Psychiatric Nursing Pt. 7

1. The nurse asks a client to roll up his sleeves so she can take his blood pressure. The client replies "If you want I can go naked for you." The most therapeutic response by the nurse is:

“You’re attractive but I’m not interested.”

“You wouldn’t be the first that I will see naked.”

“I will report you to the guard if you don’t control yourself.”

“I only need access to your arm. Putting up your sleeve is fine.”

“I only need access to your arm. Putting up your sleeve is fine.”
The nurse needs to deal with the client with sexually connotative behavior in a casual, matter of fact way. A and B. These responses are not therapeutic because they are challenging and rejecting. C. Threatening the client is not therapeutic.

Explanation

“I only need access to your arm. Putting up your sleeve is fine.”
The nurse needs to deal with the client with sexually connotative behavior in a casual, matter of fact way. A and B. These responses are not therapeutic because they are challenging and rejecting. C. Threatening the client is not therapeutic.

2. Which of the following statements is true for gender identity disorder?

It is the sexual pleasure derived from inanimate objects.

It is the pleasure derived from being humiliated and made to suffer

It is the pleasure of shocking the victim with exposure of the genitalia

It is the desire to live or involve in reactions of the opposite sex

It is the desire to live or involve in reactions of the opposite sex
Gender identity disorder is a strong and persistent desire to be the other sex. A. This is fetishism. B. This refers to masochism. C. This describes exhibitionism.

Explanation

It is the desire to live or involve in reactions of the opposite sex
Gender identity disorder is a strong and persistent desire to be the other sex. A. This is fetishism. B. This refers to masochism. C. This describes exhibitionism.

3. The charge nurse of a psychiatric unit is planning the client assignment for the day. The most appropriate staff to be assigned to a client with a potential for violence is which of the following:

A timid nurse

A mature experienced nurse

An inexperienced nurse

A soft spoken nurse

A mature experienced nurse
The unstable, aggressive client should be assigned to the most experienced nurse. A, C and D. A shy, inexperienced, soft spoken nurse may feel intimidated by the angry patient.

Explanation

A mature experienced nurse
The unstable, aggressive client should be assigned to the most experienced nurse. A, C and D. A shy, inexperienced, soft spoken nurse may feel intimidated by the angry patient.

4. Situation: Knowledge and skills in the care of violent clients is vital in the psychiatric unit. A nurse observes that a client with a potential for violence is agitated, pacing up and down the hallway and making aggressive remarks. Which of the following statements is most appropriate to make to this patient?

What is causing you to become agitated?

You need to stop that behavior now.

You will need to be restrained if you do not change your behavior.

You will need to be placed in seclusion.

What is causing you to become agitated?
In a non-violent aggressive behavior, help the client identify the stressor or the true object of hostility. This helps reveal unresolved issues so that they may be confronted. B. Pacing is a tension relieving measure for an agitated client. C. This is a threatening statement that can heighten the client’s tension. D. Seclusion is used when less restrictive measures have failed.

Explanation

What is causing you to become agitated?
In a non-violent aggressive behavior, help the client identify the stressor or the true object of hostility. This helps reveal unresolved issues so that they may be confronted. B. Pacing is a tension relieving measure for an agitated client. C. This is a threatening statement that can heighten the client’s tension. D. Seclusion is used when less restrictive measures have failed.

5. The nurse exemplifies awareness of the rights of a client whose anger is escalating by:

Taking a directive role in verbalizing feelings

Using an authoritarian, confrontational approach

Putting the client in a seclusion room

Applying mechanical restraints

Taking a directive role in verbalizing feelings
Taking a directive role in the client’s verbalization of feelings can deescalate the client’s anger. B. A confrontational approach can be threatening and adds to the client’s tension. C and D. Use of restraints and isolation may be required if less restrictive interventions are unsuccessful.

Explanation

Taking a directive role in verbalizing feelings
Taking a directive role in the client’s verbalization of feelings can deescalate the client’s anger. B. A confrontational approach can be threatening and adds to the client’s tension. C and D. Use of restraints and isolation may be required if less restrictive interventions are unsuccessful.

6. The sexual response cycle in which the sexual interest continues to build:

Sexual Desire

Sexual arousal

Orgasm

Resolution

Sexual arousal
Sexual arousal or excitement refers to attaining and maintaining the physiologic requirements for sexual intercourse. A. Sexual Desire refers to the ability, interest or willingness for sexual stimulation. C. Orgasm refers to the peak of the sexual response where the female has vaginal contractions for the female and ejaculatory contractions for the male. D. Resolution is the final phase of the sexual response in which the organs and the body systems gradually return to the unaroused state.

Explanation

Sexual arousal
Sexual arousal or excitement refers to attaining and maintaining the physiologic requirements for sexual intercourse. A. Sexual Desire refers to the ability, interest or willingness for sexual stimulation. C. Orgasm refers to the peak of the sexual response where the female has vaginal contractions for the female and ejaculatory contractions for the male. D. Resolution is the final phase of the sexual response in which the organs and the body systems gradually return to the unaroused state.

7. The inability to maintain the physiologic requirements in sexual intercourse is:

Sexual Desire Disorder

Sexual Arousal Disorder

Orgasm Disorder

Sexual Pain disorder

Sexual Arousal Disorder
This describes sexual arousal disorder. A. Sexual Desire Disorder refers to the persistent and recurrent lack of desire or willingness for sexual intercourse. C. Orgasm Disorder is the inability to complete the sexual response cycle because of the inability to achieve an orgasm. D. Sexual Pain Disorder is characterized by genital pain before, during or after sexual intercourse.

Explanation

Sexual Arousal Disorder
This describes sexual arousal disorder. A. Sexual Desire Disorder refers to the persistent and recurrent lack of desire or willingness for sexual intercourse. C. Orgasm Disorder is the inability to complete the sexual response cycle because of the inability to achieve an orgasm. D. Sexual Pain Disorder is characterized by genital pain before, during or after sexual intercourse.

8. Situation: The nurse may encounter clients with concerns on sexuality. The most basic factor in the intervention with clients in the area of sexuality is:

Knowledge about sexuality.

Experience in dealing with clients with sexual problems

Comfort with one’s sexuality

Ability to communicate effectively

Comfort with one’s sexuality
The nurse must be accepting, empathetic and non-judgmental to patients who disclose concerns regarding sexuality. This can happen only when the nurse has reconciled and accepted her feelings and beliefs related to sexuality. A,B and D are important considerations but these are not the priority.

Explanation

Comfort with one’s sexuality
The nurse must be accepting, empathetic and non-judgmental to patients who disclose concerns regarding sexuality. This can happen only when the nurse has reconciled and accepted her feelings and beliefs related to sexuality. A,B and D are important considerations but these are not the priority.

9. The client jumps up and throws a chair out of the window. He was restrained after his behavior can no longer be controlled by the staff. Which of these documentations indicates the safeguarding of the patient's rights?

There was a doctor’s order for restraints/seclusion

The patient’s rights were explained to him.

The staff observed confidentiality

The staff carried out less restrictive measures but were unsuccessful.

The staff carried out less restrictive measures but were unsuccessful.
This documentation indicates that the client has been placed on restraints after the least restrictive measures failed in containing the client’s violent behavior.

Explanation

The staff carried out less restrictive measures but were unsuccessful.
This documentation indicates that the client has been placed on restraints after the least restrictive measures failed in containing the client’s violent behavior.

10. The nurse closely observes the client who has been displaying aggressive behavior. The nurse observes that the client's anger is escalating. Which approach is least helpful for the client at this time?

Acknowledge the client’s behavior

Maintain a safe distance from the client

Assist the client to an area that is quiet

Initiate confinement measures

Initiate confinement measures
The proper procedure for dealing with harmful behavior is to first try to calm patient verbally. . When verbal and psychopharmacologic interventions are not adequate to handle the aggressiveness, seclusion or restraints may be applicable. A, B and C are appropriate approaches during the escalation phase of aggression.

Explanation

Initiate confinement measures
The proper procedure for dealing with harmful behavior is to first try to calm patient verbally. . When verbal and psychopharmacologic interventions are not adequate to handle the aggressiveness, seclusion or restraints may be applicable. A, B and C are appropriate approaches during the escalation phase of aggression.