ATI MENTAL HEALTH 1 - and says, “Back off. Leave me alone.” The c...

ATI MENTAL HEALTH 1

• As a nurse approaches a client with schizophrenia, the client looks at the nurse

and says, “Back off. Leave me alone.” The client appears tense and is pacing rapidly. Which of the following is an appropriate nursing response?

• “I can’t leave you alone when you are this upset. Sit down, and try to relax.”
• “Let’s go to your room, and you can tell me what is bothering you.”
• “I will give you space as long as you control yourself. I’d like to know what is

causing you to feel so tense.”

• “I will leave you alone for a few minutes while you try to compose yourself.”

The nurse’s first concern is to ensure safety. To avoid escalating the client’s behavior, the nurse should stay at the comfortable distance and remain calm while stressing the importance of maintaining control. Verbal intervention is the least restrictive form of action. If the client does not respond to verbal interventions, then more restrictive measures may have to be used.

• A nurse on a mental health care unit is providing care for a client diagnosed with

schizophrenia. The client is experiencing delusional thinking. Which of the following defense mechanisms is the client using when making delusional statements?

• Projection
• Dissociation – a client detaches emotional or behavioral processes from usual

conscious behavior patterns or identity. There is not indication that the client has amnesia problems

• Displacement – a client redirects an emotion from the original object to a

more acceptable substitute. Displacement is not the defense mechanism used in delusional thinking

• Regression – a client attempts to reduce anxiety and conflict by returning to

less mature behaviors that help the client better tolerate the anxiety.Regression is not the defense mechanism used in delusional thinking.

In projection a client attributes unacceptable emotions and qualities to others. This is the defense mechanism that is operative in delusive thinking

• A client diagnosed with schizophrenia says to the nurse, “They lied about me and

are trying to poison my food.” Which of the following is a therapeutic nursing response?

• “Tell me who would do such things to you?”
• “You are mistaken. Nobody has told lies about you or tried to poison you.”
• “Tell me more about your concerns about being poisoned.”
• “You’re having very frightening thoughts.”

Fear of being poisoned is a common delusion among the client with schizophrenia. The nurse is responding therapeutically to the feelings that the client is attempting to communicate. By doing this, the nurse is shifting the focus from the beliefs, which are not real, to the client’s fear, which is real.

• A client is hospitalized with schizophrenia. During a conversation with the nurse,

the client seems relaxed initially, but then com restless and begin wringing his hands. The nurse states that the client seems tens, and the client agrees. Which statement by the nurse would be appropriate at this time?

• “Did I say something wrong that made you feel tense?”
• “Do you often feel tense when you are talking to a health care provider?”
• “What were we discussing when you began to feel uncomfortable?”
• “I sometimes feel tense, too, when I am talking to stranger.”

This statement seeks clarification by asking for information about when the client became tense. This open-minded question is therapeutic because it encourages further communication and expression of feeling.

• A nurse is caring for a client whose provider has prescribed fluphenazine

decanoate (Prolixin)12.5 mg IM weekly. Available is fluphenazine decanoate 50 mg per 2 mL. How many mL should the nurse plan to administer each week?

• 0.25
• 0.5
• 0.75

• 1.0
• A nurse is caring for a client admitted for depression a week ago who was started

on paroxetine (Paxil) at the time of admission. The client states to the nurse, “My family would be better off without me.” Which of the following is an appropriate therapeutic response by the nurse?

• “I do not feel that you really believe that.”
• “Everyone feels this way when depressed.”
• “You sound upset. Are you thinking of hurting yourself?”
• “You’ll be better once your medication start working.”

This response represents the therapeutic communication technique of showing empathy. Telling the client “you are upset” focuses on the client’s feelings, which is where therapeutic communication belongs. In addition, the nurse confronts the client who believes that “my family would be better off without me” about suicidal ideation by asking the client directly whether or not she has an intent of self-harm.

• The nurse should document that a client is experiencing mild anxiety when the

nurse observes which of the following?

• The client is extremely alert.
• The client complains of a stomach ache.
• The client paces in the day room.
• The client has dilated pupils.

Mild anxiety can be therapeutic and motivating. A heightened perceptual field and increased awareness is associated with mild anxiety.

• A nurse is caring for a college student at the campus mental-health counseling

center. The student comes to see the nurse after getting a low grade in a course, and spends the entire session blaming the teacher and complaining about the lack of help seminars. The nurse recognizes this behavior as an example of which of the following defense mechanisms?

• Projection
• Displacement
• Undoing

• Conversion

Defense mechanisms are processes that serve to provide relief from emotional conflict and anxiety. Displacement is a type of defense mechanism, in which the client, operating unconsciously, takes unacceptable emotions, ideas, or wishes and transfers them from their original object to a more acceptable substitute.

• A client in a long term care facility asks the nurse to telephone her husband and

ask him if he remembered to pick up his suit at the cleaners. The nurse knows the client’s husband died five years before. Which of the following is an appropriate nursing response?

• “How long were you married to your husband?”
• “Remember? Your husband died five years ago.”
• “You’ve forgotten that your husband is dead, haven’t you?”
• “You miss your husband a lot, don’t you?”

This therapeutic nursing response uses empathy to validate the client’s feelings and acknowledge her experience. This is the best option because the nurse is responding to the feelings underlying the client’s comment. Instead of the disordered content.

• A client is admitted to the psychiatric unit for depression. The nurse observes an

improvement in the client’s grooming when the client comes to breakfast freshly bathed wearing clean clothes and with combed hair. Which of the following is an appropriate therapeutic response by the nurse?

• “You must be getting better. You look great!”
• “Let’s go put some make-up on to make you look even better.”
• “Why did you get all dressed up today? Is it a special occasion?”
• “You look nice after your bath and shampoo.”
• While taking a health history from a client in the outpatient mental health clinic,

a nurse observes that the client is persistent in making personal inquiries. Which of the following is most therapeutic response?

• Explain to the client that this time is for him.
• Introduce an unrelated topic to distract the client.
• Accept this behavior as a sign of the client developing trust.