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A community hospital is opening a mental health services department. Which document should the nurse use to develop the unit's nursing guidelines?
- A. Americans with Disabilities Act of 1990
- B. ANA Code of Ethics with Interpretive Statements
- C. ANA's Scope and Standards of Nursing Practice
- D. Patient's Bill of Rights of 1990
Correct Answer: C
Rationale: The correct document the nurse should use to develop the unit's nursing guidelines for the mental health services department is ANA's Scope and Standards of Nursing Practice. This document specifically outlines the philosophy and standards of nursing practice, including psychiatric nursing. Option A, the Americans with Disabilities Act of 1990, and option D, the Patient's Bill of Rights of 1990, focus on client rights and legal protections rather than nursing practice guidelines. Option B, the ANA Code of Ethics with Interpretive Statements, provides ethical guidelines for nursing practice but does not specifically address the development of nursing guidelines for a mental health services department.
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Which of the following mental health situations is considered a psychiatric emergency?
- A. Seasonal Affective Disorder (SAD)
- B. Depression with melancholic features
- C. Major depressive episode with psychotic features
- D. Bipolar depression
Correct Answer: C
Rationale: A major depressive episode with psychotic features is considered a psychiatric emergency because it poses a significant risk to the individual's safety. Psychotic features in depression can include hallucinations, delusions, or other severe symptoms that require immediate intervention. While Seasonal Affective Disorder (SAD) and depression with melancholic features are serious conditions, they do not inherently represent an acute emergency that necessitates immediate hospitalization. Bipolar depression, although severe, does not inherently involve psychotic symptoms that would classify it as a psychiatric emergency requiring immediate intervention. It's crucial to recognize the urgency and severity of major depressive episodes with psychotic features to ensure appropriate and timely treatment.
The home care nurse visits a client who is receiving total parenteral nutrition, and the client states, 'I really miss eating dinner with my family.' Which statement from the nurse is the most therapeutic?
- A. What you are feeling is very common.'
- B. Tell me more about your family dinners.'
- C. In a few weeks, you may be allowed to eat.'
- D. You can sit down to dinner even if you do not eat.'
Correct Answer: B
Rationale: The nurse assists the client with expressing feelings and dealing with the aspects of illness and treatment by clarifying and helping the client to focus on and explore concerns. In option 1, the nurse characterizes and classifies the feelings on the basis of an assumption. Option 3 provides false hope and option 4 blocks communication by giving advice.
A nurse is assigned to care for a close friend in the hospital setting. Which action should the nurse take first when given the assignment?
- A. Notify the friend that all medical information will be kept confidential.
- B. Explain the relationship to the charge nurse and ask for reassignment.
- C. Approach the client and ask if the assignment is uncomfortable.
- D. Accept the assignment but protect the client's confidentiality.
Correct Answer: B
Rationale: When a nurse is assigned to care for a close friend, it is essential to maintain professional boundaries to ensure the best care for the client and the nurse. The most appropriate action for the nurse to take first is to explain the relationship to the charge nurse and ask for reassignment (B). This is important to avoid potential conflicts of interest and maintain objectivity in the care provided. Option A, notifying the friend about confidentiality, may not address the underlying issue of the conflict of interest. Option C, asking the client if the assignment is uncomfortable, may not be appropriate as it puts the client in a difficult position. Option D, accepting the assignment but protecting the client's confidentiality, does not address the conflict of interest and potential ethical issues that may arise from caring for a close friend.
An 8-year-old is admitted to the hospital after being sexually abused by an adult family member. The child is withdrawn and appears frightened. Which describes the best plan for the initial nursing encounter to convey concern and support?
- A. Introduce self and explain to the child that she or he is safe now here in the hospital.
- B. Introduce self and tell the child that you would like to sit with the child for a little while.
- C. Introduce self and then ask the child to express how she or he feels about the events leading up to this hospital admission.
- D. Introduce self, explain your role, and ask the child to act out the sexual encounter with the abuser with the use of art therapy.
Correct Answer: B
Rationale: Victims of sexual abuse may exhibit fear and anxiety regarding what has just occurred. In addition, they may fear that the abuse could be repeated. When initiating contact with a child victim of sexual abuse who demonstrates a fear of others, it is best to convey a willingness to spend time and move slowly to initiate activities that may be perceived as threatening. After a rapport is established, the nurse may explore the child's feelings or use various therapeutic modalities to encourage the recounting of the sexual encounter. Option 2 conveys a plan for an initial encounter that establishes trust by sitting with the child in a nonthreatening atmosphere. Option 1 does not convey concern and support by the nurse. Options 3 and 4 may be implemented after trust and rapport are established.
The healthcare provider is assessing several clients before surgery. Which factor in a client's history poses the greatest threat for complications during surgery?
- A. Taking birth control pills for the past 2 years
- B. Taking anticoagulants for the past year
- C. Recently completing antibiotic therapy
- D. Having taken laxatives PRN for the last 6 months
Correct Answer: B
Rationale: The correct answer is taking anticoagulants for the past year. Anticoagulants increase the risk of bleeding during surgery, which can lead to complications. It is crucial for the healthcare provider to be aware of this medication. While clients taking birth control pills (option A) may be more prone to developing blood clots, these issues typically arise after surgery. Clients who recently completed antibiotic therapy (option C) or have taken laxatives PRN for the last 6 months (option D) are at lower risk compared to those taking anticoagulants (option B) during surgery.