NCLEX RN Mental Health and Psychiatric

NCLEX RN Mental Health and Psychiatric Nursing (Substance Abuse and Abuse)

• The nurse is caring for a severely depressed client who has just been admitted to the in-client

psychiatric unit. Which of the following is a priority of care?

• Nutrition
• Elimination
• Rest

• Safety

Correct Answer: D. Safety

Safety is a priority of care for the depressed client. Precautions to prevent suicide must be a part of the plan. Identify the level of suicide precautions needed. If there is a high-risk, does a hospitalization require it? Or if there is a low risk, will the client be safe to go home with supervision from a family member or a friend? A client with a high-risk will require constant supervision and a safe environment.Option A: Encourage small, high-calorie, and high-protein snacks and fluids frequently throughout the day and evening if weight loss is noted. Minimize weight loss, constipation, and dehydration.Encourage eating with others. Increases socialization, decreases focus on the food. Weight the client weekly and observe the eating patterns of the client. Give the information needed for revising the intervention.Option B: Monitor intake and output, especially bowel movements. Most of the depressed clients are constipated. If this problem is not addressed, it can lead to fecal impaction. Encourage the intake of nonalcoholic and non-caffeinated fluids, 6 to 8 glasses a day. Fluids can help prevent constipation. Offer fiber-rich foods and periods of exercise. Roughage and exercise stimulate peristalsis and help evacuation of fecal material.Option C: Provide rest periods after activities. Fatigue can intensify feelings of depression.Encourage relaxation measures in the evening (e.g., drinking warm milk, back rub, or tepid bath).These measures induce sleep and relaxation. Encourage the client to get up and dress and to stay out of bed during the day. Minimizing sleep during the day increases the likelihood of sleep at night.Reduce environmental and physical stimulants in the evening; Provide decaffeinated coffee, soft music, soft lights, and quiet activities.

• Which situation would Nurse Sally identify as placing a client at high risk for caregiver abuse?

• Antonia, an adult child, quits her job to move in and care for a parent with severe

dementia.

• Mr. Wright, an elderly man with severe heart disease, resides in a personal care

home and is frequently visited by his adult child. 1 / 4

• Mrs. Hale, an elderly parent with limited mobility, lives alone and receives help from

several adult children.

• Antoinette cares for her husband who is in early stages of Alzheimer's disease and

has a network of available support persons.Correct Answer: A. Antonia quits her job to move in and care for a parent with severe dementia.In this situation, the adult child has given up her usual role as well as moved her place of residence to care for her parents. Caring for someone with severe dementia is very stressful, requiring almost 24- hour vigilance to ensure safety and meet needs. This situation places the caregiver at high risk for stress and abuse. A combination of individual, relational, community, and societal factors contribute to the risk of becoming a perpetrator of elder abuse. They are contributing factors and may or may not be direct causes.Option B: The caregivers in option B are the staff working in the personal care home; the adult child does not have primary responsibility and, therefore, would not be a high risk for severe stress and abuse. Elder abuse is a serious problem that can have harmful effects on victims. The goal for elder abuse prevention is to stop it from happening in the first place. However, the solutions are as complex as the problem.Option C: The caregivers are receiving support and no one person has primary responsibility. This will decrease the risk for severe caregiver stress. Knowledge about what works to prevent elder abuse is growing. However, most prevention strategies and practices have not yet been rigorously evaluated to determine their effectiveness.Option D: Elder abuse is an intentional act or failure to act that causes or creates a risk of harm to an older adult. An older adult is someone age 60 or older. The abuse often occurs at the hands of a caregiver or a person the elder trusts. Abuse, including neglect and exploitation, are experienced by about 1 in 10 people aged 60 and older who live at home. From 2002 to 2016, more than 643,000 older adults were treated in the emergency department for nonfatal assaults and over 19,000 homicides occurred.

• Which of the following psychological symptoms would the nurse expect to find in a hospitalized

client who is the only survivor of a train accident?

• Denial
• Indifference
• Perfectionism
• Trust

Correct Answer: A. Denial

Denial can act as a protective response. If a situation is just too much to handle, the person may respond by refusing to perceive it or by denying that it exists. Many people use denial in their everyday lives to avoid dealing with painful feelings or areas of their life they don’t wish to admit. This is a primitive and 2 / 4

dangerous defense – no one disregards reality and gets away with it for long! It can operate by itself or, more commonly, in combination with other, more subtle mechanisms that support it.Option B: The client tends to be overwhelmed and disorganized by the trauma, not indifferent to it.The symptoms of PTSD include persistently re-experiencing the traumatic event, intrusive thoughts, nightmares, flashbacks, dissociation(detachment from oneself or reality), and intense negative emotional (sadness, guilt) and physiological reaction on being exposed to the traumatic reminder.Furthermore, problems with sleep and concentration, irritability, increased reactivity, increased startle response, hypervigilance, avoidance of traumatic triggers also occur. There is a significant impairment in social, occupational, and other areas of functioning.Option C: Perfectionism is more commonly seen in clients with eating disorders, not in clients with PTSD. Perfectionism–the tendency to hold unrealistically high standards–has been implicated in the development of and maintenance of eating disorders. Clinical perfectionism is a primary target of intervention in Cognitive Behavioral Therapy (CBT-E), the leading treatment for adults with eating disorders. Studies have shown that patients with anorexia nervosa and bulimia nervosa have higher levels of perfectionism than control subjects.Option D: Clients who have had a severe trauma often experience an inability to trust others. The initial step in the diagnosis of posttraumatic stress disorder is to obtain a detailed history. It is challenging for the patient at times to describe the nature and severity of the traumatic event, and they may choose to avoid mentioning it. However, the presentation and the duration of the symptoms are useful in making an accurate diagnosis. The health care workers must inquire about any depressive or anxiety symptoms, suicidal ideation or previous attempts, substance abuse, access to firearms.

• In planning activities for the depressed client, especially during the early stages of

hospitalization, which of the following plans is best?

• Provide an activity that is quiet and solitary to avoid increased fatigue, such as

working on a puzzle or reading a book.

• Plan nothing until the client asks to participate in milieu.
• Offer the client a menu of daily activities and insist the client participate in all of

them

• Provide a structured daily program of activities and encourage the client to

participate.Correct Answer: D. Provide a structured daily program of activities and encourage the client to participate.A depressed person experiences a depressed mood and is often withdrawn. The person also experiences difficulty concentrating, loss of interest or pleasure, low energy, fatigue, and feelings of worthlessness, and poor self-esteem. The plan of care needs to provide successful experiences in a stimulating yet structured environment. Involve the client in gross motor activities that call for very little concentration (e.g., walking). Such activities will aid in relieving tensions and might help in elevating the mood. 3 / 4

Option A: Initially, provide activities that require minimal concentration (e.g., drawing, playing simple board games). Depressed people lack concentration and memory. Activities that have no “right or wrong” or “winner or loser” minimizes opportunities for the client to put himself/herself down. When the client is in the most depressed state, Involve the client in a one-to-one activity.Maximizes the potential for interactions while minimizing anxiety levels.Option B: Eventually involve the client in group activities (e.g., group discussions, art therapy, dance therapy). Socialization minimizes feelings of isolation. Genuine regard for others can increase feelings of self-worth. Eventually maximize the client’s contacts with others (first one other, then two others, etc.). Contact with others distracts the client from self-preoccupation.Option C: This is a forceful and absolute approach. Allow the patient to engage in simple recreational activities, advancing to more complex activities in a group environment. The patient may feel overwhelmed at the start when participating in a group setting. Encourage the client to participate in group therapy where the members share the same situations/feelings that they have.

• A client with paranoid thoughts refuses to eat because he believes the food has poisoned.

The most appropriate initial action is to

• Taste the food in the client’s presence.
• Suggest that food be brought from home.

• Simply state the food is not poisoned.
• Inform the client he will be tube fed if he does not eat.

Correct Answer: C. Simply state the food is not poisoned.

This action presents reality. Interact with clients on the basis of things in the environment. Try to distract the client from their delusions by engaging in reality-based activities (e.g., card games, simple arts and crafts projects, etc). When thinking is focused on reality-based activities, the client is free of delusional thinking during that time. Helps focus attention externally.Option A: Do not touch the client; use gestures carefully. Suspicious clients might misinterpret touch as either aggressive or sexual in nature and might interpret it as a threatening gesture. People who are psychotic need a lot of personal space. Show empathy regarding the client’s feelings; reassure the client of your presence and acceptance. The client’s delusion can be distressing. Empathy conveys your caring, interest, and acceptance of the client. Important clues to underlying fears and issues can be found in the client’s seemingly illogical fantasies.Option B: Attempt to understand the significance of these beliefs to the client at the time of their presentation. Important clues to underlying fears and issues can be found in the client’s seemingly illogical fantasies. Recognize the client’s delusions as the client’s perception of the environment.Recognizing the client’s perception can help you understand the feelings he or she is experiencing.Option D: Initially do not argue with the client’s beliefs or try to convince the client that the delusions are false and unreal. Arguing will only increase a client’s defensive position, thereby reinforcing false beliefs. This will result in the client feeling even more isolated and misunderstood.

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