Term
An involuntarily committed client, when offered a dinner tray, pushes it off the bedside table onto the floor. Which intervention should a nurse prioritize to address this behavior?
|
|
Definition
The correct answer is:
D. With staff support and a show of solidarity, set firm limits on the behavior. |
|
|
Term
For select clients, physical restraint is considered to be a beneficial intervention. This is based on which premise?
|
|
Definition
Restraints are used for clients who are unable to control their behavior in order to prevent harming themselves or others.
The correct answer is: Clients with limited internal control over their behavior need external controls to prevent harm to themselves and others..
|
|
|
Term
Which client statement demonstrates improvement in terms of anger/aggression management?
|
|
Definition
The client is recognizing and taking responsibility for personal anger.
The correct answer is: “I realize I have a problem expressing my anger appropriately.”.
|
|
|
Term
A client diagnosed with paranoid schizophrenia has a history of aggravated assault. A nurse assigns “Risk for other-directed violence” as the client’s priority nursing diagnosis. Based on this diagnosis, which would be an appropriate outcome for this client?
|
|
Definition
Preventing injury to others is the appropriate outcome. Outcomes must be client centered, specific, realistic, measureable, and contain a time frame. Answer “A” does not contain a time frame.
The correct answer is: The client will not inflict harm on others during this shift..
|
|
|
Term
A student nurse has just entered a psychiatric rotation. The student asks a nursing instructor, “How will we know if someone may get violent?” Which is the most appropriate reply by the nursing instructor?
|
|
Definition
These behaviors have been identified as predictors of violent behavior.
The correct answer is: “Certain behaviors indicate a potential for violence. They are labeled as a ‘prodromal syndrome’ and include rigid posture, clenched fists, and raised voice.”.
|
|
|
Term
|
Definition
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.
The correct answer is: This type of crisis is precipitated by normal life-cycle transitions that overwhelm the client. |
|
|
Term
How does a democratic form of self-government in the milieu contribute to client therapy?
|
|
Definition
A democratic form of self-government in the milieu contributes to client therapy by setting the expectation that all clients should be treated on an equal basis. Clients participate in the decision-making and problem-solving aspects that affect treatment setting. The norms, rules, and behavioral limits are established by the staff and clients. All individuals have input.
The correct answer is: By setting community expectations wherein all clients are treated on an equal basis.
|
|
|
Term
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?
|
|
Definition
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.
The correct answer is: Psychiatric emergency crisis.
|
|
|
Term
In the role of milieu manager, which activity should the nurse prioritize?
|
|
Definition
The milieu manager should search newly admitted clients for hazardous objects. Safety of the client and others is the priority. Nurses are responsible for ensuring that the client’s safety and physiological needs are met within the milieu.
The correct answer is: Searching newly admitted clients for hazardous objects.
|
|
|
Term
|
Definition
The correct answer is:
C. Risk for self-directed violence R/T hopelessness |
|
|
Term
A nursing instructor is teaching about the concept of anger. Which student statement indicates the need for further instruction?
|
|
Definition
Further teaching is necessary when the student states that anger and aggression are essentially the same. Anger and aggression are significantly different.
The correct answer is: “Anger and aggression are essentially the same.”.
|
|
|
