Nokea
History and physical
The client is a 19-year-old male who is in the emergency room for a leg injury. He states he was returning to his dorm from a party and fell about 5 feet (1.5 meters) into a small ravine on campus.
The client states that he drinks socially and takes no medications for any health condition
In order to help the client disclose a situation that is upsetting to him, what therapeutic communication tools could the nurse use? Select all that apply.
- A. Wait until the client is completely calm
- B. Ask difficult questions first to get them out of the way
- C. Use silence as a tool
- D. Speak with the client in private
- E. Observe nonverbal behavior and react accordingly
- F. Ask several questions in a row
Correct Answer: A,C,D,E
Rationale: A: Waiting until the client is calm fosters a safe environment. C: Silence allows the client time to process thoughts. D: Privacy ensures confidentiality and comfort. E: Observing nonverbal behavior provides emotional cues. B: Difficult questions first may increase anxiety. F: Multiple questions can overwhelm the client.
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A female client is brought to the emergency department after police officers found her disoriented, disorganized, and confused. The nurse also determine the client is homeless and is exhibiting suspiciousness. This client's plan of care should include what priority problem?
- A. Ineffective community coping
- B. Disturbed sensory perception
- C. Self-care deficit
- D. Acute confusion
Correct Answer: D
Rationale: Acute confusion is the priority problem because the client is disoriented, disorganized, and confused, indicating a cognitive impairment that needs immediate attention. Ineffective community coping may be a concern for a homeless individual but is not the priority in this scenario. Disturbed sensory perception typically involves alterations in visual, auditory, tactile, or olfactory senses, which may not be the primary issue. While self-care deficit could be a concern, it is not the priority when the client is disoriented.
A client is admitted to the mental health unit with a bipolar disorder. When seeking to establish a therapeutic relationship and interacting with the client, which comment is best for the nurse to make?
- A. I understand that you're angry and unhappy. Let's explore ways in which you overreact
- B. I hear your frustration about losing control. Tell me how this affects your daily life
- C. Knowing the cause of your symptoms will make them easier to handle
- D. Do all that you can to learn all that you can while you are here. You can get better
Correct Answer: B
Rationale: This response acknowledges the client's feelings and invites further exploration, fostering a therapeutic relationship. The first option may invalidate feelings by assuming overreaction. The third shifts focus from immediate concerns. The fourth is encouraging but does not address current feelings.
The nurse notes that a client with a history of self-mutilation has increased body tension and is pacing in the hallway. Which nursing intervention is most important at this time?
- A. Alert the assigned staff to closely monitor client and intervene as needed to reduce risk of self-mutilation
- B. Provide the client time alone in the client's room to reduce external stimulation and promote relaxation
- C. Give the client firm, consistent expectations that self-mutilating behaviors are unacceptable and will not be allowed
- D. Complete a thorough room search to ensure the client does not have access to objects that can be used for self-harm
Correct Answer: A
Rationale: Alerting staff to monitor the client closely addresses the immediate risk of self-harm indicated by increased tension and pacing. Time alone may increase risk. Setting expectations is important but not immediate. Room searches are preventive but not the priority during acute distress.
During a family group meeting, the client's daughter tells the group, 'I hope I didn't cause Mom to be depressed.' Which response is best for the nurse to provide?
- A. I hear you say you worry about causing your mother's distress
- B. Are you afraid that your mother's depression will lead to her death?
- C. What do you think you did that led to your mother's depression?
- D. You are not alone in feeling responsible for others in your family
- E. You are not alone in feeling responsible for others in your family
Correct Answer: A
Rationale: This response acknowledges the daughter's feelings without assumptions or blame, fostering open communication. The second option escalates anxiety. The third may encourage self-blame. The fourth generalizes without addressing her specific concern.
Nurses' Notes
• Diagnosis: depression and post-traumatic stress disorder Diphenhydramine 12.5 mg PO every night at sleep (HS) • Buspirone hydrochloride 7.5 mg PO twice a day
During the conversation with the client, the nurse documents a statement by the client about wishing she had died in the crash.
During the conversation with the client, the nurse documents a statement by the client about wishing she had died in the crash. The statement by the client represents and should be followed up with an
- A. suicidal ideation, assessment of risk factors for suicide
Correct Answer: A
Rationale: The client's statement reflects suicidal ideation, requiring immediate assessment of suicide risk factors (e.g., history, stressors, support systems) to determine appropriate interventions, ranging from monitoring to psychiatric evaluation.