Ati n133 mental health exam 1
Ati n133 mental health exam 1
Total Questions : 46
Showing 10 questions Sign up for moreA nurse is developing a care plan for a newly admitted client who has schizophrenia and experiences frequent hallucinations and paranoid delusions. Which of the following actions should the nurse plan to take?
Explanation
Choice A Reason:
Directly telling a client that their delusions are not real is not typically recommended. This approach can be confrontational and may lead to increased anxiety or agitation in the client. It's important to maintain a therapeutic relationship by validating the client's feelings and working within their current reality, rather than directly challenging their perceptions.
Choice B Reason:
Using frequent touch to provide support may not be appropriate for all clients, especially those with schizophrenia who may have altered perceptions of reality. Some individuals may find touch comforting, while others may perceive it as threatening or invasive. It's crucial to assess each client's comfort level with physical contact and proceed accordingly.
Choice C Reason:
Placing a client in seclusion can be a traumatic experience and is generally considered a last resort when other interventions have failed and the client is a danger to themselves or others. Seclusion should not be used solely because a client is experiencing visual hallucinations.
Choice D Reason:
Limiting the number of questions during assessments can help reduce the potential for overwhelming the client. Clients with schizophrenia may have difficulty processing too much information at once, and a barrage of questions can be stressful. Simplifying communication and allowing the client to focus on one question at a time can be more effective.
A nurse is discussing culturally competent care at a nursing staff inservice. Which of the following information should the nurse include when discussing clients' cultures?
Explanation
Choice A Reason:
Nonverbal communication is a universal aspect of human interaction and plays a crucial role in all cultures. It includes gestures, facial expressions, body language, and other forms of communication that do not involve words. Understanding and interpreting nonverbal cues correctly is essential for nurses to provide culturally competent care.
Choice B Reason:
Culture significantly influences when and how clients seek medical care. Cultural beliefs can shape perceptions of health and illness, determine the types of treatments sought, and influence the level of trust in healthcare providers. Nurses must understand these cultural factors to provide effective and respectful care.
Choice C Reason:
It is unreasonable and culturally insensitive to expect clients to adapt to the care provided without consideration of their cultural background. Instead, healthcare providers should adapt their care to meet the cultural needs of their clients, ensuring that care is patient-centered and respectful of individual cultural practices.
Choice D Reason:
Focusing on clients' cultures rather than just their ethnicity allows nurses to provide more personalized and effective care. Culture encompasses a wide range of factors, including traditions, values, beliefs, and social norms, which can all impact health behaviors and needs. By understanding the cultural context of their clients, nurses can tailor their care approaches to better meet their clients' needs.
While in a therapeutic group, two clients get into a heated debate over politics that turns aggressive. The nurse makes the decision to have both patients removed from the group session. The nurse has demonstrated which leadership style?
Explanation
Choice A Reason:
Bureaucratic leadership is structured and rule-based, often relying on strict adherence to policies and procedures¹. In the scenario described, the nurse's decision to remove the patients from the group session does not necessarily reflect a bureaucratic approach, as it does not specify adherence to established rules or protocols.
Choice B Reason:
Democratic leadership involves participative decision-making, where the leader includes team members in the process¹. The nurse's action in the scenario does not suggest a democratic style, as the decision was made unilaterally without seeking input from the group.
Choice C Reason:
Autocratic leadership is characterized by individual control over all decisions with little input from group members¹. The nurse's decision to remove the patients without group discussion or input aligns with an autocratic leadership style.
Choice D Reason:
Laissez-faire leadership is a hands-off approach, where leaders allow group members to make the decisions¹. The nurse's proactive decision to remove the patients indicates a more direct and controlled approach, contrasting with the laissez-faire style.
A client diagnosed with end-stage renal disease tells the nurse he is afraid of dying from a heart attack. Which of the following responses should the nurse make?
Explanation
Choice A Reason:
While suggesting the client discuss their concerns with their physician is a valid response, it may not provide the immediate emotional support the client is seeking. It's important for the nurse to address the client's current anxiety and provide reassurance before referring them to their physician.
Choice B Reason:
This response dismisses the client's fears and may come across as insensitive. It's crucial to acknowledge the client's emotions and provide a supportive environment where they feel heard and understood.
Choice C Reason:
Encouraging the client to express their fears allows the nurse to provide emotional support and helps in understanding the client's perspective. This approach fosters a therapeutic relationship and can help alleviate the client's anxiety.
Choice D Reason:
While recommending lifestyle changes is beneficial for overall health, this response does not address the client's immediate emotional needs. The nurse should first provide support for the client's expressed fears before discussing lifestyle modifications.
A nurse is planning care for a group of clients on a mental health unit. Which of the following actions should the nurse plan to take to create a therapeutic environment?
Explanation
Choice A Reason:
Providing continuity of care by assigning the same staff is essential in creating a therapeutic environment. It allows for the development of trust and rapport, which are foundational for effective mental health treatment. Consistent caregivers can better understand the clients' needs and tailor interventions accordingly.
Choice B Reason:
While it is important to be open to discussing various topics, the nurse must ensure that discussions remain therapeutic and relevant to treatment goals. Some topics may need to be redirected or limited to maintain a safe and supportive environment.
Choice C Reason:
Allowing clients to determine the boundaries of the nurse-client relationship could lead to blurred lines that may affect the quality of care. It is the nurse's responsibility to establish clear professional boundaries while being empathetic and supportive.
Choice D Reason:
Focusing on client wellness is a broad concept that encompasses the clients' physical, mental, and social well-being. It is a goal of the therapeutic environment to promote overall wellness, but specific strategies are needed to achieve this aim.
A nurse is reviewing communication styles. Which of the following characteristics should the nurse identify as being exhibited by an aggressive communicator? (Select All that Apply.)
Explanation
Choice A Reason:
Advocating for one's rights and the rights of others is not typically seen as a characteristic of aggressive communication. It can be a feature of assertive communication, where the individual stands up for their rights in a respectful and non-confrontational manner.
Choice B Reason:
Seeking to avoid expressing personal opinions is not characteristic of aggressive communicators. Aggressive communicators are more likely to forcefully express their opinions without regard for others' feelings or perspectives.
Choice C Reason:
Being controlling during conversations is a hallmark of aggressive communication. Aggressive communicators often dominate discussions, impose their views, and may disregard others' input.
Choice D Reason:
Feeling anxious about how messages will be received is not typically associated with aggressive communication. This trait is more aligned with passive communication, where individuals may be concerned about others' reactions and thus may hold back their true thoughts.
Choice E Reason:
Blaming others for misunderstandings is a common behavior in aggressive communication. Aggressive communicators may not take responsibility for their part in a conflict and instead put the blame on others.
Choice F Reason:
Frequently interrupting others during conversation is indicative of aggressive communication. This behavior demonstrates a lack of respect for others' contributions and a desire to control the conversation.
A nurse manager on a mental health unit is discussing involuntary admissions during a staff meeting. Which of the following statements should the manager include in the discussion?
Explanation
Choice A Reason:
The statement that clients can be hospitalized for as long as the provider deems necessary is not entirely accurate. Involuntary admission is regulated by law, and there are specific criteria and time frames that must be adhered to. For example, if a person is admitted involuntarily, they must either be discharged within a certain number of days or brought to a mental health court to request a longer commitment.
Choice B Reason:
This statement is correct. Clients who are involuntarily admitted retain their rights, including the right to informed consent. They should be informed about their condition, the proposed treatments, and the potential risks and benefits, and they should be involved in their care decisions as much as possible.
Choice C Reason:
Administering medications to clients who refuse them is a complex issue. While there are circumstances where treatment may be given against a client's wishes, particularly if they pose a danger to themselves or others, this must be done within the framework of the law, which includes respecting clients' rights and obtaining necessary legal orders.
Choice D Reason:
The laws regarding the use of restraints on involuntarily admitted clients are indeed different and often more stringent. These laws are designed to protect the rights of clients and ensure that restraints are used only when absolutely necessary and as a last resort.
The nurse is caring for a client diagnosed with catatonia. Which of the following should be a priority action by the nurse?
Explanation
Choice A Reason:
Scheduling the client for a therapeutic group session may not be appropriate as a priority action. Clients with catatonia often experience significant psychomotor disturbances, which can include immobility or stupor, making participation in group activities challenging and potentially distressing.
Choice B Reason:
Encouraging the client to walk in the hallway is not the most immediate concern. While mobility is important, the safety and medical stability of the client take precedence, especially considering the potential for immobility and resistance to movement in catatonic states.
Choice C Reason:
Encouraging the client to verbalize feelings at all times is not practical as a priority action. Catatonia can involve mutism or significantly reduced responsiveness, making it difficult for the client to express themselves verbally.
Choice D Reason:
Offering small, frequent fluids throughout the day is a priority action for a client with catatonia. Due to the potential for decreased oral intake and the risk of dehydration, ensuring the client receives adequate hydration is essential. This intervention addresses a basic physiological need and can prevent further complications.
The nurse is monitoring a self-help group session when a client notifies his peers that he recently relapsed with heroin. A fellow member of the group replies, "I have relapsed more times than I can count, but I have been sober for over 7 years now." The nurse should recognize that this demonstrates which curative group factors?
Explanation
Choice A Reason:
Universality refers to the realization among group members that they are not alone in their experiences or feelings. While the interaction does show a shared experience, the primary factor demonstrated here is not just the commonality of experience but the encouragement and hope it provides.
Choice B Reason:
Imitative Behavior involves group members learning from each other by observing and copying behaviors. In this scenario, while the member who has been sober for 7 years may serve as a role model, the key element in this interaction is the hope conveyed through sharing personal success.
Choice C Reason:
Instillation of Hope is the encouragement that recovery is possible. The member's statement about overcoming multiple relapses and achieving long-term sobriety serves as a powerful testament to the possibility of recovery, thus instilling hope in others.
Choice D Reason:
Altruism is the unselfish concern for the welfare of others, which can be a byproduct of group therapy as members support each other. However, the primary factor at play in this scenario is the provision of hope rather than the act of giving support.
A nurse is caring for an older adult client following the sudden death of their spouse. The client feels stuck in their ability to deal with work and family responsibilities. The nurse should recognize that the client is experiencing which type of crisis?
Explanation
Choice A Reason:
An adventitious crisis is not applicable here. This type of crisis is usually a result of a natural or man-made disaster, war, or major accident, which is not the case with the client's situation.
Choice B Reason:
Maturational crises are associated with life transitions or developmental stages, such as retirement or menopause. While the client is older, the crisis is not due to a normal life transition but rather an unexpected event.
Choice C Reason:
Developmental crises occur as a person moves through the stages of life. The client's crisis does not stem from a developmental issue but from an external event that has disrupted their life.
Choice D Reason:
Situational crises arise from external sources that an individual may face throughout life, such as the death of a loved one, loss of a job, or severe illness. The client's inability to cope with the sudden death of their spouse is a situational crisis.
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