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The nurse manager of the psychiatric unit plans the biweekly, unit-wide interdisciplinary team case conference focused on one particular client. Which client is most important for the manager to select for discussion?
- A. A client who was admitted after a second serious suicide attempt and refuses to talk.
- B. A client toward whom the staff have sharply conflicting attitudes and actions.
- C. A client who experiences hallucinations, takes possessions from other clients, and paces continually.
- D. A client, well known and well liked by staff, whose diagnostic testing reveals a brain tumor.
Correct Answer: A
Rationale: A client with a recent serious suicide attempt who refuses to talk is at high risk for self-harm and requires urgent interdisciplinary discussion to coordinate safety and treatment plans. Other cases, while significant, are less immediately life-threatening.
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A client who is to be discharged to home with a temporary colostomy states to the nurse, 'I know I've changed this thing once, but I just don't know how I'll do it by myself when I'm home alone. Can't I stay here until the surgeon puts it back?' Which therapeutic response should the nurse make to best deal with the client's concerns?
- A. This is only temporary, but with your level of anxiety you need to hire a nurse companion until your surgery.'
- B. So you're saying that, although you've practiced changing your colostomy bag once, you don't feel comfortable on your own yet?'
- C. Well, your insurance will not pay for a longer stay just to practice changing your colostomy, so you'll have to fight it out with them.'
- D. Going home to care for yourself still feels pretty overwhelming? I will schedule you for home visits until you're feeling more comfortable.'
Correct Answer: D
Rationale: The client is expressing feelings of fear and helplessness. Option 4 assists with meeting this client's needs. Option 1 provides information that the client already knows and then problem-solves by using a client-centered action, which would probably overwhelm the client. Option 2 is restating, but this response could cause the client to feel more helpless because the client's fears are reflected back to the client. Option 3 provides what is probably accurate information, but the words 'just to practice' can be interpreted by the client as belittling.
A client who is scheduled for an abdominal peritoneoscopy states to the home care nurse, 'The surgeon told me to restrict food and liquids for at least 8 hours before this procedure and to use a Fleet enema 4 hours before entering the hospital. Do people ever get into trouble after this procedure?' Which is the most appropriate therapeutic response the nurse should make to the client?
- A. Any invasive procedure brings risk with it. You need to report any shoulder pain immediately.'
- B. You seem to understand the preparation very well. Are you having any concerns about the procedure?'
- C. Trouble? There is never any trouble with this procedure. That's why the surgeon will use local anesthesia.'
- D. There are relatively few problems, especially if you are having local anesthesia, but vaginal bleeding should be reported immediately.'
Correct Answer: B
Rationale: Abdominal peritoneoscopy is performed to directly visualize the liver, gallbladder, spleen, and stomach after the insufflation of nitrous oxide. During the procedure, a rigid laparoscope is inserted through a small incision in the abdomen. A microscope in the endoscope allows for the visualization of the organs and provides a way to collect a specimen for biopsy or remove small tumors. The appropriate response is the one that facilitates the expression of the client's feelings. Option 1 may increase the client's anxiety. In option 3, the nurse states that no problems are associated with this procedure; this is closed-ended and is incorrect. Although option 4 contains accurate information, the word immediately can increase the client's anxiety.
The nurse is caring for a client diagnosed with Hodgkin's disease who will be receiving radiation and chemotherapy. Which statement by the client indicates a positive coping mechanism to be used during these treatments?
- A. I won't leave the house bald.'
- B. Losing my hair won't bother me.'
- C. I will be one of the few who doesn't lose my hair.'
- D. I have selected a wig, even though I will miss my own hair.'
Correct Answer: D
Rationale: A combination of radiation and chemotherapy often causes alopecia. To make use of positive coping mechanisms, the client must identify personal feelings and positive interventions to deal with side effects. None of the remaining options are positive coping mechanisms.
The nurse is caring for a client in the psychiatric unit who has issues with coping and defense mechanisms. The nurse understands that which is true regarding coping and defense mechanisms? Select all that apply.
- A. Coping mechanisms are destructive ways to avoid dealing with reality.
- B. Physical symptoms, general irritability, and self-destructive behaviors are some of the signs of inadequate coping.
- C. Criticizing ineffective defense mechanisms will guide the client toward better coping techniques.
- D. Ineffective coping mechanisms allow anxiety to increase, triggering the client to utilize defense mechanisms in order to protect himself from the anxiety.
- E. The inability to cope can be caused by a lack of an adequate support system, a serious medical diagnosis, situational crises, or a lack of psychological resources.
Correct Answer: B,D,E
Rationale: Coping mechanisms are constructive, not destructive, making A incorrect. Criticizing defense mechanisms is nontherapeutic, making C incorrect. Signs of inadequate coping, anxiety escalation, and causes of poor coping are accurate.
A client experiencing urticaria (hives) and pruritus states to the nurse, 'What am I going to do? I'm getting married next week, and I'll probably be covered in this rash and itching like crazy.' Which statement made by the nurse is the most therapeutic?
- A. You're troubled that this will extend into your wedding?
- B. It's probably just due to prewedding jitters. You'll be fine.
- C. The antihistamine will help a great deal, just you wait and see.
- D. Do you think this would really be something that could ruin your wedding?
Correct Answer: A
Rationale: The therapeutic communication technique that the nurse uses in option 1 is reflection. In option 2, the nurse minimizes the client's anxiety and fears. In option 3, the nurse talks about antihistamines and asks the client to 'wait and see.' This is nontherapeutic because the nurse is making promises that may not be kept. In addition, the response is closed-ended and shuts off the client's expression of feelings. In option 4, the nurse responds without sensitivity.