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A client who has agoraphobia (a fear of crowds) is beginning desensitization with the therapist, and the RN is reinforcing the process. Which intervention has the highest priority for this client's plan of care?
- A. Encourage substitution of positive thoughts for negative ones.
- B. Establish trust by providing a calm, safe environment.
- C. Progressively expose the client to larger crowds.
- D. Encourage deep breathing when anxiety escalates in a crowd.
Correct Answer: B
Rationale: Establishing trust and providing a calm, safe environment is crucial when working with clients with agoraphobia undergoing desensitization therapy. This approach helps build a foundation of safety and security, allowing the client to feel more comfortable and supported during the exposure process. Encouraging positive thoughts (choice A) is important, but ensuring a safe environment takes precedence. Progressively exposing the client to larger crowds (choice C) should be done gradually and in a controlled manner; rushing this process can be overwhelming and counterproductive. Encouraging deep breathing (choice D) is a helpful coping mechanism, but creating a safe and trusting environment is the initial priority to facilitate successful desensitization therapy.
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A client who recently experienced the death of a significant other arrives at the mental health center. The client reports loss of interest in usual activities, expresses a wish to be with the deceased significant other, has been eating very little, and has not slept in several days. Which client statement is most important for the RN to explore at this time?
- A. Not sleeping for several days.
- B. Wishing to be with the deceased significant other.
- C. Lack of interest in usual activities.
- D. Eating very little.
Correct Answer: A
Rationale: The most important client statement for the RN to explore in this scenario is the client not sleeping for several days. The lack of sleep is a critical indicator of possible severe depression or suicidal ideation that requires immediate attention. While expressing a wish to be with the deceased significant other, having a lack of interest in usual activities, and eating very little are concerning, the immediate focus should be on the client's severe sleep disturbance as it can pose an immediate risk to their well-being and safety.
The healthcare provider documents the mental status of a female client who has been hospitalized for several days by court order. The client states, "I don't need to be here" and tells the healthcare provider that she believes that the television talks to her. The healthcare provider should document these assessment findings in which section of the mental status exam?
- A. Level of concentration
- B. Insight and judgment
- C. Remote memory
- D. Mood and affect
Correct Answer: B
Rationale: Insight and judgment should be documented as these findings assess the client's awareness of their need for treatment and understanding of their condition. In this scenario, the client's statement of not needing to be hospitalized and belief that the television talks to her reflect her insight into her situation and judgment regarding reality. The other options are incorrect: Level of concentration refers to the ability to focus and maintain attention; Remote memory evaluates the recall of past events and information; Mood and affect assess emotional state and expression, which are not directly reflected in the client's statements about her need for hospitalization and belief about the television.
A mental health worker (MHW) is caring for a client with escalating aggressive behavior. Which action by the MHW warrants immediate intervention by the nurse?
- A. Attempting to physically restrain the client.
- B. Telling the client to go to the quiet area of the unit.
- C. Using a loud voice to talk to the client.
- D. Remaining at a distance of 4 feet from the client.
Correct Answer: A
Rationale: The correct answer is A: Attempting to physically restrain the client. Physical restraint should only be performed by trained professionals in a safe manner to prevent harm to the client and staff. In this scenario, the mental health worker should not attempt physical restraint, as it can escalate the situation and potentially lead to harm. Choices B, C, and D do not pose an immediate risk and can be part of de-escalation strategies. Choice B suggests guiding the client to a quiet area, choice C involves using a loud voice for better communication, and choice D indicates maintaining a safe distance, which are appropriate interventions to manage escalating aggressive behavior.
A client is being educated by a nurse about strategies for a safety plan for intimate partner violence. Which strategies should be included in the safety plan? (Select all that apply)
- A. Have a bag ready that contains extra clothes for self and children.
- B. Establish a code with family and friends to signal violence.
- C. Purchase a gun for protection.
- D. Attend a self-defense course focused on self-protection.
Correct Answer: A
Rationale: The correct strategies for a safety plan for a victim of intimate partner violence include having a bag ready with essentials for self and children and establishing a code with family and friends to signal danger. These strategies can help the client prepare for emergencies and seek help discreetly. Purchasing a gun (Choice C) is not a safe or recommended strategy as it can escalate violence and pose more significant risks. Additionally, taking a self-defense course focused on self-protection (Choice D) is important for self-defense, but it should not involve retaliatory actions against the abuser with the intent to cause harm.
What should the nurse initially assess when a high school girl reveals engaging in self-induced vomiting as a weight-control measure?
- A. National percentile of weight and height.
- B. Frequency of bingeing and purging behaviors.
- C. Perceptions of family and social relationships.
- D. School grades and extracurricular activities.
Correct Answer: B
Rationale: The correct answer is assessing the frequency of bingeing and purging behaviors. This assessment is crucial in understanding the severity of the eating disorder and developing an appropriate treatment plan. Options A, C, and D are not the initial priority when dealing with a student engaging in harmful behaviors related to eating disorders. While weight and height, family relationships, and academic performance are important aspects to consider, the immediate focus should be on evaluating the behaviors directly linked to the reported issue.