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The scope of this Nursing Test V is parallel to the NP5 NLE Coverage: Psychiatric Nursing
Oedipal complex
Superego
Id
Ego
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“What are you going to do this time?”
Say nothing. Wait for the client’s next comment
“You seem upset. I am going to be here with you; perhaps you will want to talk about it”
“Have you felt this way before?”
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Crises are related to deep, underlying problems
Crises seldom occur in normal people’s lives
Crises may go on indefinitely.
Crises usually resolved in 4-6 weeks.
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Place restriction on the client’s activities when his behavior occurs.
Ask the client to clean the soiled floor.
Take the client to the bathroom at regular intervals.
Limit fluid intake.
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Assure the client that “ You will be well cared for.”
Introduce the client to some of the other clients.
Ask “Do you know where you are?”
Take the client to the assigned room.
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What food she likes.
Her desired weight.
Her body image.
What causes her behavior.
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Do not bring it up unless the client asks.
Tell the client that her roommate went home.
Tell the client, if asked, “You should ask the doctor.”
Tell the client that her closest roommate died.
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Depression
Withdrawal
Apathy
Anger
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“ I won’t let anyone get you.”
“Who are they?”
“I don’t see anyone coming.”
“You look frightened.”
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“What do you think is the connection between your not getting enough love and overeating?”
“Tell me what you think the therapist means.”
“You need to ask your therapist.”
“ We are here to deal with your diet, not with your psychological problems.”
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“I doubt that he feels that way.”
“What makes you feel that way?”
“Have you discussed your feelings with your husband?”
Ask the husband, in front of the wife, how he feels about this.
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Ignoring the child.
Flat affect.
Expressions of guilt.
Acting overly solicitous toward the child
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Focus on the feelings conveyed rather than the thoughts expressed.
Speak loudly and rapidly to keep the client’s attention, because the client is easily distracted.
Allow the client to talk freely.
Encourage the client to complete one thought at a time.
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Competitive play
Nonverbal play
Cooperative play
Solitary play
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“Tell me about your hate.”
“I will stay with you as long as you feel this way.”
“For whom do you have these feelings?”
“I understand how you can feel this way.”
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Identification.
Rationalization.
Denial.
Compensation.
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Indifference
Denial
Resignation
Anger
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The children and the injustice done to them by their father’s death are the woman’s main concern.
To explain the woman’s reaction, the nurse needs more information about the relationship and breakup.
The woman is not reacting normally to the news.
The woman is experiencing a normal bereavement reaction.
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Solitary activity, such as walking with the nurse, to decrease stimulation.
Competitive activity, such as bingo, to increase the client’s self-esteem.
Group activity, such as basketball, to decrease isolation.
Intellectual activity, such as scrabble, to increase concentration.
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“What were you expecting to happen?”
“It usually takes 2-3 weeks to be effective.”
“Do you want to refuse this medication? You have the right.”
“That’s a long time wait when you feel so depressed.”
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Isocarboxazid (Marplan)
Chlorpromazine HCI (Thorazine)
Trihexyphenidyl HCI (Artane)
Trifluoperazine HCI (Stelazine)
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Focus on the there-and-then rather the here-and-now.
Limit in the number of visitors, to minimize confusion.
Variety in their daily life, to decrease depression.
A structured environment, to minimize regressive behaviors.
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Delusion.
Hallucination.
Negativism.
Illusion.
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Ignore the client as long as he or she is talking about suicide, because suicide attempt is unlikely.
Administer medication.
Relax vigilance when the client seems to be recovering from depression.
Maintain constant awareness of the client’s whereabouts.
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Constipation, increased appetite.
Anorexia, insomnia.
Diarrhea, anger.
Verbosity, increased social interaction.
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Acknowledge that the word has some special meaning for the client.
Try to interpret what the client means.
Divert the client’s attention to an aspect of reality.
State that what the client is saying has not been understood and then divert attention to something that is really bound.
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Repression.
Suppression.
Undoing.
Rationalization.
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Hallucination.
Ideas of reference.
Delusion of persecution.
Illusion.
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Nausea.
Gait disturbances.
Bowel movements.
Voiding.
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Give the parents time alone with the body.
Ask the physician for permission.
Complete the postmortem care and quietly accompany the family to the child’s room.
Suggest the parents to wait until the funeral service to say “good-bye.”
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Tremor, drowsiness.
Seizures, suicidal tendencies.
Visual disturbance, headache.
Excessive diaphoresis, diarrhea.
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Mention that the “voices” would want the client to participate.
Demand that the client must join a group activity.
Give the client a long explanation of the benefits of activity.
Tell the client that the nurse needs a partner for an activity.
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“Be a big kid! Everyone’s waiting for you.”
“Lie still now and I’ll let you have one of your presents before you even have your operation.”
“Take a nice, big, deep breath and then let me hear you count to five.”
“You look so scared. Want to know a secret? This won’t hurt a bit!”
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Hypertensive crisis.
Diet restrictions.
Taking medication with meals.
Exposure to sunlight.
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Tell the client to work it out with her father.
Tell the client to discuss it with her mother.
Ask the father about it.
Ask the mother what she thinks.
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Acknowledge that this is the client’s belief but not the nurse’s belief.
Ask how that makes the client feel.
Show the client that no one is behind.
Use logic to help the client doubt this belief.
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Suggest the teen meet with a counselor to discuss his feelings about his girlfriend.
Tell the teen that his feelings are normal, and recommend that he find another girlfriend to take his mind off the problem.
Recall the teenage boys often say things they really do not mean and ignore the comment.
Regard the comment seriously and notify the teen’s primary health care provider and parents
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A student at exam time
A married woman, age 40, with 6 children.
A person who is an alcoholic.
A person who made a previous suicide attempt.
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Seek attention from the staff.
Control unacceptable impulses or feelings.
Do what the voices the patient hears tell him or her to do.
Punish himself or herself for guilt feeling.
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Advance the science of psychiatry by initiating research and gathering data for current statistics on emotional illness.
Plan activity programs for clients.
Understand various types of family therapy and psychological tests and how to interpret them.
Maintain a therapeutic environment.
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Touch her and tell her exactly what was done for her baby.
Allow the mother to continue her present behavior while sitting quietly with her.
“No, all clients are given the same good care.”
“Yes, you’re probably right. Your son did not get better care.”
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Gratify the client’s inner needs.
Give the client opportunities to test reality.
Provide external controls.
Reinforce the client’s self-concept.
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“Do you get upset and confused often?”
“You won’t need your glasses or hearing aid. The nurses will take care of you.”
“I understand. You will be able to cooperate best if you know what is going on, so I will find out how I can arrange to have your glasses and hearing aid available to you in the recovery room.”
I understand you might be more cooperative if you have your aid and glasses, but that is just not possible. Rules, you know.”
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A staff member has frequent contacts with the client.
Restraints are applied.
The client is allowed to come out after 4 hours.
All the furniture is removed form the isolation room.
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“Have you considered birth control?”
“This isn’t the purpose of either of you being here.”
“I see you’ve made a new friend.”
“Think about what you are doing.”
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Avoid stairs without banisters.
Use restraints while the client is in bed to keep him or her from wandering off during the night.
Use restraints while the client is sitting in a chair to keep him or her from wandering off during the day.
Provide a night-light and a big clock.
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“Do you think so?”
“It’s not likely.”
“What will be different?”
“I hope so, for your sake.”
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Denial of the possibility of carcinoma.
Signs of grief reaction.
Relief that the operation is over.
Signs of deep depression.
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Use simple questions that call for a response.
Encourage discussion of feelings.
Look through a photo album together.
Bring up neutral topics.
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Deemphasizing preoccupation with elimination, nourishment, and sleep.
Protecting against harm to others.
Providing motor outlets for aggressive, hostile feelings.
Reducing interpersonal contacts.
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