166 C LIENT M ANAGEMENT AND L EADERSHIP S UCCESS

24. The client in the psychiatric setting tells the nurse, “There were so many people at the team meeting; I am not sure what the psychiatric social worker is suppose to do for me.” Which statement is the psychiatric nurse’s best response?

1. “The social worker evaluates the effectiveness of the client’s medication.” 2. “This person provides activities that promote constructive use of leisure time.” 3. “The social worker will assist you in keeping your job or help you find a new one.” 4. “This person works with your family and community and makes referrals if

needed.”

25. The male client diagnosed with paranoid schizophrenia is yelling, talking to himself, and blocking the view of the television. The other clients in the day room are becoming angry. Which action should the nurse take first?

1. Obtain a restraint order from the HCP. 2. Escort the other clients from the day room.

3. Administering an intramuscular (IM) antipsychotic medication. 4. Approach the client calmly along with two MHWs.

26. A young child, Joey, was admitted to the pediatric unit with a fractured jaw, bruises, and multiple cigarette burns to the arms. The mother reported the father hurt the child. A man comes to the nurse’s station saying, “I am Joey’s father, can you tell me how he is doing?” Which statement is the nurse’s best response?

1. “Your son has a fractured jaw and some bruises but he is doing fine.” 2. “I am sorry I cannot give you any information about your son.” 3. “You should go talk to your wife about your son’s condition.” 4. “The social worker can discuss your son’s condition with you.”

27. During an interview, the female client tells the psychiatric nurse in a mental health clinic, “Sometimes I feel like life is not worth living. I am going to kill myself.” Which interventions should the nurse implement? Select all that apply.

1. Make a no-suicide contract with the client. 2. Place the client on a 1-to-1 supervision. 3. Ask the client whether she has a plan. 4. Commit the client to the psychiatric unit. 5. Assess the client’s support system.

28. The psychiatric nurse is caring for clients on a closed unit. Which client would warrant immediate intervention by the nurse?

1. The client who refuses to attend the anger management class. 2. The client who is requesting to go outside to smoke a cigarette. 3. The client who is nauseated and has vomited twice.

4. The client who has her menses and has abdominal cramping.

29. The clinical manager wants to reward the staff on the psychiatric unit for having no tardies or absences for 1 month. Which action would be most appropriate for the clinical manager?

1. Provide pizza, drinks, and dessert for all the shifts.

2. Post a thank you note on the board in the employee lounge. 3. Individually acknowledge this accomplishment with the staff. 4. Place official documentation in each staff’s employee file.

30. The nurse is working in an outpatient psychiatric clinic. The male client tells the nurse, “I am going to kill my wife if she files for divorce. I know I can’t live without her.” Which action should the nurse implement?

1. Take no action because this is confidential information. 2. Document the statement in the client’s nurse’s notes.

3. Inform the client’s psychiatric health-care provider (HCP) of the comment. 4. Encourage the client to talk to his wife about the divorce.

PRACTICE QUESTIONS ANSWERS AND RATIONALES

Setting Priorities When Caring

for Clients

1. 1. The client with a histrionic personality has excessive emotionality and seeks attention. Her saying “something important” must be understood within this context and would not warrant the psychiatric nurse’s calling this client first.

2. The nurse should contact this client first because the client realizes the voices are telling him to hurt his mother. The nurse should inform this client to come to the clinic immediately, and he should be admitted to a psychi- atric unit.

3. Because the wife called the clinic, the client is being watched and should be safe from killing himself. The nurse should call this client immediately but not before a client who made the phone call and who may be by himself and hearing voices.

4. The nurse should expect the client who is manic not to be sleeping; therefore, this is expected behavior. The nurse should call this client immediately but not before the client who is hearing voices telling him to hurt his mother.

2. 1. Oppositional defiant disorder consists of a pattern of uncooperative, defiant, and hos- tile behavior toward authority figures. Not following the MHW’s directions would be expected behavior in a child diagnosed with this disorder and would not require imme- diate intervention by the nurse.

2. Refusal to talk and/or make eye contact is a sign of autism, the best known of the perva- sive developmental disorders; therefore, this client would not require immediate inter- vention by the nurse.

3. The child with conduct disorder is aggressive to people and animals, bul- lies, threatens, destroys property, and sets fires. The child’s throwing furniture could endanger the child or other clients. This behavior warrants immedi- ate intervention.

4. Eating dirt and sand is pica, or the ingestion of non-nutritive substances such as paint, hair, cloth, leaves, sand, clay, or soil. It is

commonly seen in mentally retarded chil- dren, but it is not life threatening unless a medical complication such as a bowel obstruction, infection, or a toxic condition (e.g., lead poisoning) occurs. This behavior would not require immediate intervention. MAKING NURSING DECISIONS:When deciding which client to assess first, the test taker should determine whether the signs/symptoms the client is exhibiting are normal for the client’s situation. After elim- inating the expected options, the test taker should determine which situation is more life threatening.

3. 1. The nurse should discuss how the visit went, but it is not the first intervention. 2. The nurse should make sure the client took

his medications during the weekend pass, but it is not the first intervention. 3. The client should discuss how the visit

went, but it is not the first intervention.

4. The nurse’s first intervention should be to ensure the client’s safety by checking to make sure the client has no sharps or dangerous objects that he could use to hurt himself because he is diagnosed with major depression.

4. 1. The nurse must document the client’s behavior that prompted the need for seclu- sion, but it is not the first intervention. 2. The day room area should be cleaned up,

but it is not the nurse’s first intervention.

3. The use of restraints and seclusion requires a HCP’s order every

24 hours. The nurse must obtain this order first after placing the client in the seclusion room. The nurse can place the client in seclusion for the safety of the client/staff/other clients, but the nurse must then immediately obtain a HCP’s order.

4. The charge nurse should make sure the other clients are not injured, but the first intervention is to keep the client who is acting out safe and legally put into seclusion.

5. 1. The client may or may not want the police notified, but this is not the triage nurse’s first intervention. The triage nurse should first care for the client.

2. The SANE nurse is a nurse who is special- ized in caring for clients who have been raped. The SANE nurse is able to spend time with the client, is knowledgeable of legal issues, and would be an appropriate in- tervention, but it is not the triage nurse’s first intervention.

3. The triage nurse’s first intervention is to address the client’s physiologic needs, which means to assess for any type of trauma or injury.

4. The client can complete the admission form while in the room; the triage nurse’s first in- tervention should be to care for the client, not paperwork.

MAKE NURSING DECISIONS:When the question asks which intervention to imple- ment first, the test taker should determine whether any of the options concern the physiologic needs of the client and then ap- ply Maslow’s Hierarchy of Needs to find the correct answer. Remember, physiologic needs take priority over all other needs.

6. 1. The client with agoraphobia is afraid to leave the house; therefore, canceling a clinic appointment would be expected of this client. The nurse would not need to return this client’s phone call first.

2. The client with a somatoform disorder has physical symptoms without a physiologic cause; therefore, complaining of numbness in the legs is expected behavior. The nurse would not need to return this client’s phone call first.

3. The client with hypochondriasis is preoccu- pied with the fear that one has or will get a serious disease; fearing breast cancer is then expected behavior. The nurse would not need to return this client’s phone call first.

4. Post-traumatic stress disorder is an ill- ness that occurs to someone who has experienced a traumatic event. The client feels a numbing of general responsiveness but has outbursts of anger. The nurse should return this call first and assess the situation to deter- mine whether the client should be seen in the clinic.

MAKING NURSING DECISIONS:When deciding which client to assess first, the test taker should determine whether the signs/symptoms the client is exhibiting are normal or expected for the client situa- tion. After eliminating the expected options, the test taker should determine which situation is more life threatening.

7. 1. The client who is depressed would be expected to look dejected; therefore, the nurse would not need to assess this client first.

2. This client who says he wants to go to heaven to be with his wife may be suici- dal and should be assessed first to see whether he has a plan.

3. This client needs to be assessed for anorexia but not before a client who may be suicidal.

4. The nurse should not interrupt a client who is acting compulsively. The nurse should wait until the client finishes the behavior before talking to the client.

8. 1. The nurse needs to remove the man from the room so that the nurse can talk to the client and discuss probable abuse. Taking the client to the x-ray department may not rouse suspicion in the man and may allow the client to discuss the situation.

2. This may be needed, but it is not the first intervention. This action may cause the man to get angrier in the emergency room department, or it may cause more problems for the woman if she goes home with him. 3. The nurse could demand the man leave the

room, but this action may cause the man’s anger to escalate; therefore, the first intervention is to remove the client from the room.

4. The nurse should not allow the man to see the nurse discussing a woman’s shelter with the client or providing a client with a brochure. This could cause further anger in the man, especially if the woman goes home with the man.

9. 1. The therapeutic serum level for lithium is 0.6 to 1.5 mEq/L. Because the client’s 1.0 mEq/L level is within normal limits, the charge nurse would not need to notify the psychiatric HCP.

2. The WBC count is elevated, which may indicate that the client is experiencing agranulocytosis, a life-threatening com- plication of clozapine. This laboratory data would warrant notifying the psychi- atric health-care provider.

3. The client’s serum potassium level is within normal limits; therefore, this laboratory data does not warrant notifying the psychi- atric health-care provider.

4. This glucose level is slightly elevated but would not warrant notifying the psychiatric health-care provider.

10. 1. This is an appropriate medication for an anxiety attack, but it will take at least 15 to 30 minutes for the medication to treat the physiologic signs/symptoms. Therefore, this is not the first intervention. 2. The nurse should discuss the panic attack

and what prompted it, but it is not the nurse’s first intervention.

3. The first intervention is to remove the client from the busy day room to a quiet area to help decrease the anxiety attack.

4. The client’s vital signs should be taken, but this is not the nurse’s first intervention.

Delegating and Assigning

Nursing Tasks

11. 1. Providing phone numbers for the client and family is an intervention that the nurse should discuss with the client and would not warrant intervention by the clinical manager.

2. Follow-up appointments are important for the client after being discharged from a psychiatric facility; therefore, this instruc- tion would not warrant intervention by the clinical manager.

3. The client should be given a 7-day supply of antidepressants because safety of the client is priority. As anti- depressant medications become more effective, the client is at a higher risk for suicide; therefore, the nurse should ensure that the client cannot take an overdose of medication. This instruc- tion warrants intervention by the clinical manager.

4. The client should not take any OTC medications without talking to the HCP or pharmacist. This instruction would not warrant intervention by the clinical manager.

12. 1. The client diagnosed with dementia would be expected to have confusion and disorientation; therefore, the LPN could be assigned this client. This client is not experiencing any poten- tially life-threatening complication of dementia.

2. The client is experiencing tardive dyski- nesia, a potentially life-threatening com- plication of antipsychotic medication. An experienced RN should be assigned to this client.

3. The therapeutic serum level for lithium is 0.6 to 1.5 mEq/L. The client’s level is toxic, and an experienced RN should care for the client.

4. This client is experiencing a potentially life-threatening complication of alcohol withdrawal. An experienced RN should be assigned to this client.

MAKING NURSING DECISIONS:The test taker must determine which client is the most stable, which makes this an “except” question. Three clients are either unstable or have potentially life- threatening conditions.

13. 1. Clients are allowed, encouraged, and expected to participate in the multidisci- plinary team meeting. This is an appropri- ate task to delegate to the MHW.

2. One of the MHW’s primary responsibilities is to watch clients in the day room area. This is an appropriate task to delegate. 3. The MHW can remain with a client who

is on 1-to-1 suicide watch. This is an appropriate nursing task to delegate.

4. The MHW does not draw blood, and this would be an inappropriate task to delegate. The laboratory technician draws the client’s blood work.

14. 1. Telling the client to place the letter in the mailbox is empowering the client to take responsibility. This action would not war- rant intervention by the nurse.

2. The nurse should explain to the MHW that mental health clients retain all of the civil rights afforded to all persons, except the right to leave the hospital in the case of involuntary commitments. The client has the right to mail and receive letters.

3. Mailing the client’s letter is an appropriate action to take; therefore, this would not warrant intervention by the nurse. 4. Reporting the client mailed a letter to his

family at the team meeting may or may not be pertinent to the client’s care, but this action would not warrant intervention by the nurse.

15. 1. Whenever the nurse is given informa- tion that indicates a complication or is potentially life threatening, the nurse must first assess the client.

2. The client is unstable; therefore, the nurse should not instruct the UAP to take the client’s vital signs.

3. The nurse should not notify the health- care provider before assessing the client.

4. Librium is a medication used for alcohol withdrawal, not for heroin withdrawal. MAKING NURSING DECISIONS:If the test taker wants to select “notify the HCP” as the correct answer, the test taker must examine the other three options. If infor- mation in any of the other options is data the HCP would need to make a decision, then the test taker should eliminate the “notify the HCP” option.

16. 1. The client with lithium toxicity is unsta- ble, and the nurse should not delegate this task to an MHW.

2. Having someone stay with the client after a meal will prevent the client from inducing vomiting and could be delegated to an MHW. The client diagnosed with bulimia needs someone there to prevent vomiting, which is a sign of this mental health problem.

3. The nurse should not delegate teaching. Helping the client with anger manage- ment would be the responsibility of the nurse or possibly the therapy department.

4. The client has a right to talk to his mother on the phone without someone listening.

17. 1. The RN should be assigned to update the individualized care plans.

2. The MHW should be assigned to watch the clients in the day area.

3. The LPN’s scope of practice allows the administration of medication. This is an appropriate assignment.

4. The LPN can transcribe HCP’s orders, but the unit secretary can also transcribe orders, which the RN/LPN can co-sign. This would not be the most appropriate assignment for the LPN.

18. 1. All psychiatric staff members are taught how to “take down” a client physically if the client is a danger to himself or herself or to others. The nurse should assist the MHW in sub- duing the client so that no one is injured.

2. The psychiatric staff members are trained to deal with clients who are angry and aggressive; there is no need to contact hospital security.

3. The nurse can document the occurrence, but because the nurse observed the “take down,” the nurse should assist the MHW. The psychiatric staff members have to be able to depend on each other no matter what the situation.

4. The nurse can have other staff members remove clients from the day room area; the psychiatric nurse should help the MHW with the “take down.”

19. 1. The nurse should address the behavior with the clients and not delegate this task to the MHW. This inappropriate behavior needs further investigation to determine whether it is consensual or under duress. 2. The inappropriate behavior should be

addressed immediately with both clients. 3. If the behavior does not stop, one of the

clients may need to be transferred to another unit, but this is not the appropri- ate action at this time.

4. The nurse needs to talk to the clients to determine whether the kissing was consensual or under duress. Either way, the behavior is inappropriate, and the clients should be told there is no kissing or sexual activity allowed between clients while they are hospitalized on the psychiatric unit. 20. 1. The MHW could walk with the client

who is agitated. This may help decrease the client’s agitation and anxiety.

2. The nurse should not assign a task that is the responsibility of another staff member. The housekeeping or custodial depart- ment should be assigned to clean the floor.

3. The MHW cannot take or transcribe

In document Client Management and Leadership Success (Page 179-187)