The Client with Interpersonal Violence
4. Encourage safe verbalizations of her emotions, especially anger
87. The nurse is planning care for a group of clients. Which client should the nurse identify as needing the most assistance in accepting being ill?
1. An 8-year-old boy who alternately cries for his mother and is angry with the nurse about being hospitalized after a bike accident.
2. A 32-year-old woman diagnosed with depression related to lupus erythematosus who discusses her medication's adverse effects with the nurse.
3. A 45-year-old man who just suffered a severe myocardial infarction and talks to the nurse about concerns regarding resuming sexual relations with his wife.
4. A 60-year-old woman diagnosed with chronic obstructive pulmonary disease who refuses to wear an oxygen mask even though poor oxygenation makes her confused.
88. The nurse judges that a client is ready to be released from seclusion and restraints when the client demonstrates which of the following behaviors?
1. Is adequately sedated.
2. Struggles less against the restraints.
3. Stops swearing and yelling.
4. Shows signs of self-control.
89. Despite education and role-play practice of restraint procedures, a staff member is injured when actually restraining a client. When helping the uninjured staff deal with the incident, the nurse should address which of the following about the injured member?
1. The emotional responses may be similar to those of other crime victims.
2. The member is likely to resign after experiencing such an injury.
3. Legal action against the client will take time and energy.
4. The member must debrief with the assaultive client before returning.
90. A nurse calls the unit manager to report that her purse has been stolen from the locked break room. The nurse says she thinks she knows which of the staff stole the purse. Which of the following actions by the nurse manager would be appropriate? Select all that apply.
1. Confront the person the nurse suspects stole the purse.
2. Call hospital security to initiate an investigation.
3. Ask the nurse to document all the facts related to the stolen purse.
4. Alert nursing administration that a staff's purse has been stolen.
5. Ask other staff to report any suspicious activity they may have observed.
91. A nurse's ex-boyfriend enters the unit and states, “If I can't have her, then no one will.” Hospital security escorts him out of the building and warned him not to return. The unit manager held a staff meeting to confirm that which of the following workplace violence policies and procedures will be implemented?
Select all that apply.
1. Give a quick overview of the hospital's workplace violence policies and procedures.
2. Offer counseling for the nurse threatened by her ex-boyfriend.
3. Work with security and the nurse to initiate workplace precautions related to the ex-boyfriend.
4. Ask security to help the nurse understand how to initiate a protective order against her ex-boyfriend.
5. Ask the nurse to take a leave of absence until her ex-boyfriend is notified of the protective order.
Answers, Rationales, and Test-Taking Strategies
The answers and rationales for each question follow below, along with keys ( ) to the client need (CN) and cognitive level (CL) for each question. As you check your answers, use the Content Mastery and Test-Taking Skill Self- Analysis worksheet (tear-out worksheet in back of book) to identify the reason(s) for not answering the questions correctly. For additional information about test- taking skills and strategies for answering questions, refer to pages 10–21 and pages 31–32 in Part 1 of this book.
The Client Managing Stress
1. 4. The client expressing doubts about his wife's response to his amputation as well as possible doubt on his part is still struggling with body image issues.
Looking forward to participating in walkathons and helping others indicates plans for the future that imply an acceptance of his amputee status.
Remembering that his friend died in the accident that caused his amputation indicates that the client is aware that there was a worse end result to the accident than his amputation.
CN: Psychosocial integrity; CL: Evaluate
2. 2. A short explanation followed by quick completion of the procedure minimizes anxiety. The client may be fearful of pain, and assuring him that there will be no pain offers false reassurance. A demonstration may cause increased anxiety. Informing the client that his feelings are common normalizes anxiety and puts the client more at ease, but it is not the most reassuring approach.
CN: Psychosocial integrity; CL: Synthesize
3. 1. Anxiety, especially at higher levels, interferes with learning and memory retention. After the client's anxiety lessens, it will be easier for him to learn the steps of the blood glucose monitoring. Because the client's illness is a chronic, lifelong illness that severely changes his lifestyle, it is unlikely that he is uninterested in the illness or how to treat it. It is also unlikely that dementia would be the cause of the client's frustration and lack of memory. The client's response indicates anxiety. Client responses that would indicate lessening anxiety would be questions to the nurse or requests to repeat part of the
instruction.
CN: Psychosocial integrity; CL: Analyze
4. 3. An explanation of what to expect decreases anxiety about upcoming events that could be seen as traumatic by the client. Distraction, such as with games or television, only decreases anxiety temporarily and does not fulfill the client's need for information about the procedure. Reassurance about an uncomplicated outcome is not appropriate; the nurse cannot guarantee that the client will come through surgery without problems. Referring the client to a psychiatrist is not indicated for moderate, expected preoperative anxiety.
CN: Physiological adaptation; CL: Synthesize
5. 3. With mild anxiety, perceptions are accurate. Slight muscle tension reflects a motor response. Occasional irritability is an emotional response. Loss of contact with reality is a cognitive characteristic of severe anxiety.
CN: Physiological adaptation; CL: Analyze
6. 1. Suicide attempts and violence are psychomotor responses to a panic level of anxiety. Desperation and rage are emotional responses. Disorganized reasoning and loss of contact with reality are cognitive responses.
CN: Physiological adaptation; CL: Analyze
7. 2. Mild anxiety motivates the client to focus on issues and resolve them.
Therefore, learning and problem solving can occur at a mild level of anxiety.
Taking control for the client is reserved for a near-panic level of anxiety. Severe anxiety interferes with reasoning and functioning. Therefore, reducing stimuli and pressure is crucial at a severe level. Tension reduction is appropriate at a moderate level to help the client think more clearly and engage in problem solving.
CN: Physiological adaptation; CL: Analyze
8. 4. Minimal functioning, causing new problems to develop, is a reflection of dysfunctional coping. The ability to objectively and rationally problem solve demonstrates adaptive coping. Tension reduction activities demonstrate palliative coping. However, such activities alone do not solve problems; they must be followed by problem solving. Anger management alone may prevent new problems, such as violence toward oneself or others, but it does not solve problems directly. It is considered maladaptive coping.
CN: Physiological adaptation; CL: Analyze
9. 4. Because relationships inherently lead to stress and anxiety, conflict
resolution skills are essential for solving relationship problems. Dealing with anger is more effective than suppressing it. Suppression is a mechanism that avoids the issue rather than solving it. Balancing a checkbook involves calculations, not coping skills. Following directions is a passive activity that reflects a lack of problem solving by the client.
CN: Psychosocial integrity; CL: Analyze
10. 4. The client's statement that he and his wife listen to each other reflects improved efforts at communicating about issues. The other statements provide some insight into the need for better communication. However, they are but steps along the way to coping effectively with the problem.
CN: Psychosocial integrity; CL: Evaluate
11. 1. Assessment examines the client's thoughts, feelings, and behaviors within a context. Whether the client's behavior is appropriate for the situation is important assessment data. Setting priorities is part of making nursing diagnoses and planning; motivation to change and identifying the need for a no harm contract are part of the planning stage.
CN: Psychosocial integrity; CL: Analyze
12. 3. Writing a list of strengths and needs is short-term, achievable, and measurable. Achieving positive self-esteem would occur over the long term.
Going to school involves complex future steps to a long-term goal. Using skills is likely to be stressful and is best attempted after the client has done a self- assessment.
CN: Psychosocial integrity; CL: Synthesize
13. 4. The ultimate outcome is to have the client solve problems by himself, collaborating in his own care. Client follow-up with the psychiatrist, while desirable, does not ensure that the client will fully comply with treatment or medication. Knowledge of the medication's effects and adverse effects and compliance can help the client but alone will not ensure success unless the client knows how to address and solve problems without help from others.
CN: Health promotion and maintenance; CL: Synthesize
14. 1. Substituting rational beliefs is a major goal when using cognitive- behavioral models, which focus more on thinking and behaviors than feelings.
Unconscious processes are the focus of psychoanalytic models. Analysis of fears and barriers to growth is the focus of developmental models. Tension and stress are targets of the stress models.
CN: Psychosocial integrity; CL: Apply
15. 3. Displacement refers to a defense mechanism that involves taking feelings out on a less-threatening object or person instead of tackling the issue or problem directly. Talking to his wife directly reflects insight into the client's use of the defense mechanism and his ability to overcome it. Not thinking about the weekend is suppression. Here, the client is focusing on the issue with the highest priority. Focusing on academic rather than athletic achievement is compensation, highlighting one's strengths instead of weaknesses. Not remembering the molestation is repression.
CN: Psychosocial integrity; CL: Evaluate
16. 3. Legally, there is a duty to warn a potential victim of a client's intent to harm. Staff can be held accountable if the client injures the ex-partner and the staff failed to warn that person. The client's permission is needed to share information with a spouse. Only client initials are used in student papers.
Release of information is made directly to the client's insurance company, not to the employer.
CN: Management of care; CL: Apply
17. 2, 5. The client is showing increased anxiety and anger as well as refusing to stay in the hospital, which are immediate and crucial concerns at admission. The client is not likely to give permission to talk to his wife and boss at this point. Housing issues and divorce counseling may be relevant before discharge, but not initially. Suspiciousness and grandiosity may be relevant after the client's anxiety and anger are under control.
CN: Management of care; CL: Create
18. 2. The nurse is required to set limits on inappropriate behavior while conveying respect and acceptance of that person. Doing so conveys to the client that he is worthy without posing any harm or embarrassment to the client. Touch is a complex issue that must be used cautiously. Touch may be misinterpreted or misperceived by a client who has been abused or who has perceptual or thought disturbances. Mutual sharing reflects a social friendship, not a therapeutic one.
Total confidentiality is not desirable. For example, treatment team members and insurance companies need selected information to ensure quality services.
CN: Psychosocial integrity; CL: Apply
19. 2. Growth of the fetus is important, so nausea and anorexia that would interfere with the young woman's nutrition would cause the most harm to the developing fetus. It could also lead to electrolyte imbalance if she did not take in enough fluid. While insomnia could cause problems long-term, this side effect
could be mitigated through adjustment of the dosing time (earlier in the day) or decrease of the dosage to her former 20 mg daily or even every other day dosing of 40 mg since Prozac has a long half-life. Headaches are uncomfortable but can be treated with mild analgesics or other treatments such as cold cloths that would not harm the fetus. Decreased libido, while not enjoyable for the client or her sexual partner, does not pose any risks for the fetus.
CN: Pharmacological and parenteral therapy; CL: Analyze
20. 3. Asking for descriptions of changes in behavior (what the client did differently) encourages evaluation. Conveying empathy, such as stating that it is still hard for the client to talk about it, encourages data collection. Asking for meaning helps with the nursing diagnosis. Asking the client about what her husband said the previous night is part of evaluation.
CN: Psychosocial integrity; CL: Apply
21. 1. With the shorter lengths of stay, the processes and goals of a particular stage are chosen according to the client's current needs and abilities. Building trust (orientation stage) is a priority with psychotic and suspicious clients. It is less crucial for the client ready to work on issues. Making referrals (termination stage) is appropriate for all clients regardless of their needs. The other needs will be addressed in counseling after discharge. Teaching skills (working stage) is appropriate for clients with insight and readiness for change. They may not be appropriate for clients with severe psychosis or suspiciousness, especially if denial is present.
CN: Management of care; CL: Apply
22. 4. Practicing new behaviors builds confidence and reinforces appropriate behaviors. Reality testing, asking about fears, and teaching new communication skills are some of the many steps when trying out new behaviors.
CN: Psychosocial integrity; CL: Apply
The Client Coping with Physical Illness
23. 4. While the client does have a right to accept or reject treatment, she has not explored her feelings, her possible mastectomy, or the future. The nurse should assist the client in exploring her feelings and moving toward a fuller understanding of her options. Giving the client survival rates indicates that the nurse feels she should have the surgery and negates her fears and concerns.
While the chaplain might be helpful, this step should be done after the client has explored her feelings.
CN: Management of care; CL: Synthesize
24. 2. Diagnosis of a serious illness would be a shock to anyone but particularly a young person. Feelings of anger are normal and should be expressed. Gaining an intellectual understanding of his illness would also be necessary, but such learning will not take place if the client's feelings have not been addressed. There is no indication that the client needs to conserve energy because of his condition, nor is it clear that death is imminent. Neither situation is likely at the point of first diagnosis unless the disease is well advanced, which is not indicated here.
CN: Management of care; CL: Apply
25. 2. The psychotropic drugs used to treat chronic mental illnesses have side effects that can lead to noncompliance. Therefore, teaching the clients measures to deal with the common side effects would be most important. Teaching should be focused on the need for compliance and the specific interests of the target audience. Teaching should concentrate on the medications commonly used to treat chronic mental illness, not on many psychotropic drugs or those used in acute illness. Such topics as the role of medication in the treatment of chronic mental illness and the effects of using common street drugs with psychotropic medication should be discussed after the issue of compliance is addressed.
CN: Health promotion and maintenance; CL: Create
26. 2. When the client seems to be questioning the primary health care provider's goals, it is best for the nurse to present an open statement and ask the client what he means. This technique helps the client express his feelings.
Telling the client about the surgery is less therapeutic when he is upset.
Chastising the client and defending the primary health care provider are likely to inhibit communication about the client's needs and feelings. Making assumptions can also interfere with communication, especially if the assumption is incorrect.
CN: Psychosocial integrity; CL: Synthesize
27. 2. When the client has hostile outbursts, it is best for the nurse to help her express her feelings. This serves as a release valve for the client. Offering positive reinforcement for cooperation does not help the client express herself appropriately. Continuing with assigned tasks ignores the client's feelings and may lead to further escalation. Encouraging the client to direct anger to the staff is inappropriate. The client needs to express her feelings appropriately.
CN: Psychosocial integrity; CL: Synthesize
28. 3. Preoperative visits and talks with others who have made successful
adjustments to colostomies are helpful and tend to make the client less fearful of the operation and its consequences. Knowing about resources in the community will be helpful as the client approaches discharge. Supporting the primary health care provider is less important than supporting the client and giving him information. The client will have a change in body image, with disfigurement due to the creation of a colostomy. However, the client should be able to lead a full life.
CN: Management of care; CL: Apply
29. 2. The nurse must present reality to the client about his condition to help decrease his denial about his physical status. By stating the name of the condition and talking about what it means, the nurse provides the client with information and conveys concerns about him and a willingness to help him understand his illness. It may not be true that the client would be made more upset by the call; the news might be good. However, this statement does not provide the client with the reality of his condition. Telling the client that he really doesn't care or asking the client if he realizes that he has a life-threatening condition is belittling and may make the client defensive.
CN: Psychosocial integrity; CL: Synthesize
30. 1. Leaving the hospital and immediately flying to a meeting indicate poor judgment by the client and little understanding of what she needs to change regarding her lifestyle. The other statements show that the client understands some of the changes she needs to make to decrease her stress and lead a more healthy lifestyle.
CN: Psychosocial integrity; CL: Evaluate
31. 1, 3, 5. Suicide is a risk with chronic illnesses. The husband needs validation of his feelings and support, as well as suggestions for helping his wife with her concerns. Telling him to be strong and optimistic ignores the client's needs. It is false to assume that the client will no longer be suicidal when the lupus is under control.
CN: Safety and infection control; CL: Synthesize
32. 4. The nurse's best response is one that directly expresses the nurse's observations to the client and offers the client the opportunity to talk about his feelings or concerns to decrease somatization (the need to express feelings through physical symptoms). Leaving, offering to provide pain medication, and stating that anger does not bother the nurse ignore the client's needs.
CN: Psychosocial integrity; CL: Synthesize