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A client commits suicide in an acute mental health facility. Which of the following is the priority intervention for staff following this incident?
- A. Provide professional counseling for staff members.
- B. Change policies for staff observation of clients who are suicidal.
- C. Identify cues in the client's behavior that might have warned them that he was contemplating suicide.
- D. Give the family an opportunity to talk about their feelings.
Correct Answer: C
Rationale: The correct answer is C: Identify cues in the client's behavior that might have warned them that he was contemplating suicide. This is the priority intervention because understanding the warning signs can help prevent future suicides by recognizing and addressing high-risk behaviors. Providing counseling (A) is important but not the immediate priority. Changing policies (B) may be necessary in the long term but does not address the current situation. Giving the family an opportunity to talk (D) is important for support but does not directly address staff intervention.
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A nurse is providing teaching about confidentiality with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
- A. "The courts might require me to discuss confidential information."
- B. "I am required to provide confidential information to insurance companies."
- C. "If questioned during a police investigation, I am required to divulge confidential information."
- D. "I am legally allowed to discuss confidential information with the client's former therapist."
Correct Answer: A
Rationale: Confidentiality may be broken if required by law, such as with a court order.
A nurse is discussing obsessive-compulsive disorder (OCD) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the underlying reason clients with OCD perform ritualistic behaviors?
- A. "The ritualistic behavior provides sexual satisfaction."
- B. "The client performs ritualistic behavior to boost self-esteem."
- C. "The ritualistic behavior temporarily relieves anxiety."
- D. "The client performs ritualistic behavior to decrease feelings of shame."
Correct Answer: C
Rationale: OCD rituals are performed to reduce anxiety, even if they are illogical or excessive.
A nurse is teaching a group of nursing students about ageism. Which of the following statements should the nurse include?
- A. "Ageism refers to a higher level of respect that Eastern cultures give to their elders."
- B. "Ageism refers to the stereotype that older adults are not able to understand new information."
- C. "Ageism refers to assumptions about an older adult client based on gender and economic status."
- D. "Ageism refers to the increase in physical care required by older adults."
Correct Answer: B
Rationale: Ageism involves stereotypes that portray older adults as cognitively incapable.
A client who is about to undergo abdominal surgery states that he is very anxious about the operation. Which of the following responses should the nurse make?
- A. Ask him to describe what he is feeling.
- B. Give the client some reading material as a distraction.
- C. Suggest that he take a walk around the unit.
- D. Refer him to the pastoral care team.
Correct Answer: A
Rationale: The correct response is A: Ask him to describe what he is feeling. This option encourages the client to express his emotions, which can help alleviate anxiety by providing an outlet for his concerns. By actively listening and acknowledging his feelings, the nurse can establish trust and rapport, leading to better emotional support. Choice B may provide a temporary distraction but does not address the underlying anxiety. Choice C may be physically beneficial but does not address the client's emotional state. Choice D may be helpful for spiritual support but does not directly address the client's anxiety.
How should a nurse address compulsive behaviors in a newly admitted client with OCD?
- A. Isolate the client
- B. Confront the client about the behavior
- C. Encourage participation in group activities
- D. Set strict limits on behaviors
- E. Allow additional time for rituals
Correct Answer: D
Rationale: Correct Answer: D. Set strict limits on behaviors
Rationale:
1. Setting strict limits helps establish boundaries and structure for the client.
2. It assists in reducing compulsive behaviors by providing clear guidelines.
3. It promotes a sense of control and safety for the client.
4. Allows for gradual exposure and response prevention therapy.
Summary:
A: Isolating the client can exacerbate feelings of loneliness and increase anxiety.
B: Confrontation may trigger defensiveness and hinder therapeutic rapport.
C: While group activities can be beneficial, they may not directly address the compulsive behaviors.
E: Allowing additional time for rituals reinforces maladaptive behaviors.