Nurse Tina is caring for a client with delirium and states that “look at the spiders on the wall”. What should the nurse respond to the client?
When hallucination is present, the nurse should reinforce reality with the client.
Nurse Jonel is providing information to a community group about violence in the family. Which statement by a group member would indicate a need to provide additional information?
Personal characteristics of abuser include low self-esteem, immaturity, dependence, insecurity and jealousy.
A long term goal for a paranoid male client who has unjustifiably accused his wife of having many extramarital affairs would be to help the client develop:
Helping the client to develop feeling of self-worth would reduce the client’s need to use pathologic defenses.
A 23-year-old client has been admitted with a diagnosis of schizophrenia says to the nurse “Yes, its march, March is little woman”. That’s literal you know”. These statements illustrate:
Loose associations are thoughts that are presented without the logical connections usually necessary for the listening to interpret the message
Mario is admitted to the emergency room with drug-included anxiety related to over ingestion of prescribed antipsychotic medication. The most important piece of information the nurse in charge should obtain initially is the:
In an emergency, lives saving facts are obtained first. The name and the amount of medication ingested are of outmost important in treating this potentially life threatening situation.
Nurse Nina is assigned to care for a client diagnosed with Catatonic Stupor. When Nurse Nina enters the client’s room, the client is found lying on the bed with a body pulled into a fetal position. Nurse Nina should?
Clients who are withdrawn may be immobile and mute, and require consistent, repeated interventions. Communication with withdrawn clients requires much patience from the nurse. The nurse facilitates communication with the client by sitting in silence, asking open-ended question and pausing to provide opportunities for the client to respond
During electroconvulsive therapy (ECT) the client receives oxygen by mask via positive pressure ventilation. The nurse assisting with this procedure knows that positive pressure ventilation is necessary because?
A short acting skeletal muscle relaxant such as succinylcholine (Anectine) is administered during this procedure to prevent injuries during seizure.
When planning the discharge of a client with chronic anxiety, Nurse Chris evaluates achievement of the discharge maintenance goals. Which goal would be most appropriately having been included in the plan of care requiring evaluation?
Recognizing situations that produce anxiety allows the client to prepare to cope with anxiety or avoid specific stimulus.
Nurse Tina is caring for a client with depression who has not responded to antidepressant medication. The nurse anticipates that what treatment procedure may be prescribed?
Electroconvulsive therapy is an effective treatment for depression that has not responded to medication.
A male client who is experiencing disordered thinking about food being poisoned is admitted to the mental health unit. The nurse uses which communication technique to encourage the client to eat dinner?
Open ended questions and silence are strategies used to encourage clients to discuss their problem in descriptive manner.
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