NCLEX Practice Exam for Psychosocial Adaptation

EXPLANATION

 

✔Correct answer:

Exhibits a relaxation response upon request. The first goal in treating a client with a phobic disorder, such as a fear of elevators, is to help them learn to manage their anxiety through relaxation techniques. Teaching the client to exhibit a relaxation response upon request is fundamental because it provides them with a tool to control their anxiety. This skill is essential before attempting more challenging steps, such as role-playing or exposure to the feared object.

Imagine preparing for a challenging hike. The first step is to ensure you have the proper gear, like sturdy boots, to handle the terrain. Similarly, learning relaxation techniques equips the client with the necessary tools to handle their anxiety before facing their fear directly.

Nurse Thompson should focus on teaching the client relaxation techniques such as deep breathing, progressive muscle relaxation, or guided imagery. These techniques can help reduce physiological arousal and anxiety. Once the client is proficient in these methods, they can gradually be introduced to more direct exposure to their fear, starting with less intense steps, such as discussing the fear or visualizing using an elevator, and gradually moving towards actual use.

 

✘Incorrect answer options:

Articulates the fundamental reason behind the phobia. Understanding the underlying reason for the phobia can be beneficial, but it is not the immediate priority. Managing the physical symptoms of anxiety is more critical in the initial stages of treatment.

Accompanies the nurse on an elevator ride. Taking an elevator ride is an exposure technique that should be introduced only after the client has learned to manage their anxiety. It is a later goal in the treatment process.

Engages in a role-playing exercise involving the use of an elevator. Role-playing can be a useful step in exposure therapy, but like riding an elevator, it should come after the client has developed effective anxiety management skills.

 

References

• Townsend, M. C. (2018). Psychiatric Mental Health Nursing: Concepts of Care in Evidence-Based Practice (9th ed.). Philadelphia, PA: F.A. Davis.
• Varcarolis, E. M. (2020). Essentials of Psychiatric Mental Health Nursing: A Communication Approach to Evidence-Based Care (4th ed.). St. Louis, MO: Elsevier.

EXPLANATION

 

✔Correct answer:

Employing gentle touch while assisting and guiding the client through ADLs. Gentle touch can provide comfort and reassurance to clients experiencing confusion. It helps establish a sense of connection and can guide the client through activities of daily living (ADLs) in a non-threatening manner. This approach is particularly effective in fostering trust and cooperation, which are crucial for clients who may be feeling disoriented or anxious.

Think of guiding someone through a dark room by gently holding their hand. The touch provides reassurance and direction, helping them navigate the space more confidently.

Emma should use a combination of verbal cues, gentle physical guidance, and a calm, reassuring tone to assist the client with ADLs. It's important to be patient and allow extra time for the client to process information and respond. Consistent use of these techniques can help reduce confusion and anxiety, making daily care routines more manageable for the client.

 

✘Incorrect answer options:

Communicating with the client by speaking at a very high volume. Speaking loudly can be startling and may increase confusion or agitation. It's more effective to speak clearly and at a normal volume, using a calm and reassuring tone.

Providing written instructions for the client to follow during bathing. Clients experiencing significant confusion may have difficulty understanding and following written instructions. Direct, hands-on assistance is more appropriate.

Maintaining a flat, non-expressive facial expression when interacting with the client. A flat, non-expressive facial expression can be perceived as unengaged or uncaring, which may increase the client's anxiety. Using a warm, expressive demeanor can help convey empathy and support.

 

References

• Townsend, M. C. (2018). Psychiatric Mental Health Nursing: Concepts of Care in Evidence-Based Practice (9th ed.). Philadelphia, PA: F.A. Davis.
• Varcarolis, E. M. (2020). Essentials of Psychiatric Mental Health Nursing: A Communication Approach to Evidence-Based Care (4th ed.). St. Louis, MO: Elsevier.

EXPLANATION

 

✔Correct answer:

Inquiring about her romantic relationships, such as having a boyfriend. While inquiring about a client's romantic relationships can provide some insight into their social interactions and support system, it is the least useful assessment for developing a care plan specifically for an eating disorder. Eating disorders are complex and multifaceted, often influenced by a variety of psychological, familial, and social factors. Therefore, gathering information about mood changes, family dynamics, and peer interactions are more directly relevant and beneficial in understanding and addressing the root causes and maintenance factors of the eating disorder.

When trying to understand why a plant is not thriving, focusing on the quality of soil, water, and sunlight is more important than knowing if it was moved from one pot to another. Similarly, understanding mood, family dynamics, and social interactions provides more crucial information for treating an eating disorder.

In developing the care plan, Nurse Johnson should prioritize assessments that provide comprehensive insights into the client’s mental and emotional health, family relationships, and social interactions. These factors are critical in formulating effective interventions for eating disorders. The nurse should also consider involving a multidisciplinary team, including therapists, dietitians, and social workers, to address the complex needs of the client.

 

✘Incorrect answer options:

Gathering information about recent changes in her mood or emotional state. This assessment is crucial as mood changes and emotional states are closely linked to eating disorders. Understanding these aspects can help identify underlying issues such as depression, anxiety, or stress.

Assessing family dynamics and relationships using a genogram. Family dynamics play a significant role in the development and maintenance of eating disorders. A genogram helps visualize family relationships and patterns, which can be valuable in identifying areas for intervention.

Evaluating her ability to socialize and interact with peers. Social interactions and peer relationships are important in understanding the client's social support network and identifying any social pressures or issues contributing to the eating disorder.

 

References

• Townsend, M. C. (2018). Psychiatric Mental Health Nursing: Concepts of Care in Evidence-Based Practice (9th ed.). Philadelphia, PA: F.A. Davis.
• Varcarolis, E. M. (2020). Essentials of Psychiatric Mental Health Nursing: A Communication Approach to Evidence-Based Care (4th ed.). St. Louis, MO: Elsevier.

EXPLANATION

 

✔Correct answer:

Ask the client to explain why they believe the food is poisoned and listen attentively. Asking the client to explain their belief and listening attentively is the most respectful and trust-building approach. This action demonstrates empathy and understanding, creating an opportunity for the nurse to gather more information about the client's concerns. It also allows the nurse to build rapport and establish trust, which is essential for managing paranoid beliefs. By listening without immediately challenging or dismissing the client's fears, the nurse can better address the client's anxiety and work towards a solution collaboratively.

Imagine a friend tells you they are scared of eating a certain food because they think it’s contaminated. Rather than dismissing their fear, you ask them to share more about why they think that, showing that you care and are willing to understand their perspective.

The nurse should engage in active listening, validate the client's feelings, and explore the underlying reasons for their belief. This can lead to a more effective and therapeutic approach in addressing the client's paranoia. Following this initial conversation, the nurse can gently introduce reality orientation and suggest alternative safe food options or involve the client in meal preparation to build trust.

 

✘Incorrect answer options:

Agree with the client and remove the food immediately to reduce their anxiety. While this may temporarily reduce anxiety, it reinforces the paranoid belief and does not address the underlying issue.

Insist that the client eat the food to prove that it is safe and not poisoned. This approach can increase the client's anxiety and mistrust, potentially escalating the situation and damaging the therapeutic relationship.

Inform the client that their belief is irrational and there is no need to worry. Dismissing the client's belief as irrational can be perceived as invalidating and may lead to increased resistance and mistrust, hindering effective communication and care.

 

References

• Townsend, M. C. (2018). Psychiatric Mental Health Nursing: Concepts of Care in Evidence-Based Practice (9th ed.). Philadelphia, PA: F.A. Davis.
• Varcarolis, E. M. (2020). Essentials of Psychiatric Mental Health Nursing: A Communication Approach to Evidence-Based Care (4th ed.). St. Louis, MO: Elsevier.

EXPLANATION

 

✔Correct answer:

Holding delusions of grandeur or superiority. The patient with a history of alcohol dependence and a diagnosis of cirrhosis is likely experiencing symptoms related to alcohol withdrawal, known as delirium tremens (DTs). Common symptoms of DTs include increased disorientation, agitation, elevated blood pressure and heart rate, sensory misperceptions or illusions, sweating, and tremors. Delusions of grandeur or superiority are less likely in this context. These types of delusions are more commonly associated with psychiatric conditions such as bipolar disorder during manic episodes or certain types of schizophrenia, rather than alcohol withdrawal.

Imagine a person who has stopped drinking coffee suddenly after years of heavy consumption. They might experience headaches, irritability, and fatigue as their body adjusts, but they are unlikely to start believing they are the president. Similarly, alcohol withdrawal involves physical and sensory symptoms, not delusions of grandeur.

To manage alcohol withdrawal symptoms, Nurse Brown should monitor the patient closely for signs of severe withdrawal, such as seizures or severe agitation. Administering prescribed medications like benzodiazepines can help manage withdrawal symptoms. Providing a calm environment, ensuring the patient is hydrated, and offering supportive care are essential. Educating the patient and family about the nature of alcohol withdrawal and the importance of continued medical care and support is also crucial.

 

✘Incorrect answer options:

Elevated blood pressure and heart rate. Elevated blood pressure and heart rate are common symptoms of alcohol withdrawal and are due to the hyperadrenergic state caused by the sudden absence of alcohol.

Sensory misperceptions or illusions. Sensory misperceptions or illusions, such as seeing or hearing things that are not there, are common in severe alcohol withdrawal and can contribute to the patient's agitation and disorientation.

Sweating excessively and experiencing tremors. Sweating excessively and experiencing tremors are hallmark signs of alcohol withdrawal. These autonomic symptoms are a direct result of the body's reaction to the lack of alcohol.

 

References

• Townsend, M. C. (2018). Psychiatric Mental Health Nursing: Concepts of Care in Evidence-Based Practice (9th ed.). Philadelphia, PA: F.A. Davis.
• Varcarolis, E. M. (2020). Essentials of Psychiatric Mental Health Nursing: A Communication Approach to Evidence-Based Care (4th ed.). St. Louis, MO: Elsevier.

EXPLANATION

 

✔Correct answer:

It's possible to control one's reaction to stress.  Nurse Davis emphasizes that while people may not always be able to control the stressful events that occur in their lives, they can control how they respond to these events. This belief is a cornerstone of effective stress management. By focusing on developing healthy coping mechanisms and emotional regulation strategies, individuals can better manage their stress responses and improve their overall well-being.

Think of stress like bad weather. You can't control when it rains, but you can control how you prepare for it, such as carrying an umbrella and wearing appropriate clothing. Similarly, you can prepare and control your reactions to stressful situations.

In the stress-management workshop, Nurse Davis can teach clients techniques such as deep breathing, mindfulness, progressive muscle relaxation, and cognitive restructuring. These strategies help clients develop resilience and a sense of control over their reactions to stress, ultimately leading to better mental health outcomes.

 

✘Incorrect answer options:

It's crucial to avoid stress entirely to live a healthy life. Avoiding stress entirely is unrealistic and impractical. Stress is a natural part of life, and learning to manage it effectively is more beneficial than trying to avoid it completely.

People generally lack control over the amount of stress they experience. While certain stressors may be unavoidable, this belief promotes a sense of helplessness. Focusing on the aspects of stress that individuals can control, such as their reactions, is more empowering.

It's essential to have significant others around to provide care and emotional support. While social support is important and beneficial for managing stress, relying solely on others does not foster personal resilience and coping skills. Developing individual coping mechanisms is crucial for long-term stress management.

 

References

• Townsend, M. C. (2018). Psychiatric Mental Health Nursing: Concepts of Care in Evidence-Based Practice (9th ed.). Philadelphia, PA: F.A. Davis.
• Varcarolis, E. M. (2020). Essentials of Psychiatric Mental Health Nursing: A Communication Approach to Evidence-Based Care (4th ed.). St. Louis, MO: Elsevier.

EXPLANATION

 

✔Correct answer:

Choosing activities that are conducive to achieving the clients' therapeutic goals. The most important aspect when selecting group activities in a therapeutic milieu is to ensure that the activities are conducive to achieving the clients' therapeutic goals. These goals are typically established to address specific mental health needs and promote overall well-being. Activities should be purposefully chosen to facilitate progress towards these goals, such as improving social skills, enhancing self-esteem, fostering emotional expression, or reducing anxiety.

Imagine a fitness coach selecting exercises for a training program. The coach chooses activities that help clients achieve their fitness goals, such as improving strength or endurance, rather than just focusing on what the clients enjoy or are already good at.

When planning group activities, Nurse Thompson should first consider the therapeutic goals for each client and select activities that will help meet these objectives. This approach ensures that the activities are meaningful and effective in supporting the clients' mental health recovery. Additionally, incorporating a variety of activities that address different therapeutic needs can enhance the overall efficacy of the treatment program.

 

✘Incorrect answer options:

Aligning the activities with the clients' existing skills. While considering clients' existing skills can help ensure participation and reduce frustration, it is not as crucial as ensuring that the activities align with therapeutic goals.

Focusing on activities that enhance skills in group participation. Enhancing group participation skills is beneficial, but the primary focus should be on activities that directly contribute to the clients' therapeutic goals.

Tailoring activities to match the clients' personal preferences. Considering personal preferences can increase engagement, but it should not override the importance of selecting activities that are aligned with therapeutic goals.

 

References

• Townsend, M. C. (2018). Psychiatric Mental Health Nursing: Concepts of Care in Evidence-Based Practice (9th ed.). Philadelphia, PA: F.A. Davis.
• Varcarolis, E. M. (2020). Essentials of Psychiatric Mental Health Nursing: A Communication Approach to Evidence-Based Care (4th ed.). St. Louis, MO: Elsevier.

EXPLANATION

 

✔Correct answer:

"Would you like to join Garry and me for a game of Chinese Checkers?"  This statement is the most inviting and non-threatening way to encourage a client to engage with others. It offers a specific activity and includes an invitation from the nurse, which can make the client feel more comfortable and supported. By suggesting a casual game and including the nurse in the activity, it lowers the barrier to participation and creates a more welcoming atmosphere.

Imagine being invited to a small, friendly gathering with people you trust. It's more appealing and less intimidating than being told you have to attend a large social event because it's good for you. Similarly, inviting the client to join in a specific, low-pressure activity makes engagement easier.

Nurse Thompson should focus on creating opportunities for the client to engage in activities that are enjoyable and non-threatening. This approach helps build the client's confidence and encourages social interaction in a supportive environment. Additionally, being part of the activity with the client can provide reassurance and foster a sense of connection.

 

✘Incorrect answer options:

"Participation in group activities is an important part of your treatment." While this statement is true, it may feel more like an obligation than an invitation, which can be overwhelming for someone with severe depression.

"Your doctor believes that spending time with others will be beneficial for you." This statement may come across as authoritative and less personal, which could discourage the client from engaging due to feeling pressured.

"Engaging in painting this picture can contribute to your recovery process." This statement suggests a specific activity but does not include an invitation to join others, which is key to encouraging interaction with other clients.

 

References

• Townsend, M. C. (2018). Psychiatric Mental Health Nursing: Concepts of Care in Evidence-Based Practice (9th ed.). Philadelphia, PA: F.A. Davis.
• Varcarolis, E. M. (2020). Essentials of Psychiatric Mental Health Nursing: A Communication Approach to Evidence-Based Care (4th ed.). St. Louis, MO: Elsevier.

EXPLANATION

 

✔Correct answer:

An increased interest in romantic activities. Depression is typically associated with a decreased interest in activities that were once pleasurable, including romantic and sexual activities. This symptom, known as anhedonia, reflects a loss of interest or pleasure in nearly all activities. Therefore, an increased interest in romantic activities would be the least likely symptom for Nurse Clark to observe in a patient with depression.

Imagine a person who loves playing a musical instrument but suddenly loses all interest and stops playing due to feeling overwhelmed and sad. This loss of interest is similar to how people with depression often lose interest in activities they once enjoyed.

Nurse Clark should focus on assessing the patient's current emotional state, history of depression, and any difficulties they are experiencing in daily functioning. Understanding these aspects will help in developing a comprehensive care plan that addresses both the psychological and physical symptoms of depression. Encouraging the patient to engage in therapeutic activities and providing support for decision-making can also be beneficial.

 

✘Incorrect answer options:

A family history of depression. A family history of depression is a common risk factor and can indicate a genetic predisposition to the condition. It is relevant to understanding the patient's background and potential inherited factors.

Persistent feelings of hopelessness. Feelings of hopelessness are a core symptom of depression. Patients often feel a pervasive sense of despair and a lack of optimism about the future.

Difficulties in making decisions. Indecisiveness and difficulty concentrating are common cognitive symptoms of depression. Patients may struggle with making decisions, even about simple matters, due to impaired cognitive function.

 

References

• Townsend, M. C. (2018). Psychiatric Mental Health Nursing: Concepts of Care in Evidence-Based Practice (9th ed.). Philadelphia, PA: F.A. Davis.
• Varcarolis, E. M. (2020). Essentials of Psychiatric Mental Health Nursing: A Communication Approach to Evidence-Based Care (4th ed.). St. Louis, MO: Elsevier.

EXPLANATION

 

✔Correct answer:

Maintaining the client's safety. The first priority in caring for a client with severe depression is maintaining their safety. Clients with severe depression are at a higher risk for self-harm or suicide. Ensuring the client's safety involves conducting a thorough risk assessment, implementing appropriate safety measures, and closely monitoring the client for any signs of suicidal ideation or behavior.

Think of it as ensuring the foundation of a building is solid before addressing other aspects like painting or interior design. Similarly, safety is the foundation of care for a severely depressed client, upon which other aspects of care can be built.

Nurse Thompson should immediately implement safety protocols, such as creating a safe environment free of harmful objects, ensuring regular supervision, and developing a safety plan. Following the establishment of safety, she can then focus on other important aspects of care, including rest, nutrition, and managing elimination needs.

 

✘Incorrect answer options:

Ensuring the client gets adequate rest. Adequate rest is important for overall well-being and recovery, but it is not the first priority when the client's immediate safety is at risk.

Providing proper nutrition for the client. Proper nutrition is essential for physical health and recovery, but it should be addressed after ensuring the client's safety.

Managing the client's elimination needs. While managing elimination needs is important for comfort and health, it is secondary to ensuring the client's safety in cases of severe depression.

 

References

• Townsend, M. C. (2018). Psychiatric Mental Health Nursing: Concepts of Care in Evidence-Based Practice (9th ed.). Philadelphia, PA: F.A. Davis.
• Varcarolis, E. M. (2020). Essentials of Psychiatric Mental Health Nursing: A Communication Approach to Evidence-Based Care (4th ed.). St. Louis, MO: Elsevier.

EXPLANATION

 

✔Correct answer:

One week. Electroconvulsive therapy (ECT) is known for its rapid onset of therapeutic effects, particularly in individuals with severe depression, treatment-resistant depression, or acute mania. Positive outcomes and improvements in mood and symptoms can often be observed within one week of initiating ECT. This relatively quick response is one of the reasons ECT is considered for patients who require rapid relief from severe psychiatric symptoms.

Think of ECT like turning on a light switch in a dark room. The room brightens almost immediately, providing quick relief from the darkness. Similarly, ECT can provide rapid improvement in severe psychiatric symptoms.

Nurse Thompson should reassure the client about the effectiveness of ECT and provide information on what to expect during and after the treatment. It is important to monitor the client for any side effects, such as short-term memory loss or confusion, and provide support throughout the treatment process. Additionally, Nurse Thompson should ensure that the client understands the need for follow-up sessions and maintenance therapy if recommended by their healthcare provider.

 

✘Incorrect answer options:

Three weeks. While some patients may continue to see improvement over several weeks, initial positive effects of ECT typically begin within the first week of treatment.

Four weeks. Four weeks is a longer timeline than typically expected for the initial therapeutic effects of ECT. Most patients experience significant improvement much sooner.

Six weeks. Six weeks is beyond the usual timeframe for experiencing the initial benefits of ECT. Most patients show marked improvement well before this period.

 

References

• Townsend, M. C. (2018). Psychiatric Mental Health Nursing: Concepts of Care in Evidence-Based Practice (9th ed.). Philadelphia, PA: F.A. Davis.
• Varcarolis, E. M. (2020). Essentials of Psychiatric Mental Health Nursing: A Communication Approach to Evidence-Based Care (4th ed.). St. Louis, MO: Elsevier.

EXPLANATION

 

✔Correct answer:

"You seem to be upset. Is there something on your mind that you'd feel comfortable discussing?" This statement reflects the use of therapeutic interaction techniques effectively by acknowledging the client's emotional state and inviting them to share their thoughts and feelings in a non-judgmental and supportive manner. It shows empathy and opens the door for the client to discuss their concerns, thereby fostering an open and supportive environment.

Think of a friend who notices you're quiet and asks, "You seem down. Do you want to talk about it?" This approach shows concern and provides a safe space for sharing, similar to how the nurse's statement invites the client to express their feelings.

In therapeutic interactions, it is essential to use active listening, empathy, and open-ended questions that encourage clients to explore and express their emotions. This helps build trust and rapport, making clients feel understood and supported. The nurse should continue to use these techniques to facilitate meaningful conversations and provide effective care.

 

✘Incorrect answer options:

"I'm interested in learning more about your family. Could you share some details about them?" While this statement shows interest, it is more focused on gathering information rather than addressing the client's immediate emotional state and encouraging them to share their feelings.

"I understand you've lost your partner. I can't imagine continuing on if I were in your situation." This statement may inadvertently convey a lack of hope and can be overwhelming or unhelpful to the client. It is important to provide support without projecting personal feelings.

"You appear quite sad. Can you tell me how long you've been feeling this way?" Although this statement acknowledges the client's sadness, it focuses on gathering factual information rather than encouraging the client to explore and share their feelings in a supportive manner.

 

References

• Townsend, M. C. (2018). Psychiatric Mental Health Nursing: Concepts of Care in Evidence-Based Practice (9th ed.). Philadelphia, PA: F.A. Davis.
• Varcarolis, E. M. (2020). Essentials of Psychiatric Mental Health Nursing: A Communication Approach to Evidence-Based Care (4th ed.). St. Louis, MO: Elsevier.

EXPLANATION

 

✔Correct answer:

Performing a baptism by pouring fluid over the forehead towards the back of the head while saying, “I baptize you in the name of the Father, the Son, and the Holy Spirit. Amen.”  In the Roman Catholic faith, baptism is considered a sacrament of great importance, particularly for a neonate in critical condition. Roman Catholic doctrine holds that baptism is necessary for salvation, and in emergency situations, anyone, including a nurse, can perform the baptism if a priest is not available. The ritual involves pouring water over the forehead while saying the specific words, ensuring that the neonate is baptized in accordance with the faith's beliefs and practices.

Think of it as a critical step to ensure the neonate receives a spiritual blessing according to the family's beliefs, similar to making sure a patient receives essential medical treatment in an emergency.

Nurse preparedness includes understanding and respecting the religious practices of patients and their families. In this scenario, the nurse should be ready to perform the emergency baptism if requested, ensuring they have the necessary materials (such as sterile water or saline) and knowledge of the proper procedure. This action provides comfort and reassurance to the family during a deeply distressing time.

 

✘Incorrect answer options:

Preparing for a church elder to be at the emergency department upon arrival for a "laying on hands" ritual. While spiritual support from church elders can be important, the immediate concern in this critical situation is the baptism, which can be performed by the nurse.

Expecting a refusal of any treatment for the mother and neonate until consultation with a reader. This option is more aligned with the beliefs of Christian Science rather than Roman Catholicism.

Placing a rosary necklace around the neonate’s neck and ensuring it remains unless removal is absolutely necessary. While a rosary may hold significant spiritual meaning, the priority in this critical situation is performing the sacrament of baptism.

 

References

• Catechism of the Catholic Church (1992).
• Townsend, M. C. (2018). Psychiatric Mental Health Nursing: Concepts of Care in Evidence-Based Practice (9th ed.). Philadelphia, PA: F.A. Davis.

EXPLANATION

 

✔Correct answer:

Alterations in the sensory environment. Sundown syndrome, also known as sundowning, is primarily attributed to alterations in the sensory environment. This condition often affects elderly individuals, particularly those with dementia or cognitive impairments, and is characterized by increased confusion and agitation in the late afternoon and evening. Changes in lighting, reduced visibility, and the transition from day to night can contribute to sensory overload or deprivation, leading to disorientation and agitation.

Imagine trying to read a book in a room where the lighting is gradually dimming. As the light fades, it becomes harder to see and focus, causing frustration and confusion. Similarly, changes in the environment can increase confusion and agitation in individuals with cognitive impairments.

To manage sundown syndrome, Nurse Martinez should recommend strategies to the family and caregivers such as maintaining a consistent routine, ensuring adequate lighting in the evening, reducing noise and stimulating activities before bedtime, and providing a calm and reassuring environment. Additionally, promoting daytime activities and ensuring adequate rest can help minimize the impact of sundowning.

 

✘Incorrect answer options:

The presence of an underlying depressive disorder. While depression can contribute to cognitive and behavioral changes, it is not the primary cause of sundown syndrome. Sundowning is more closely related to environmental factors and cognitive impairments.

Insufficient cerebral blood flow. Insufficient cerebral blood flow can lead to cognitive decline and confusion, but it is not specifically linked to the time-of-day pattern seen in sundown syndrome.

Variations in oxygen exchange levels. Variations in oxygen exchange levels can impact overall brain function, but they do not specifically explain the late-day pattern of confusion and agitation seen in sundown syndrome.

 

References

• Townsend, M. C. (2018). Psychiatric Mental Health Nursing: Concepts of Care in Evidence-Based Practice (9th ed.). Philadelphia, PA: F.A. Davis.
• Varcarolis, E. M. (2020). Essentials of Psychiatric Mental Health Nursing: A Communication Approach to Evidence-Based Care (4th ed.). St. Louis, MO: Elsevier.

EXPLANATION

 

✔Correct answer:

Consult the attending physician and report the discovery of the pills. The most appropriate initial action is to consult the attending physician and report the discovery of the pills. This ensures that the healthcare team is aware of the situation and can take appropriate steps to evaluate the contents and assess any potential risks to the client. Given the context of anorexia nervosa, there is a high risk that the pills could be misused or harmful, and it is essential to involve the physician to make an informed decision about how to proceed.

Imagine finding a bottle of unknown medication in a friend’s room. Before making any assumptions or decisions, you would likely want to inform someone knowledgeable, like a doctor, to ensure safety. Similarly, Nurse Carter should consult the physician to address potential risks properly.

Nurse Carter should take the following steps:

1. Secure the pills and document the discovery.
2. Inform the attending physician and provide details about the pills and the client’s explanation.
3. Collaborate with the healthcare team to determine the next steps, such as analyzing the pills and developing a safe medication plan if necessary.

 

✘Incorrect answer options:

Ask the client to take the pills as needed and monitor her for any side effects. This approach is unsafe as it does not address the potential risks associated with unknown medications, especially in a client with anorexia nervosa.

Allow the client to keep the pills but remind her to use them responsibly. Allowing the client to keep the pills without understanding their contents and purpose can be dangerous and does not ensure responsible use.

Ignore the pills since they are likely harmless and focus on other aspects of care. Ignoring the pills is not a responsible action, as it overlooks the potential risks and fails to ensure the client’s safety.

 

References

• Townsend, M. C. (2018). Psychiatric Mental Health Nursing: Concepts of Care in Evidence-Based Practice (9th ed.). Philadelphia, PA: F.A. Davis.
• Varcarolis, E. M. (2020). Essentials of Psychiatric Mental Health Nursing: A Communication Approach to Evidence-Based Care (4th ed.). St. Louis, MO: Elsevier.

EXPLANATION

 

✔Correct answer:

Ensuring Mr. Wilson's safety by restricting his privileges. During a manic phase, individuals with bipolar disorder often engage in risky and impulsive behaviors due to hyperactivity and poor judgment. Mr. Wilson's lack of sleep and disheveled appearance indicate that he may not be taking care of his basic needs, further increasing the risk of harm. Ensuring his safety by restricting his privileges is the most essential nursing action at this time. This involves closely monitoring his activities, setting clear boundaries, and preventing him from engaging in potentially dangerous behaviors. Safety is the primary concern before addressing other needs such as sleep, nutrition, or hygiene.

Think of someone who is running around a busy street without looking at the traffic. The first step is to ensure their safety by getting them out of the street. Only after they are safe can you address other needs like getting them food or helping them clean up.

The nurse should implement safety measures such as supervision and possibly a low-stimulation environment to reduce hyperactivity and agitation. Once Mr. Wilson's safety is assured, other interventions can follow, such as coordinating with the psychiatrist for medication management, providing opportunities for rest and nutrition, and assisting with personal hygiene. Creating a structured and supportive environment helps manage the manic symptoms and promotes stabilization.

 

✘Incorrect answer options:

Coordinating with the psychiatrist to prescribe a hypnotic to encourage sleep. While encouraging sleep is important, it is not the immediate priority when the client's safety is at risk due to hyperactivity and impulsive behavior. Medication management can be considered after ensuring safety.

Offering a meal and drink for Mr. Wilson to consume in the dining area. Providing food and drink is important for nutritional support, but it does not address the immediate concern of safety. Additionally, eating in a common area might increase overstimulation and agitation.

Providing Mr. Wilson with linens and toiletries to take care of his personal hygiene. Personal hygiene is important for overall well-being, but it is not the most immediate concern compared to ensuring safety. Addressing safety issues takes precedence over hygiene in the context of acute mania.

 

References

• Townsend, M. C. (2018). Psychiatric Mental Health Nursing: Concepts of Care in Evidence-Based Practice (9th ed.). Philadelphia, PA: F.A. Davis.
• Varcarolis, E. M. (2020). Essentials of Psychiatric Mental Health Nursing: A Communication Approach to Evidence-Based Care (4th ed.). St. Louis, MO: Elsevier.

EXPLANATION

 

✔Correct answer:

"I have attempted to leave several times, but I've always found myself returning." This statement is highly indicative of a pattern often seen in domestic violence situations. Victims of domestic violence frequently attempt to leave their abuser multiple times before permanently leaving. The cycle of abuse, coupled with factors such as emotional attachment, fear, financial dependence, and hope for change, often leads to the victim returning to the abusive situation. This cycle of leaving and returning is a key red flag for ongoing domestic violence.

Imagine someone trying to leave a maze but keeps finding themselves back at the start because of obstacles and confusion. Similarly, victims of domestic violence often try to leave but face various barriers that lead them back to their abuser.

Nurse Wilson should conduct a thorough assessment, ensuring the client's safety and privacy. It is crucial to ask direct questions about the nature and frequency of the abuse, provide information about available resources, and offer support and guidance on creating a safety plan. Ensuring the client knows they are not alone and that help is available can be an important step towards breaking the cycle of abuse.

 

✘Incorrect answer options:

"We've only been married for a very short period, just 2 months." While a short marriage duration might be relevant in the context of domestic violence, it is not as directly indicative of abuse as the repeated attempts to leave and return.

"I'm the only one in the family who has been subjected to this kind of treatment." This statement can be concerning, but it does not specifically indicate the cyclical nature of abuse as strongly as the correct answer.

"I am firmly resolved to leave my home within the next week." This statement reflects a decision to leave, which can be significant, but it does not provide as clear an indication of a history of abuse and the associated challenges as the statement about repeatedly returning.

 

References

• Townsend, M. C. (2018). Psychiatric Mental Health Nursing: Concepts of Care in Evidence-Based Practice (9th ed.). Philadelphia, PA: F.A. Davis.
• Varcarolis, E. M. (2020). Essentials of Psychiatric Mental Health Nursing: A Communication Approach to Evidence-Based Care (4th ed.). St. Louis, MO: Elsevier.

EXPLANATION

 

✔Correct answer:

Attaching a wander-guard sensor band to the client’s wrist. Attaching a wander-guard sensor band to the client's wrist is the best strategy for ensuring the safety of a client with dementia who tends to wander. This approach effectively monitors the client’s movements and helps prevent them from leaving safe areas without restricting their autonomy or causing distress. Wander-guard systems are designed to alert caregivers if the client approaches a restricted area, allowing for prompt intervention while respecting the client’s dignity and independence.

Think of a security system in a home that alerts you if someone tries to open a door to the outside. It keeps everyone safe without locking anyone in or restricting their movement within the house.

Implementing a wander-guard sensor system helps maintain a safe environment for clients with dementia while minimizing the need for more restrictive measures. It is important to regularly check the functionality of the system and ensure the client is comfortable with the device. Additionally, the nurse should provide regular supervision and engage the client in meaningful activities to reduce the urge to wander.

 

✘Incorrect answer options:

Applying soft restraints to the client. Using restraints can cause physical and psychological harm, increase agitation, and reduce the client’s autonomy and dignity. Restraints should only be used as a last resort and under strict guidelines.

Regularly orienting the client to time and place. While regular orientation is beneficial for cognitive support, it is not sufficient alone to prevent wandering and ensure the client’s safety.

Clearly explaining the dangers of wandering and getting lost. Clients with dementia may have difficulty understanding and remembering explanations about the dangers of wandering. This approach is unlikely to be effective in preventing wandering behavior.

 

References

• Townsend, M. C. (2018). Psychiatric Mental Health Nursing: Concepts of Care in Evidence-Based Practice (9th ed.). Philadelphia, PA: F.A. Davis.
• Varcarolis, E. M. (2020). Essentials of Psychiatric Mental Health Nursing: A Communication Approach to Evidence-Based Care (4th ed.). St. Louis, MO: Elsevier.

EXPLANATION

 

✔Correct answer:

The client has started participating in group activities and expresses interest in hobbies. Participation in group activities and expressing interest in hobbies are strong indicators of recovery in a client with depression. Depression often leads to a lack of interest in activities that were once enjoyed, social withdrawal, and isolation. When a client begins to re-engage with group activities and shows interest in hobbies, it signals an improvement in mood and a movement towards normal functioning. These behaviors reflect an increase in energy, motivation, and a more positive outlook, which are crucial steps in the recovery process.

Think of a plant that has been wilting but begins to grow new leaves and flowers. This growth indicates that the plant is recovering and becoming healthier, just as re-engaging in activities indicates recovery in a person with depression.

Nurse Taylor should continue to encourage the client’s participation in group activities and hobbies, providing positive reinforcement for these behaviors. It is also important to monitor the client for any setbacks and provide ongoing support to ensure continued progress. Engaging in therapeutic activities, maintaining social connections, and fostering interests can significantly contribute to the client’s overall well-being and recovery from depression.

 

✘Incorrect answer options:

The client reports sleeping for more than 10 hours a day. While sleep is important, sleeping excessively can be a sign of ongoing depression or another underlying issue. It is not necessarily a positive indicator of recovery.

The client has a decreased appetite and significant weight loss. Decreased appetite and weight loss are common symptoms of depression and are not signs of recovery. Improvement would typically involve a normalized appetite and weight stabilization.

The client often isolates themselves and avoids social interactions. Isolation and avoidance of social interactions are symptoms of depression, indicating that the client may still be struggling. Recovery would involve increased social engagement and interaction.

 

References

• Townsend, M. C. (2018). Psychiatric Mental Health Nursing: Concepts of Care in Evidence-Based Practice (9th ed.). Philadelphia, PA: F.A. Davis.
• Varcarolis, E. M. (2020). Essentials of Psychiatric Mental Health Nursing: A Communication Approach to Evidence-Based Care (4th ed.). St. Louis, MO: Elsevier.

EXPLANATION

 

✔Correct answer:

A dispositional crisis. A dispositional crisis occurs in response to an external situational stressor, which in this case is the husband's work-related frustrations leading to abusive behavior at home. This type of crisis involves an acute response to an identifiable event or situation that disrupts an individual's equilibrium. It is characterized by a sudden and acute onset of stress that overwhelms the individual's coping mechanisms, leading to maladaptive behaviors such as domestic abuse.

Imagine a person carrying a heavy load suddenly dropping it because it becomes too overwhelming. The dropping of the load represents a sudden and acute response to an external stressor, similar to how the husband’s abusive behavior is a reaction to work-related stress.

In managing a dispositional crisis, Nurse Carter should provide immediate support and safety planning for the client. This includes assessing the risk of harm, offering resources such as counseling and legal assistance, and developing a safety plan. The nurse should also work with the client to identify coping strategies and support systems that can help mitigate the effects of the crisis and prevent further abuse.

 

✘Incorrect answer options:

A developmental crisis. A developmental crisis occurs as part of the normal growth and development process, such as transitioning to adolescence, becoming a parent, or retiring. It is not triggered by an external situational stressor but by internal developmental challenges.

A psychiatric emergency crisis. A psychiatric emergency crisis involves a sudden, severe psychological disturbance that requires immediate intervention, such as suicidal behavior, severe depression, or psychosis. While domestic abuse is a serious issue, it does not typically fall under this category unless there is imminent danger to life.

An anticipated life transition. An anticipated life transition refers to expected life changes, such as moving to a new city, starting a new job, or having a baby. These transitions are generally planned and expected, unlike the sudden onset of a dispositional crisis.

 

References

• Townsend, M. C. (2018). Psychiatric Mental Health Nursing: Concepts of Care in Evidence-Based Practice (9th ed.). Philadelphia, PA: F.A. Davis.
• Varcarolis, E. M. (2020). Essentials of Psychiatric Mental Health Nursing: A Communication Approach to Evidence-Based Care (4th ed.). St. Louis, MO: Elsevier.