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In the situation presented, which nursing intervention constitutes false imprisonment?
- A. The client is combative and will not redirect, stating, No one can stop me from leaving. The nurse seeks the physicians order after the client is restrained.
- B. The client has been consistently seeking the attention of the nurses much of the day. The nurse institutes seclusion.
- C. A psychotic client, admitted in an involuntary status, runs off the psychiatric unit. The nurse runs after the client and the client agrees to return.
- D. A client hospitalized as an involuntary admission attempts to leave the unit. The nurse calls the security team and they prevent the client from leaving.
Correct Answer: A
Rationale: The correct answer is A because false imprisonment occurs when a person is unlawfully restrained. In this scenario, the client is restrained without a physician's order, which is considered unlawful. Seeking a physician's order after the client is already restrained does not justify the action.
Choice B is incorrect because seclusion is a valid nursing intervention for managing disruptive behavior, as long as it is done in a safe and ethical manner.
Choice C is incorrect because the nurse's actions of running after the client and convincing them to return do not constitute false imprisonment.
Choice D is incorrect because preventing a client hospitalized as an involuntary admission from leaving with the help of security is a valid intervention to ensure the safety of the client and others.
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A despondent client, who has recently lost her husband of 30 years, tearfully states, Ill feel a lot better if I sell my house and move away. Which nursing reply is most appropriate?
- A. Im confident you know whats best for you.
- B. This may not be the best time for you to make such an important decision.
- C. Your children will be terribly disappointed.
- D. Tell me why you want to make this change.
Correct Answer: B
Rationale: The correct answer is B because it acknowledges the client's emotions and gently suggests caution in making a big decision during a vulnerable time. It shows empathy and encourages the client to reconsider the decision later. Choice A lacks exploration of client's feelings, Choice C introduces unnecessary guilt, and Choice D focuses on the change rather than the emotional state.
Which therapeutic communication technique is being used in this nurseclient interaction? Client: When I get angry, I get into a fistfight with my wife or I take it out on the kids. Nurse: I notice that you are smiling as you talk about this physical violence.
- A. Encouraging comparison
- B. Exploring
- C. Formulating a plan of action
- D. Making observations
Correct Answer: D
Rationale: The correct answer is D, Making observations. The nurse is objectively stating what they notice, which is the client smiling while discussing physical violence. This technique helps bring awareness to the client's behavior without judgment. Encouraging comparison (A) involves asking the client to compare similarities and differences, which is not present in this interaction. Exploring (B) involves delving deeper into the client's thoughts and feelings, which is not demonstrated here. Formulating a plan of action (C) involves working with the client to create a plan for addressing issues, which is not the focus of the nurse's statement.
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.
Which therapeutic communication technique should the nurse use when communicating with a client who is experiencing auditory hallucinations?
- A. My sister has the same diagnosis as you and she also hears voices.
- B. I understand that the voices seem real to you, but I do not hear any voices.
- C. Why not turn up the radio so that the voices are muted.
- D. I wouldnt worry about these voices. The medication will make them disappear.
Correct Answer: B
Rationale: The correct answer is B because it demonstrates empathy and validation without reinforcing the hallucinations. By acknowledging the client's experience while maintaining reality orientation, the nurse can build trust and rapport. Choice A may unintentionally normalize the hallucinations. Choice C could dismiss the client's experience and avoid addressing the underlying issue. Choice D minimizes the client's distress and relies solely on medication without addressing the client's emotional needs.
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.