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Mental Health Nursing II: Exam 2 Unit 5-7

Terms in this set (76)

A client is diagnosed with terminal cancer. Which situation represents Kübler-Ross's grief stage of "anger"?
1.
The client registers for an Ironman marathon to be held in 9 months.
2.
The client is a devout Catholic but refuses to attend church and states that his faith has failed him.
3.
The client promises God to give up smoking if allowed to live long enough to witness a grandchild's birth.
4.
The client gathers family in order to plan a funeral and make last wishes known.
2

The nurse should assess that the client is in the "anger" stage of grieving when the client refuses to attend church and states that his faith has failed him. Anger is the second stage of Kübler-Ross's grief process, in which the reality of the situation is realized, and the individual has feelings of sadness, guilt, shame, helplessness, and hopelessness.
A nurse is caring for an Irish client who has recently lost his wife. The client tells the nurse that he is planning an elaborate wake and funeral. According to George Engel, what purpose would these rituals serve?
1.
To delay the recovery process initiated by the loss of the client's wife
2.
To facilitate the acceptance of the loss of the client's wife
3.
To avoid dealing with grief associated with the loss of the client's wife
4.
To eliminate emotional pain related to the loss of the client's wife
2

The nurse should anticipate that the purpose of these rituals is to facilitate the acceptance of the loss of the client's wife. Resolution of the loss is the fourth stage in Engel's grief process, in which the bereaved experiences a preoccupation with the loss, which gradually decreases over time.
A nurse discharges a female client to home after delivering a stillborn infant. The client finds that neighbors have dismantled the nursery that she and her husband planned. According to Worden, how could this intervention affect the woman's grieving task completion?
1.
This intervention may hamper the woman from continuing a relationship with her infant.
2.
This intervention would help the woman forget the sorrow and move on with life.
3.
This intervention communicates full support from her neighbors.
4.
This intervention would motivate the woman to look to the future and not the past.
1

The nurse should anticipate that this intervention could hinder the woman from continuing a relationship with her infant. The first task in Worden's grief process is to accept the reality of the loss. It is common for individuals to refuse to believe that the loss has occurred.
A teenager has recently lost a parent. Which grieving behavior should a school nurse expect when assessing this client?
1.
Denial of personal mortality
2.
Preoccupation with the loss
3.
Clinging behaviors and personal insecurity
4.
Acting-out behaviors, exhibited in aggression and defiance
4

The school nurse should anticipate that the teenager will exhibit aggression and acting out. Adolescents have the ability to understand death on an adult level yet have difficulty tolerating the intense feelings associated with the death of a loved one. It is often easier for adolescents to talk with peers about feelings than with other adults.
What term should a nurse use when assessing a response to grieving that includes a sudden physical collapse and paralysis, and which cultural group would be associated with this behavior?
1.
"Falling out" in the African American culture
2.
"Body rocking" in the Vietnamese American culture
3.
"Conversion disorder" in the Jewish American culture
4.
"Spirit possession" in the Native American culture
1

The nurse should use the term falling out to describe a sudden physical collapse and paralysis in the African American culture. The individuals may also experience an inability to see or speak yet maintain hearing and understanding.
Which grieving behaviors should a nurse anticipate when caring for a Navajo client who recently lost a child?
1.
Celebrating the life of a deceased person with festivities and revelry
2.
Not expressing grief openly and reluctance to touch the dead body
3.
Holding a prayerful vigil for a week following the person's death
4.
Expressing grief openly and publicly and erecting an altar in the home to honor the dead
2

The nurse should identify that a Navajo client who recently lost a child would not express grief openly and would be reluctant to touch the dead body. Navajo Indians do not bury the body of a deceased person for four days after death, and they conduct a cleaning ceremony prior to burial. The dead are buried with their shoes on the wrong feet and rings on their index fingers.
A nursing instructor is teaching about the typical grieving behaviors of Chinese Americans. Which student statement would indicate that more instruction is necessary?
1.
"In this culture, the color red is associated with death and is considered bad luck."
2.
"In this culture, there is an innate fear of death."
3.
"In this culture, emotions are not expressed openly."
4.
"In this culture, death and bereavement are centered on ancestor worship."
1
The nursing instructor should evaluate that more instruction is needed if a student states that the color red is associated with death and bad luck in the Chinese culture. Chinese Americans consider the color white as associated with death and is considered bad luck. Red is the ultimate color of luck in this culture.
A nurse assigns a client the nursing diagnosis of complicated grieving. According to Bowlby, which long-term outcome would be most appropriate for this nursing diagnosis?
1.
The client will accomplish the recovery stage of grief by year one.
2.
The client will accomplish the acceptance stage of grief by year one.
3.
The client will accomplish the reorganization stage of grief by year one.
4.
The client will accomplish the emotional relocation stage of grief by year one.
3

The nurse should identify that, according to Bowlby, an appropriate long-term outcome for this client is to accomplish the reorganization stage of grief by year one. Until the client can recognize and accept personal feelings regarding the loss, grief work cannot progress.
A nurse assesses a woman whose husband died 13 months ago. She isolates herself, screams at her deceased spouse, and is increasingly restless. According to Bowlby, this widow is in which stage of the grieving process?
1.
Stage I: Numbness or protest
2.
Stage II: Disequilibrium
3.
Stage III: Disorganization and despair
4.
Stage IV: Reorganization
3

The nurse should identify that this client is in the third stage of Bowlby's grief process, called disorganization and despair. This stage is characterized by feelings of despair in response to the realization that the loss has occurred. The individual experiences helplessness, fear, and hopelessness. Perceptions of visualizing or being in the presence of the lost one may occur.
Which is the most accurate description of the nursing diagnosis of dysfunctional grieving?
1.
Inability to form a valid appraisal of a loss and to use available resources
2.
The experience of distress, with accompanying sadness, which fails to follow norms
3.
A perceived lack of control over a current loss situation
4.
Aloneness perceived as imposed by others and as a negative or threatening state
2

The nurse should define dysfunctional grieving as the experience of distress, with accompanying sadness, which fails to follow norms.
A nurse is leading a bereavement group. Which of following members of the group should the nurse identify as being at high risk for complicated grieving? (Select all that apply.)
1.
A widower who has recently experienced the death of two good friends
2.
A man whose wife died suddenly after a cerebrovascular accident
3.
A widow who removed life support after her husband was in a vegetative state for a year
4.
A woman who had a competitive relationship with her recently deceased brother
5.
A young couple whose child recently died of a genetic disorder
1, 2, 4, 5

The nurse should identify that individuals are at a high risk for complicated grieving when the individual experienced a number of recent losses, when the bereaved person was strongly dependent on the lost entity, the relationship with the lost entity was highly ambivalent, the loss is that of a young person.
An instructor is teaching nursing students about Worden's grief process. According to Worden, which of the following client behaviors would delay or prolong the grieving process? (Select all that apply.)
1.
Refusing to allow oneself to think painful thoughts
2.
Indulging in the pain of loss
3.
Using alcohol and drugs
4.
Idealizing the object of loss
5.
Recognizing that time will heal
1, 3, 4

The nurse should identify that refusing to allow oneself to think painful thoughts, using alcohol and drugs, and idealizing the object of loss will delay or prolong the grieving process
Which of the following types of care should the interdisciplinary team of hospice provide? (Select all that apply.)
1.
Physical care available on a 24/7 basis
2.
Counseling on the addictive properties of pain-management medications
3.
Discussions related to death and dying
4.
Explorations of new aggressive treatments
5.
Assistance with obtaining spiritual support and guidance
1, 3, 5

The nurse should identify that the interdisciplinary team of hospice provides physical care available on a 24/7 basis, that the interdisciplinary team of hospice provides discussions related to death and dying, and the interdisciplinary team of hospice provides assistance with obtaining spiritual support and guidance.
Order the stages of normal grief, according to John Bowlby.
________ Reorganization
________ Disequilibrium
________ Disorganization and despair
________ Numbness/protest
4, 2, 3, 1

John Bowlby hypothesized four stages in the grief process. He implies that these behaviors can be observed in all individuals who have experienced the loss of something or someone of value, even in babies as young as 6 months of age.
1. Numbness/protest
2. Disequilibrium
3. Disorganization and despair
4. Reorganization
Order the stages of normal grief, according to J. William Worden.
________ Finding an enduring connection with the lost entity in the mist of embarking on a new life
________ Accepting the reality of the loss
________ Adjusting to a world without the lost entity
________ Processing the pain of grief
4, 1, 3, 2

Worden views the bereaved person as active and self-determining rather than a passive participant in the grief process. He proposes that bereavement includes a set of tasks that must be reconciled in order to complete the grief process.
1. Accepting the reality of the loss
2. Processing the pain of grief
3. Adjusting to a world without the lost entity
4. Finding an enduring connection with the lost entity in the mist of embarking on a new life
______________________ grieving is the experiencing of the feelings and emotions associated with the normal grief response before the loss actually occurs.
anticipatory

Anticipatory grieving is the experiencing of the feelings and emotions associated with the normal grief response before the loss actually occurs. Anticipatory grieving may serve as a defense for some individuals to ease the burden of loss when it actually occurs.
A kindergarten student is frequently violent toward other children. A school nurse notices bruises and burns on the child's face and arms. What other symptom should indicate to the nurse that the child may have been physically abused?
1.
The child shrinks at the approach of adults.
2.
The child begs or steals food or money.
3.
The child is frequently absent from school.
4.
The child is delayed in physical and emotional development.
1
The nurse should determine that a child who shrinks at the approach of adults in addition to having bruises and burns may be a victim of abuse. Maltreatment is considered, whether or not the adult intended to harm the child.
A woman presents with a history of physical and emotional abuse in her intimate relationships. What should this information lead a nurse to suspect?
1.
The woman may be exhibiting a controlled response pattern.
2.
The woman may have a history of childhood neglect.
3.
The woman may be exhibiting codependent characteristics.
4.
The woman may be a victim of incest.
4

The nurse should suspect that this client may be a victim of incest. Many women who are battered have low self-esteem and have feelings of guilt, anger, fear, and shame. Women in abusive relationships often grew up in an abusive home.
A nursing instructor is developing a lesson plan to teach about domestic violence. Which information should be included?
1.
Power and control are central to the dynamic of domestic violence.
2.
Poor communication and social isolation are central to the dynamic of domestic violence.
3.
Erratic relationships and vulnerability are central to the dynamic of domestic violence.
4.
Emotional injury and learned helplessness are central to the dynamic of domestic violence.
1

The nursing instructor should include the concept that power and control are central to the dynamic of domestic violence. Battering is defined as a pattern of coercive control founded on physical and/or sexual violence or threat of violence. The typical abuser is very possessive and perceives the victim as a possession.
A client is brought to an emergency department after being violently raped. Which nursing action is appropriate?
1.
Discourage the client from discussing the rape, because this may lead to further emotional trauma.
2.
Remain nonjudgmental while actively listening to the client's description of the violent rape event.
3.
Meet the client's self-care needs by assisting with showering and perineal care.
4.
Probe for further, detailed description of the rape event.
2

The most appropriate nursing action is to remain nonjudgmental and actively listen to the client's description of the event. It is important to also communicate to the victim that he/she is safe and that it is not his/her fault. Nonjudgmental listening provides an avenue for catharsis, which contributes to the healing process.
A raped client answers a nurse's questions in a monotone voice with single words, appears calm, and exhibits a blunt affect. How should the nurse interpret this client's responses?
1.
The client may be lying about the incident.
2.
The client may be experiencing a silent rape reaction.
3.
The client may be demonstrating a controlled response pattern.
4.
The client may be having a compounded rape reaction.
3

This client is most likely demonstrating a controlled response pattern. In the controlled response pattern, the client's feelings are masked or hidden, and a calm, composed, or subdued affect is seen. In the expressed response pattern, feelings of fear, anger, and anxiety are expressed through crying sobbing, smiling, restlessness, and tension.
A client who is in a severely abusive relationship is admitted to a psychiatric inpatient unit. The client fears for her life. A staff nurse asks, "Why doesn't she just leave him?" Which is the nursing supervisor's most appropriate response?
1.
"These clients don't know life any other way, and change is not an option until they have improved insight."
2.
"These clients have limited cognitive skills and few vocational abilities to be able to make it on their own."
3.
"These clients often have a lack of financial independence to support themselves and their children, and most have religious beliefs prohibiting divorce and separation."
4.
"These clients are paralyzed into inaction by a combination of physical threats and a sense of powerlessness."
4

The nursing supervisor is accurate when stating that clients who are in abuse relationships are paralyzed into inaction by a combination of physical threats and a sense of powerlessness. Women often choose to stay with an abusive partner: for the children, for financial reasons, for fear of retaliation, for lack of a support network, for religious reasons, or because of hopefulness.
A woman comes to an emergency department with a broken nose and multiple bruises after being beaten by her husband. She states, "The beatings have been getting worse, and I'm afraid next time he will kill me." Which is the appropriate nursing response?
1.
"Leopards don't change their spots, and neither will he."
2.
"There are things you can do to prevent him from losing control."
3.
"Let's talk about your options so that you don't have to go home."
4.
"Why don't we call the police so that they can confront your husband with his behavior?"
3

he most appropriate response by the nurse is to talk with the client about options so that the client does not have to return to the abusive environment. It is essential that clients make decisions on their own without the nurse being the "rescuer."
A college student was sexually assaulted when out on a date. After several weeks of crisis intervention therapy, which client statement should indicate to a nurse that the student is handling this situation in a healthy manner?
1.
"I know that it was not my fault."
2.
"My boyfriend has trouble controlling his sexual urges."
3.
"If I don't put myself in a dating situation, I won't be at risk."
4.
"Next time I will think twice about wearing a sexy dress."
1

The client who realizes that sexual assault was not her fault is handling the situation in a healthy manner. The nurse should provide nonjudgmental listening and communicate statements that instill trust and validate self-worth.
A client asks, "Why does a rapist use a weapon during the act of rape?" Which is the most appropriate nursing response?
1.
"To decrease the victimizer's insecurity"
2.
"To inflict physical harm with the weapon"
3.
"To terrorize and subdue the victim"
4.
"To mirror learned family behavior patterns related to weapons"
3

The nurse should explain that a rapist uses weapons to terrorize and subdue the victim. Rape is the expression of power and dominance by means of sexual violence. Rape can occur over a broad spectrum of experience, from violent attack to insistence on sexual intercourse by an acquaintance or spouse.
When questioned about bruises, a woman states, "It was an accident. My husband just had a bad day at work. He's being so gentle now and even brought me flowers. He's going to get a new job, so it won't happen again." This client is in which phase of the cycle of battering?
1.
Phase I: The tension-building phase
2.
Phase II: The acute battering incident phase
3.
Phase III: The honeymoon phase
4.
Phase IV: The resolution and reorganization phase
3

The client is in the honeymoon phase of the cycle of battering. In this phase, the batterer becomes extremely loving, kind, and contrite. Promises are often made that the abuse will not happen again.
Which information should the nurse in an employee assistance program provide to an employee who exhibits symptoms of domestic physical abuse?
1.
Have ready access to a gun and learn how to use it.
2.
Research lawyers that can aid in divorce proceedings.
3.
File charges of assault and battery.
4.
Have ready access to the number of a safe house for battered women.
4

The nurse should provide information about the accessibility of safe houses for battered women when working with a client who has symptoms of domestic physical abuse. Many women feel powerless within the abusive relationship and may be staying in the abusive relationship out of fear.
A survivor of rape presents in an emergency department crying, pacing, and cursing her attacker. A nurse should recognize these client actions as which behavioral defense?
1.
Controlled response pattern
2.
Compounded rape reaction
3.
Expressed response pattern
4.
Silent rape reaction
3

The nurse should recognize that this client is exhibiting an expressed response pattern. In the expressed response pattern, feelings of fear, anger, and anxiety are expressed through crying, sobbing, smiling, restlessness, and tension.
Which assessment data should a school nurse recognize as a sign of physical neglect?
1.
The child is often absent from school and seems apathetic and tired.
2.
The child is very insecure and has poor self-esteem.
3.
The child has multiple bruises on various body parts.
4.
The child has sophisticated knowledge of sexual behaviors.
1

The nurse should recognize that a child who is often absent from school and seems apathetic and tired may be a victim of neglect. Other indicators of neglect are stealing food or money, lacking medical or dental care, being consistently dirty, lacking sufficient clothing, or stating that there is no one home to provide care.
A client diagnosed with an eating disorder experiences insomnia, nightmares, and panic attacks that occur before bedtime. She has never married or dated, and she lives alone. She states to a nurse, "My father has recently moved back to town." What should the nurse suspect?
1.
Possible major depressive disorder
2.
Possible history of childhood incest
3.
Possible histrionic personality disorder
4.
Possible history of childhood physical abuse
2

The nurse should suspect that this client may have a history of childhood incest. Adult survivors of incest are at risk for developing posttraumatic stress disorder, sexual dysfunction, somatization disorders, compulsive sexual behavior disorders, depression, anxiety, eating disorders, and substance abuse disorders.
In planning care for a woman who presents as a survivor of domestic abuse, a nurse should be aware of which of the following data? (Select all that apply.)
1.
It often takes several attempts before a woman leaves an abusive situation.
2.
Substance abuse is a common factor in abusive relationships.
3.
Until children reach school age, they are usually not affected by abuse between their parents.
4.
Women in abusive relationships usually feel isolated and unsupported.
5.
Economic factors rarely play a role in the decision to stay.
1, 2, 4

When planning care for a woman who is a survivor of domestic abuse, the nurse should be aware that it often takes several attempts before a woman leaves an abusive situation, that substance abuse is a common factor in abusive relationships, and women in abusive relationships usually feel isolated and unsupported.
Which of the following nursing diagnoses are typically appropriate for an adult survivor of incest? (Select all that apply.)
1.
Low self-esteem
2.
Powerlessness
3.
Disturbed personal identity
4.
Knowledge deficit
5.
Nonadherence
1, 2

An adult survivor of incest would most likely have low self-esteem and a sense of powerlessness
A nursing instructor is teaching about intimate partner violence. Which of the following student statements indicate that learning has occurred? (Select all that apply.)
1.
"Intimate partner violence is a pattern of abusive behavior that is used by an intimate partner."
2.
"Intimate partner violence is used to gain power and control over the other intimate partner."
3.
"Fifty-one percent of victims of intimate violence are women."
4.
"Women ages 25 to 34 experience the highest per capita rates of intimate violence."
5.
"Victims are typically young married women who are dependent housewives."
1, 2, 4

Intimate partner violence is a pattern of abusive behavior that is used by an intimate partner; it is used to gain power and control over the other intimate partner; and women ages 25 to 34 experience the highest per capita rates of intimate violence.
Order the description of the progressive phases of Walker's model of the "cycle of battering."
________ This phase is the most violent and the shortest, usually lasting up to 24 hours.
________ In this phase, the man's tolerance for frustration is declining.
________ In this phase, the batterer becomes extremely loving, kind, and contrite.
2, 1, 3


Feedback: In her classic studies of battered women and their relationships, Walker identified a cycle of predictable behaviors that are repeated over time. The behaviors can be divided into three distinct phases that vary in time and intensity both within the same relationship and among different couples.
A pattern of coercive control founded on and supported by physical and/or sexual violence or threat of violence of an intimate partner is termed ______________________.
battering

Battering is a pattern of behavior used to establish power and control over another person with whom an intimate relationship is or has been shared through fear and intimidation, often including the threat or use of violence. Battering happens when one person believes they are entitled to control another.
Physical ________________ of a child includes refusal of or delay in seeking health care, abandonment, expulsion from the home or refusal to allow a runaway to return home, and inadequate supervision.
neglect

Physical neglect of a child includes refusal of or delay in seeking health care, abandonment, expulsion from the home or refusal to allow a runaway to return home, and inadequate supervision. Children are vulnerable and relatively powerless, and the effects of maltreatment are infinitely deep and long lasting.
A new mother is concerned about her ability to perform her parental role. She is quite anxious and ambivalent about leaving the postpartum unit. To offer effective client care, a nurse should be familiar with what information about this type of crisis?
1.
This type of crisis is precipitated by unexpected external stressors.
2.
This type of crisis is precipitated by preexisting psychopathology.
3.
This type of crisis is precipitated by an acute response to an external situational stressor.
4.
This type of crisis is precipitated by normal life-cycle transitions that overwhelm the client.
4

The nurse should understand that this type of crisis is precipitated by normal life-cycle transitions that overwhelm the client. Reassurance and guidance should be provided as needed, and the client should be referred to services that can provide assistance.
A wife brings her husband to an emergency department after an attempt to hang himself. He is a full-time student and works 8 hours at night to support his family. He states, "I can't function any longer under all this stress." Which type of crisis is the client experiencing?
1.
Maturational/developmental crisis
2.
Psychiatric emergency crisis
3.
Anticipated life transition crisis
4.
Traumatic stress crisis
2

The nurse should determine that the client is experiencing a psychiatric emergency crisis. Psychiatric emergencies occur when crisis situations result in severe impairment, incompetence, or an inability to assume personal responsibility.
A client comes to a psychiatric clinic experiencing sudden extreme fatigue and decreased sleep and appetite. The client works 12 hours a day and rates anxiety as 8/10 on a numeric scale. What long-term outcome is realistic in addressing this client's crisis?
1.
The client will change his type-A personality traits to more adaptive ones by one week.
2.
The client will list five positive self-attributes.
3.
The client will examine how childhood events led to his overachieving orientation.
4.
The client will return to previous adaptive levels of functioning by week six
4

The nurse should identify that a realistic long-term outcome for this client is to return to previous adaptive levels of functioning. The nurse should work with the client to develop attainable outcomes that reflect immediacy of the situation.
high school student has learned that she cannot graduate. Her boyfriend will be attending a college out of state that she planned to attend. She is admitted to a psychiatric unit after overdosing on Tylenol. Which is the priority nursing diagnosis for this client?
1.
Ineffective coping R/T situational crisis AEB powerlessness
2.
Anxiety R/T fear of failure
3.
Risk for self-directed violence R/T hopelessness
4.
Risk for low self-esteem R/T loss events AEB suicidal ideations
3

The priority nursing diagnosis for this client is risk for self-directed violence R/T hopelessness. Nurses should prioritize diagnoses and outcomes based on potential safety risk to the client or others.
after threatening to jump off of a bridge, a client is brought to an emergency department by police. To assess for suicide potential, which question should a nurse ask first?
1.
"Are you currently thinking about harming yourself?"
2.
"Why do you want to harm yourself?"
3.
"Have you thought about the consequences of your actions?"
4.
"Who is your emergency contact person?"
1

The nurse should first assess the client for current harmful or suicidal thoughts to minimize risk of harm to the client and provide appropriate interventions. A suicidal client is experiencing a psychiatric emergency. The crisis team's priority is to assess client safety.
An involuntarily committed client, when offered a dinner tray, pushes it off the bedside table onto the floor. Which nursing intervention should a nurse implement to address this behavior?
1.
Initiate forced medication protocol.
2.
Help the client to explore the source of anger.
3.
Ignore the act to avoid reinforcing the behavior.
4.
With staff support and a show of solidarity, set firm limits on the behavior.
4

The most appropriate nursing intervention is to set firm limits on the behavior
A college student, who was nearly raped while jogging, completes a series of appointments with a rape crisis nurse. At the final session, which client statement most clearly suggests that the goals of crisis intervention have been met?
1.
"You've really been helpful. Can I count on you for continued support?"
2.
"I work out in the college gym rather than jogging outdoors."
3.
"I'm really glad I didn't go home. It would have been hard to come back."
4.
"I carry mace when I jog. It makes me feel safe and secure."
4

The nurse should evaluate that the client who has developed adaptive coping strategies has achieved the goals of crisis intervention. The final phase of crisis intervention involves evaluating the outcome of the crisis intervention and anticipatory planning.
A despondent client who has recently lost her husband of 30 years tearfully states, "I'll feel a lot better if I sell my house and move away." Which nursing response is most appropriate?
1.
"I'm confident you know what's best for you."
2.
"This may not be the best time for you to make such an important decision."
3.
"Your children will be terribly disappointed."
4.
"Tell me why you want to make this change."
2

During crisis intervention, the nurse should guide the client through a problem-solving process. The nurse should help the individual confront the source of the problem, encourage the individual to discuss changes he or she would like to make, and encourage exploration of feelings about aspects of the crisis that cannot be changed.
An inpatient client with a known history of violence suddenly begins to pace. Which additional client behavior should alert a nurse to escalating anger and aggression?
1.
The client requests prn medications.
2.
The client has a tense facial expression and body language.
3.
The client refuses to eat lunch.
4.
The client sits in group with back to peers.
2

The nurse should assess that tense facial expressions and body language may indicate that a client's anger is escalating.
What is the best nursing rationale for holding a debriefing session with clients and staff after a take-down intervention has taken place in an inpatient unit?
1.
Reinforce unit rules with the client population.
2.
Create protocols for the future release of tensions associated with anger.
3.
Process client feelings and alleviate fears of undeserved seclusion and restraint.
4.
Discuss the situation that led to inappropriate expressions of anger.
4

The nurse should determine that the purpose for holding a debriefing session with clients and staff after a take-down intervention is to discuss the situation that led to inappropriate behavior. It is important to determine the factors leading to the inappropriate behavior in order to develop future intervention strategies. It is also important to help clients and staff process feelings about the situation.
A nursing instructor is teaching about the Roberts' Seven-stage Crisis Intervention Model. Which nursing action should be identified with Stage IV?
1.
Collaboratively implement an action plan.
2.
Help the client identify the major problems or crisis precipitants.
3.
Help the client deal with feelings and emotions.
4.
Collaboratively generate and explore alternatives.
3

Stage IV: Deal with Feelings and Emotions
Which of the following nursing statements or questions represent appropriate communication to assess an individual in crisis? (Select all that apply.)
1.
"Tell me what happened."
2.
"What coping methods have you used, and did they work?"
3.
"Describe to me what your life was like before this happened."
4.
"Let's focus on the current problem."
5.
"I'll assist you in selecting functional coping strategies."
1, 2, 3

These are appropriate statements to encourage the client to communicate, and evaluate current coping strategies for effectiveness.
Which of the following interventions should a nurse use when caring for an inpatient client who expresses anger inappropriately? (Select all that apply.)
1.
Maintain a calm demeanor.
2.
Clearly delineate the consequences of the behavior.
3.
Use therapeutic touch to convey empathy.
4.
Set limits on the behavior.
5.
Teach the client to avoid "I" statements related to expression of feelings.
1, 2, 4

The nurse should determine that, when working with an inpatient client with difficulty expressing anger appropriately, it is important to maintain a calm demeanor, clearly define the consequences, and set limits on the behavior
Which of the following are behavior assessment categories in the Broset Violence Checklist? (Select all that apply.)
1.
Confusion
2.
Paranoia
3.
Boisterousness
4.
Panic
5.
Irritability
1, 3, 5

The Broset Violence Checklist is a quick, simple, and reliable tool that can be used to assess the risk of potential violence. Assessment categories can include confusion, boisterousness, and irritability.
Order the following stages of Roberts' Seven-stage Crisis Intervention Model.
________ Deal with feelings and emotions.
________ Generate and explore alternatives.
________ Rapidly establish rapport.
________ Psychosocial and lethality assessment.
________ Identify the major problems or crisis precipitants.
________ Follow up.
________ Implement an action plan.
4, 5, 2, 1, 3, 7, 6

The stages of Roberts' Seven-stage Crisis Intervention Model include: 1. Psychosocial and lethality assessment; 2. Rapidly establish rapport; 3. Identify the major problems or crisis precipitants; 4. Deal with feelings and emotions; 5. Generate and explore alternatives; 6. Implement an action plan; 7. Follow up.
sudden event in one's life that disturbs homeostasis, during which usual coping mechanisms cannot resolve the problem, can be defined as a ______________________.
crisis

A crisis is a sudden event in one's life that disturbs homeostasis, during which usual coping mechanisms cannot resolve the problem. Crises result in a disequilibrium, from which many individuals require assistance to recover.
A nurse discovers a client's suicide note that details the time, place, and means to commit suicide. What should be the priority nursing intervention and the rationale for this action?
1.
Administering lorazepam (Ativan) prn, because the client is angry about the discovery of the note
2.
Establishing room restrictions, because the client's threat is an attempt to manipulate the staff
3.
Placing this client on one-to-one suicide precautions, because the more specific the plan, the more likely the client will attempt suicide
4.
Calling an emergency treatment team meeting, because the client's threat must be addressed
3

The priority nursing action should be to place this client on one-to-one suicide precautions, because the more specific the plan, the more likely the client will attempt suicide. The appropriate nursing diagnosis for this client would be risk for suicide.
During the planning of care for a suicidal client, which correctly written outcome should be a nurse's first priority?
1.
The client will not physically harm self.
2.
The client will express hope for the future by day three.
3.
The client will establish a trusting relationship with the nurse.
4.
The client will remain safe during the hospital stay.
4

The nurse's priority should be that the client will remain safe during the hospital stay. Client safety should always be the nurse's priority.
A client diagnosed with major depressive disorder with psychotic features hears voices commanding self-harm. The client refuses to commit to developing a plan for safety. What should be the nurse's priority intervention at this time?
1.
Obtaining an order for locked seclusion until client is no longer suicidal
2.
Conducting 15-minute checks to ensure safety
3.
Placing the client on one-to-one observation while monitoring suicidal ideations
4.
Encouraging client to express feelings related to suicide
3

The nurse's priority intervention when a client hears voices commanding self-harm is to place the client on one-to-one observation while continuing to monitor suicidal ideation.
A client with a history of three suicide attempts has been taking fluoxetine (Prozac) for 1 month. The client suddenly presents with a bright affect, rates mood at 9/10, and is much more communicative. Which action should be the nurse's priority at this time?
1.
Give the client off-unit privileges as positive reinforcement.
2.
Encourage the client to share mood improvement in group.
3.
Increase frequency of client observation.
4.
Request that the psychiatrist reevaluate the current medication protocol.
3

The nurse should be aware that a sudden increase in mood rating and change in affect could indicate that the client is at risk for suicide and client observation should be more frequent. Suicide risk may occur early during treatment with antidepressants. The return of energy may bring about an increased ability to act out self-destructive behaviors prior to attaining the full therapeutic effect of the antidepressant medication.
A nurse admitted a client to an inpatient unit after a suicide attempt. A health-care provider orders amitriptyline (Elavil) for the client. Which intervention related to this medication should be initiated to maintain this client's safety upon discharge?
1.
Provide a 6-month supply of Elavil to ensure long-term compliance.
2.
Provide a 3-day supply of Elavil with refills contingent on follow-up appointments.
3.
Provide a pill dispenser as a memory aid.
4.
Provide education regarding the avoidance of foods containing tyramine.
2

The health-care provider should provide no more than a 3-day supply of Elavil with refills contingent on follow-up appointments as an appropriate intervention to maintain the client's safety. Tricyclic antidepressants have a narrow therapeutic range and can be used in overdose to commit suicide. Distributing limited amounts of the medication decreases this potential. In addition, clients may gain energy to carry out a suicide once they begin to have more energy from taking the antidepressants.
During a one-to-one session with a client, the client states, "Nothing will ever get better," and "Nobody can help me." Which nursing diagnosis is most appropriate for a nurse to assign to this client at this time?
1.
Powerlessness R/T altered mood AEB client statements
2.
Risk for injury R/T altered mood AEB client statements
3.
Risk for suicide R/T altered mood AEB client statements
4.
Hopelessness R/T altered mood AEB client statements
4

The client's statements indicate the problem of hopelessness. Prior to assigning either risk for injury or risk for suicide, a further evaluation of the client's suicidal ideations and intent would be necessary.
The treatment team is making a discharge decision regarding a previously suicidal client. Which client assessment information should a nurse recognize as contributing to the team's decision?
1.
No previous admissions for major depressive disorder
2.
Vital signs stable; no psychosis noted
3.
Able to comply with medication regimen; able to problem-solve life issues
4.
Able to participate in a plan for safety; family agrees to constant observation
4

Participation in a plan of safety and constant family observation will decrease the risk for self-harm.
The family of a suicidal client is very supportive and requests more facts related to caring for their family member after discharge. Which information should the nurse provide?
1.
Address only serious suicide threats to avoid the possibility of secondary gain.
2.
Promote trust by verbalizing a promise to keep suicide attempt information within the family.
3.
Offer a private environment to provide needed time alone at least once a day.
4.
Be available to actively listen, support, and accept feelings.
4
Being available to actively listen, support, and accept feelings increases the potential that a client would confide suicidal ideations to family members.
A stockbroker commits suicide after being convicted of insider trading. In speaking with the family, which statement by the nurse demonstrates accurate and appropriate sharing of information?
1.
"Your grieving will subside within 1 year; until then I recommend antidepressants."
2.
"Support groups are available specifically for survivors of suicide, and I would be glad to help you locate one in this area."
3.
"The only way to deal effectively with this kind of grief is to write a letter to the brokerage firm to express your anger with them."
4.
"Since stigmatization often occurs in these situations, it would be best if you avoid discussing the suicide with anyone."
2

Bereavement following suicide is complicated by the complex psychological impact of the act on those close to the victim. Support groups for survivors can provide a meaningful resource for grief work.
After years of dialysis, an 84-year-old states, "I'm exhausted, depressed, and done with these attempts to keep me alive." Which question should the nurse ask the spouse when preparing a discharge plan of care?
1.
"Have there been any changes in appetite or sleep?"
2.
"How often is your spouse left alone?"
3.
"Has your spouse been following a diet and exercise program consistently?"
4.
"How would you characterize your relationship with your spouse?"
2

This client has many risk factors for suicide. The client should have increased supervision to decrease likelihood of self-harm.
A nursing instructor is teaching about suicide in the elderly population. Which information should the instructor include?
1.
Elderly people use less lethal means to commit suicide.
2.
Although the elderly comprise less than 13 percent of the population, they account for 15 percent of all suicides.
3.
Suicide is the second leading cause of death among the elderly.
4.
It is normal for elderly individuals to express a desire to die, because they have come to terms with their mortality.
2

Although the elderly comprise less than 13 percent of the population, they account for 15 percent of all suicides.
A nurse is caring for a client who has threatened to commit suicide by hanging. The client states, "I'm going to use a knotted shower curtain when no one is around." Which information would determine the nurse's plan of care for this client?
1.
The more specific the plan is, the more likely the client will attempt suicide.
2.
Clients who talk about suicide never actually commit it.
3.
Clients who threaten suicide should be observed every 15 minutes.
4.
After a brief assessment, the nurse should avoid the topic of suicide.
1

Clients who have specific plans are at greater risk for suicide.
A suicidal client says to a nurse, "There's nothing to live for anymore." Which is the most appropriate nursing reply?
1.
"Why don't you consider doing volunteer work in a homeless shelter?"
2.
"Let's discuss the negative aspects of your life."
3.
"Things will look better in the morning."
4.
"It sounds like you are feeling pretty hopeless."
4

This statement verbalizes the client's implied feelings and allows him or her to validate and explore them. This statement also shows empathy toward the client and may help them open up and discuss their feelings.
A new nursing graduate asks the psychiatric nurse manager how to best classify suicide. Which is the nurse manager's best reply?
1.
"Suicide is a DSM-5 diagnosis."
2.
"Suicide is a mental disorder."
3.
"Suicide is a behavior."
4.
"Suicide is an antisocial affliction."
3

Suicide is a behavior.
A nursing student is developing a plan of care for a suicidal client. Which documented intervention should the student implement first?
1.
Communicate therapeutically.
2.
Observe the client.
3.
Provide a hazard-free environment.
4.
Assess suicide risk.
4

Assessment is the first step of the nursing process to gain needed information to determine further appropriate interventions. Suicide risk assessment should always be the first step taken when working with depressed or suicidal patients.
which is a correctly written, appropriate outcome for a client with a history of suicide attempts who is currently exhibiting symptoms of low self-esteem by isolating self?
1.
The client will not physically harm self.
2.
The client will express three positive self-attributes by day four.
3.
The client will reveal a suicide plan.
4.
The client will establish a trusting relationship.
Although the client has a history of suicide attempts, the current problem is isolative behaviors based on low self-esteem. Outcomes should be client-centered, specific, realistic, and measurable and contain a time frame.
A nursing instructor is teaching about suicide. Which student statement indicates that learning has occurred?
1.
"Suicidal threats and gestures should be considered manipulative and/or attention-seeking."
2.
"Suicide is the act of a psychotic person."
3.
"All suicidal individuals are mentally ill."
4.
"Between 50 and 80 percent of all people who kill themselves have a history of a previous attempt."
4

It is a fact that between 50 and 80 percent of all people who kill themselves have a history with a previous attempt.
A nurse is caring for four clients diagnosed with major depressive disorder. When considering each client's belief system, the nurse should conclude which client would potentially be at highest risk for suicide?
1.
Roman Catholic
2.
Protestant
3.
Atheist
4.
Muslim
3

An atheist does not believe in punishment for suicide by a higher power.
Which nursing intervention strategy is most important to implement initially with a suicidal client?
1.
Ask a direct question such as, "Do you ever think about killing yourself?"
2.
Ask client, "Please rate your mood on a scale from 1 to 10."
3.
Establish a trusting nurse-client relationship.
4.
Apply the nursing process to the planning of client care.
1

The risk of suicide is greatly increased if the client has suicidal ideations, if the client has developed a plan, and particularly if the means exist for the client to execute the plan.
A client is newly committed to an inpatient psychiatric unit. Which nursing intervention best lowers this client's risk for suicide?
1.
Encouraging participation in the milieu to promote hope
2.
Developing a strong personal relationship with the client
3.
Observing the client at intervals determined by assessed data
4.
Encouraging and redirecting the client to concentrate on happier times
3

The nurse should observe the actively suicidal client continuously for the first hour after admission. After a full assessment the treatment team will determine the observation status of the client. Observation of the client allows the nurse to interrupt any observed suicidal behaviors.
Which client data indicates that a suicidal client is participating in a plan for safety?
1.
Compliance with antidepressant therapy
2.
A mood rating of 9/10
3.
Disclosing a plan for suicide to staff
4.
Expressing feelings of hopelessness to nurse
3

A degree of the responsibility for the suicidal client's safety is given to the client. When a client shares with staff a plan for suicide, the client is participating in a plan for safety by communicating thoughts of self-harm that would initiate interventions to prevent suicide.
A client is newly admitted to an inpatient psychiatric unit. Which of the following is most critical to assess when determining risk for suicide?
1.
Family history of depression
2.
The client's orientation to reality
3.
The client's history of suicide attempts
4.
Family support systems
3

A history of suicide attempts places a client at a higher risk for current suicide behaviors. Knowing this specific data will alert the nurse to the client's risk. Of those who commit suicide, 50-80 percent had a previous attempt.
A client has been brought to the emergency department for signs and symptoms of chronic obstructive pulmonary disease (COPD). The client has a history of a suicide attempt 1 year ago. Which nursing intervention would take priority in this situation?
1.
Assessing the client's pulse oximetry and vital signs
2.
Developing a plan for safety for the client
3.
Assessing the client for suicidal ideations
4.
Establishing a trusting nurse-client relationship
1

It is important to prioritize client interventions that assess the symptoms of COPD prior to any other nursing intervention. Physical needs must be prioritized according to Maslow's hierarchy of needs. This client's problems with oxygenation will take priority over assessing for current suicidal ideations as they can lead to death more quickly if not reversed.
After a teenager reveals that he is gay, his father responds by beating him. The next morning, the teenager is found hanging in his closet. Which paternal grief responses should a nurse anticipate? Select all that apply.
1.
"I can't believe this is happening."
2.
"If only I had been more understanding."
3.
"How dare he do this to me!"
4.
"I'm just going to have to accept that he was gay."
5.
"Well, that was a selfish thing to do."
1, 2, 3

Suicide of a family member can induce a whole gamut of feelings in the survivors, including shock, guilt, and anger
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