Ati mental health exam f24
Total Questions : 55
Showing 25 questions, Sign in for moreA nurse is caring for a client who has bipolar disorder. The client says to the nurse, “Give me your pen to cut the pain out of my chest.” The nurse should identify that the client is at risk for which of the following?
Explanation
Choice A reason:
An illusion is a misinterpretation of a real external stimulus. For example, seeing a shadow and thinking it is a person. The client’s statement does not indicate a misinterpretation of reality but rather a desire to inflict harm on themselves.
Choice B reason:
A hallucination is a false sensory perception without any real external stimulus, such as hearing voices or seeing things that are not there. The client’s statement does not suggest they are experiencing a hallucination but rather expressing a desire to self-harm.
Choice C reason:
Attention-seeking behavior involves actions taken to gain attention from others. While the client’s statement could be seen as a cry for help, it is more accurately identified as a risk for self-mutilation due to the explicit mention of wanting to cut themselves.
Choice D reason:
Self-mutilation refers to deliberate self-inflicted harm, often as a way to cope with emotional pain. The client’s statement, “Give me your pen to cut the pain out of my chest,” clearly indicates a risk for self-mutilation, as they are expressing a desire to harm themselves to alleviate emotional distress.
A nurse is explaining advance care directives, or “living wills,” to a client and the client’s spouse. Which detail would the nurse include in the description of an advance care directive?
Explanation
Choice A reason:
An advance care directive, or “living will,” is a legal document that specifies what medical treatments the client wishes to receive or omit if they become unable to make decisions for themselves. This document guides healthcare providers and family members in making decisions that align with the client’s preferences.
Choice B reason:
A client is not required to sign the “living will” document with an attorney present. While it is advisable to consult with an attorney when creating legal documents, it is not a requirement for the validity of an advance care directive.
Choice C reason:
An attorney may assist in drafting the advance care directive, but it is not necessary for the attorney to draw up the papers. The client can create the document with the help of healthcare providers or legal advisors.
Choice D reason:
The client’s physician does not need to act as a witness when the client signs the document. Typically, witnesses are required to ensure the document is signed voluntarily and without coercion, but they do not have to be the client’s physician.
A nurse working on a psychiatric unit receives a telephone call from a client’s employer. The employer asks for a copy of the client’s latest laboratory work and psychological testing results so that the client’s medical records in employee health can be updated. Based on the nurse’s knowledge of breach of confidentiality, which response would be appropriate?
Explanation
Choice A reason:
Agreeing to send the information without the client’s consent is a breach of confidentiality. Healthcare providers must protect patient privacy and cannot disclose medical information without explicit permission from the client.
Choice B reason:
While obtaining the client’s signed consent is necessary before releasing information, this response still acknowledges that the person in question is a client, which could be a breach of confidentiality.
Choice C reason:
Stating that the information cannot be given out is correct, but it still indirectly confirms that the person is a client, which could be a breach of confidentiality.
Choice D reason:
“I am unable to acknowledge whether or not your employee is a client on this unit” is the most appropriate response. This statement protects the client’s privacy by not confirming or denying their presence in the unit, thus maintaining confidentiality.
While working with an older client, a nurse begins to think of the client as a grandparent and responds to the client as a grandchild. The nurse is developing what type of emotional reaction?
Explanation
Choice A reason:
Countertransference occurs when a healthcare provider projects their own feelings and experiences onto the client. In this case, the nurse is responding to the client as if they were their grandparent, which indicates that the nurse’s personal feelings are influencing their professional relationship.
Choice B reason:
Empathy involves understanding and sharing the feelings of another person. While empathy is important in nursing, it does not involve projecting personal relationships onto the client.
Choice C reason:
Transference occurs when a client projects feelings about important figures in their life onto the healthcare provider. This is the opposite of countertransference, where the provider projects their feelings onto the client.
Choice D reason:
Modeling involves demonstrating behaviors for others to imitate. It does not describe the emotional reaction of projecting personal feelings onto a client.
A nurse in a mental health clinic is conducting a staff education session on schizophrenia. Which of the following manifestations should the nurse identify as negative symptoms? (Select all that apply.)
Explanation
Choice A reason:
Anhedonia, or the inability to experience pleasure, is a negative symptom of schizophrenia. Negative symptoms reflect a decrease or loss of normal functions and are often more challenging to treat than positive symptoms.
Choice B reason:
Hallucinations are positive symptoms of schizophrenia. Positive symptoms involve the presence of abnormal behaviors or experiences, such as hearing voices or seeing things that are not there.
Choice C reason:
Poor judgment is not classified as a negative symptom of schizophrenia. It can be a feature of cognitive impairment associated with the disorder but is not specifically a negative symptom.
Choice D reason:
Delusions are positive symptoms of schizophrenia. They involve false beliefs that are not based in reality, such as believing one has special powers or is being persecuted.
Choice E reason:
Blunt affect, or reduced emotional expression, is a negative symptom of schizophrenia. It involves a lack of emotional responsiveness and is indicative of the diminished capacity to express emotions.
A nurse is providing education to a group of staff members about schizophrenia. Which of the following age groups should the nurse include as the age when schizophrenia is typically diagnosed?
Explanation
Choice A reason:
Schizophrenia is rarely diagnosed in preschool-aged children. Early-onset schizophrenia can occur, but it is extremely uncommon in this age group.
Choice B reason:
While schizophrenia can develop in school-age children, it is still relatively rare. The typical age of onset is later, during adolescence or young adulthood.
Choice C reason:
Young adulthood is the most common age group for the onset of schizophrenia. Symptoms often begin to appear in late adolescence to early adulthood, typically between the ages of 16 and 30.
Choice D reason:
Schizophrenia is not typically diagnosed in older adulthood. While older adults can experience symptoms of schizophrenia, the onset of the disorder usually occurs much earlier in life.
While working with an older client, a nurse begins to think of the client as a grandparent and responds to the client as a grandchild. The nurse is developing what type of emotional reaction?
Explanation
Choice A reason:
Countertransference occurs when a healthcare provider projects their own feelings and experiences onto the client. In this case, the nurse is responding to the client as if they were their grandparent, which indicates that the nurse’s personal feelings are influencing their professional relationship.
Choice B reason:
Empathy involves understanding and sharing the feelings of another person. While empathy is important in nursing, it does not involve projecting personal relationships onto the client.
Choice C reason:
Transference occurs when a client projects feelings about important figures in their life onto the healthcare provider. This is the opposite of countertransference, where the provider projects their feelings onto the client.
Choice D reason:
Modeling involves demonstrating behaviors for others to imitate. It does not describe the emotional reaction of projecting personal feelings onto a client.
A nurse is talking with a client who has schizophrenia. Suddenly the client states, “I’m frightened. Do you hear that? The voices are telling me to do terrible things.” Which of the following responses by the nurse is appropriate?
Explanation
Choice A reason:
Asking “What are the voices telling you to do?” is an appropriate response because it allows the nurse to assess the content of the hallucinations and determine if the client is at risk of harming themselves or others. This approach shows empathy and concern while gathering important information for the client’s safety.
Choice B reason:
Telling the client “You need to understand that there are no voices” dismisses the client’s experience and can increase their distress. It is important to acknowledge the client’s feelings and perceptions, even if they are not based in reality.
Choice C reason:
Asking “Why do you think you are hearing the voices?” may not be helpful in the moment of distress. The client may not be able to provide a rational explanation for their hallucinations, and this question could increase their confusion and anxiety.
Choice D reason:
Telling the client “You need to tell the voices to leave you alone” may not be effective, as the client may not have the ability to control their hallucinations. It is more important to assess the content of the hallucinations and provide support.
The Psychiatrist calls Jake’s father to obtain collateral information, pending Jake’s discharge home. Jake’s father reports Jake’s mother died when he was 14 years old. Jake is unable to tell the nurse or Psychiatrist how old he was or the year she died. Which defense mechanism is being depicted?
Explanation
Choice A reason:
Regression involves reverting to an earlier stage of development in response to stress. This defense mechanism is not indicated by Jake’s inability to recall specific details about his mother’s death.
Choice B reason:
Projection involves attributing one’s own unacceptable thoughts, feelings, or flaws to others. This defense mechanism does not explain Jake’s inability to remember details about his mother’s death.
Choice C reason:
Repression is a defense mechanism where distressing memories, thoughts, or feelings are unconsciously pushed out of conscious awareness. Jake’s inability to recall how old he was or the year his mother died suggests that he may be repressing these painful memories.
Choice D reason:
Suppression is a conscious effort to push distressing thoughts or feelings out of awareness. Since Jake is unable to recall specific details, it is more likely that repression, an unconscious process, is at play.
A nurse is interviewing a client who is experiencing negative symptoms of psychosis about their family history of schizophrenia. In which of the following phases of the nursing process should this take place?
Explanation
Choice A reason:
Implementation involves carrying out the interventions outlined in the care plan. This phase focuses on executing the planned actions to achieve the desired outcomes and does not include gathering initial information about the client’s history.
Choice B reason:
Evaluation involves assessing the effectiveness of the interventions and determining whether the goals of the care plan have been met. This phase occurs after the initial assessment and implementation of interventions.
Choice C reason:
Assessment is the first phase of the nursing process, where the nurse gathers comprehensive information about the client’s health status, including their family history of schizophrenia. This information is crucial for developing an accurate diagnosis and care plan.
Choice D reason:
Planning involves setting goals and determining the appropriate interventions based on the assessment data. While planning is essential, it follows the assessment phase and relies on the information gathered during the assessment.
A nurse is providing education to a group of staff members about schizophrenia. Which of the following age groups should the nurse include as the age when schizophrenia is typically diagnosed?
Explanation
Choice A reason:
Schizophrenia is rarely diagnosed in preschool-aged children. Early-onset schizophrenia can occur, but it is extremely uncommon in this age group.
Choice B reason:
While schizophrenia can develop in school-age children, it is still relatively rare. The typical age of onset is later, during adolescence or young adulthood.
Choice C reason:
Young adulthood is the most common age group for the onset of schizophrenia. Symptoms often begin to appear in late adolescence to early adulthood, typically between the ages of 16 and 30.
Choice D reason:
Schizophrenia is not typically diagnosed in older adulthood. While older adults can experience symptoms of schizophrenia, the onset of the disorder usually occurs much earlier in life.
A nurse is conducting a group therapy session for several clients. The group is laughing at a joke one of the clients told, when a client who is schizophrenic jumps up and runs out of the room yelling, “You are all making fun of me!” The nurse should identify this behavior as which of the following characteristics of schizophrenia?
Explanation
Choice A reason:
Delusions of grandeur are a type of delusion where an individual believes they have exceptional abilities, wealth, or fame. This is not the correct answer because the client’s reaction of thinking others are making fun of them does not align with the belief of having grandiose qualities. Delusions of grandeur typically involve an inflated sense of self-importance, which is not evident in the scenario described.
Choice B reason:
Loose association refers to a thought disorder where ideas are presented with little or no logical connection. This is not the correct answer because the client’s reaction is more about misinterpreting the actions of others rather than displaying disorganized thinking. Loose associations would manifest as speech that is difficult to follow due to the lack of coherent connections between thoughts.
Choice C reason:
Ideas of reference involve the belief that insignificant remarks, events, or objects in one’s environment have personal meaning or significance. This is the correct answer because the client believes that the group’s laughter is directed at them, interpreting it as a personal attack. This misinterpretation of external events is a hallmark of ideas of reference, which is a common symptom in schizophrenia.
Choice D reason:
Magical thinking involves believing that one’s thoughts, words, or actions can cause or prevent specific outcomes in a way that defies the laws of cause and effect. This is not the correct answer because the client’s reaction does not involve any belief in their own ability to influence events through supernatural means. Instead, the reaction is based on a misinterpretation of the group’s behavior.
A nurse is caring for a client who has a mental illness. Which of the following actions by the nurse demonstrates the ethical concept of autonomy?
Explanation
Choice A reason:
Explaining unit rules and policies regarding unacceptable behaviors is important for maintaining order and safety within the facility. However, this action is more about setting boundaries and expectations rather than supporting the client’s autonomy. Autonomy involves respecting the client’s right to make their own decisions, which is not directly addressed by merely explaining rules.
Choice B reason:
Supporting the client’s wish to refuse prescribed medications demonstrates respect for the client’s autonomy. Autonomy is the ethical principle that recognizes the right of individuals to make informed decisions about their own care. By supporting the client’s decision to refuse medication, the nurse acknowledges and respects the client’s right to make choices about their treatment, even if those choices differ from medical advice.
Choice C reason:
Making sure the client understands expectations for client participation is essential for clear communication and effective treatment planning. However, this action is more about ensuring compliance and understanding rather than promoting autonomy. While it is important for clients to understand what is expected of them, this does not necessarily empower them to make their own decisions.
Choice D reason:
Encouraging client feedback about satisfaction with the facility experience is a valuable practice for improving care and ensuring that clients feel heard. However, this action focuses on gathering feedback rather than directly supporting the client’s autonomy. While it contributes to a client-centered approach, it does not specifically address the client’s right to make independent decisions about their care.
A nurse is developing a plan of care integrating Maslow’s hierarchy of needs. Which area would the nurse identify as the priority?
Explanation
Choice A reason:
A predictable social environment is important for providing stability and security, which can contribute to a client’s overall well-being. However, according to Maslow’s hierarchy of needs, physiological needs such as food and water must be met before higher-level needs like social stability can be addressed. Therefore, while important, a predictable social environment is not the immediate priority.
Choice B reason:
Adequate food is a fundamental physiological need according to Maslow’s hierarchy of needs. Physiological needs are the most basic and must be satisfied before an individual can focus on higher-level needs such as safety, love, and self-esteem. Ensuring that the client has adequate food is essential for their survival and overall health, making it the top priority in the plan of care.
Choice C reason:
A positive self-image is associated with self-esteem needs, which are higher up in Maslow’s hierarchy. While fostering a positive self-image is important for a client’s mental health and well-being, it cannot be effectively addressed until basic physiological needs are met. Therefore, it is not the immediate priority in the plan of care.
Choice D reason:
Acceptance from family relates to the need for love and belonging, which is also higher up in Maslow’s hierarchy. While family acceptance is crucial for emotional support and social well-being, it is not as immediate a priority as ensuring that the client’s basic physiological needs, such as adequate food, are met first.
A nurse is preparing to assist with electroconvulsive therapy (ECT). Which of the following pieces of equipment should the nurse set up in the room prior to the treatment? (Select all that apply)
Explanation
Choice A reason:
An electroencephalogram (EEG) monitor is essential for monitoring the brain’s electrical activity during ECT. This equipment helps ensure that the treatment is administered safely and effectively by providing real-time data on the patient’s brain waves. The EEG monitor is crucial for assessing the patient’s response to the therapy and detecting any abnormalities.
Choice B reason:
An ophthalmoscope is used to examine the interior structures of the eyes, which is not relevant to the ECT procedure. Therefore, it is not necessary to set up an ophthalmoscope in the room prior to ECT. The focus of ECT preparation is on monitoring the patient’s neurological and cardiovascular status, not on eye examinations.
Choice C reason:
A cardiac monitor is vital for tracking the patient’s heart rate and rhythm during ECT. This equipment helps detect any cardiac abnormalities or arrhythmias that may occur as a result of the treatment. Continuous cardiac monitoring ensures that any potential complications can be promptly addressed, making it an essential piece of equipment for ECT.
Choice D reason:
A blood pressure monitor is necessary for measuring the patient’s blood pressure before, during, and after the ECT procedure. Monitoring blood pressure is crucial for detecting any significant changes that could indicate cardiovascular stress or other complications. This equipment helps ensure the patient’s safety throughout the treatment.
Choice E reason:
A portable X-ray machine is not required for ECT. X-rays are used for imaging purposes, which are not part of the standard ECT procedure. The primary focus during ECT is on monitoring the patient’s neurological and cardiovascular status, making the portable X-ray machine unnecessary for this context.
After being scolded by his supervisor at work, a man comes home and punches several holes in his walls and yells at his significant other. Which of the following defense mechanisms does this scenario depict?
Explanation
Choice A reason:
Projection involves attributing one’s own unacceptable thoughts or feelings to others. This is not the correct answer because the man’s behavior of punching walls and yelling at his significant other is an outward expression of his own frustration, rather than projecting his feelings onto someone else. Projection would involve accusing others of having the feelings or thoughts that he himself is experiencing.
Choice B reason:
Denial is a defense mechanism where an individual refuses to accept reality or facts, blocking external events from awareness. This is not the correct answer because the man’s actions indicate that he is reacting to his frustration rather than denying its existence. Denial would involve ignoring or refusing to acknowledge the feelings or situation that is causing distress.
Choice C reason:
Displacement is the redirection of emotions or impulses from a threatening target to a safer one. This is the correct answer because the man redirects his anger from his supervisor, who is the source of his frustration, to a less threatening target, which is his significant other and the walls at home. Displacement allows the individual to express their emotions in a way that feels safer or more acceptable.
Choice D reason:
Passive-aggression involves expressing negative feelings indirectly rather than openly addressing them. This is not the correct answer because the man’s behavior is direct and aggressive, rather than passive. Passive-aggressive actions might include sulking, procrastination, or subtle resistance, none of which are evident in the described scenario.
After experiencing increasing conflict in the home, a social worker calls and schedules a therapy meeting. A 24-year-old, his sister, his mother, and the mother’s live-in boyfriend are asked to attend the therapy meeting. Who is the “client” who will be treated during this session?
Explanation
Choice A reason:
The 24-year-old only being the client would imply that the therapy session is focused solely on the individual issues of the 24-year-old. However, the context of the therapy session, which includes multiple family members, suggests that the focus is on addressing family dynamics and conflicts. Family therapy typically involves working with the entire family unit to improve relationships and resolve conflicts, rather than focusing on a single individual.
Choice B reason:
The entire family being the client is the correct answer because family therapy aims to address issues within the family system as a whole. By involving the 24-year-old, his sister, his mother, and the mother’s live-in boyfriend, the therapy session is designed to explore and resolve conflicts that affect the entire family. This approach recognizes that individual issues are often interconnected with family dynamics, and addressing these dynamics can lead to more effective and lasting solutions.
Choice C reason:
The 24-year-old and his mother being the clients would limit the scope of the therapy to the relationship between these two individuals. While this might address some aspects of the family conflict, it would not provide a comprehensive approach to resolving issues that involve other family members, such as the sister and the mother’s live-in boyfriend. Family therapy is most effective when all relevant members are included in the process.
Choice D reason:
The sister, mother, and 24-year-old being the clients would exclude the mother’s live-in boyfriend, who is also part of the family dynamic. Excluding any family member who is involved in the conflict can limit the effectiveness of the therapy. Family therapy aims to include all relevant members to fully understand and address the issues affecting the family as a whole. Therefore, this option is not as comprehensive as involving the entire family.
A nurse is reviewing the medical record of a client who has a new prescription for chlorpromazine for the treatment of schizophrenia. Which of the following findings indicates a contraindication to chlorpromazine?
Explanation
Choice A reason:
Fasting blood glucose of 120 mg/dL is slightly elevated but does not contraindicate the use of chlorpromazine. This medication is primarily contraindicated in conditions that affect the central nervous system, cardiovascular system, or blood cell counts. Elevated blood glucose levels should be monitored, but they do not pose an immediate risk when starting chlorpromazine.
Choice B reason:
Hypertension is a condition that requires careful monitoring when a patient is on chlorpromazine, but it is not an absolute contraindication. Chlorpromazine can cause orthostatic hypotension, so blood pressure should be monitored regularly. However, hypertension alone does not prevent the use of this medication.
Choice C reason:
Asthma is not a contraindication for chlorpromazine. While respiratory conditions should be monitored, chlorpromazine does not have a direct adverse effect on asthma. The primary concerns with chlorpromazine involve its effects on the central nervous system and blood cell counts.
Choice D reason:
A WBC count of 3,300/mm³ indicates leukopenia, which is a significant contraindication for chlorpromazine. This medication can cause agranulocytosis, a severe reduction in white blood cells, making patients more susceptible to infections. Therefore, a low WBC count is a critical factor in deciding against the use of chlorpromazine.
A nurse is assessing a client who has schizophrenia and has been on long-term treatment with chlorpromazine. He notes the client is experiencing some involuntary movements of the tongue and face. The nurse should suspect the client has developed which of the following adverse effects?
Explanation
Choice A reason:
Dystonia involves muscle contractions causing twisting and repetitive movements or abnormal postures. It typically occurs early in treatment and affects the neck, face, and back muscles. The involuntary movements described in the scenario are more characteristic of tardive dyskinesia rather than dystonia.
Choice B reason:
Parkinsonism is characterized by symptoms similar to Parkinson’s disease, such as tremors, bradykinesia, and rigidity. While it can occur with long-term use of antipsychotics, the specific involuntary movements of the tongue and face described are more indicative of tardive dyskinesia.
Choice C reason:
Akathisia involves a feeling of inner restlessness and an urgent need to move. It does not typically present with the involuntary movements of the tongue and face described in the scenario. Akathisia is more about the inability to stay still rather than specific muscle movements.
Choice D reason:
Tardive dyskinesia is a well-known adverse effect of long-term antipsychotic use, characterized by repetitive, involuntary movements, especially of the face, tongue, and limbs. The description of involuntary movements of the tongue and face fits the profile of tardive dyskinesia, making it the most likely diagnosis.
During group therapy, the nurse observes that a client is pacing, agitated, and presenting with aggressive gestures. The client’s speech pattern is rapid, and affect is belligerent. Based on the observations, the nurse’s immediate priority of care is to:
Explanation
Choice A reason:
While assisting the staff in caring for the client in a controlled environment is important, the immediate priority is to ensure safety. This choice does not directly address the immediate need to protect all clients from potential harm.
Choice B reason:
Providing safety for the client and other clients on the unit is the immediate priority. The client’s aggressive behavior poses a risk to themselves and others, and ensuring safety is the first step in managing the situation. This involves de-escalation techniques and possibly removing the client from the group setting to prevent harm.
Choice C reason:
Providing a sense of comfort and safety is important but secondary to ensuring immediate physical safety. The client’s aggressive behavior needs to be managed first to prevent any potential harm.
Choice D reason:
Offering the client a less stimulated area to calm down is a good strategy for de-escalation, but it comes after ensuring the immediate safety of all clients. The primary concern is to prevent any aggressive actions that could harm others.
A nurse is planning care for a client who has paranoid schizophrenia. Which of the following interventions should be included in the plan of care?
Explanation
Choice A reason:
Assigning assistive personnel to feed the client at mealtimes is not typically necessary for clients with paranoid schizophrenia unless there are specific physical limitations. This intervention does not address the unique needs of managing paranoia and ensuring medication adherence.
Choice B reason:
Using touch to calm the client during periods of anxiety is not recommended for clients with paranoid schizophrenia. These clients may misinterpret touch as a threat, exacerbating their paranoia and anxiety.
Choice C reason:
Rotating staff assignments for this client can increase anxiety and paranoia. Consistency in caregivers helps build trust and reduces the client’s suspicion and anxiety.
Choice D reason:
Checking the client’s mouth after the client takes medication is crucial to ensure that the client has swallowed the medication. Clients with paranoid schizophrenia may hide or refuse medication due to their distrust, so this intervention helps ensure they receive their prescribed treatment.
The charge nurse is talking with another nurse who states, “I feel like my clients have no interest in their care and do not care that I am trying to help.” Which response should the charge nurse make?
Explanation
Choice A reason:
While this response acknowledges the nurse’s feelings, it does not provide a constructive solution or address the underlying issue. It may come across as dismissive rather than supportive.
Choice B reason:
Establishing a therapeutic relationship is fundamental to effective nursing care. This response encourages the nurse to build rapport and trust with the clients, which can improve their engagement and cooperation in their care. It is a proactive and supportive suggestion.
Choice C reason:
Offering to assign another nurse does not address the issue of building a therapeutic relationship and may not be feasible. It also does not help the nurse develop skills to improve client interactions.
Choice D reason:
While clients in pain may exhibit disinterest, this response does not address the broader issue of establishing a therapeutic relationship. It focuses on a specific cause rather than providing a general strategy for improving client engagement.
A nurse is discussing quality of life with a client who has schizophrenia. Which of the following statements should the nurse include?
Explanation
Choice A reason:
This statement is supportive and realistic. It acknowledges that while complete symptom elimination may not be possible, adherence to the treatment plan can still significantly improve the client’s quality of life. It encourages the client to continue with their treatment in a positive and hopeful manner.
Choice B reason:
This statement is confrontational and may make the client feel defensive. It does not provide support or encouragement and may hinder the therapeutic relationship.
Choice C reason:
This statement is misleading and dismissive. The medical model does not guarantee the elimination of all symptoms, and suggesting the client see another doctor may undermine their confidence in the current treatment plan.
Choice D reason:
This statement is negative and may discourage the client. It implies that the client will not improve and suggests a drastic change without offering hope or support for their current treatment plan.
A psychiatric-mental health nurse is working on an inpatient unit that uses a privilege system. The nurse understands that this intervention integrates which group of theories?
Explanation
Choice A reason:
Developmental theories focus on the progression of human growth and development through various stages of life. While these theories are important in understanding patient behavior and needs, they do not directly relate to the implementation of a privilege system in an inpatient unit. Privilege systems are more aligned with behavioral theories, which emphasize the modification of behavior through reinforcement and consequences.
Choice B reason:
Humanistic theories emphasize the individual’s capacity for self-actualization and personal growth. These theories focus on the holistic development of the person and the importance of empathy and unconditional positive regard in therapeutic relationships. Although humanistic approaches are valuable in mental health care, they do not specifically address the structured reinforcement strategies used in privilege systems.
Choice C reason:
Cognitive theories focus on the role of thought processes in influencing emotions and behaviors. These theories are crucial in understanding and treating mental health conditions, particularly through cognitive-behavioral therapy (CBT). However, the privilege system, which relies on tangible rewards and consequences to shape behavior, is more closely related to behavioral theories rather than cognitive ones.
Choice D reason:
Behavioral theories are directly related to the use of a privilege system. These theories emphasize the use of reinforcement and punishment to modify behavior. In an inpatient setting, a privilege system is used to encourage desirable behaviors by providing rewards (privileges) and discouraging undesirable behaviors through the removal of privileges. This approach is grounded in the principles of operant conditioning, a key concept in behavioral theories.
A nurse is caring for a client who is hospitalized for a mental disorder. The nurse is legally obligated to breach the client’s confidentiality if the client makes which statement?
Explanation
Choice A reason:
The statement “I think that the federal government is spying on me” reflects a delusional belief, which is a symptom of certain mental health disorders. While this statement indicates the need for further assessment and possibly treatment, it does not pose an immediate threat to the safety of the client or others. Therefore, it does not warrant breaching confidentiality.
Choice B reason:
Expressing anger towards a doctor, as in the statement “That doctor I had today really made me angry,” is not uncommon in a mental health setting. While it may indicate dissatisfaction or a need for conflict resolution, it does not suggest an immediate risk of harm to the client or others. Confidentiality should be maintained unless there is a clear and imminent threat.
Choice C reason:
The statement “I get really ‘turned on’ by your appearance” is inappropriate and may indicate boundary issues or sexual attraction towards the nurse. While this requires professional handling and possibly setting boundaries, it does not constitute a threat that would necessitate breaching confidentiality.
Choice D reason:
The statement “When I get out of here, I’m going to make my neighbor sorry” indicates a specific threat of harm towards another person. Nurses are legally and ethically obligated to breach confidentiality in situations where there is a clear and imminent risk of harm to the client or others. This duty to warn and protect overrides the obligation to maintain confidentiality.
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