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An inpatient client is newly diagnosed with dissociative identity disorder (DID) stemming from severe childhood sexual abuse. Which nursing intervention takes priority?
- A. Encourage exploration of sexual abuse
- B. Encourage guided imagery
- C. Establish trust and rapport
- D. Administer antianxiety medications
Correct Answer: C
Rationale: The correct answer is C: Establish trust and rapport. This is the priority because building a therapeutic relationship is essential for effective treatment of DID. Trust and rapport are foundational for the client to feel safe and supported in exploring and processing traumatic experiences. Encouraging exploration of sexual abuse (Option A) may be overwhelming and retraumatizing without a solid therapeutic alliance. Guided imagery (Option B) might not be appropriate at this stage as the client needs to establish trust first. Administering antianxiety medications (Option D) alone does not address the root cause or provide the necessary support for the client's complex trauma history.
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To promote self-reliance, how should a psychiatric nurse best conduct medication administration?
- A. Encourage clients to request their medications at the appropriate times.
- B. Refuse to administer medications unless clients request them at the appropriate times.
- C. Allow the clients to determine appropriate medication times.
- D. Take medications to the clients bedside at the appropriate times.
Correct Answer: A
Rationale: The correct answer is A because it promotes self-reliance by empowering clients to take responsibility for their own medication schedule. By encouraging clients to request their medications at the appropriate times, the nurse fosters autonomy and self-management.
Choice B is incorrect as it is too extreme and may compromise client safety by withholding medications based solely on client request. Choice C is incorrect as it puts the responsibility solely on the client without appropriate guidance from the nurse. Choice D is incorrect as it does not actively involve the client in the medication administration process.
A nurse moving out of state speaks to a client about the need to work with a new nurse. The client states, Im not well enough to switch to a different nurse. What does this client response indicate to the nurse?
- A. The client is using manipulation to receive secondary gain.
- B. The client is using the defense mechanism of denial.
- C. The client is having trouble terminating the relationship.
- D. The client is using splitting as a way to remain dependent on the nurse.
Correct Answer: B
Rationale: The correct answer is B because the client's statement indicates denial of the upcoming change in nurses due to their belief that they are not well enough to switch. This defense mechanism helps the client avoid the reality of the situation. Choice A is incorrect as there is no evidence of manipulation for secondary gain. Choice C is incorrect as the client is not expressing difficulty in terminating the relationship. Choice D is incorrect as splitting involves seeing people as all good or all bad, which is not evident in the client's statement.
At what point should the nurse determine that a client is at risk for developing a mental disorder?
- A. When thoughts, feelings, and behaviors are not reflective of the DSM-5 criteria
- B. When maladaptive responses to stress are coupled with interference in daily functioning
- C. When the client communicates significant distress
- D. When the client uses defense mechanisms as ego protection
Correct Answer: B
Rationale: The correct answer is B. When maladaptive responses to stress are coupled with interference in daily functioning, the nurse should determine that a client is at risk for developing a mental disorder. This is because maladaptive responses to stress, such as excessive worry or avoidance behaviors, can be early signs of mental health issues. When these responses start impacting daily functioning, such as affecting work or relationships, it indicates a higher level of risk for a mental disorder. Choices A, C, and D are incorrect because they do not specifically address the combination of maladaptive responses to stress and interference in daily functioning, which are key indicators of potential mental health issues.
A client diagnosed with post-traumatic stress disorder is admitted to an inpatient psychiatric unit for evaluation and medication stabilization. Which therapeutic communication technique used by the nurse is an example of a broad opening?
- A. What occurred prior to the rape, and when did you go to the emergency department?
- B. What would you like to talk about?
- C. I notice you seem uncomfortable discussing this.
- D. How can we help you feel safe during your stay here?
Correct Answer: B
Rationale: The correct answer is B because it allows the client to lead the conversation and express their concerns freely. By asking, "What would you like to talk about?" the nurse demonstrates empathy, respect, and openness to the client's needs, facilitating a client-centered approach. Choice A is specific and may not be what the client wants to discuss. Choice C reflects the nurse's observation rather than encouraging the client to share. Choice D focuses on the nurse's agenda rather than the client's preferences.
In the role of milieu manager, which activity should the nurse prioritize?
- A. Setting the schedule for the daily unit activities
- B. Evaluating clients for medication effectiveness
- C. Conducting therapeutic group sessions
- D. Searching newly admitted clients for hazardous objects
Correct Answer: D
Rationale: The correct answer is D, searching newly admitted clients for hazardous objects. As a milieu manager, ensuring the safety of clients is a top priority. Searching for hazardous objects upon admission is crucial to prevent harm. Setting schedules (A) can be important but not as urgent as ensuring safety. Evaluating medication effectiveness (B) is important but not the primary role of a milieu manager. Conducting group sessions (C) is valuable for therapy but ensuring physical safety takes precedence.