Nokea
A nurse observes a client sitting alone and talking. When asked, the client reports that he is 'talking to the voices.' The nurse's next action should be:
- A. touching the client to help him return to reality
- B. leaving the client alone until reality returns
- C. asking the client to describe what is happening
- D. telling the client there are no voices
Correct Answer: C
Rationale: Asking the client to describe the hallucinations validates their experience and provides insight into their condition, aiding therapeutic communication. Touching may be intrusive, leaving them alone is non-therapeutic, and denying the voices dismisses their reality.
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In performing a psychosocial assessment, the nurse begins by asking questions that encourage the client to describe problematic behaviors and situations. The next step is to elicit the client's:
- A. feelings about what has been described
- B. thoughts about what has been described
- C. possible solutions to the problem
- D. intent in sharing the description
Correct Answer: B
Rationale: Eliciting the client's thoughts after describing issues provides insight into their perspective and interpretation, guiding further assessment. Feelings and solutions come later.
A nurse is reviewing a patient's serum glucose levels. Which of the following scenarios would indicate abnormal serum glucose values for a 30 year-old male.
- A. 70 mg/dl
- B. 55 mg/dl
- C. 110 mg/dl
- D. 100 mg/dl
Correct Answer: B
Rationale: 60-115 mg/dl is standard range for serum glucose levels.
A client tells the nurse that his wife's nagging really gets on his nerves. He asks the nurse to talk with her about her nagging during their family session tomorrow afternoon. Which of the following responses is the most therapeutic for the client?
- A. Tell me more specifically about her complaints.
- B. Can you think why she might nag you so much?
- C. I'll help you think about how to bring this up yourself tomorrow afternoon.
- D. Why do you want me to initiate this in tomorrow's session rather than you?
Correct Answer: C
Rationale: The client needs to learn how to communicate directly with his wife about her behavior. The nurse's assistance enables him to practice a new skill and communicates confidence in his ability to confront this situation. Choices 1 and 2 inappropriately direct attention away from the client and toward his wife, who isn't present. Choice 4 implies that there might be a legitimate reason for the nurse to assume responsibility for something that rightfully belongs to the client. Instead of focusing on his problems, he'll waste precious time convincing the nurse that he or she should do his work.
An elderly client denies that abuse is occurring. Which of the following factors could be a barrier for the client to admit being a victim?
- A. knowledge that elder abuse is rare
- B. personal belief that abuse is deserved
- C. lack of developmentally appropriate screening tools
- D. fear of reprisal or further violence if the incident is reported
Correct Answer: D
Rationale: Barriers to reporting elder abuse include victim shame, fear of reprisals, fear of loss of caregiver, and lack of knowledge of agencies that provide services. Many elders fear that reporting abuse results in their placement in long-term care because the current caregiver is the abuser.
How does the ANA define the psychiatric nursing role?
- A. a specialized area of nursing practice that employs theories of human behavior as its science and the powerful use of self as its art.
- B. assisting the therapist to relieve the symptoms of clients.
- C. to solve clients' problems and give them the answers.
- D. having a client committed to long-term therapy with the nurse.
Correct Answer: A
Rationale: The ANA sets standards of practice for psychiatric and mental health nursing roles. Quality of care, performance appraisal, education, ethics, collaboration, and research are covered through the use of the Nursing Process.