious client:
a I s acutely aware of his or her surroundings
b Often forgets some of what is said in the unfamiliar
surroundings c Has a keen memory in his or her heightened state
told It is helpful to limit the amount of information thrust on a client during the
early admission process Written information about rules, regulations, and
expectations on the unit
is often helpful The anxious client is not acutely aware of his or her
surroundings and does
not have a keen memory during this time Having no recollection of what the
staff has said is an extreme reaction
DIF: Cogniti ve Level: Comprehension REF: p 135 OBJ: 7
TOP: Admission and Discharge KEY: Nursing Process Step: Planning
MSC: Client Needs: Psychosocial Integrity
12 Bright colors in the environment of the client are often:
these colors promote calm emotions and behavior Dark colors are considered
more depressing Color usually is not associated with eliciting fright
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DIF: Cognitive Level: Comprehension REF: p 132 OBJ: 3
TOP: Physiological Needs KEY: Nursing Process Step: Assessment
MSC: Client Needs: Psychosocial Integrity
13 The nurse should monitor the temperature of the environment of a
client who becomes easily
agitated, with awareness that increased temperatures sometimes may cause the client to become: a Calm
Increased environmental temperatures often cause easily agitated clients to
become more agitated It is important for the nurse to monitor a client’s individual response to his or her environment
DIF: Cognitive Level: Comprehension REF: p 132 OBJ: 3
TOP: Physiological Needs KEY: Nursing Process Step: Assessment
MSC: Client Needs: Psychosocial Integrity
14 A male client is in the process of being admitted to a mental health facility He
is sure that the
nurse is the administrator of the hospital, despite the nurse’s insistence that he is
a staff nurse on the unit This client is experiencing: a Acute confusion b Visual hallucinations c
involves seeing something that is not there, and an auditory hallucination is
hearing something that is not present
DIF: Cognitive Level: Comprehension REF: p 136 OBJ: N/A
TOP: Admission and Discharge KEY: Nursing Process Step: Assessment
MSC: Client Needs: Psychosocial Integrity
Trang 1215 When establishing a client’s level of consciousness, the nurse is aware
that this is determined by assessing the client’s: a Level of awareness
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time c Accuracy in expressing the current month, date, or
DIF: Cognitive Level: Comprehension REF: p 136 OBJ: N/A
TOP: Admission and Dischar ge KEY: Nursing Process Step: Assessment
MSC: Client Needs: Psychosocial Integrity
16 A 16-year-old client is in the lounge with other clients on the inpatient unit when he suddenly
becomes agitated Which action by the nurse would be most appropriate in this situation? a Turn up the volume on the television to distract the client
b Bring him to sit at the nurses’ station while the staff is doing shift report c Keep him in the lounge and attempt to converse with him d
Accompany him to a room where soft music is playing ANS: D
High noise levels can lead to distorted perceptions, altered thinking, and sensory overload
Calm music, the sound of ocean waves, or a light rain can produce relaxation When noise
levels become too intense, clients tend to become distracted and agitated Turning
up the volume on the television, bringing him to a crowded nurses station, and keeping him in the
lounge do not decrease noise levels and may increase his agitation
DIF: Cognitive Level: Comprehension REF: p 132
OBJ: 4 TOP: Therapeutic Environment and Client Needs
KEY: Nursing Process Step: Assessment MSC: Client Needs: Psychosocial Integrity
17 The goal in treating a client with a chronic mental illness is to
prevent recidivism Which factor is crucial in this e ffort?
a Increased use of psychotherapeutic
medications b Increased lengths of stay on the
inpatient unit
c Increased commitment to the plan of care by the client
d Group residential homes with vocational training
ANS: D
One of the most important factors in preventing recidivism is adequate
community resources where clients receive support and educational
and vocational opportunities With the focus on
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in
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homelike, sheltered group settings within the
community DIF: Cognitive Level: Comprehension REF:
p 130 OBJ: 2 TOP: The Chronically Mentally
Ill Population
KEY: Nursing Process Step: Assessment MSC: Client Needs: Psychosocial
Integrity
18 The use of therapeutic touch as a relaxation technique in the mental
health setting is beneficial for clients displaying which symptoms? a
TOP: Safety and Security Needs KEY: Nursing Process Step: Assessment
MSC: Client Needs: Psychosoc ial Integrity
19 A 22-year-old woman is brought to the inpatient unit for attempting
suicide Her clothes are
clean, and her general appearance is neat and well groomed She appears to be well nourished
In considering Maslow’s hierarchy of needs, which is a priority for this
client? a Physiological b Love and belonging c Selfactualization d
Safety and security
ANS: D
The safety and security of the therapeutic environment are the most important factors in mental health care Safety and security needs within the therapeutic environment include the
feeling of physical safety, the security of a limited setting, and the ability to feel secure with
others For clients who are depressed or suicidal, the therapeutic environment offers special
protection from self-harm with the client’s best interest in mind
DIF: Cognitive Level: Comprehension REF: p 133
OBJ: 4